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Columbia  ^nibetsiiti) 


Srpartmpnt  of  ^urgrrg       ^ 
(Sift  of  ir-  3o0ppl?  A.  llakr 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons  (for  the  Medical  Heritage  Library  project) 


http://www.archive.org/details/principlespractiOOpark 


■riiK 


PlilNClPLES  AND  PRACTICE 


MODERN  SURGERY 


BY 

ROSWELL  PAEK,  A.M.,  M.D.,  LL.D.  (Yale) 

I'HOl'ESSOU    OF    THE  PRINCIPLES    AND    PRACTICE    OF    SURGERY   AND    OF    CLINICAL    SURGERY    IN    THE    MEDICAL 

DEPARTMENT    OF    THE    UNIVERSITY    OF    BUFFALO,    BUFFALO,    NEW    YORK  ;    MEMBER    OF    THE 

GERMAN,  ITALIAN  AND  FRENCH  SURGICAL  SOCIETIES;     EX-PRESIDENT  OF  THE 

AMERICAN  SURGICAL  ASSOCIATION    AND  OF    THE  MEDICAL  SOCIETY  OF 

THE    STATE    OF    NEW    YORK  ;     SURGEON    TO    THE    BUFFALO 

GENERAL    HOSPITAL,    ETC. 


WITH    722    ENGRAVINGS   AND   60    FULL-PAGE    PLATES   IN    COLORS 
AND    MONOCHROME 


LEA  BROTHERS  &  CO. 

PHILADELPHIA   AND   NEW  YORK 
1907 


Entered  according  to  Act  of  Congress,  in  the  year  1907.  hy 
LEA  BROTHERS  &  CO. 
in  the  Office  of  the  Librarian  of  Congress.    All  rights  reserved. 


PREFACE. 


A  NEW  work  oil  Snr^'cry  enters  a  field  of  literature  already  rich  in  exeelleiit 
books  differing  widely  in  plan  and  viewpoint.  Fortunately  nothing  else  i.s  po.s.sible 
in  representing  so  vast  a  subject,  for  it  is  obviously  advantageous  that  the  reader 
should  have  the  benefit  of  the  personal  equation  of  his  author  as  reflected  in  his 
knowledge,  experience,  and  assimilation  from  the  writings  of  others.  When  Surgery 
can  be  represented  by  a  conventional  and  well-settled  type  of  book  it  \\ill  have 
ceased  to  advance.  There  is  still  room  for  many  a  serious  effort  to  place  the 
subject  before  students  and  practitioners  in  a  way  to  instruct  from  the  beginning 
through  to  the  operative  and  postoperative  treatment.  This  has  been  the  object 
of  the  present  volume,  upon  which  the  author  has  brought  to  bear  the  experience 
of  many  years  as  a  teacher  and  surgeon,  and  into  which  he  has  also  endeavored  to 
infuse  the  most  advanced  k'lowledge  gleaned  from  the  surgical  literature  of  America 
and  Europe. 

To  the  extent  of  the  author's  ability  the  work  therefore  represents  the  net 
Surgery  of  to-day,  obsolete  and  obsolescent  material  having  been  excluded,  and 
the  pages  being  devoted  to  sound  principles  and  practice,  stated  as  clearly  and 
succinctly  as  possible.  The  author  has  been  free  to  employ  illustrations  wherever 
a  point  could  be  so  explained  to  the  eye.  In  the  pictorial  department  utility  and 
effectiveness  have  been  considered  of  more  importance  than  extreme  and  unusual 
cases.  Simple  drawings  and  even  diagrams  are  often  most  instructive,  and  such 
have  been  accordingly  liberally  used. 

With  every  effort  at  conciseness  it  has  not  been  practicable  to  cover  the  subject 
in  less  than  the  equivalent  of  about  fifteen  hundred  ordinary  octavo  pages.  By 
adopting  a  larger  form  the  publishers  have  presented  this  material  in  a  convenient 
volume.  In  justification  of  the  size  of  the  w'ork  it  should  be  borne  in  mind  that  its 
scope  is  very  extensive,  for  it  aims  to  cover  the  Principles  as  well  as  the  Practice  of 
Surgery,  thus  supplying  the  needs  of  students  and  general  practitioners,  and,  the 
author  hopes,  also  interesting  his  surgical  confreres. 

He  takes  this  opportunity  to  extend  his  warmest  acknowledgments  to  his  fellow- 
collaborators  of  the  Treatise  on  Surgery  by  American  Authors,  who  on  the 
exliaustion  of  the  third  edition  most  kindly  consented  to  allow  it  to  be  succeeded 
by  this  individual  work,  placing  their  material  and  illustrations  freely  at  his 
command.  He  also  wishes  to  acknowledge  the  kindness  of  Dr.  H.  R.  Gaylord, 
who  has  contributed  certain  material  utilized  in  the  chapter  on  Tumors,  the 
assistance  of  Dr.  E.  R.  ■McGuire,  who  has  helped  in  many  ways  during  the 
preparation  of  the  book,  and  that  of  other  colleagues  who  have  furnished  illus- 
trations that  are  dulv  credited  in  their  proper  places. 

R.  P. 
Buffalo,  X.  Y., 

1907.  ( iii ) 


CONTENTS, 


INTrvOlHC'i'ION 


vm;k 
17 


PAKT  I. 
SURGICAL  PATHOLOGY. 

CHAPTER  I. 
HYrEREMIA:     ITS  CONSEQUENCES  AND  TREATMENT 

CHAPTER   II. 
SITRGICAL  PATHOLOGY  OF  THE  BLOOD  ..... 


INFLAMMATK  )N 


LLCER  AND  ULCERATION 


CHAPTER    HI. 


CHAPTER  IV. 


CHAPTER  V. 


GANGRENE 


19 


28 


43 


C5 


73 


PART  II. 

SURGICAL  DISEASES. 

CHAPTER  VI. 
AUTO-INFECTION,  ESPECIALLY  IN  SURGICAL  PATIENTS    .      .      . 

CHAPTER  VII. 
THE  SURGICAL  FEVERS  AND  SEPTIC  INFECTIONS    ..... 

CHAPTER  VIII. 
SURGICAL  DISEASES  COMMON  TO  MAN  AND  DOMESTIC  ANIMALS 


70 


85 


97 


(V) 


vi  CONTENTS 

CHAPTER  IX. 

PAGE 

SURGICAL  DISEASES  COMMON  TO  MAN  AND  DOMESTIC  ANIMALS  (Continued)     111 

CHAPTER  X. 
SYPHILIS 122 

CHAPTER  XL 
CHANCROID  OR  VENEREAL  ULCER «„,....     144 

CHAPTER  XII. 

GONORRHEA .,.„.,..      140 

CHAPTER  XIII. 
SCURA'Y  AND  lilCKETS ,.,....      160 

CHAPTER  XI^^ 
THE  STATUS  LYMPHATICUS 163 

CHAPTER  X\\ 
SURGICAL  ASPECTS  AND  SEQUELS  OF  OTHER  INFECTIONS  AND  DISEASES     166 

CHAPTER  X\I. 
POISONING  BY  ANIMALS  AND  PLANTS 171 

CHAPTER  XVII. 
ACT^TE  INTOXIC.VnONS,  INCLUDING  DELIRIUM  TREMENS      ......      174 


PAKT  III. 

SURGICAL  PRINCIPLES,  METHODS  AND  MINOR  PROCEDURES. 

CHAPTER  XVIII. 
DISTURBANCES  OF  BLOOD-PRESSURE;  SHOCK  AND  COLLAPSE 177 

CHAPTER  XIX. 

ABSTRACTION   OF  BLOOD;  COUNTERIRRITATION ;  PARACENTESIS;  TRANS- 
FUSION; CATHETERIZATION;  SKIN  GRAFTING;  BANDAGING      ....      182 

CHAPTER  XX. 
ANESTHESIA  AND  ANESTHETICS,  GENERAL  AND  LOCAL  .......     192 


('<).\tI':nts  vu 

•  TART  IV. 
INJURY  AND  REPAIR. 
( 'II A  ITER  XXI. 

PAdK 

WOUNDS  AND  'rilMIK   KKI'AIK -      .      •      -      •     '^'1 

('11 A  ITER  XXII. 
GUNSHOT  WOUNDS 220 

niAlTER  XXIII. 
PREVENTION  AND  CONTROi.  OF  HEMORRHAGES;  SUTURES;  KNOTS  ...     234 

CII.MTER  XXIV. 
ASEI'SIS  .\ND  ANTISEPSIS;  TREATMENT  OF  WOUNDS     ,  213 

CHAPTER  XXV. 

PREPARATION      OF     PATIENTS     FOR     OPERATION     AND     THEIR     AFTER- 
TREATMENT    250 


PART  V. 
SURGICAL  AFFECTIONS  OF  THE  TISSUES  AND  TISSUE  SYSTEMS. 

CHAPTER  XXVI. 
CYSTS  AND  TUMORS 255 

CHAPTER  XXVII. 
THE  SKIN 299 

CHAPTER  XXVIII. 

SURGICAL     DISEASES    OF    THE    FASCIA;    APONEUROSES;    TENDONS    AND 

TENDON  SHEATHS;  MUSCLES  AND  BURS^ 319 

CHAPTER  XXIX. 
SURGICAL  DISEASES  OF  THE  HEART  AND  VASCULAR  SYSTEM 334 

CHAPTER  XXX. 
INJURIES  AND  DISEASES  OF  THE  LYMPH  VESSELS  AND  NODES    ....     368 

CHAPTER  XXXI. 
SURGICAL  DISEASES  OF  THE  JOINTS  AND  JOINT  STRUCTURES       ....     379 


viii  CONTENTS 

CHAPTER  XXXil. 

PAGE 

SURGICAL  DISEASES  (Jl-   THE  OSSEOUS  SYSTEM    .....  -116 

CHAPTER  XXXIII. 

DElOlLMITIES  DUE  TO  COXGEXITAL  DEFECTS  OR  ACQUIRED  DISEA8F:s  Ol 

THE  LOCOMOTOR  APPARATUS;  ORTHOPEDICS 444 

CHAl'TEU  XXXI\'. 
FRACTLTIES 479 

CHAPTER  XXXV 
DISLOCATIOXS 524 


PART  VI. 
SPECIAL  OR  REGIONAL  SURGERY. 

CHAPTER  XXXVI. 
L\.JL'RlE.->  AM)  SURGICAL  DISEASES  OF  THE  HEAD 545 

CHAPTER  XXXMI. 

THE  ORBIT  AND  ITS  ADXEXA:  THE  EXTERNAL  AIDITORY  APPARATUS; 
THE  ACCESSORY  SIXUSES:  THE  CRAXLA.L  AXD  CERVICAL  XERVES;  THE 
ORBITAL  CONTEXTS  AXD  ADXEXA 592 

CHAPTER  XXXVIII. 
THE  SPIXE,  THE  SPIXAL  CURD  AXD  THE  PERIPHERAL  XERVES         ...     621 

CHAPTER  XXXIX. 
THE  FACE  AXD  EXTERIOR  OF  THE  XOSE  AXD  MOUTH 638 

CHAPTER  XL. 
THE  MOUTH.  THE  TOXGUE,  THE  TEETH  AXD  THE  JAWS 652 

CHAPTER  XLI. 
THE  RESPIRAT(JRY  PASSAGES  PROPER 671 

CHAPTER  XLII. 
THE  NECK 698 

CHAPTER  XLIII. 
THE  THORAX  AXD  ITS  CONTENTS 718 


CONTENTS  ix 

CIIAITER  XLIV. 

PAGE 

rUE  15UEAST 755 

CHAPTER  XLV. 
THE  ABDOMEN  AND  AIU:>()MINAL  VISCERA  .„,...  7(i7 

CHAPTER  XLVI. 
THE  PERITONEUM  AND  ITS  DISEASES     ....  7.S5 

CHAPTER  XLVII. 
INJURIES  AND  SURGICAL  DISEASES  OF  THE  STOMACH  .      .     793 

CHAPTER  XLVIII. 
THE  SMALL  INTESTINES 822 

CHAPTER  XLIX. 
THE  APPENDIX  AND  ITS  DISEASES     ...  ,...,..     851 

CHAPTER  L. 
THE  LARGE  INTESTINES  AND  THE  RECTUM  .  .      ,      ,      ,      ,      «      .     869 

CHAPTER  LI. 
HERNIA ..,.,.     o      ..     890 

CHAPTER  LII. 
THE  LIVER ......     910 

CHAPTER  LIII. 
THE  OMENTUM,  THE  MESENTERY,  THE  SPLEEN  AND  THE  PANCREAS    .      .     934 

CHAPTER  LIV. 
THE  KIDNEYS 955 

CHAPTER  LV. 
THE  BLADDER  AND  PROSTATE 977 

CHAPTER  LVI. 
THE  MALE  GENITAL  ORGANS 1004 

CHAPTER  LVII. 
AMPUTATIONS  . ..,..,...   1023 


GENERAL    SURGERY. 


INTRODUCTION. 

An  ultinijito  analysis  of  the  primary  causes  of  disease,  excluding  traumatisms,  will 
permit  their  reduction  to  one  or  the  other  of  the  following  categories:  mdritional  (func- 
tional) and  parasitic.  These  may  co-exist,  in  which  case  each  tends  to  modify  the  other 
more  or  less,  usually  unpleasantly,  or  either  may  y)recede  and  perhaps  pave  the  way 
for  the  other.  In  general,  it  may  be  said  that  |)arasitism  perverts  nutrition,  locally  or 
generally,  antl,  per  contra,  that  perverted  nutrition  often  prepares  the  way  ff)r  ])arasitic 
infection,  so  that  even  between  these  primary  causes  there  may  occur  all  possible  com- 
binations. 

With  traumatisms  surgery  alone  is  mainly  concerned,  but  its  conceded  scope  is  now 
widened  to  include  an  ever-increasing  number  of  morbid  conditions,  which,  in  time  past, 
were  treated  medicinally — or  not  at  all.  Thus  it  has  come  to  pass  that  it  is  no  longer 
possible  to  make  an  abrupt  distinction  between  medicine  and  surgery,  nor  even  brieflv  to 
define  the  words  "surgery"  and  "surgeon,"  nor  yet  to  ascribe  to  either  the  physician 
or  the  surgeon  his  exact  functions  as  such.  In  centuries  past  ])hysicians  were  exceed- 
ingly jealous  of  their  vested  rights,  and  with  )>ropriety,  when  the  only  surgeons  were  un- 
educated barbers.  But  about  one  hundred  years  ago  conditions  were  materially  altered 
for  the  better,  and  surgery,  liberated  from  its  medieval  environment,  and  from  the 
restrictions  imposed  by  the  clergy,  rapidly  developed  into  both  a  science  and  an 
art,  while  the  surgeon  came  to  take  that  po.sition  in  society  to  which  his  increasing 
attainments  entitled  him.  During  the  past  thirty  years  surgery,  thanks  to  earnest 
workers  in  the  surgical  laboratories  of  the  world,  has  made  progress  scarcely  equalled 
by  the  science  of  electricity,  and  the  impossibilities  of  yesterday  have  become  the 
routine  of  today. 

Thus  has  come  about  the  earlier  separation,  and  now,  in  some  respects  at  least,  the 
closer  appreciation  of  the  respective  scope  and  functions  of  the  physician  and  the 
surgeon.  Between  them  lies  yet  what  has  been  felicitously  called  the  "borderland," 
where  they  meet  on  common  ground,  too  often  as  rivals  and  not  often  enough  as 
co-workers.  Nowhere  do  comprehensive  knowledge,  wide  experience,  and  trained 
judgment  appear  to  better  advantage,  nor  lead  to  better  results,  than  when  exhibited 
where  co-operation  in  these  respects  is  most  hearty.  Someone  has  most  happily  said  that 
"the  surgeon  is  a  physician  who  knows  how  to  use  his  hands,"  yet  to  regard  a  course  in 
surgery  as  one  in  manual  training  would  be  a  most  lamentable  conception  of  its  purpo.ses. 
Rather  is  it  to  be  regarded  as  a  superstructure,  to  be  built  upon  a  thorough  familiarity 
with  anatomy,  physiology,  pathology,  and  therapeutics.  In  fact,  the  better  general 
practitioner  a  man  is,  the  better  surgeon  may  he  thereby  become,  providing  he  pos.sess 
the  other  necessary  attributes.  John  Hunter  took  this  view,  but  too  many  since  his 
day  have  forgotten  or  never  realized  it. 

In  the  pages  which  follow  it  has  been  impossible  to  do  more  than  epitomize  our  present- 
day  knowledge  of  surgery,  an  early  disavowal  which  is  intended  to  save  too  frequent 
repetition  of  the  advice  to  consult,  as  needed,  other  larger  and  more  specialized  works. 
The  attempt  here  has  been  rather  to  build  up  a  framework  upon  which  the  student 
and  the  investigator  may  build  with  such  other  material  as  they  may  later  select  from 
the  quarries  which  are  accessible  to  them.  Hence  it  has  been  impossible  to  describe  or 
even  mention  all  the  operations  which  have  been  devised  to  meet  various  indications. 
2  .  (17) 


18  INTRODUCTION 

PreferoMce  has  therefore  been  <fiven  to  those  which  have  best  served  the  author  in  liis 
personal  ex])erieiiee. 

Because  of  the  numerous  interrchitions  between  surgery  and  internal  mccHcine,  so 
called,  1  have  not  hesitated  to  insert  paragraphs  and  even  whole  cha])ters  on  subjects 
hitherto  oniitlcd  from  the  later  works  on  surgery.  To  teach  a  student  how  to  recog- 
nize naso})haryngcal  adenoids,  to  appreciate  the  widespread  harm  they  may  cause  and 
how  to  cope  with  tiiem,  and  at  the  same  time  to  leave  him  cpiitc  unfamiliar  with 
their  too  frequent  relation  to  the  status  lymi)haticus  and  its  dangers,  and  to  omit  in  such 
a  work  all  reference  to  the  latter,  is  to  put  knowledge  and  instruments  into  his 
possession  without  teaching  him  how  rightly  to  employ  them.  A  case  of  exophthalmic 
goitre  affords  another  equally  apt  illustration,  as  being  one  in  which  the  physician  and 
the  surgeon  should  heartily  co-operate. 

The  surgeon  and  the  physician  have  drifted  too  far  a()art.  It  is  time  that  they  met 
again  in  the  ])resence  of  the  ])athologist.  Such  a  group,  when  pro|)erly  constituted, 
forms  an  almost  invincible  triumvirate. 

It  has  been  said  that  "the  resources  of  surgery  are  rarely  successful  when  practised 
on  the  dying."  Throughout  these  pages  the  attempt  has  been  made  to  impress  the 
fact  that  delay,  in  many  of  the  borderland  cases,  is  dangerous,  and,  often  fatal,  and 
that  it  is  not  just  to  charge  to  surgery  the  blame  for  such  a  result  due  to  the  physician's 
dilatoriness. 

It  may  lead  to  a  better  understanding  of  the  teaching  contained  in  the  following  jmges 
if  it  is  here  made  clear  just  what  is  understootl  by  the  suffix  "tto"  in  medical  termin- 
ology. The  old  tendency  was  to  regard  all  morbid  contlitions  as  expressions  of  inflam- 
mation in  some  of  its  protean  manifestations.  The  attem|)t  has  been  made  in  this  work 
to  distinguish  as  clearly  as  possible  between  in^ammatkm,  as  an  exprcs.non  of  infection, 
and  the  vascular,  nutritional,  and  other  changes  which  may  be  brought  about  by 
perverted  nutrition  without  necessary  participation  of  ])arasites.  To  describe  "  ostitis," 
for  example,  as  "  inflammation  of  bone,"  is  to  revert  to  an  obsolete  definition. 
Let  us,  then,  always  translate  the  termination  "itis"  as  implying  an  affection,  not 
necessarily  an  inflammation,  of  the  structure  named  in  the  word  to  which  it  is  affixed. 
With  this  conception  of  the  word  or  the  term  there  can  be  no  contradiction  in  its  use 
under  various  conditions,  and  one  does  not  necessarily  connnit  himself,  by  using  it,  to 
any  definite  view  concc-rning  the  jxithology  of  the  afl'cction  which  is  thereby  im])lied. 

With  regard  to  one  other  feature  there  has  been  also  a  tle])arture  from  previous  nomen- 
clature. The  term  "lym])h  glands"  or  "lymphatic  glands"  has  always  seemetl  objec- 
tionable, because,  although  they  belong  to  the  lymphatic  system,  they  are  in  no  sense 
glands,  having  no  ducts,  and  no  distinct  secretron  to  be  discharged  through  passageways. 
Whether  in  any  sense  they  are  to  be  regarded  as  fin-nishing  an  "internal  secretion"  is 
not  the  question  here,  their  most  obvious  function  being  to  act  as  filters.  Throughout 
the  work,  then,  the  term  "lym})h  gland"  has  been  carefully  excluded  and  the  more 
accurate  and  far  preferable  term  "lymph  node"  has  been  substituted.  This  seems 
to  be  a  suitable  place  to  explain  the  substitution  and  the  reason  therefor. 


PART   I. 
SUEGICAL   PATHOLOGY. 


CHAPTER    I. 

HYPEREMIA:    ITS  CONSEQUENCES  AND  TREATIMENT. 

The  reiictionarv  results  of  injury  to  various  tissues  and  the  first  local  appearances 
due  to  the  surgical  infectious  diseases  are  indicated  \)y  certain  ap])earances,  which,  for 
a  few  hours  at  least,  are  in  large  measure  common  to  both.  Their  beginnings  being 
pathologically  similar,  their  results  depend  not  alone  on  the  violence  or  intensity  of  the 
process,  but  also,  and  in  predominating  measure,  upon  the  primary  influences  at  work. 
The  consequences  of  mere  mechanical  injury — such  as  strain,  laceration,  etc. — are  in 
healthy  individuals  ])romptly  repaired  by  ])rocesses  which  will  be  taken  into  considera- 
tion in  the  ensuing  chapters.  They  are  throughout  conservative  and  reparative,  and  are 
directed  toward  restoring,  as  far  as  possible,  the  original  condition.  The  consequences, 
on  the  other  hand,  of  the  surgical  infections  are  more  or  less  disastrous  from  the  outset, 
although  the  extent  of  the  disaster  may  be  localized  within  a  very  small  area,  as  after 
a  trifling  furuncle,  or  they  may  be  so  widespread  as  to  disable  a  liml)  or  an  organ,  or 
they  may  even  be  fatal.  It  is  of  the  greatest  importance,  not  alone  for  scientific 
reasons,  but  also  because  treatment  must  in  large  measure  depend  upon  the  underlying 
conditions,  to  differentiate  between  these  two  general  classes  of  disturbance,  which  we 
speak  of  as — 

A.  Those  produced  hij  external  or  extrinsic  disturbances,  i.  e.,  traumatisms,  sprains, 
lacerations,  etc. ;  and 

B.  Those  produced  bj/  internal  and  intrinsic  causes,  which,  for  the  main  part,  are  the 
now  well-known  microorganisms,  such  as  cause  the  various  surgical  diseases. 

These  latter  disturbances  may  be  imitated  or  simnlated  in  the  ]:)resence  of  certain 
irritants  within  the  tissues,  such  as  the  poisons  of  various  insects  and  plants;  the  irrita- 
tion produced  by  foreign  bodies,  minute  or  large;  and  possibly  the  presence  within  the 
system  of  certain  poisons  whose  nature  is  not  yet  known,  such  as  that  of  syphilis,  or  cer- 
tain others  whose  chemistry  is  fairly  well  understood,  but  whose  presence  cannot  be 
easily  explained,  as  uric  acid,  etc. 

Clinically,  all  these  distin-l)ances  are  manifested  by  certain  phenomena  common 
to  each,  which  may  jjresent  themselves  at  one  time  more  prominently,  at  another 
less  so.  These  significant  ajipearances  have  been  recognized  from  time  immemorial 
as  the  color,  rubor,  dolor,  tumor,  et  functio  lesa  of  our  ancestors,  or  as  the  heat,  redness, 
pain,  swelling,  and  loss  of  function  of  our  common  experience.  When  one  or  more  of 
these  are  present,  the  surgeon  cannot  afford  to  disregard  the  fact,  while  he  should, 
moreover,  be  able  to  account  for  each  on  general  principles  w^hich  should  to  him  be 
well  known. 

To  their  more  exact  study  we  must,  however,  make  some  preface  in  the  w^ay  of  general 
remarks  concerning  a  phenomenon  everywhere  easily  recognized,  l)ut  as  yet  incom- 
pletely understood.  This  ])lienomenon  has  reference  to  an  undue  su]i]>ly  of  blood  to  a 
part,  and  is  commonly  known  under  two  terms  which  are    practically  synonymous, 

(19) 


20  SURGICAL  PATHOLOGY 

namely,  congestion  and  hypcrcviia.     To  begin  with  these,  then,  we  must  note,  fii'st  of 
ail,  that  congestion  and  hyperemia  may  be — 

A.  Active;  and 

B.  Passive. 

They  may  also  be  spoken  of  as — 

1.  Acute;  and 

2.  Chronic. 

Considering  first  the  two  latter  distinctions,  it  will  be  fonnd  that  the  acute  hy])eremias 
are  met  with  most  often  in  consequence  of  sharp  mechanical  disturbances.  I'lie  chronic 
hyperemias,  on  the  contrary,  are  conditions  which  in  many  individuals  are  more  or  less 
permanent.  Note  accurately  here  the  proper  significance  of  certain  terms.  Hyper- 
emia means,  in  effect,  an  oversupply  of  blood  to  the  given  part;  the  term  should  have 
only  a  local  significance.  When  the  entire  body  seems  to  be  too  well  su])]>lied  with 
blood,  the  condition  is  known  as  •plethora,  the  counterpart  of  which  term  is  usually 
anemia.  The  direct  counterpart  of  the  term  Jit/prremia  should  j^erhaps  l)e  isrhniiia, 
meaning  a  perverted  blood  supply  in  reduced  amount.  With  jilethora  and  anemia  as 
terms  implying  general  conditions,  with  hyperemia  and  ischemia  implying  local  con- 
ditions, there  should  be  little  room  for  confusion  in  phraseology. 

The  active  form  of  hyperemia  used  to  be  called  "fiuxion,"  a  term  now  rarely  used. 
Active  hyperemia  means  an  increased  supply  of  arterial  blood.  In  passive  hi/peremia 
the  oversupply  is  rather  of  venous  blood.  In  the  former  case  the  condition  seems  due 
to  overactivity  of  the  heart,  with  such  local  tissue  changes  as  permit  it  to  occur. 
In  passive  hyperemia  the  blood  current  is  slower — there  is  a  tendency  toward,  and 
sometimes  an  actual,  stagnation;  all  of  which  is  usually  due  to  obstruction  of  the 
return  of  blood  to  the  heart.  The  conditions  permitting  these  two  results  may  be 
widely  variant. 

Active  Hyperemia. — Active  hyperemia  may  be  produced  by  purely  nervous  influ- 
ences, even  those  of  emotional  origin.  The  flushing  of  the  face  which  is  known  as 
"blushing"  is,  perhaps,  the  most  common  illustration  of  this  fact.  It  is  well  known 
also  that  this  is,  in  some  degree  at  least,  the  result  of  division  of  certain  nerves  which 
have  to  do  with  the  regulation  of  the  blood  supply.  The  cervical  sympathetic  is  the 
best  known  and  most  often  studied  of  these,  and  the  consequences  of  division  of  this 
nerve  in  the  neck  are  stated  in  all  the  text-books  on  physiology.  So  also  by  electrical 
stimulation  of  certain  nerves  the  parts  supplied  by  them  can  be  made  to  show  a  very 
active  hyperemia,  which  will  subside  shortly  after  discontinuance  of  stimulation,  pro- 
viding this  has  not  been  kept  up  too  long.  In  active  hyperemia  there  is  absolute  increase 
of  intra-arterial  tension,  and  under  these  circumstances  pulsation  may  be  noted  in  those 
small  vessels  in  which  commonly  it  is  not  seen  nor  felt.  This  is  the  explanation  of  the  throb- 
bing pain  complained  of  under  many  actively  hyperemic  conditions.  This  hyperemia 
affords  the  explanation  of  the  clinical  signs  to  which  attention  has  already  been  called. 
The  increased  heat  of  the  part  is  the  result  of  greater  access  of  blood,  which  prevents 
cooling  by  radiation  and  evaporation;  the  peculiar  redness  is  due  to  the  greater  filling 
of  the  capillaries  with  the  blood,  which  gives  the  peculiar  hue  to  the  skin  and  visible 
textures;  while  to  the  increased  jiressure  upon  sensory  nerves  is  also  due  the  pain.  The 
minuter  changes  occurring  within  the  congested  part  call  for  more  accurate  descrij^tion. 
Whether  or  not  there  is  actual  dilatation  of  cajiillaries  under  these  circumstances  is 
a  matter  still  under  dispute,  but  of  the  dilatation  of  the  larger  vessels  there  can  be  no 
possible  question. 

As  hyperemia  is  to  such  a  great  extent  brought  about  by  action  of  the  nervous  system, 
it  is  well  to  divide  it  more  accurately  into  the  hyperemia  of  ])aralysis,  or  neuroparah/tir 
congestion,  which  is  the  result  of  a  paralysis  of  the  constrictor  fibers  of  the  vasomotor 
system,  and  into  the  hyperemia  of  irritation,  or  neurotonic  congestion,  which  is  due  to 
the  irritation  of  the  dilators  (Recklinghausen) .  Physiologists  are  fairly  well  agreed 
that  as  between  the  dilating  and  the  constricting  apparatus  of  the  vasomotor  system 
there  is  ordinarily  preserved  a  certain  degree  of  efpiilibrium;  to  which  fact  is  probably 
due  that  normal  condition  of  affairs  inaugurated  after  temporary  disturbance, 
since  overaction  in  one  direction  succeeds  reaction  in  the  other.  As  Warren  has 
illustrated  this,  our  common  treatment  of  frostbite  by  cold  applications  is  a  concession 
to  this  fact,  since  by  the  cold  ap])lications  we  endeavor  to  limit  the  reaction  wliich  would 
otherwise  follow  after  thawing  out  the  frozen  part. 


nYi'i:ia:Mi.\:  its  cos  sequences  and  treatmest  21 

'I'lic  Ix'st  cxainitlcs  of  llic  liijj)<r<  unit  oj  pardli/sis  jirc  pcrliiips  to  he  met  with  alter 
(rrtaiii  iiijiirit's  to  nerves,  as,  for  iiistaiiee,  (lusliiii<f  ol  the  I'aee  and  li\  perseerelioii  of 
nasal  niui  us,  tears,  etc.,  aftei- in  jnry  to  the  cervical  s\  ni])atlielie.  Sneh,  too,  in  its  essen- 
tials, is  that  form  of  shock  known  as  brain  conenssion,  which  is  often  followed  hv  nnlri- 
tive  (listnrl)ances  anion<>;  the  hrain  cells,  with  eonse(|nent  ])erversion  of  brain  function. 

\Vallcr's  exjK'rinient  of  placinff  a  frcezin<f  mixture  over  the  uhuir  nerve  at  the  back 
of  the  elbow  is  also  significant,  the  result  beinif  coiiffcstion  and  elevation  of  surface  tem- 
perature of  the  fintjers  supplied  by  this  nerve.  ( 'on<:;esti()n  and  swellinfj;  have  also  l)een 
observed  after  fracture  of  the  internal  condyle  of  the  humerus,  by  which  this. nerve 
was  pressed  upon;  and  similar  phenomena  may  be  noted  in  finjjers  or  toes  as  the  result 
of  injuries  of  other  nerves. 

Hyperemia  due  to  p(ir<i/i/:<is  oj  the  pen r(i.scu/(ir  (/(iiu/hii  is  obsci'vcd  sometimes  in  trans- 
j)lanti'd  flaps,  in  the  suffusion  of  a  limb  after  I'cmoval  of  llu-  Hsmarch  bandai^e,  in  the 
congestion  of  certain  sac  walls  after  ta|)pin<i;,  in  the  hyperemia  of,  ])erhaps  even  hemor- 
rhage from,  the  bladder  wall  after  too  (piickly  relieving  its  overdistention,  and  in  the 
swelling  of  the  extremities  when  they  begin  to  be  first  used  after  having  been  i)Ut  at 
rest  because  of  injury. 

The  hi/jM'trmin.'i  of  dilatation  are  more  acute  in  course  and  manifestation.  Along 
witii  them  go  sharp  pain,  hypersecretion  of  glands,  edema,  and  sometimes  desquama- 
tion of  suj)erficial  parts.  The  facial  blush  due  to  effusion;  the  temporary  flushing 
due  to  indulgence  in  alcohol;  the  suffusion  of  the  conjunctiva,  perhaj)s  the  face,  with 
hyj)erlacrymation,  accom])anying  facial  neiu'algia  or  hemicrania;  and  the  hyperemia 
eonse(juent  upon  herpes  zoster,  urticaria,  etc.,  are  illustrative  examples  of  this  form. 
The  erythema  due  to  nerve  irritation  or  injury,  the  swelling  of  the  joints  which  a])|)ears 
after  similar  lesions,  and  that  condition  described  by  Mitchell  as  n-ijtliroinrlalgia,  j)rob- 
ably  also  belong  here.  In  fact,  almost  all  the  reflex  hyperemias  are  hyperemias  of 
dilatation. 

The  forms  of  hyperemia  considered  above  belong  mainly  to  the  designation  of 
active. 

Passive  Hyperemia. — Passive  hyperemia  is  most  often  a  mechanical  consequence 
of  obstruction  of  the  return  of  blood,  which  can  be  imitated  at  will,  and  which  is  not 
infrequently  the  result  of  carelessness,  as  when  an  injured  limb  is  bandaged  too  tightly. 
Experiment  shows  that  when  such  mechanical  obstruction  has  taken  place  there  is 
temporary  increase  of  intravenous  pressure,  which  soon  returns  to  the  normal  standard, 
such  readjustment  meaning  that  blood  has  found  its  way  back  by  collateral  circulation. 
Only  when  such  rearrangement  is  possible  do  we  have  anything  like  permanent  passive 
hyperemia.  In  organs  with  a  single  vein,  such  as  the  kidneys,  the  question  of  obstruc- 
tion may  assume  a  very  important  aspect.  Under  these  circumstances  the  appearance 
of  the  involved  part,  when  visible,  is  sj)oken  of  as  cyanotic,  while  its  surface,  instead  of 
being  abnormally  warm,  is  the  reverse,  due  to  impeded  access  of  warm  blood  and  more 
rapid  surface  cooling.  The  blood  under  such  conditions  is  often  darker  than  natural, 
because,  remaining  longer  in  the  part,  it  absorbs  more  carbonic  dioxide,  or  at  least  gives 
up  more  of  its  oxygen.  As  long  as  actual  gangrene  is  not  threatened,  the  blood  column 
has  a  communicated  pulsation,  at  least  in  the  large  veins.  Escape  of  corpuscular  ele- 
ments may  occur  after  the  phenomena  above  noted  have  been  present  for  some  time; 
but  the  corpuscles  rarely,  if  ever,  escape  until  there  has  been  more  or  less  copious  trans- 
udation of  the  fluid  portion  of  the  blood — i.  c,  the  serum.  When  anatomical  changes 
can  be  grossly,  yet  carefully,  observed,  as  in  the  fundus  of  the  eye,  it  is  seen  that  under 
these  circumstances  the  arteries  become  smaller,  although  whether  this  is  a  primary 
or  secondary  change  is  not  to  be  determined.  Discoloration  of  the  integument  is  the 
frequent  result  of  leakage  of  blood  corpuscles  and  their  pigmentary  substance  into  the 
tissues,  and  is  consequently  a  frequent  accompaniment  of  chronic  passive  edema.  It 
is  seen  often  in  connection  with  varicose  veins  of  the  legs. 

Another  form  of  passive  congestion  or  hyperemia  is  that  due  to  enfeeblement  of  the 
heart's  action  by  serious  injury  or  wasting  disease.  When  under  these  circumstances 
the  lung  has  become  more  or  less  infiltrated  with  fluid,  with  hemorrhagic  extravasation, 
the  condition  is  known  as  hypostatic  pneumonia — a  misnomer,  nevertheless  indicating  a 
condition  which  is  only  too  frequent  in  the  aged  and  feeble. 


22  SURGICAL  PATHOLOGY 

RESULTS  OF  HYPEREMIA  AND  CONGESTION. 

These  may  be — 

1.  Speedy  subsidence  of  all  hyperemic  phenomena — resolution. 

2.  Ac-ute  swelling. 

3.  Chronic  swelling. 

4.  (Jangrcne. 

5.  Xutritinnal  changes — atrophy  and  hypertrophy. 

1.  Resolution. — The  speedy  subsidence  of  hy|)eremic  phenomena  is  known  as 
resolution — a  term  which  has  also  been  applied  to  the  retrograde  jjhenoraena  after 
a  genuine  inflammation.  For  present  purposes  it  implies,  first,  the  subsidence  into 
inactivity  of  the  exciting  cause  or  its  complete  removal.  This  may  include  the  passing 
of  an  emotion,  the  removal  of  an  irritant,  the  loosening  of  a  bandage,  the  resort  to  cer- 
tain applications  or  to  constringing  or  astringing  measures  by  which  the  effect  is  counter- 
acted. A  particle  of  dust  in  the  conjunctiva  may  within  a  few  moments  produce 
an  active  congestion  of  the  conjunctival  vessels,  which,  ordinarily  scarcely  visible, 
becomes  prominent  and  easily  noted.  The  removal  of  the  offending  substance  permits 
a  return  to  their  original  size  in  perhaps  a  half-hour.  This  is  an  example  of  the 
speedy  subsidence  of  the  hyperemia  of  dilatation  after  removal  of  the  cause.  Should 
the  hyperemia  not  subside  promptly,  it  is  well  to  use  cold  ap])lications,  or  in  this  instance 
an  astringent  coUyrium,  or  some  agent  whose  physiological  effect  it  is  to  produce 
vascular  contraction,  as  cocjtine,  adrenal  extract,  etc. 

2.  Acute  Swelling. — When  the  effusion  above  referred  to  takes  place  into  loose  con- 
nective tissues  tlie  condition  is  spoken  of  technically  as  edema,  while  when  it  occurs  into 
a  previously  existing  cavity,  such  as  that  of  a  joint,  it  is  known  as  an  efjiiaion.  The 
amount  of  blood  thus  effused  will  be  influenced  by  the  anatomical  and  mechanical 
conditions  existing  al^out  the  part.  It  may  be  presumed,  as  a  general  rule,  that 
when  the  extravascular  pressure  equals  the  intravascular  pressure  little  or  no  more 
fluid  may  escape.  As  a  matter  of  fact,  it  is  seldom  that  the  former  rises  to  the 
degree  of  the  latter.  Conversely,  one  method  of  treating  such  edemas  and  effusions 
is  by  some  device  which  shall  make  the  extravascular  pressure  exceed  the  intravascular, 
when  the  fluid  is,  as  it  were,  forced  back  into  the  vessels,  and  is  made  to  resume  its  proper 
place  within  the  same.  This  is  often  done  by  taking  advantage  of  elastic  compression, 
as  when  a  rubber  bandage  is  applied  about  the  part.  In  certain  parts  of  the  body  it 
may  be  done  by  pressure  brought  about  by  some  other  device.  Pressure  may  be  used 
for  two  purposes: 

.1.  To  so  increase  extravascular  pressure  as  to  limit  the  possible  amount  of  an 
effusion,  as  when  it  is  put  on  early  after  an  injury;  or, 

B.  When  it  is  used  as  a  later  resort  for  the  purpose  of  reducing  swelling  which  has 
already  occurred, 

3.  Chronic  Swelling. — This  is  something  more  than  the  swelling  alluded  to  under 
Acute  Sirelling.  Chronic  swelling  implies  either  a  continuous  passive  hyperemia,  or, 
what  is  more  common,  a  positive  increase  in  tissue  elements  as  the  result  of  an 
oversupplv  of  nutrition  brought  by  the  blood,  which  itself  was  furnished  to  the  part 
in  a  degree  far  in  excess  of  its  needs.  The  result  is  a  more  rapid  reproduction  of  cell 
elements,  with  result  in  the  shape  of  ti.ssue  thickenings  or  tissue  enlargements, 
known  as  hypertrophy,  or,  more  properly  speaking,  hj/perplasia,  of  a  part,  and  to 
the  laity  as  "overgrowth."  This  chronic  swelling  or  chronic  enlargement  is  in 
some  degree  also  connected  with  the  phenomena  of  escape  of  white  corpuscles  from 
the  bloodvessels  and  mitotic  division  of  certain  tissue  cells,  which  have  up  to  this  time 
been  usually  regarded  as  a  feature  of  the  true  inflammatory  process. 

4.  Gangrene. — This  may  be  the  result  of  hyperemia — for  the  most  part  the 
passive  forms — though  most  instances  of  gangrene  due  to  intrinsic  cau.ses  are  inseparable 
from  the  presence  of  infectious  microorganisms.  The  gangrene  which  is  spoken  of 
here  includes  that  due  to  the  pressure  of  tumors,  tight  dressings,  or  any  natural 
or  intrinsic  agency,  and  that  due  to  pressure  from  without  when  not  so  pronounced 
as  to  produce  immediate  and  total  loss  of  circulation  in  a  part.  It  includes  the  forma- 
tion of  manv  bed-sores  and  sf)-calle(l  pressure-sores,  which  may  be  due  to  an  enfeebled 
heart,  to  an  obstructed  pulmonary  circulation,  or  to  external  pressure  in  conjunction 


TREATMENT  OF  CONGESTION  AM)  HYPEREMIA 


23 


with  cardiac  dchility.  While  insisting,  then,  that  gangrene  shonUl  he  recognized  as  a 
possihh'  resuU  oi  hy|)ereniia,  it  may  he  added  tiiat  it  is  in  eft'ect  a  tissne  death,  and  that 
di-ad  lissne  is  always  and  everywhere  practically  the  same  thing,  no  matter  hy  what 
causes  hroiight  ahout.  Conse(|nently,  the  snl)j<'ct  of  gangrene  will  he  considered  under 
a  separate  heading. 

').  Nutritional  Changes  will  he  considered  later. 

'J' he  c(>us((ninicc  of  prr.sisfnit  fii/pcrniii(i  /.v  trdiisiidation — i.  e.,  cscnpr  oj  h/ood  phisvi 
frotii  thr  rrs.sr/.s  into  hadi/  cainties  (ind  //.s-.v/zr  interspaces.  This  leads  to  consideration 
under  a  distinct  lieading  of — 


TRANSUDATES  AND  EXUDATES. 


Exudation  may  occur  in  vascular  ;nid  non-vascular,  in  firm  and  soft  tissues,  in, 
under,  and  u|)on  nuMuhrancs.  With  respect  to  location,  exudates  are  descrihcd  as 
jrcc,  when  found  u|)on  free  surfaces  or  within  natural  cavities;  intrr.stitiul,  when  found 
between  the  tissues  or  j)arts  of  tissues;  and  pareneJiijinatoiis,  when  they  are  situated 
within  the  ti.ssues  themselves,  particularly  in  epithelial  and  glandular  cells  of  any  kind. 

Eixudates  are  serous,  mucous,  fibrinous,  or  mixed,  the  mixed  forms  including  the 
so-called  seropiirnlent,  the  mucopurulent,  the  croupous,  and  the  diphtheritic. 

When  any  exudate  contains  red  glohules  in  sufficient  (juantity  to  stain  it,  it  is  called 
hcniorrhacjic. 

S(M'()Us  transudates  from  free  surfaces  are  sometimes  spoken  of  as  serous  catarrhs; 
when  into  cavities,  as  dropsies;  when  into  tissues,  as  edema;  when  occurring  hcneath  the 
epidermis  they  form  serous  vesicles  or  blebs  or  bulla'. 

Fibrinous  exudation  refers  to  the  fluid  which  coagulates  soon  after  its  exit  fi-om  the 
ve.s.sels  within  those  spaces  into  which  it  has  oozed.  When  fiocculi  of  coagula  float  in 
serous  fluid  it  is  known  as  a  serofibrinous  exudate.  Pure  fihrinous  exudate  occurs 
rarely,  save  in  and  upon  mucous  membranes.  The  extent  to  which  exposure  to  the 
air  is  resj^onsible  for  the  firm  coagulation  of  the  fibrin  previously  held  in  solution  is 
uncertain.  The  most  potent  factors  in  producing  such  coagulation  are  bacteria,  but  it 
is  not  yet  dis|)roved  that  coagulation  may  occur  without  their  aid.  When  such  coagu- 
lation occurs  U]ion  the  surface  of  a  mucous  membrane  it  has  been  spoken  of  as  croupous. 
When  the  epithelial  covering  as  well  as  the  basement  membrane,  and  often  the  sub- 
mucous tissues,  are  involvetl,  so  that  the  membrane  cannot  be  stripped  off  without 
tearing  across  minute  bloodvessels,  the  exudate  has  been  known  as  diphtheritic.  These 
terms  may  possibly  be  still  retained  in  an  adjective  sense  as  implying  the  exact  location 
of  a  surface  exudate,  but  are  scarcely  to  be  used  in  any  other  significance. 

The  following  table  illustrates  significant  differences  whose  full  importance  cannot 
be  impressed  before  a  study  of  inflammation  has  been  carefully  entered  upon: 


Hyperemic  Transudates. 

Poor  in  albumin. 

Rarely  coagulate  in  the  tissues. 

Contain  few  cells. 

l/ow  specific  gravity. 

Contain  no  peptone. 


Inflammatory  Exudates. 

Rich  in  albumin. 
Usually  coagulate  in  the  ti.ssues. 
Contain  numerous  cells. 
High  specific  gravity. 
Contain  peptone  (product  of  cell 
disintegration). 


TREATMENT  OF  CONGESTION  AND  HYPEREMIA. 

These  disturbances  are  to  be  combated,  first  of  all,  by  insisting  upon  physiological 
rest.  This,  perhaps,  is  the  most  important  measure  of  all.  The  profession  is  indebted 
to  Hilton  for  the  decided  advance  which  he  made  in  the  treatment  of  congestive  and 
inflammatory  afTections  by  insisting  upon  this  principle  in  his  celebrated  work  on 
Rest  and  Pain,  which  every  young  practitioner  should  read.  Aside  from  this  first  and 
underlying  principle,  the  treatment  must,  in  some  measure  at  least,  be  based  upon 
the  time  at  which  we  are  called  upon  to  treat  the  case.     If  seen  at  once,  before  exudation 


24  SURGICAL  PATHOLOGY 

has  been  excessive  or  the  other  (hsturhaiHcs  marked,  we  may  carry  out  a  certain  line 
of  treatment  for  the  purpose  of  hmiting  all  these  unpleasant  features.  On  the  other 
hand,  if  seen  late,  when  exudation  has  been  copious  and  when  pain  and  other  disturb- 
ances are  due  to  its  ])resence,  a  distinctly  different  course  will  be  adopted. 

Toward  the  end  first  mentioned — namely,  the  limitation  of  hyperemia — we  may 
adoj)t  local  and  general  measures.  Local  measures  include  graduated  j)re.ssure, 
providing  this  is  not  intolerable  to  the  patient,  so  equalized  that  outside  of  the 
ves.sels  it  shall  equal  that  inside.  This  may  be  done  by  careful  bandaging,  extreme 
care  being  taken  that  the  pressure  be  applied  from  the  very  extremity  of  the  limb; 
otherwise,  passive  exudation  might  be  augmented  and  gangrene  be  precipitated. 
Elevation  of  a  limb  will  often  accomplish  the  same  purpose.  Cold,  which  is  in  effect 
an  astringent  and  which  tends  to  contract  bloodvessels,  is  another  measure  in  the 
same  direction,  and  if  applied  early  will  do  much  to  limit  the  degree  of  the  attack. 
This  may  be  a])plied  as  dry  or  moist  cold,  and  should  be  gradually  mitigated  as  the  con- 
gestion subsides.  It  acts  through  the  \asomotor  system,  and  is  a  measure  to  be  resorted 
to  with  caution.  An  efficient  way  of  applying  dry  cold  can  be  extemporized  by  a  few 
yards  of  rubber  tubing,  held  in  place  by  wire  or  sewed  in  place  to  a  piece  of  cloth, 
through  which  a  stream  of  cold  water  is  permitted  to  pa.ss. 

Heat  is  another  efficient  means,  acting,  however,  in  a  rather  different  way.  Heat  is 
a  measure  to  be  employed  to  hasten  the  disa|)pearance  of  exudation — in  other  words  to 
quicken  resorption,  which  it  does  by  ecpializing  blood  pressure,  dilating  the  caj)illaries, 
stimulating  the  lymphatic  current,  and  in  every  way  helping  to  clear  the  tissues  of  that 
which  has  left  the  bloodvessels. 

It  is  necessary  also,  at  least  in  extreme  cases,  to  employ  some  detergent  or  derivative 
measures,  including  bloodletting,  to  which  we  do  not  resort  sufficiently  often.  When  used 
for  this  purpose,  depletion  should  be  applied  at  the  area  involved,  if  possible.  This 
may  be  done  either  as  venesection,  by  leeching,  either  with  the  natural  or  the  artificial 
leech,  or  by  a  series  of  minute  punctures  or  incisions,  which  give  relief  to  tension,  permit 
the  rapid  escape  of  fluid  exudate,  and  often  save  tissues  from  the  disastrous  effects  of 
strangulation.  In  some  cases  of  deep-seated  congestions  these  measures  are  inappli- 
cable, and  venesection  at  the  point  of  election — say  the  cephalic  vein  in  the  arm — may 
be  followed  by  great  benefit.  Another  method  of  depletion  is  by  administration  of 
cathartics,  such  intestinal  activity  being  stimulated  as  shall  lead  to  copious  watery 
evacuations.  The  salines  rank  high  as  measures  directed  to  this  end,  but  in  emergency 
much  stronger  and  more  drastic  drugs  nuiy  be  administered,  such  as  jalap,  calomel, 
elaterium,  etc.  Diaphoretics  and  diuretics  help  to  reduce  temperature  and  in  some 
degree  to  deplete,  but  their  action  is  usually  slow.  When  exudation  is  considerable 
in  amount  and  confined  to  some  one  of  the  body  cavities,  it  is  often  best  combated, 
if  at  all  obstinate,  by  the  method  of  aspiration.  This  includes  any  suitable  suction 
apparatus  by  which  the  fluid  may  be  withdrawn  through  a  small  needle  or  cannula, 
the  operation  being  trifling  in  difficulty,  but  one  to  be  performed  under  strictest  aseptic 
precautions,  lest  infection  of  an  exudate  already  at  hand  be  ])ermitted. 

Certain  individuals,  especially  the  neurotic,  will  need  more  or  less  anodyne,  particu- 
larlv  when  local  apjjlications  fail  to  give  relief.  Sometimes  a  small  dose  of  nior])hine 
administered  hypodermically  will  act  magically  in  making  efficient  those  measures 
which  would  otherwise  be  inefficient.  In  little  children  some  anodyne  or  hypnotic 
will  be  of  great  service.  Under  all  circumstances  it  is  well  to  keep  the  lower  bowel 
emptv,  and  certain  elderly  individuals  with  weak  and  enfeebled  hearts  will  need  the 
stimulation  to  be  afTorded  by  digitalis,  quinine,  and  alcohol,  or  preferably  strychnine 
administered  subcutaneously. 

In  cases  of  chronic  hyperemia  and  its  consecpient  hyperj^lasias  (induration,  thick- 
ening, etc.)  there  is  no  one  measure  so  generally  applicable  and  efl'ective  as  the  continued 
use  of  cold-water  dressings.  These  are  generally  s])oken  of  as  "cold  wet  packs,"  and 
may  be  continued — constantly  or  intermittently — for  many  days. 

Massage  is  also  an  invaluable  agent  in  the  reduction  of  swelling  and  tissue  overpro- 
duction. It  promotes  absorption,  even  of  acute  effusions,  by  equalizing  the  blood 
and  hastening  the  lymph  circulation,  and  under  its  scientific  application  it  is  surprising 
how  firm  exudates  and  old  adhesions  seem  to  disappear. 


ATh'OPny   AM)  in  rERTROPHY 


25 


ATROPHY   AND   HYPERTROPHY,   AND   THE   CONSEQUENCES   OF   ALTERED, 
DIMINISHED,  AND  PERVERTED  NUTRITION. 

As    a    consccnuMicc    ol"    increase    of    luitritioii    we     luive    a    coiKlilion    known    eoni- 
monly  as  liijpr  tiro  phi/,  more  accurately  as  /iijprrp/asid.     Ilypertrojjhy  literally  means 
overfjrowth,    whereas    hyperj)lasia   more   accurately   describes    that    which    constitutes 
hy|)ertro])hy — namely,   numerical   increase   of  constituent  cells,     ('omnion    usaj^e   has 
made   the   more   inaccurate   name   "hy|)ertroj)hy"   cover   nearly   all   the.se   conditions. 
II i/prrtrop/ii/,  or  hy|)er|)lasia,  inranfi  nilarfjniirnf  of  a  part  or  of  an   orcjan  hcijotid  its 
usuaWnuits,  and  as  the  result  of  increased  function  or  increased  nutrition.      It  is  to  he 
distinijuished    from    (/u/anfisni,  which    means    inordinate  enlargement  as  the  result  of 
a  congenital  tendency  or  condition.     Hypertrophy  is — 
I  ].   Compensatory; 
\  2.   l''rom  deficient  u.se. 
Local; 
(ieneral; 
SeniL  ; 
I  ().  Congenital. 

A.  Physiological  Hypertrophy.— 1.  This  includes  many  of  the  compensatory 
enlargements  of  an  organ  or  a  |)art  when  extra  work  is  put  upon  it,  owing  to  deficiency 
of  some  other  organ  or  part.     This  is  spoken  of  as  coinpt'tisatoni  enlargement.      Illus- 


FlG.     1 


A.   P/iijsiohx/ira/ 


3. 


B. 


Pathological    i  - 


Congenital  hypertrophy:  gigantism  of  both  lower  extremities.     (Case  of  Dr.  Graefe  [Sandusky] .) 

trative  examples  may  be  seen  in  the  heart,  which  becomes  larger  and  stronger  when  the 
blood ves.sel  walls  are  diseased  and  their  lumen  marrowed,  or  when  other  obstructions 
to  circulation  are  brought  about;  again,  in  enlargement  of  one  kidney  after  extirpation 
of  the  other,  or  of  the  wall  of  the  stomach  w^hen  the  pylorus  is  constricted  or  obstructed; 
again,  of  the  fibula  after  weakening  or  more  or  less  destruction  of  the  tibia,  or  of  the 
shaft  of  any  bone  when  it  has  been  weakened  at  some  point  by  not  too  acute  disease; 
or,  again,  of  the  walls  of  bursse  after  constant  friction. 

2.  The  best  examples  of  physiological  hypertrophy  owing  to  deficient  use  are  perhaps 
seen  in  some  of  the  lower  animals;  as,  for  instance,  in  the  teeth  of  such  rodents  as 
beavers  when  kept  in  ca))tivity  and  prevented  from  natural  use. 


26  SURGICAL  PATHOLOGY 

B.  Pathological  Hypertrophy. — 3,  4.  Instances  of  this  are  everywhere  and  every 
day  are  met  in  the  results  of  so-called  chronic  infiammatinn,  a  term  which  is  a  com[)lete 
misnomer  and  should  be  expunged  from  text-hook  use.  So-called  chronic  inflannnation 
simply  means  increase  of  nutrition  owing  to  a  certain  degree  of  hyj:)ereniia,  which  may 
have  been  j)roduced  in  the  first  place  as  the  result  of  traumatism,  which  may  have  come 
from  chemical  irritants  circulating  in  the  fluids  of  the  part — as,  for  exampl(\  uric  acid, 
etc.— or  which  is  brought  about  as  the  result  of  ])erverted  trophic--nerve  iiiHuence. 
Instances  of  local  ])athological  hyiHM'trophy  may  l)e  seen  in  the  thickened  j)eriosteum 
after  injury,  in  the  enlargement  of  a  phalanx  known  as  the  "basel)all  finger,"  and  in 
numerous  other  places;  or  they  may  be  general,  in  which  case  they  are  brought  about 
mainly  by  some  irritating  material  in  the  general  circulation.  The  unknown  poison  of 
syphilis  generally  provokes  such  nutritive  disturbances. 

5.  Senile  liijpcrfrophy  is  connected  with  nutritional  disturbances  characteristic  of 
old  age,  as  to  whose  remote  causes  we  are  still  uncertain.  Instances  of  senile  hyper- 
troj)hy,  however,  are  common,  particularly  in  the  prostates  of  elderly  men,  which  are 
liable  to  undergo  extensive  enlargement. 

C).  Of  congenital  hypertroj^hy  and  that  of  unknown  origin  we  se(\  for  instance, 
examples  in  certain  rare  cases  of  hyjiertrojihy  of  the  breast,  in  leontiasis,  jierhaps  even 
in  acromegaly,  etc.;  and  these  are  to  be  distinguished  from  gif/(i)iiis-m,  because  in  most 
instances  of  the  former  type  the  hypertrophic  tendency  is  not  manifested  until  youth 
or  adult  life,  whereas  gigantism  is  a  condition  in  which  the  tendency  was  apparent 
even  before  the  birth  of  the  individual. 


ATROPHY. 

Atrophy  implies  impaired  nutrition,  and  means  diminution  in  the  size  of  an  organ  or 
part,  and  is  the  converse  of  hypertrophy.     It  is  necessary  to  make  plain  that  in  atro])hy 
nutrition  is  only  impaired  and  not  arrested,  since  complete  arrest  of  nutrition  means 
necrosis — i.  e.,  gangrene  or  disappearance  of  parts.     It  may  be — 
fl.  From  disuse  without  disease; 

A.  Physiological  <  2.  Biological  or  developmental; 

[  3.  Senile. 

f  4.  Result  of  acute  tissue  losses; 
.         J  5.  Result  of  phagocvtic  activity; 

B.  Pathological    j  ^.    Result  of  continuous  pressure; 

[  7.  Sjiecific. 

A.  Physiological  Atrophy. — 1.  This  is  always  the  result  of  disuse  or  impaired 
function  from  any  cause.  Its  evidences  are  generally  seen  in  the  fatty  structures  and 
muscles — i.  e.,  in  the  soft  parts.  It  is  true,  however,  even  of  the  bones,  or,  of  greater 
interest,  even  in  the  brain  cells.  We  see  evidences  of  it  also  in  minute  organs;  as,  for 
example,  in  the  digestive  glands  in  certain  cases  where  diet  is  restricted.  Again,  we 
see  it  in  the  diminution  of  the  size  of  the  heart  after  hip  amputation,  less  being  required 
of  that  organ,  and  also  in  the  entire  structure  of  the  rectum  after  colostomy. 

2.  Examples  of  the  developmental  type  are  best  seen  in  the  natural  disa)i]icarance  of 
the  hypogastric  arteries,  the  ductus  arteriosus,  the  vitelline  duct,  the  Wolffian  bodies, 
and  in  the  various  generative  ducts  (Gartner's,  etc.)  shortly  after  the  birth  of  the  human 
individual.  We  sometimes  see  it  also  in  the  prostate  after  orchidectomy.  P>jually 
illustrative  is  the  disappearance  of  the  tail  and  gills  of  the  tadpole,  the  eyes  of  animals 
living  in  caverns,  and,  in  a  general  way,  of  organs  which  become  useless  owing  to  a 
different  environment. 

3.  Senile  atrophy  is  seen  equally  well  in  the  hair  follicles,  the  teeth,  the  bones,  and 
the  sexual  organs  of  elderly  people — in  fact,  in  all  their  tissues,  even  in  the  brain. 

B.  Pathological  Atrophy. — 4.  Acute  atrojihy  of  surrounding  tissues  is  the  necessary 
accompaniment  of  destruction  by  suppurative  or  other  disturbances;  that  is,  parts 
disappear  by  absorption  which  have  not  been  interfered  with  by  pyogenic  organisms. 
So  complete  may  atrophy  occur  under  these  circumstances  as  to  cause  disablement 
of  an  organ  or  part.  This  kind  of  senile  disappearance  is  merely  an  expression  of 
phagocytic  activity,  although  not  now  a  question  of  bacteria. 


ATROPHY  27 

5.  Tlir  sanic  is  ivur  of  thai  variety  spoken  ol"  above  as  lyiolixjiral  or  dcvelojnnfntai, 
since  |)Iia»ioeytes  are  the  active  a};'ents  in  |)r(Mhuiii<;-  the  (hsa|)])earanee  of  the  tadpole's 
tail. 

0.  A  more  slow  I'onn  of  patholoffieal  atrophy  is  seen  in  the  (jradiinl  ilisapprarfnicc 
of  tissues  in  the  neiifhhorhood  of  advancing  tnniors,  enlar<^in<;  <"ysls,  etc.  'J'his  is  |)er- 
haps  hut  another  e.\|)ression  oi"  atrophy  from  eoiitimions  pressure.  But  a  still  better 
illustration  is  the  atr()j)hy  which  comes  from  immobilization  of  a  ])art  without  pressure. 
This  is  usually  the  case  when  splints  or  orthopedic  ajiparatus  liave  to  be  kept  in  place 
for  some  time. 

7.  Sprrific  forius  of  pathol()<fi<ai  atrophy  are  lar<2;ely  connected  with  di.sturbances  in 
the  central  nervous  system.  'I'hey  are  often  referred  to  as  fropliouciirollc  Their  exact 
mechanism  is  not  yet  understood,  and  cases  may  l)e  confused  under  this  head  whose 
remote  causes  are  widely  different.  Here  should  be  included,  for  instance,  the  atrophy 
of  a  deeji  bone  which  occurs  after  extensive  burn  of  the  surface;  also  that  peculiar  form 
of  atrophy  of  tissues  in  the  stump  which  produces  the  so-called  conical  siinii}).  These 
ca.ses  arc  of  a  more  complicated  character,  for  if  pressure  is  removed  from  the  bone 
end,  especially  in  younj]i;  peojile,  the  bone  tends  to  grow  fa.ster  than  it  should,  while 
the  soft  parts  disappear,  partly  as  the  result  of  mere  disu.se  or  lo.ss  of  function.  In 
this  way  conicity  is  produced,  which  sometimes  calls  for  subsequent  re-amputation. 
Under  this  head  miifht  also  be  included  the  so-called  "trophic  infiannuation"  (misnomer) 
of  some  writers,  such,  for  example,  as  ulceration  of  the  cornea  after  division  of  the 
trigeminus.  The  general  subject  of  atrophic  ehmgaium  also  belongs  here,  referring  to  the 
fact  that  as  a  result  of  disuse,  or  .sometimes  of  active  disease,  the  bones,  while  showing 
atro|)hic  changes  in  other  respects,  actually  increase  in  length.  Should  such  increase 
occur  in  one  bone  of  those  portions  of  the  limbs  which  are  supplied  with  two,  the  result 
would  be  posture  deformity  and  displacement  of  the  terminal  portion. 


CHAPTEK    II. 

SURGICAL  PATHOLOCiY  OF  TUK  BLOOD. 

The  part  played  by  the  constitiUMit  clcinents  of  the  blood  in  iiiflaniiiiatioii,  siijipiiration, 
and  other  still  more  disastrous  conditions  is  so  great  and  so  inijjortant  that,  before  pro- 
ceeding to  discussion  of  these  lesions,  it  seems  necessary  to  set  forth  a  resume  of  facts 
illustrating  the  importance  of  accurate  knowledge  concerning  this  most  important  fluid. 

The  total  amount  of  blood  in  the  human  body  has  been  variously  estimated  at  from 
one-eleventh  to  one-twenty-fifth  of  the  body  weight,  the  average  being  about  one-six- 
teenth. The  amount  which  the  body  may  lose  and  still  retain  vitality  is  very  vague  and 
differs  not  only  with  individuals,  but  very  greatly  under  various  conditions.  Severe 
loss  of  blood  is  one  to  be  atoned  for  as  (juickly  as  })ossil)le,  and  is  to  be  prevented  as  far 
as  it  can  be  after  accidents  or  during  o|)eration.  For  this  reas(»n  the  so-called  bloodless 
method  of  operating  upon  limbs,  by  the  use  of  the  rubber  bandage,  constituted  a  great 
advance  in  surgery.  For  the  same  reason  the  use  of  hemostatic  forceps  is  of  e(iual  value 
in  oj)erating  upon  other  parts  of  the  body;  other  things  being  equal  the  quickest  and 
most  satisfactory  recoveries  follow  the  bloodless  operations,  and  it  is  an  advantage  to 
conserve  this  vital  fluid  as  far  as  possible. 

It  has  been  roughly  estimated  that  the  blood  is  divided  about  as  follows,  between  the 
different  parts  of  the  body:  the  heart,  lungs,  and  large  vessels  holding  one-fourth,  the 
skeletal  muscles  one-fourth,  the  liver  one-fourth,  the  remaining  (juarti-r  l)eing  distributed 
over  the  balance  of  the  body. 

The  blood  varies  within  wide  limits  in  its  coagulability,  and  this  variation  occurs 
apparently  even  within  conditions  of  health.  In  some  patients  the  blood  may  be  .seen 
to  coagulate  almost  as  rapidly  as  it  collects  upon  the  surface,  while  in  others  the  expo.sed 
parts  continue  to  ooze,  and  the  checking  of  hemorrhage  is  a  difficult,  sometimes  almost 
impossible,  matter.  There  are  certain  diseases  in  which  the  blood  is  known  to  have 
reduc(;d  power  in  this  direction;  for  example.  In  the  toxemias,  especially  those  connected 
with  biliary  obstruction  and  jaundice.  There  were  not  a  few  of  these  cases  of  slow 
bleeding  to  death  in  days  gone  by,  simply  because  the  caj)illary  hemorrhage  could  not 
be  controlled.  Recently,  it  has  been  shown  that  calcium  chloride  administered  inter- 
nally has  a  marked  effect  in  favoring  coagulation,  and  when  opportunity  is  afforded 
it  should  be  given  for  several  days  previous  to  op(M-ating  and  as  part  of  the  necessary 
preparation.  It  may  be  administered  in  doses  of  from  1  to  2  CJm.,  and  should  be  given 
three  or  four  times,  at  lea.st,  in  twenty-four  hours. 

A  test  of  the  coagulation  time,  normally  three  to  five  minutes,  but  lengthened  under 
circumstances  like  those  mentioned  above,  even  to  an  hour,  will  often  prove  of  great  value. 

There  are  certain  albumoses  who,se  effect  on  coagulation  of  the  blood  is  very  sug- 
gestive and  very  mysterious.  A  very  minute  dose  of  cobra  poison,  for  instance,  will 
make  the  blood  of  an  experimental  animal  remain  fluid  for  days,  unless  this  animal 
has  been  previously  immunized  against  it,  in  which  case  coagulation  takes  place  even 
more  rapidly  than  normally.  A  trace  of  serum  from  an  immunized  rabbit  is  enough 
to  prevent  the  fluidifying  effect  of  the  cobra  poison,  but  (piite  insuflicient  to  neutralize 
its  toxic  effects.  The  surgeon  practically  never  desires  to  reduce  coagulability  of 
the  blood,  but  frequently  to  increase  it.  When  it  is  increased  by  natural  conditions  or 
those  not  easily  controlled,  then  it  may  lead  to  thrombosis  and  produce  trouble 
in  that  way. 

Fibrin. — Increase  of  fibrin,  hijperino.ns,  accompanies  the  l(Mikocytosis  of  inflam- 
mation and  su[)puration.  It  may  be  a])proximately  estimated  on  the  cover-gla.ss  by 
noting  the  closeness  of  the  network  resulting  after  fifteen  minutes'  exposure.  The 
inflammatory  indication  of  leukocytosis  may,  therefore,  be  inferred  from  its  determina- 
tion, while  the  leukocytosis  of  malignant  dis(>ase  will  not  be  so  accompanied.  Ilyiieri- 
nosis  is  most  marked  in  pyogenic  processes,  pneumonia  and  rheuniatisni.  Its  opposite, 
hupinosis,  is  met  with  in  pernicious  anemia.  There  is  no  change  in  the  percentage  of 
(28) 


SURGICAL  PATIIOIJHIY   OF   Till-:   Hl.OOl)  29 

fibrin  in  the  ordiiiarv  aiu-niias  or  chlorosis.  In  luinopliilia  and  |)ur|)ina  licinorrlia<;i(a 
till"  ((la^iilation  time  i>  ^Tcally  increased. 

The  Formed  Elements  oif  the  Blood.— The  speciahzed  elements  of  ihe  hlood  which 

are  of  |)articiilar  interest  to  tlu>  sin-<;eon  are  the  red  and  the  white  cor|)Uscles.  These 
may  both  varv  in  relative  size  within  certain  physioloifical  limits.  The  red  cells  esj)e- 
ciallyure  nt)t  oi'  nnit'orni  size  and  vary  from  (i  to  i)  microns  in  diameter.  There  are  also 
present  in  normal  blood  a  small  number  of  red  cells  havin<:j  a  diameter  of  only  (i  microns, 
whicli  are  known  as  microcytes.  In  infancy  there  are  present  uLso  so-called  fj^iant  cor- 
puscles, or  megalocytes,  with  a  diameter  of  10  microns  or  more.  Considerable  variation 
occurs  in  disease,  especially  in  the  severe  anemias.  Red  corpuscles  ordinarily  stain 
with  acid  dyes,  which  facilitate  their  examination  and  a  com|)utation  of  the  number 
present.  When  present  in  unusually  lartre  nund)er  the  condition  is  spoken  of  as  a 
po/i/ci/tlintua;  when  in  reduced  number  as  o/igori/tlirniia.  In  .several  of  the  anemias 
variations  in  size,  shape,  and  color  occur,  and  in  certain  of  them  numy  of  the  red  cor- 
puscles are  found  to  be  luicleated.  Red  cells  which  are  nucleated  are  known  as 
cnithroblnsts,  and  according  to  their  size  are  sj)c)ken  of  as  inicrohlasis ,  normobla^sis ,  and 
mccjaloblaMs.  Again,  under  certain  diseased  conditions  the  ordinary  discoid  form  of  the 
cells  becomes  irregular  and  crenated,  and  to  tho.se  which  are  thus  altered  is  given  the 
name  of  poik-ilocytcs. 

There  is  another  form  of  tlegeneration  which  consists  in  death  or  necrobiosis  of  the 
cell,  whereby  it  loses  its  capacity  for  staining,  or,  at  all  events,  stains  irregularly  and 
abnormally.  This  is  seen  also  in  ca.ses  of  severe  anemia  and  in  conditions  where  the 
blood  has  been  altered  by  the  addition  of  toxic  matenal,  such  as  chloroform,  etc.  Occa- 
sionally also  the  red  cells  show  a  tendency  to  a  granular  change,  which  is  probably 
entirely  degenerative. 

The  red  corpuscles  have  a  certain  degree  of  elasticity  which  helps  them  to  pass  through 
capillaries  which  are  smaller  even  than  their  own  diameter;  after  escaping  from  these 
the  corpuscles  regain  their  original  form.  In  the  presence  of  carl)on  dioxide  they  lose 
this  elasticity  and  become  distorted  or  crenate.  The  influence  of  high  altitudes  in  in- 
creasing the  niuubcr  of  corpuscles  is  known,  but  unexplained.  For  instance,  a  residence 
of  less  than  a  month  in  the  mountains  will  cause  an  increa.se  of  from  2,000,000  to 
3,000,000  corpuscles  per  cubic  millimeter.  It  has  been  surmised  that  under  the  influ- 
ence of  oxygen  red  corpuscle  formation  is  stimulated  to  greater  activity;  in  other  words, 
that  the  red  marrow  becomes  more  active  in  the  production  of  the  hematoblasts. 

In  general  terms  it  may  be  said  that  the  blood  of  a  normal  adult  male  contains 
5,000,000  red  corpuscles  per  cubic  millimeter,  and  that  of  an  adult  female  4,500,000. 
These  figures  are,  of  course,  approximate  and  variable.  When  the  number  is  reduced 
to  3,000,000  by  common  consent  the  case  will  be  regarded  as  oligocythemia,  and  when 
increased  to  6,000,000  as  one  of  polycythemia. 

The  latter  condition  is  most  evident  in  cases  of  newly  born  infants.  The  excess 
rapidly  diminishes  during  the  first  week  of  extrauterine  life.  It  is  to  be  explained  by 
the  loss  of  fluid  suffered  by  the  infant  upon  the  establishment  of  respiration.  The 
proportion  of  red  cells  also  varies  according  to  the  nutrition  of  the  individual,  the  season 
of  the  year,  the  altitude  (as  above),  and  climate,  and  varies  during  menstruation,  preg- 
nancy, lactation,  and  at  the  climacteric.  With  the  loss  of  red  cells  the  number  is  reduced 
in  proportion  to  the  hemoglobin,  although  the  change  in  one  respect  is  not  exactly  pro- 
portionate to  that  in  the  other. 

That  the  colorless  corpuscles,  or  leukocytes,  are  not  all  of  one  kind  has  been  recognized 
for  nearly  sixty'  years,  and  long  ago  they  were  divided  into  granular  and  nucleated  cells. 
A  vast  impetus  to  the  stiuly  of  hemocytology  was  given  l)y  Ehrlich,  in  1S7S,  when  he 
introduced  the  u.se  of  aniline  dyes.  The  reader  must  be  reminded  that  some  of  these, 
like  eosin,  are  acid  in  reaction,  and  others,  like  methyl  blue,  are  basic;  while  a  third  group 
has  been  supposed  to  be  neutral  in  reaction,  like  a  mixture  of  methyl  blue  and  acid 
fuchsin;  but  it  has  been  found  that  the  so-called  neutral  dyes  have  really  a  slightly  acid 
reaction.  We  may,  therefore,  divide  the  cells  according  to  the  reaction  of  the  dyes  with 
which  they  usually  are  distinguished  into  the  acid  and  ba.sic,  or,  more  technically,  into 
oxyphile,  which  includes  neutrophile,  and  basophile. 

This  is  not  the  place  in  which  to  go  into  any  minute  discussion  of  this  subject  nor 
further  than  should  be  of  practical  interest  to  the  surgeon;  nevertheless  an  examination 
of  the  blood  by  some  common  and  routine  procedure  is  so  necessary  in  many  surgical 


30  SURGICAL  PATHOLOGY 

conditions  that  it  is  impossible  to  entirely  avoid  the  subject  in  a  work  like  this.  1  have 
accordingly  condensed  it  and  put  the  salient  facts  about  leukocytes  into  the  following 
table : 

Classification  of  Leukocytes. 

Granular.  Non-f/raniilttr. 

(Oxyphile.  A.  With  fine  granules  (polynuclcar)  C.  Hyaline.   Transitional  (large 
Neutrophile.  The  so-called  60-75  i)er  cent.                                          mononuclear)  4-8  per  cent, 
neutral  .stain  being  slightly   B.  With    coarse   granules    (eosino-  D.  Lymphocytes  (small  mono- 
acid,  philes)  2-5  per  cent.                                nuclear)  20-30  per  cent. 
(  Basophile  ^-  I'ine  and  coarse  granules  (base-  G.  Atypical     hyaline     (myelo- 
Pathological.      ,,,.,'  ^  philes   mast-cells   etc.).                        cytes). 
L  O.xyphile.  F.  Atypical  (myelocytes). 

In  normal  blood  by  far  the  greater  part  of  the  leukocytes  consists  of  A  and  D.  Lympho- 
cytosis means  a  relatively  high  percentage  of  C  and  D.  Eosinophilla  means  an  in- 
crease in  the  proportion  of  B.  Basophile  cells  are  not  absolutely  ])athological,  for  they 
may  be  present  in  very  small  numl)ers  in  normal  blood. 

The  number  of  leukocytes  in  normal  l)lood  will  average  about  7000  to  10,000  per  cubic 
millimeter,  the  percentage  of  each  variety  being  given  in  the  above  table.  Leukocytes 
are  sometimes  diminished  in  number;  under  diseased  conditions  they  are  often  increased, 
and  these  are  then  included  under  the  term  leukocytosis.  Variations  occur  daily  and 
almost  hourly  under  normal  conditions.  Increase  naturally  occurs  after  digestion, 
when  the  number  of  leukocytes  may  be  almost  doubled,  the  same  being  due  principally 
to  lymphocytes  which  are  washed  into  the  blood  system  from  the  lymph  nodes  by  the 
flow  of  lymph  or  chyle.  In  starvation,  however,  the  number  may  be  remarkably 
reduced  and  in  the  case  of  the  fasting  man,  Succi,  the  leukocytes  were  reduced  at  the 
end  of  the  first  week  to  SGO  per  cubic  millimeter.  The  rather  unusual  condition  of 
reduction  of  the  number  of  corpuscles  is  called  leukopenia. 

Leukocytosis  is  usually  the  rule  in  carcinoma,  with  increase  in  A  and  F;  the  more 
rapid  the  growth,  the  greater  this  increa.se.  In  sarcoma  this  is  even  more  pronounced; 
when  occurring  without  hyperinosis  the  probability  of  malignancy  is  greater.  Non- 
malignant  tumors  produce  no  such  changes. 

The  blood  platelets  or  plaques  first  described  by  Bizzozero,  in  1882,  have  no  small 
interest  for  physiologists  and  pathologists,  but  little  for  the  practising  surgeon.  They 
number  perhaps  5,()00,000  per  cubic  millimeter  and  sustain  a  fairly  constant  ratio  to 
the  red  cells.  Their  surgical  interest  is  limited  to  the  role  which  they  may  play  in 
the  formation  of  thrombus. 

The  term  phagoci/tosis  has  to  do  in  a  general  way  with  those  leukocytes  which  act  as 
scavengers  by  removing  from  the  blood  its  noxious  elements,  presumably  by  a  process 
of  ingestion  and  digestion  (see  Chapter  III). 

Examination  and  estimation  of  the  various  formed  elements  of  the  blood  are  very 
valuable  to  the  surgeon  in  the  study  of  the  anemias,  of  acute  inflammation  when  the 
presence  of  pus  is  suspected,  in  the  presence  of  suspected  cancer,  and  in  the  presence 
of  such  conditions  as  Hodgkin's  disease,  the  various  disorders  of  the  spleen,  etc.  The 
so-called  primary  anemias  include  only  the  pernicious  anemias  and  chlorosis;  all  others 
are  designated  as  secondary.  This  distinction  is  not  for  convenience  only,  but  serves  a 
useful  purpose. 

Pernicious  anemias  produce  a  reduction  both  of  the  red  corpuscles  and  the  hemo- 
globin, the  former  usually  in  a  greater  degree  than  the  latter,  so  that  the  color  index 
(see  below)  is  usually  plus.  Many  of  the  cells  become  nucleated  and,  in  general,  their 
size  is  increased.  In  chlorosis  the  reduction  of  the  hemoglobin  is  relatively  large  and 
the  color  index  is  extremely  low.  In  the  secondary  anemias  the  red  cells  and  hemo- 
globin are  reduced  disproportionately,  so  that  the  color  index  is  minus.  There  may  or 
may  not  be  a  relative  increase  of  leukocytes  and  of  the  nucleated  red  cells,  but  these 
latter  are  not  so  likely  to  be  as  large  as  those  seen  in  primary  anemias.  The  color  index 
is  obtained  by  dividing  the  percentage  of  the  hemoglobin  present  by  the  percentage  of 
the  red  cells. 

Leukocytosis  becomes  pathological  in  conditions  of  acute  inflammation  where  the 
neutrophiies  (A)  show  the  greatest  relative  increase.  The  degree  of  leukocytosis 
depends  on  two  different  factors:  the  intensity  or  the  virulence  of  the  infection,  and  the 
vitality  or  resisting  power  of  the  individual.  These  vary  within  such  wide  limits  that 
it  is  hard  to  predicate  anything  definite  in  a  given  case.     In  general  the  increase  is  sup- 


SURGICAL  PATIIOLOCY  OF   rilE  BLOOD  31 

j)().si-(l  ((»  he  proportioiijitc  to  the  severity  of  the  infection,  (houj^h  the  fj^reater  the  reac- 
tionary ahility  of  tlie  i)atient  the  hirger  the  nninl)er  of  white  cells.  \Vhere  vitality  is 
very  low  leukocytosis  is  less  proiiouncetl.  It  is  possible  to  have  toxemia  to  such  a  degree 
that  the  activity  of  the  ItMikocytes  seems  to  he  destroyed.  The  following  summary 
from  Cahot  |)uts  things  in  very  distinct  form. 

Infection  mild,  vital  reaction  good — small  leukocytosis. 

Infection  less  mild,  vital  reaction  less  good—  moderate  leukocytosis. 

Infection  .severe,  vital  reaction  good — very  marki'd  leukocytosis. 

Infection  severe,  vital  reaction  poor — no  leukocytosis. 

From  this  it  will  appear  that  the  absence  of  leukocytosis  in  ea.ses  where  it  naturally 
would  be  ex])cctcd  is  a  serious  indication  and  justifies  an  unfavorable  prognosis;  or  else 
it  may  be  iiitciprctcd  in  evidently  favorable  cases  as  indicating  infection  of  very  mild 
grade. 

There  art'  but  few  diseases  in  which  leukocytosis  by  itself  (or  for  that  matter  any  other 
indication  wiiicli  the  ordinary  examination  or  l)lood  count  may  give)  is  wholly  siiliicicnt 
for  diagnostic  ])urposcs.  But  a  blood  count  and  estimate  of  the  amount  of  hemoglobin 
|)resent  will  ofttMi  be  of  such  advtintage  to  the  surgeon  that  he  may  well  aiford  to  wait 
in  order  to  secure  them.  This  is  rarely  necessary  in  acut(>  cases,  but  in  chronic  cases, 
and  esiXH'ially  the  anemias,  he  may  gain  great  benefit  by  such  investigation.  In  trichi- 
nosl'i,  for  example,  eosinophilia  is  most  pronounced,  B  forming  even  as  high  as  70  per 
cent,  of  the  leukocytes  present. 

The  anemias  which  are  of  particular  interest  to  the  surgeon  may  be  classified  as 
follows: 

1.  Anemias  wlflioid  marked  Iriikori/to.ns. 

A.  Characterized  by  oligocythemia. 

B.  Characterized  by  diminution  of  hemoglobin. 

2.  Anemias  with  marked  leukocijfosis. 

A.  Leukemia  (leukocythemia). 

B.  P.seiidoleukemia  (Hodgkin's  disease). 

1.  A.  Anemias  due  to  hemorrhage  may  assume  one  of  two  forms,  that  resulting  from 
sudden  and  extensive  loss  of  blood  or  that  resulting  from  constant  oozing.  Example 
of  the  former  is  seen  in  hemorrhages  of  the  stomach  or  intestines  after  perforating  ulcer, 
etc.  Examples  of  the  latter  are  met  with  in  hemophilia  and  in  uterine  hemorrhages,  or 
in  excessive  menstruation  where  the  loss  of  blood  extends  over  a  considerable  length  of 
time.  It  is  known,  moreover,  that  certain  entozoa  in  the  intestines  will  produce  a 
chronic  anemia.  Thus  the  red  corpuscles  may  be  reduced  to  even  less  than  1,000,000 
per  cubic  millimeter.  Immediately  after  acute  hemorrhage  the  hemoglobin  percentage 
is  still  normal,  but  after  a  short  time  it  becomes  reduced.  If  such  cases  do  not  speedily 
end  fatally,  nucleated  red  corpuscles  appear  in  the  blood  and  the  observer  will  recog- 
nize both  normoblasts  and  megaloblasts.  At  the  same  time  the  bone-marrow,  which 
is  normally  yellow,  becomes  red,  vascular,  and  richly  cellular,  and  seems  to  furnish  these 
cells  just  mentioned.  Certain  drugs,  like  potassium  chlorate  and  glycerin,  affect  also 
the  number  of  red  corpuscles,  but  such  poisons  as  these  cause  not  only  disintegration 
of  the  red  cells,  but  produce  also  jaundice  and  hemoglobinuria.  Pernicious  anemia 
sometimes  interferes  with  or  fatally  complicates  surgical  treatment.  It  is  character- 
ized by  the  extreme  changes  already  mentioned,  with  which  it  marches  steadily  to  a 
fatal  termination.  Quincke  has  reported  an  instance  in  which  their  number  was  reduced 
to  43,000  per  cubic  millimeter,  while  the  hemoglobin  w^as  reduced  to  20  or  25  per  cent, 
of  the  normal  amount. 

1.  B.  The  best  example  of  anemia  which  depends  upon  diminution  of  the  hemo- 
globin content  of  the  red  cells  is  that  known  as  chlorosis.  In  this  there  are  few'  recog- 
nizable signs  of  destruction  of  corpuscles,  even  under  chemical  microscopic  examination; 
consequently  the  blood  picture  is  very  simple.  The  color  index  is  very  low,  yet  similar 
conditions  may  also  be  seen  in  syphilis,  tuberculosis,  and  cancer.  The  underlying 
feature  of  all  of  these  cases  is  malnutrition. 

Within  a  few  years  a  peculiar  form  of  intense  anemia  has  been  described  by  Banti 
and  others,  and  is  often  spoken  of  as  s'plenic  anemia  or  Bantis  disease.  It  is  charac- 
terized by  three  stages:  first,  of  splenic  enlargement  and  anemia;  second,  a  transitional 
stage;  third,  a  stage  of  ascites  which  increases  up  to  death.  It  is  quite  closely  allied  to 
Hanot's  hypertrophic  cirrhosis  of  the  liver.     It  is  quite  generally  regarded  as  an  example 


32  SURGICAL  PATHOLOGY 

of  an  infection  by  some  as  yet  unknown  organism.  It  is  of  interest  to  the  surgeon 
because  if  tlie  spleen  is  removed  early  there  are  fair  prospects  of  recovery. 

2.  A.  Anctnias  with  marked  leukocytosis  include  especially  those  first  sjioken  of  by 
Virchow  as  leukemia.  Originally  he  applied  the  term  to  a  particular  alteration  of  the 
blood,  but  it  is  now  made  to  cover  a  group  of  diseases,  all  of  which  are  characterized 
by  peculiar  and  more  or  less  similar  increase  of  white  corpuscles.  Sometimes  these 
are  increased  to  such  an  extent  as  to  make  the  blood  grossly  resemble  a  mixture  of 
blood  and  pus.  This  resemblance  led  some  of  the  earlier  observers  to  speak  of  the 
condition  as  "suppuration  of  the  blood."  The  number  of  leukocytes  is  sometimes 
enormously  increased;  1  to  10  of  the  red  cells  is  quite  common  and  1  to  5  not 
exceedini^lv  rare.  Cases  have  Ix'en  known  in  which  the  white  cells  outnumbered  the 
red.  In  well-marked  cases  of  leukemia,  the  red  cells  will  be  somewhat  diminished, 
while  the  white  will  number  from  100,000  to  500,000  jier  cubic  millimeter.  Accom- 
panving  this  change  in  the  blood  there  are  alterations  in  the  spleen,  the  l\Tnph  nodes, 
and  the  bone-marrow,  sometimes  one  predominating,  sometimes  another.  It  has  been 
customary  in  fact  to  speak  of  splenic,  lymphatic,  and  medullary  leukemia,  but  these 
forms  are  not  sharply  difi'ercntiated  and  a  pure  type  of  either  form  is  rare.  In  this 
countrv  we  speak  mainly  of  lijmphafir  and  splrnomeduUary  forms,  the  latter  being  much 
more  common.  The  latter  is  accompanied  by  enlargement  of  the  sjileen,  while  in  the 
Ivmphatic  form  the  lymph  nodes  are  involved  and  may  become  as  large  as  walnuts. 
In  the  lymphatic  form  over  \)()  per  cent,  belong  to  C  and  D;  in  the  splenomedullary 
or  splenomvelogenous  form  the  increase  of  F  and  G  is  most  marked,  while  A  will  be 
reduced  to  50  per  cent,  and  D  to  about  10  per  cent.  The  red  corpuscles  are  decreased 
in  number,  but  not  necessarily  in  an  inverse  ratio;  their  number  may  be  reduced  even 
to  2,000,000  in  extreme  cases. 

In  these  cases,  besides  the  change  in  number  and  form  of  the  leukocytes  already 
described,  there  are  frequently  found  in  the  blood  very  minute  crystals  first  described 
by  Charcot.  These  are  small,  often  adherent  to  the  leukocytes,  and  most  fre- 
quently found  when  eosinophile  cells  predominate;  their  exact  significance  is  not  known. 
The  pathology  of  leukemia  is  too  remote  from  the  purpose  of  this  work  to  receive  con- 
sideration here.  Without  asserting  its  germ  character  one  may  say  that  it  is  under  sus- 
picion, and  that  various  observers  have  described  appearances  supposed  to  indicate  a 
specific  cause,  probably  a  protozoon. 

2.  B.  Pseudoleukemia. — This  has,  in  time  past,  gone  under  many  different  names, 
of  which  the  most  common  is  Ilodcjkins  di.^ea.'ie  (q.  v.).  !Many  speak  of  it  as  malig- 
nant hjmphoma.  This  is  doubtless  a  disease  with  a  specific  cause,  as  yet  unrecognized, 
which  jiroduces  very  significant  changes  in  the  bood,  especially  in  the  white  corpuscles. 
The  spleen  and  lymph  nodes  are  both  involved,  mainly  the  latter.  The  general  blood 
changes  are  quite  varial)le  and  one  may  find  many  types.  As  a  rule,  these  comprise 
not  .so  much  an  increase  in  the  number  of  leukocytes  as  a  decrease  in  the  number  of  red 
cells  by  which  an  apparent  leukocytosis  is  brought  about;  hence  the  expression  pseudo- 
leukemia. ]\Iany  cases,  however,  will  present  a  certain  degree  of  actual  leukocytosis, 
the  proportion  of  the  whites  to  the  reds  being  about  40  to  50. 

What  interpretation  in  general  is  to  he  given  to  leukocytosis.''  A  condition  deserving 
this  name  is,  first  of  all,  essentially  temporary.  In  acute  infectious  diseases  it  shows 
itself  during  the  febrile  stage  and  the  principal  increa.se  is  in  the  finely  granular  oxyphile 
cells.  In  such  diseases  as  erysipelas,  as  well  as  pneumonia,  it  lasts  but  a  short  time 
after  the  crisis  has  been  reached  and  the  temperature  has  fallen.  In  diseases  like  acute 
appendicitis  and  acute  peritonitis  from  any  cause  a  marked  leukocytosis  may  be  regarded 
as  indicating  the  presence  of  pus;  it  should  be  em])hasized,  however,  that  pus  may  he 
present  without  this  indication,  and  it  has  been  previously  stated  that  such  a  fact  is  to 
be  interpreted  either  as  an  example  of  a  mild  degree  of  infection  or  an  exceedingly 
reduced  vitality. 

DifEerential  Leukocyte  Count. — It  .seems  to  be  now  quite  clearly  demonstrated  that 
the  mere  estai)lishment  of  a  certain  degree  of  leukocytosis  does  not  furnish  the  surgeon 
a  relial)le  guide  for  determining  the  presence  of  pus,  it  being  an  index  of  reaction  rather 
than  of  actual  severity  of  any  particular  kind  of  infection.  A  much  more  reliable  guide 
is  found  in  the  proportion  of  j)olynuclear  cells  to  the  total  number  of  leukocytes  counted, 
/.  e.,  by  what  may  be  called  a  differential  count.  In  order  to  make  this  reliable,  the 
normal  ratio  should  first  be  determined.     This  is  put  at   a  point  between  OS  and  80 


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PLATE    I. 

BLOOD. 

(I'.lirlioli  triple  stain.) 
(Preimred  by  I)n.  I.  P.  Lyon.) 

FMg.  I.    TYPES   OF   LEUCOCYTES. 

a.  Polymorphonuclear  Neutrophile.  b.  Polymorphonuclear  Eosinophile.  c.  Myelocyte 
(Neutrophilic),  d.  .Eosinophilic  Myelocyte,  e.  Large  Lymphocyte  (large  Mononuclear). 
/.  Small  Lymphocyte  (small  Mononuclear). 

Fig.  n.     NORMAL   BLOOD. 
Fie';d  contains  one  neutrophile.     Reds  are  normal. 

Fig.  III.     ANEMIA,  POST-OPERATIVE  (secondary). 

The  reds  are  fewer  than  normal,  and  are  deficient  in  haemoglobin  and  somewhat 
irregular  in  form.  One  normoblast  is  seen  in  the  field,  and  two  neutrophiles  and  on^s 
small  lymphocyte,  showing  a  marked  post-hsemorrhagic  anaemia,  with  leucocytosis. 

Fig.  IV.     LEUCOCYTOSIS,  INFLAMMATORY. 

The  reds  are  normal.  A  marked  leucocytosis  is  shown,  with  five  neutrophiles  and 
one  small  lymphocyte.  This  illustration  may  also  serve  the  purpose  of  showing  th3 
leucocytosis  of  malignant  tumor. 

Fig.  V.     TRICHINOSIS. 
A  marked  leucocytosis  is  shown,  consisting  of  an  eosinophilia. 

Fig.  VI.     LYMPHATIC  LEUKEMIA. 

Slight  anaemia.  A  large  relative  and  absolute  increase  of  the  lymphocytes  (chiefly 
the  small  lymphocytes)  is  show^n. 

Fig.  VII.     SPLENO-MYELOGENOUS   LEUKEMIA. 

The  reds  show  a  secondary  anaemia.  Two  normoblasts  are  shown.  The  leucocytosis 
is  massive.  Twenty  leucocytes  are  shown,  consisting  of  nine  neutrophiles,  seven  myelo- 
cytes, two  small  lymphocytes,  one  eosinophile  (polymorphonuclear)  and  one  eosinophilic 
myelocyte.  Note  the  polymorphous  condition  of  the  leucocytes,  i.e.,  their  variations 
from  the  typical  in  size  and  form. 

Fig.  VIII.     VARIETIES   OF    RED    CORPUSCLES. 

a.  Normal  Red  Corpuscle  (normocyte).  b,c.  Anaemic  Red  Corpuscles,  d-g.  Poikilocytes 
h.  Microcyte.  i.  Megalocyte.  j-n.  Nucleated  Red  Corpuscles.  j,k.  Normoblasts.  I.  Micro- 
blast,    m.n.  Megaloblasts. 


iii:m()(;j.()HI.\  33 


jxT  (rill,  by  various  writers.     As  (j!il)s()ii  (Aiina/.s  <if  Surf/rry,  April,  1000)  says,  75  t)cr 
cent,  may  be  considered  the  best  working  averajje.     Tliis  avera{,'e  should  be  maintained 


P 

cent,  may  oe  considered  uie  uesi  worKmfjf  averajije.      i  ins  averaj^e 

as  the  total  number  of  leukocytes  increases,  or  else  there  is  a  dis|)ro|)orti()n  which  becomes 

significant.     With  a  moderate  leukocytosis  there   is  a   notable  increase  in   polynuclear 

cells,  and  it  may  be  estimated  that  there  is  either  a  .severe  form  (jf  lesion  or  less  resistance 

to  absor|)tion,  or  both. 

(Jibson  has  suggested  the  formation  of  a  chart  where  the  number  10, ()()()  of  leukocytes 
shall  a|)i)ear  upon  the  same  line  with  7")  per  cent,  as  the  average  normal  proj)orti(m  of 
polynuclears.  'I'hen  drawing  a  |)arallel  line,  which  shall  indicate  on  one  side  each 
1000  in  increa.se  of  the  former  and  each  advance  of  one  in  the  j)ercentage,  it  will  be  .seen 
that  15,000  leukocytes  will  correspond  to  80  per  cent,  of  polynuclears,  20,000  to  85  per 
cent.,  etc.  When  uiJon  this  chart  there  is  drawn  a  line  between  that  dot  which  represents 
the  total  leukocytosis  on  one  side  and  that  on  the  other  which  in<licat(>s  the  percentage 
of  j)olynucU-ars,  then  the  more  horizontal  this  line  the  less  the  disproportion,  while  the 
more  marked  the  angle  it  makes  with  the  base  line  the  greatei'  the  dis|)n)porti(jn  apjjcars. 
It  furnishes  an  admirable  graphic  record  which  the  eye  apprcciati-s  at  once. 

It  would  aj)})ear,  then,  that  a  differential  blood  count  made  in  this  way,  and  thus 
recorded,  affords  the  most  valuable  diagnostic  and  |)rognostic  aid  in  acute  surgical 
di.sea.ses.  indicating  especially  the  presence  of  suppuration  or  of  gangrene. 

Glycogen  in  the  Blood  and  the  Iodine  Reaction. — Glycogen  occurs  in  the  blood 

esjJccially  in  three  classes  of  cases:  those  where  there  is  marked  respiratory  disturbance 
in  certain  of  the  anemias,  and,  what  is  of  especial  interest  to  the  surgeon,  toxemias,  either 
of  chemical  or  bacterial  origin.  It  is  usually  present  in  the  .secondary  and  pernicious 
anemias  as  well  as  in  acute  and  late  leukemias.  It  is  considered  by  .some  that  in  these 
cases  it  really  indicates  the  occurrence  of  some  bacterial  infection.  Especially  is  gly- 
cogen present  in  cases  of  suj)j)uration  and  surgical  sepsis,  i.  c,  in  those  ca.ses  where 
leukocytosis  is  usually,  but  not  invariably,  present;  indeed,  it  would  .seem  to  be  a  most 
significant  indication.  While  the  iodine  test  is  more  easily  carried  out  than  is  a  blood 
count,  the  latter  affords  more  information.  The  reaction  is  reliable  and  its  relative 
intensity  gives  an  idea  of  the  intensity  of  the  inflammatory  process.  In  many  cases 
with  obscure  symptoms  and  without  leukocytosis  its  presence  will  afford  much  aid  in 
diagno.sis.  It  is  of  great  a.ssistance  also  in  di.stinguishing  between  a  dcep-.seated  pneu- 
monia and  .serous  ])leurisy,  .since  in  the  latter  there  is  no  reaction,  or  in  distinguishing 
between  pleurisy  with  effusion  and  empyema;  again,  in  distinguishing  gonorrheal  arthri- 
tis from  true  rheumatism.  In  a  case  of  strangulated  hernia  the  presence  of  the  iodine 
reaction  would  indicate  that  pressure  had  produced  gangrene,  whereas  its  absence  would 
indicate  a  relatively  lesser  degree  of  destruction.  It  has  been  aptly  said  that  the 
presence  of  iodine  reaction  indicates  that  the  patient  is  .seriously  sick. 

It  is  easily  obtained  by  staining  a  cover-glass  with  a  blood  smear  in  a  gummy  solution 
of  iodine  and  potassium  iodide.  W  hen  the  blood  is  normal  all  the  cells  take  on  a 
uniform,  bright-yellow  color,  while  the  white  cells  stain  more  lightly  than  does  their 
protoplasm.  When  the  glycogen  reaction  is  present,  brown  granules  are  seen  in  the 
protoplasm  of  the  polynuclear  leukocytes,  which  may  often  take  on  a  different  brown 
tint.  Frequently  brown  particles  are  to  be  seen  outside  of  the  corpuscles,  while 
occasionally  the  other  forms  of  leukocytes  show  also  the  reaction. 

The  value  of  a  careful  blood  examination  is  well  illustrated  by  Plate  I,  prepared 
by  Dr.  Irving  P.  Lyon,  in  which  are  displayed  the  alterations  of  greatest  interest  to 
the  surgeon. 

HEMOGLOBIN. 

The  principal  interest  of  the  red  blood  corpuscles  for  the  surgeon,  aside  from  their 
relative  number  and  shape,  inheres  in  their  relation  to  hemoglobin,  and  hemoglobin 
is  of  particular  interest  here  because  much  can  be  learned  by  estimating  the  proportion  in 
which  it  is  present.  Hemoglobin  has,  furthermore,  an  interest  which  rcachcK  beyond  the 
mere  blood  appearance,  since  it  is  considered  to  be  the  apparent  source  from  which  both 
the  urinary  and  biliary  pigments  are  produced.  That  the  amount  contained  in  the  blood 
varies  within  wide  limits  under  different  conditions  has  long  been  known.  When  notably 
reduced  in  amount  the  conflition  is  referred  to  as  oligorlirninemia.  The  ideal  normal 
.standard  is  present  in  but  a  small  proportion  of  cases,  even  in  strong  j'oung  men  in  the 
3 


34  SURGICAL  PATIIOLOaV 

third  dociuio  of  life.  The  average  is  eonsiderahly  lower  and  can  scarcely  be  placed 
above  90  jK'r  cent.  Females  show  a  smaller  amount  than  males — 3  or  4  per  cent.  less. 
In  anemia  its  reduction  is  not  usually  proi)ortiona(e  to  that  in  the  numl)er  of  red  cells. 
After  hemoglobin  loss,  as  after  surgical  operations,  much  can  be  gained  in  the  matter 
of  prognosis  by  estimating  the  speed  of  its  regeneration.  With  regard  to  how  much 
actual  hemoglobin  loss  a  patient  can  bear,  it  seems  to  be  more  important  to  determine 
how  much  still  remains  in  the  body.  The  minimum  is  apparently  20  per  cent.  In 
three  cas(\s  dving  of  colla])se  after  o])eration,  Mikulicz  found  only  15  per  cent,  remaining. 
The  rapidityOf  regeneration  is  a  fairly  accurate  indication  of  improvement  in  every  other 
respect.  Regeneration  is  interfered  with  by  constitutional  syphilis,  and,  on  the  other 
hand,  is  often  ai)parently  favored  in  cases  of  tubi-rculosis.  In  malignant  tumors  the 
average  of  hemoglobin  is"  reduced  to  about  00  per  cent.,  and  in  these  cases  also  complete 
regeneration  is  materially  ri-tarded.  Incomplete  removal  or  recurrence  of  cancer  pre- 
vents typical  regeneration  or  restoration,  while,  after  succ(\ssful  or  radical  removal, 
complete  restoration  to  the  previous  standard,  often  with  positive  gain,  is  obtained. 
Thus,  a  woman  wdio  had  gained  thirty  jxnmds  after  resection  of  a  cancerous  pylorus, 
showed,  after  three  months,  hemoglobin  repair  to  the  amount  of  65  per  cent.  A  prog- 
nostic significance  often  attaches  to  the  accurate  estimation  of  hemoglobin  at  intervals 
after  removal  of  malignant  tumors. 

A  very  convenient  method  for  the  ready  estimation  of  hemoglobin  is  afforded  by  the 
TalUjuist  color  scale.  It  can  be  practised  at  the  bedside  and  is  sufficiently  accurate 
for  the  surgeon's  general  purposes. 

THROMBOSIS. 

Throiribosis  is  a  term  a})plied  to  the  formation  of  a  thrombus — i.  e.,  a  clot  within 
the  cavity  of  the  heart  or  one  of  the  bloodvessels— the  term  being  limited  to  coagu- 
lation of  blood  within  these  natural  cavities,  and  without  specifying  the  exciting  cause 
of  the  same.  A  clot  so  formed  is  called  a  thrombus.  To  be  accurate,  a  distinction 
should  be  made  between  a  thrombus,  which  is  caused  always  before  death — or, 
rather,  during  life — and  the  clot,  which  is  essentially  a  postmortem  affair.  Our  appli- 
cation, then,  of  the  terms  "thrombosis"  and  "thrombus"  refers  solely  to  that  which 
takes  place  during  life.  In  order  to  appreciate  the  conditions  which  lead  to  thrombosis 
it  is  necessary  to  fully  apjM-eciate  the  nHi])rocal  conditions  which  must  normally  be 
maintained  between  the  circulating  blootl  and  the  walls  of  the  vessels  in  which  it  flows. 
Fluidity  of  blood  depends  always  upon  integrity  of  the  vessel  wall.  As  long  as  its 
linino-  membrane  is  absolutely  undisturbed  and  normal,  moving  blood  will  never 
coao-ulate  within  it,  and  the  only  thrombi  that  may  be  met  within  it  are  those  which  are 
propagated  from  a  distance.  Coagulation  of  blood  is,  for  the  main  part,  associated 
with  the  peculiar  ])roperties  of  fibrin. 

Fibrin  is  produced  from  phrinogen,  a  globulin  which  is  held  in  solution  under  ordinary 
circumstances,  which  has  certain  peculiarities  of  its  ow'n.  When  th(>  change  occurs 
it  is  entirelv  consumed  and  none  remains  in  the  blood  serum.  Fibrinogen  is  split  u))  by 
a  peculiar"  ferment  called  thrombin  into  what  we  ordinarily  speak  of  as  fibrin  and  a 
small  amount  of  a  soluble  globulin,  which  remains  in  solution  in  the  serum.  Thrombin 
is  not  a  normal  constituent  of  the  blood,  but  is  formed  when  it  escapes,  as  the  result 
of  the  reaction  between  certain  calcium  salts  and  a  nucleoproteid,  which  has  been  called 
prothrombin.  The  latter  arises  from  the  disintegration  of  the  leukocytes,  especially 
the  polynuclear,  and  the  blood  placpies,  after  the  blood  leaves  the  bloodvessels.  Cal- 
cium salts  seem  absolutely  necessary  for  coagulation;  hence  the  value  of  the  adminis- 
tration of  calcium  chloride  in  certain  cases  previous  to  operation.  Another  essential 
feature  seems  to  be  the  absolute  integrity  of  the  endothelial  lining  of  the  bloodvessels, 
althouidi  for  this  fact  there  is  no  satisfactory  explanation.  If  a  portion  of  a  vein  is 
removed  from  tiie  body  after  double  ligation  its  contained  blood  will  not  coagulate  for 
a  long  time.  Blood  which  is  kept  circulating  through  the  lungs  and  heart  alone  .soon 
loses  fts  coagulability;  hence  the  liver  seems  to  be  concerned  in  some  way  in  maintaining 
it.  Certain  other  substances  also  seem  to  retard  coagulation,  such  as  the  albumo.ses  of 
snake  vemon,  and  certain  synthetic,  colloid,  proteid-like  substances,  which  can  be  intro- 
duced very  gradually.     If,  however,  they  are  introduced  rapidly,  or  in  large  quantities, 


PLATE  II 


FIG.  1 


c       I, 


Small  Vein  showing  Diapedesis  of  Leukocytes.     (Engelmann.) 

.,  leukocyte  escaping  between  endothelial  cells  ;  b,  c,  leukocytes  escaped  ;  /,  leukocytes 
migrating  toward  centre  of  attraction. 


FiG.  2 


*  <9 


Septic  Thrombosis  of  Pulmonary  Capillaries  after  Puerperal  Septicemia, 
showing  Rapidly  Increasing  Colonies  of  Streptococci.     (Klebs.) 


TiiRO}fi{nsrs 


35 


throinhosis  occurs  pr()inj)(ly.  We  liavc  iinicli  to  Icurii  al)()ut  the  coafjulatiori  of  the 
hlood,  l)iit  till'  ahovc  lads  arc  at  least  siii^t^cstivc  to  the  siiri;eoii. 

Causes. — Tlie  uiulerlyinij  caii.sr  ol"  all  tlironihi  is,  then,  (ilUratioii  of  the  nidotliclium. 
In  coiiseiiueiiee,  when  it  is  (lesiral)le  to  |)ro(liice  coa<julation  artificially,  advantage  mav 
he  taken  of  this  fact,  and  mechanical  injury  to  the  vessel  walls  may  he  (juiekly  followeil 
hy  the  d(\sircd  results.  Advantajje  is  also  taken  of  this  fact  in  surgery,  espeeiallv  in 
certain  nu-thods  of  treating  aneurysm,  hy  rude  handling,  by  needling,  hy  the  introduction 
of  horsehairs.  Hue  wire,  etc.  A  venous  thrombosis  is  certainly  favored  h\-  the  thimiess 
of  the  venous  walls,  hy  which  jjoorer  protection  is  afiorded  to  their  lining  endothelium, 
and  infection  mori-  easily  occurs.  Arterial  thrombosis  is  favored  when  cardiac  vigor  is 
impaired  and  vessel  walls  are  thickened  so  as  to  obstruct  the  blood  current.  This  occurs 
particularly  in  syphilitic  endarteritis,  where  the  intima  suii'ers  most,  and  final  occlusion 
is  due  to  the  thrombus  thus  formcil.  Arteriosclerosis  docs  not,  by  itself,  often  pro- 
duce this  trouble;  it  comes  rather  with  atheromatous  and  calcareous  degenerations. 
The  local  ischemia  which  is  occasioned  by  ergotism,  by  |)ellagra  (due  to  use  of  certain 
kinds  of  maize),  by  the  vasomotor  spasm  of  Raynaud's  disease  (see  under  Gangrrnc), 
by  too  long-continued  constriction,  or  by  frostbite,  causes  results  comparable  to  tho.se 
|)roduced  experimentally  in  ])arts  supjilied  by  a  teruiinal  artery,  c.  g.,  in  the  kidnev 
after  temporary  occlusion  of  its  artery.  All  the  tissues  involved  undergo  profound 
alterations,  in  which  throiubosis  figures  very  largely  and  may  lead  to  gangrene. 

While  such  endothelial  lesions  are  essential,  there  are,  nevertheless,  numerous  other 
accessory  causes  which  should  be  mentioned.     These  com|irise: 

A.  The  presence  of  foreign  bodies,  as,  for  example,  needles,  booklets  of  echinococci, 
parasites,  particles  of  tumors,  fragments  from  the  heart  valves,  and,  most  of  all,  that 
which  is  essentially  a  foreign  body,  a  clot  which  has  come  from  some  other  point. 
Around  such  foreign  ]iarticles  will  quickly  group  themselves  a  relatively  large  number 
of  leukocytes,  thus  affording  another  example  of  ])hagocytosis,  soon  to  be  described. 
Mere  slowing  of  blood  stream  without  some  such  mechanical  irritation  is  not  sufficient 
to  produce  coagulation.  If,  for  instance,  a  section  of  vein  is  isolated  between  two 
ligatures,  the  ligation  being  aseptically  tlone  and  the  surroundings  of  the  vein  wall 
disturbed  as  little  as  possible,  the  blood  thus  shut  up  within  the  vein  remains  fluid 
indefinitely.  If,  however,  the  vessel  wall  is  separated  from  its  surroundings,  so  that 
its  nourishment  is  compromised,  the  contained  fluid  quickly  coagulates. 

B.  Necrosis,  gangrene,  etc.,  lead  to  quick  involvement  of  the  endothelium  of  the 
vessels  contained  within  the  involved  part,  and  consequently  to  quick  coagulation  of 
the  blood  which  they  contain. 

C.  Temperature  has  also  an  influence  in  the  same  direction,  and  extremes  in  either 
direction,  or  drying  of  vessels  which  may  happen  to  be  exposed  to  the  air  for  some 
time,  lead  to  the  same  resvilts. 

I).  Infiamviaiory  and  degenerative  processes  occurring  in  and  about  the  vessel  walls 
tend  always  to  produce  coagulation.  This  is  well  seen  in  the  influence  exerted  by 
the  so-called  atheromatous  ^ilcers — i.  e.,  the  degeneration  of  certain  areas  in  the  walls  of 
large  vessels. 

E.  Microorganisms  and  their  products  are  perhaps  the  most  frequently  effective  of 
all  the  accessory  causes  of  thrombosis.  In  other  words,  in  all  the  surgical  infectious 
diseases  we  may  expect  to  find  more  or  less,  sometimes  extensive,  thrombosis  in  the 
vessels  of  the  afl'ected  part.  This  may  so  far  shut  off  circulation  as  to  produce  tem- 
porary or  permanent  edema,  or  it  may  lead  to  gangrene,  which  may  be  local  or  may 
terminate  the  life  of  the  patient. 

Thrombi  are  classified  as: 

1.  Primari/;  and 

2.  Propagated. 

The  primari/  thrombus  is  one  which  has  originated  at  the  spot  where  it  has  been  first 
produced,  and  is  usually  co-extensive  with  its  cause.  The  propagated  thrombus  may 
be  one  which  has  been  carried  to  a  considerable  distance,  and  is  met  with  at  a  point 
widely  different  from  that  where  it  originated,  or  one  which  has  extended  along  the 
vascular  channel  in  which  it  was  first  formed,  but  far  beyond  the  limits  of  its  j)rime 
cause.  When  a  thrombus  attaches  itself  to  a  part  of  the  vessel  wall  it  is  called  parietal 
or  valvular,  because  it  does  not  completely  occlude  the  vessel;  when  it  involves  the  entire 
circumference  of  the  vessel,  but  does  not  completely  occlude  it,  it  is  spoken  of  as  annular. 


36  SURGICAL  PATHOLOGY 

The  obstructive  thrombus  i.s  that  which  coinplctcly  fills  si  given  vessel  and  sliuts  off 
all  circulation  through  it. 

The  propagated  thrombus  extends  usually  in  both  directions,  and  always  much  farther 
in  veins  than  in  arteries.  Thus,  thrombi  may  be  met  with  extending  from  the  ankles 
even  into  the  inferior  vena  cava.  The  venous  valves  may  on  one  hand  excite  coagu- 
lation, or  on  the  other  tend  to  fix  the  coagula  more  firmly  in  their  place.  In  arteries 
thrombi  usually  extend  only  to  the  first  collateral  channel  on  the  cardiac  side,  but 
occasionally  they  s{)rea(l  farther.  The  raufie  of  a  primarij  throtnhu.s  is  to  be  sought 
at  the  site  of  its  lodgement;  the  eanse  of  propagated  thrombi  is  often  observed  at  a  wide 
distance  front  the  effect. 

Thrombosis  is,  again,  to  be  spoken  of  as — 

a.  Marasmic; 

b.  Mechanical  or  traumatic; 

c.  Infective. 

a.  The  marasmic  forms  are  due  to  essential  alterations  in  the  constituents  of  the 
blood,  which  are  due  mainly  to  starvation  or  wasting  disease.  Marasmic  thrombi 
seldom  give  rise  to  serious  disturl)ance  during  life  until  the  condition  is  so  complex  and 
grave  that  the  patient  is  at  death's  door.  Postmortem  evidences  of  marasmic  thrombi, 
however,  are  often  found,  and  yet  have  but  little  surgical  significance.  They  are  seen 
perhaps  as  often  in  the  cranial  sinuses  as  anywhere. 

b.  Thrombi  of  mechanical  or  traumatic  origin  are  those,  for  instance,  which  are  due 
to  the  presence  of  foreign  bodies,  to  stagnation  of  blood  as  the  result  of  ischemia  or 
local  anemia,  to  compression  by  tumors,  etc. 

c.  Infective  thrombi  are  those  distinctly  due  to  the  injurious  effects  of  micro-organisms, 
and  are  those  mainly  concerned  in  the  various  manifestations  of  sepsis  which  are  of 
interest  to  surgeons. 

While  the  ordinary  evidences  of  thrombosis  are  most  often  looked  for  in  the  veins  of 
the  extremities,  in  the  lungs,  and  in  the  cranial  sinuses,  it  must  not  be  forgotten  that 
thrombosis  may  occur  equally  easily  in  the  portal  system  of  vessels;  in  which  case  we 
find  the  most  marked  expressions  in  this  system  and  in  the  liver.  In  cases  also  of 
pyemia  proceeding  from  lesions  in  the  rectum  or  in  the  bowels  there  are  evidences 
of  infection,  abscess,  etc.,  in  the  liver,  but  not  in  the  lungs,  to  which  point  infective 
thrombi  from  other  sources  are  promptly  carried. 

The  ultimate  fate  of  a  thrombus  depends  entirely  upon  the  presence  or  absence  of 
bacteria.  If  septic,  it  invariably  breaks  dowai.  If  aseptic,  it  may  imdergo  one  or  more 
of  the  following  metamorphoses: 

A.  Decolor ization. — This  is  noted  particularly  in  the  red  thrombi,  and  is  due  to  dis- 
integration of  the  red  corpuscles,  their  coloring  matter  being  diffused  and  resorbed  or 
transformed  into  hematoiflin.  It  would  be  a  mistake,  however,  to  suppose  that  all 
light-colored  thrombi  are  those  which,  originally  red,  have  been  decolorized.  The 
possibility  of  white  thrombi  must  always  be  remembered. 

B.  Organization. — This  is  the  result  of  time,  and  means  a  metamorphosis  into  solid 
vascular  connective  tissue.  Newly  formed,  minute,  vascular  loops  project  from  the 
vasa  vasorum  into  the  thrombus,  and  it  becomes  thus  vascularized,  while  the  com- 
pletion of  the  organization  is  due,  in  the  main,  to  s])indle-cell  connective  tissue, 
which  is  formed  by  wandering  cells  that  penetrate  into  the  thrombus  from  without. 
This  gives  the  organized  thrombus  a  certain  resemblance  to  a  sponge,  and  makes  the 
original  vein  resemble  a  cranial  sinus,  since  its  interior  is  spanned  by  bands  of  con- 
nective tissue.  Typical  illustrations  of  this  kind  are  seen,  for  instance,  where  the  iliac 
veins  join  to  form  the  inferior  cava,  by  which  a  certain  amoimt  of  ol)struction  to  venous 
return  is  produced  without  its  being  total.  The  length  of  time  required  for  these  changes 
is  indefinite.  They  begin,  however,  within  a  short  time  after  hgature  of  a  vein,  and 
proceed  with  a  rapidity  varying  according  to  circumstances. 

C.  Calcification. — Calcium  salts  are  occasionally  deposited  in  thrombi,  usually  not 
until  they  have  undergone  considerable  contraction  and  alteration ;  as  the  result  of  wdiich 
we  have  formation  of  small  masses,  essentially  minute  calculi,  to  which  the  name  of 
phlebollths  has  been  given.  These  jihleboliths  are  not  infrequently  found  in  more  or 
less  occluded  and  much  distended  varicose  veins  of  the  extremities,  and  they  prohibit 
the  occurrence  of  softening. 


TUh'OMJiOSIS  37 

I).  Sojtru'uH). — This  is  tlu-  most  serious  tcniiiiiatioii  of  llic  llironihotic  accident, 
and  is  usually  due  (o  the  agency  of  int"ectin<^  organisms.  A  non-iiifeclious  form  is, 
however,  recognizi'd,  hy  which  there  is  a  melamorpiiosis  of  original  clot  into  an  oily 
or  pulpy  fluid,  usually  dark  colored,  hut  in  the  white  (hrond)i  often  yellowish  white, 
reminding  one  crudely  of  pus.  The  discovery  of  such  material  under  these  circumstances 
has  led  in  time  i)ast  to  the  suj)i)osition  that  |)us,  as  such,  was  found  floating  in  the  hlood 
— u  condition  that  does  not  exist  except  under  extraordinary  circumstances.  It  is 
with  infection  of  thrombi  and  consequent  softening,  however,  that  surgeons  have  most 
to  (U'al,  and  the  paramount  importance  to  them  of  such  disturbances  is  emj)liasized  in 
the  artic-le  undi'r  Pyiinia. 

A  closely  allied  topic  to  that  above  considered  is  tiie  subject  of  f/inmihop/i/rhitis. 
This  means,  in  ell'ccl,  inilanunation  of  one  or  more  veins,  which  is  directly  due  to  the 
presence  therein  of  thrombi.  Such  a  condition  is,  in  its  strict  s(>nse,  an  inflammalion, 
since  it  is  always  an  infectious  process.  If  in  the  veins  of  a  non-infected  regicju  simple 
thrombi  form,  they  may  be  occluded  by  organization  of  the  included  masses,  but  such  a 
process  never  extends  beyond  the  immecliate  area  involved.  ( )n  the  other  hand,  if 
the  process  is  essentially  an  infectious  one,  either  from  without  or  from  within,  then 
both  vessel  and  its  contained  thrombi  succumb  completely  to  the  infectious  process, 
which  is  also  essentially  a  spreading  one;  and  this  is  limited  only  by  m(>chanical  barriers, 
by  conservative  suppuration,  or  often  only  by  tlu>  life  of  the  individual.  Excellent 
examj)les  of  thr()ml)()])hlebitis  are  seen  in  the  involved  uterine  sinuses  in  cases  of 
j)uerperal  septicemia,  and  in  the  cranial  sinuses  after  infected  compound  fractures,  or 
particularly  after  disease  originating  in  the  middle  ear  has  extended  to  them. 

Thrombosis  is,  at  times,  a  distinctly  surgical  condition,  and  often  a  surgical 
complication  of  febrile  and  other  diseases,  especially  typhoid,  in  which  it  constitutes 
a  serious  complication  and  prolongs  convalescence  for  a  period  of  several  months.  If 
foreseen  it  can  scarcely  be  prevented,  and  when  present  calls  for  treatment  varying 
with  the  location  of  the  lesion  and  the  exciting  causes.  In  the  earlier  stage  anything 
like  rude  manipulation  or  massage  is  very  unfortunate,  since  soft  clots  might  thus  be 
broken  up  and  distributed  to  other  parts  of  the  body.  Absolute  physiological  rest 
combined  with  the  application  of  silver  ointment,  of  ichthyol-mercurial  ointment, 
which  should  be  covered  with  some  non-absorbent  material,  will  probably  give  the 
best  results.  If  the  lower  limbs  are  affected  it  may  be  well  to  elevate  the  feet  so  as  to 
favor  return  of  blood  through  vessels  not  yet  obstructed.  After  a  certain  length  of  time 
the  thrombi  may  be  regarded  as  at  least  adherent  if  not  organized,  and  massage  will 
prove  an  important  remedy,  since  by  it  the  lymphatics  will  be  better  enabled  to  take 
up  the  fluids  which  have  leaked  from  the  bloodvessels  and  produced  the  edema 
which  ahvays  characterizes  these  cases.  Sluggishness  of  circulation  is  nearly  always 
followed  by  more  or  less  laxness  of  tissue,  or  actual  hypertrophy,  and  a  limb  thus 
involved  may  never  regain  its  original  size  or  flexibility.  Veins  once  compromised, 
if  not  occluded,  frequently  become  varicose,  or  varicosities  develop  in  adjoining  veins 
and  still  further  complicate  the  case.  For  such  difficulty  the  measures  discussed  in  the 
chapter  on  the  Veins  may  be  later  required. 

In  every  fresh  case  of  thrombosis  or  thrombophlebitis  great  care  should  be  taken  in 
order  that  by  no  means  shall  the  clots  be  disengaged  and  float  away.  The  dangers 
correspond  to  those  existing  in  variocele  and  nevi,  often  treated  by  the  older  methods 
of  injection  of  coagulating  material.  In  one  instance  reported,  a  child  died  within  half 
an  hour  after  the  injection  of  an  iron  salt  into  a  small  nevus  of  the  face.  Coagulation 
was  excited  to  a  point  far  beyond  the  limits  intended. 

ThrombopJilchitis  is  esserdiaUy  a  surgical  condition,  occasionally  terminating  favorably 
by  suppuration  and  spontaneous  evacuation,  but  calling  for  surgical  intervention  when- 
ever it  can  be  recognized  and  the  parts  are  accessible.  The  principles  of  treatment 
of  these  conditions  are  positive  and  unmistakable.  They  comprise  evacuation  of  the 
infective  material  and  disinfection  of  the  involved  cavities  and  tissues.  Thus,  in 
sinus  phlebitis — i.  e.,  thrombophlebitis  of  the  lateral  sinus — it  has  been  made  practicable 
not  only  to  open  the  sinus  in  the  mastoid  region,  but  to  expose  the  jugular  vein  in  the 
neck,  to  ligate  it,  and  to  wash  through  from  one  opening  to  the  other,  effectually  getting 
rid  in  this  way  of  a  long  mass  of  infected  thrombi.  Only  by  such  bold  and  radical 
measures  in  many  of  these  instances  may  life  be  saved. 


38  SURGICAL  PATHOLOGY 


EMBOLISM. 

Embolism  means  the  fransportation  of  anij  viaicrial  hi)  which  a  bloodvessel  can  he 
occluded  or  plugged  from  one  j)art  of  the  vaseular  system  to  some  other.  The  under- 
lying idea  is  that  of  transport  at  icm  or  earriage.  An  embolus  is  anything  so  transjjorted, 
witiiout  implying  its  exact  character.  The  name  is  even  applied  to  so  unsubstantial  an 
affair  as  a  minute  bubble  of  air,  which,  however,  in  a  tube  containing  a  circulating 
fluid  is  a  possible  source  of  considerable  disturbance.  A  single  bubble  thus  carried 
would,  by  itself,  be  a  trifling  affair,  but  when  numerous  bubbles  are  thus  transported 
the  result  is  such  local  disturbance  as  may  lead  to  loss  of  function.  Thus,  air  embolism, 
so  called,  may  j)r()Voke  profound,  even  fatal,  disturbances,  as,  when,  with  the  returning 
blood  stream  through  the  cranial  sinuses  or  one  of  the  large  veins  in  the  neck,  when  opened 
by  accident  or  o])eration,  air  is  sucked  in,  it  is  carried  to  the  right  side  of  the  heart,  whose 
action  is  perhajrs  completely  perverted  because  of  the  new  and  strange  substance 
which  thus  enters  it,  so  different  from  that  for  which  its  lining  membrane  is  ))repared 
and  to  which  it  reacts.  The  entrance  of  air  into  veins,  which  constitutes  in  effect  air 
embolism,  has  been  in  time  past  a  bugbear  to  surgeons,  but  nevertheless  is  a  source  of 
probable  danger  when  large  venous  trunks  in  proximity  to  the  heart  are  thus  exposed. 
Air  embolism  is  certainly  a  rarity.  On  the  other  hand,  those  substances  which  figure 
most  often  as  emboli  are  rrgrtatious  from  the  valves  of  the  heart;  drops  of  fat;  fracpuents 
of  tumors;  pieces  of  softened  and  disintegrated  thrombi;  foreign  Ijodies,  as  booklets  of 
echinococcus  cysts;  and,  perhaps  most  often  of  all,  the  vi icrocirgan isms  cYmgiw^  to  some 
minute  fragment  of  throinl)Us  which  has  been  dislodged.  Embolism  is  al.so  j)rodnced 
experimentally  by  the  artificial  introduction  into  the  circulating  blood  of  cinnabar  or 
small  particles  of  pith  or  other  material.  Emboli  differ  in  number  and  .size  from  the 
smallest  appreciable  up  to  the  largest,  which  may  be  met  with  in  the  larger  venous 
trunks.  They  are  dislodged  from  their  primary  site  sometimes  by  accident,  as  by  rude 
manipulation,  injury,  etc.;  sometimes  by  vndne  cardiac  activity,  as  when  detachetl  from 
a  valve  wall;  sometimes  by  the  process  of  softening  of  thrombus  and  a  sub.sequent  intro- 
duction into  the  blood  stream  as  a  result  of  some  trifling  motion;  or  even  by  spontaneous 
processes.  Emboli  also  differ  in  numbers  according  to  the  nature  of  the  primary  lesion. 
In  cases  of  so-called  fat  emfjolism  fluidified  fat  is  taken  into  the  returning  blood  stream, 
carried  to  the  heart,  churned  up  with  the  contained  blood,  and  distributed  to  the  lungs 
in  such  a  way  that  myriads  of  minute  fat  masses  are  distril)uted  throughout  the  capil- 
laries of  the  lungs,  and  free  circulation  of  blood  through  them  is  thereby  impeded. 

It  will  thus  be  seen  that  the  relations  between  thrombosis  and  embolism  are  most 
intimate,  but  that  either  one  may  occur  without  the  occurrence  of  the  other. 

Among  the  viscera,  with  the  exception  possibly  of  the  brain,  the  disastrous 
consequences  of  such  processes  as  those  just  described  are  more  apparent  and 
indicative  than  in  thrombosis  and  embolism  of  the  mesenteric  bloodvessels— a.  condition 
not  so  rare  as  journal  articles  would  imply,  yet,  nevertheless,  one  .seldom  recognized 
either  during  life  or  after  death.  Its  principal  symptoms  consist  of  inten.se  abdominal 
pain,  bloody  diarrhea,  subnormal  temperature,  sometimes  with  vomiting,  j)erhaps  in 
the  latter  stages  vomiting  of  blood.  Shock  is  usually  also  extremely  marked.  The 
consequence  of  this  condition  is  almost  inevitably  gangrene  of  the  intestine  supplied  by 
that  particular  portion  of  the  mesenteric  vessels.  The  pain  comes  on  within  a  .short 
time  after  the  occurrence,  and  under  the  peculiar  circimistances  gangrene  may  be  prac- 
tically determined  within  a  few  hours.  Some  two  hundred  and  fifty  cases  of  this  kind 
are  now  on  record,  and  the  condition  is  one  well  worth  the  prompt  attention  of  the  sur- 
geon, because  only  by  surgical  intervention — ?'.  e.,  by  resection  of  the  necrotic  ma.ss  of 
intestine — can  life  possibly  be  saved.  That  when  a  limited  portion  of  the  intestine  is 
involved  the  gangrenous  part  may  be  successfully  removed  has  been  proved  by  several 
operators.     (See  Chapter  LI  I.) 

It  will  thus  be  seen  that  embolism  constitutes  often  a  distinctly  surgical  condition  for 
which  unfortunately  only  radical  measures  are  suitable.  Many  cases  of  gangrene  of 
the  toes  and  feet,  extending  to  the  legs,  are  produced  by  embolism  of  the  femoral  and 
popliteal  arteries,  similar  conditions  being  noted  le.ss  often  in  the  upper  extremities. 
Amputation  offers  the  only  resource  in  such  instances,  at  the  same  time  affording  no 
guarantee  against  any  similar  embolic  disturbance  elsewhere.     In  only  most  exceptional 


KM  HOLISM 


39 


iiistaiHcs  is  it  possible,  by  rcsortiiitf  (o  moist  liciit,  position,  vU-.,  to  cnroura^o  circulation 
tosncli  an  extent  as  vo  ()l)viiitc  the  necessity  ol' amputation.      (See  ('lia])ter  V.) 

Fat  Embolism. — Fat  embolism  as  a  distinct,  sometimes  fatal,  surgical  condition  lia.s 
received  of  laic  so  much  study  as  to  be  entitled  to  consideration  l)y  itself.  \\\  this 
term  is  meant  a  plu^'^iiifj;  of  small  arteries  by  minute  drops  of  fat,  which,  havinji;  been 
set  free  somewhere  about  the  j)eri|)hery,  are  carried  into  the  venous  circulation  and 
thence  distributed  to  various  parts  of  the  .system.  Inasmuch  as  the  capillaries  of  the 
lungs  are  often  their  first  lodginji"  j)lace,  fat  embolism  lierc  is  most  often  met  with,  and 
eonse(|uently  recofjnized  and  studied.  But  it  may  occur  in  the  brain,  the  choroid,  the 
kidneys,  or  other  parts,  provided  only  that  there  has  been  sufKcient  i7.<f  a  trn/o  on  the 
part  of  the  heart  to  force  the  fat  globules  through  the  pulmonary  capillaries  and  into  the 
.syst(Miiic  circulation. 

Fat  embolism  occurs  fi'cquently,  and  to  a  slight  extent  in  nearly  every  case  of  fracture 
and  laceration.  So  connnon  is  it,  and  so  closely  allied  are  some  of  its  most  prominent 
syni|)toms  to  those  of  shock,  that  as  a  matter  of  fact  many  ca.ses  heretofore  considered 
shock  are  to  be  n'garded  as  instances  of  this  condition.  Indeed,  even  in  a  miscellaneous 
series   of  2(J0   dead  bodies   fat  embolism   was   found   in  10  per   cent.     The   injuries 

Fig.  2 


Fat  embolism  of  lungs.     Large  branching  pulmonary  artery  filled  with  spherical,  o\al,  cylindrical,  and  branching 
nias.ses  of  fat.      l''re.>sh  mashed  preparation  in  potassium  hydrate.     (Kaiserling.) 

most  likely  to  be  followed  by  it  are  simple,  and  particularly  compound  fractures  of 
bones;  laceration  of  soft  parts,  especally  of  adi})ose  tissues;  certain  surgical  operations; 
acute  infections  of  bone  and  periosteum;  rupture  of  fatty  liver;  and  certain  pathological 
conditions  where  the  phenomena  are  not  so  easily  explained,  e.  g.,  icterus  gravis, 
diabetes,  etc. 

Drops  of  fat  may  be  seen  floating  on  fluid  or  semifluid  blood  after  many  operations 
and  compound  injuries,  and  the  possibility  of  escape  of  fat — or,  more  accurately,  its 
suction  into  the  vessels  from  which  this  blood  has  escaped — is  easily  appreciable.  But 
it  has  also  been  shown  that  absorption  of  fat  is  possible  even  from  serous  surfaces,  and 
that  fat  embolism  may  occur  when  fluid  fat  has  been  passed  into  the  heart  through  the 
thoracic  duct,  although  more  slowly.  Oil  drops  are  also  foxmd  in  the  interior  of  the 
tissues,  while  in  a  piece  of  lung  spread  out  in  water  in  the  visible  vcs.sels  highly  re- 
fracting fatty  material  may  be  noted.  Fatty  injarction,  particularly  in  the  lower  lobes, 
is  sometimes  plainly  visible  to  the  naked  eye.  Under  a  low  objective,  especially  with 
osmic-acid  staining,  the  presence  of  fat  is  easily  demonstrated. 

The  es.sential  clanger  in  ca.se  of  fat  embolism  is  of  so  clogging  the  pulmonary  capil- 
laries that  oxygenation  shall  becom.e  so  imperfect  as  to  lead  to  absolute  asphyxiation 


40  SrRCICAL  PATHOLOGY 

from  carbonic  dioxide  poisoninj^.  Wlicn  this  fact  is  understood,  the  cyanosis,  the 
rapid  breathing,  the  overactioii  of  the  heart,  etc.,  are  easily  and  correctly  interj)reted. 

Fat  embolism  by  itself  cannot  cause  inflammation  nor  infection,  nor  sepsis  in  any 
sense.  It  may,  however,  lead  to  ecchymoses  in  conjunction  with  fatty  infarcts  in  the 
organs  most  affected.  The  minute  hemorrhages  are  easily  explained  by  the  l)ursting 
of  the  capillaries  in  the  attempt  to  force  blood  through  them.  Fatty  emboli,  however, 
take  the  same  course  as  do  septic — are  carried  first  to  the  right  side  of  the  heart  and 
distributed  over  the  lungs;  are,  if  the  patient  lives,  forced  through  the  lungs  into  the 
systemic  circulation,  and  are  then  carried  to  the  brain,  kidneys,  etc.  The  first  symptoms 
are  referable  to  the  |)lugging  of  the  pulmonary  capillaries;  the  secondary  symptoms  to 
the  systemic  disturbance. 

SyTnptoms.  —  Pallor  of  countenance  with  facial  expression  of  anxiety  and  distress, 
followed  by  cyanosis  and  contracted  ])upils,  are  seen.  Patients  are  usually  first  excited, 
sometimes  more  or  less  disturbed,  then  become  somnolent,  and,  finally,  comatose  in 
the  fatal  cases.  The  resj)iration  rate  increases  from  normal  uj)  to  50  or  GO,  and  breathing 
is  sometimes  stertorous.  Dyspnea,  increasing  in  intensity  until  it  becomes  agonizing, 
sometimes  marks  these  cases.  Occasionally  foam,  possil)ly  blood,  jjroceeds  from  the 
mouth,  as  in  edema  of  the  lungs.  Sometimes  hemoj)tysis  occurs.  The  pul.se  becomes 
weak,  frefjuent,  and  irregular,  while  toward  the  close  it  is  fluttering.  Temperature  is  not 
notably  disturbed,  at  least  not  typically. 

These  .symptoms  .set  in  usually  within  thirty-six  to  .seventy-two  hours  after  the  lesion 
which  has  caused  them.  I  have,  however,  known  death  to  occur  in  one  or  more  cases 
within  eighteen  hours  after  reception  of  injury. 

After  fat  has  been  forced  through  the  lungs  and  carried  to  the  kidneys  it  will  be  elimi- 
nated with  the  urine,  and  may  be  found  floating  upon  it  in  the  shape  of  oil-like  drops. 
Discovery  of  this  condition  is  positive  evidence  of  fat  embolism.  It  is  to  be  distinguished 
from  shock  in  that  by  the  time  the  .symptoms  of  embolic  disturbance  are  at  their  height, 
all  or  nearly  all  symptoms  of  pure  shock  have  subsided.  Furthermore,  cyanosis  and 
embarrassment  of  respiration  are  not  indicative  of  shock;  and,  finally,  the  discovery  of 
fat  in  the  urine  will  be  corroborative. 

A  mild  degree  of  fat  eml)olism  may  be  noted,  if  looked  for,  after  almost  all  .serious 
fractures.  It  will  give  ri.se  to  slight  embarrassment  of  respiration  and  cyanosis  and  to 
the  elimination  of  fat  by  the  kidneys. 

Prognosis. — Prognosis  varies  according  to  the  extent  of  the  injury  and  the 
proximity  of  the  lesion  to  the  heart  and  lungs;  also  to  the  {)o.ssi}»ility  of  continuous 
entrance  of  fat,  i.  e.,  from  its  continual  absorption.  Prognosis  really  depends  upon 
w^hether  the  heart  can  be  given  sufficient  vigor  and  endurance  to  continue  pumping 
blood  with  its  burden  of  fat  through  the  pulmonary  circulation.  A  secondary  danger 
may  come  from  the  circulation  of  this  fat-ladened  blood  through  the  capillaries  of  the 
brain.  Should  the  source  of  motive  power  thus  become  paralyzed  with  resulting  general 
enfeeblement,  death  may  ensue.  When  well-marked  evidences  oi  fat  embolism  are 
pr(>sent,  but  are  followed  by  recovery,  the  worst  of  the  trouble  is  usually  over  within 
forty-eight  hours  after  it  begins. 

T?reatment. — Obviously  treatment  is  mainly  directed  toward  the  lieart,  so  that  we  may 
stimulate  it  to  carry  its  load  of  fat  through  from  the  venous  into  the  arterial  .system.  If 
it  can  do  this,  the  fat  is  dispo.sed  of  by  oxidation  or  is  .saponified  by  the  alkalies  in  the 
blood.  Physiological  rest  of  the  injured  part  is  the  first  indication,  however,  and  if 
this  occurs  in  a  patient,  say  with  delirium  tremens,  powerful  mechanical  restraint  may 
be  necessary.  The  mo.st  effective  cardiac  stimulants  are  called  for — alcohol,  adrenalin, 
strychnine.  In  other  respects  treatment  is  largely  .symptomatic.  Next  to  giving  the 
heart  vigor  in  this  way,  inhalations  of  oxygen  give  the  most  promise,  because  of  the 
crying  need  of  the  .system  during  this  ordeal  for  this  life-giving  gas.' 

PHYSICAL  PROPERTIES  OF  THE  LEUKOCYTES. 

Phagocytosis. — All  leukocytes  have  the  power  of  .shifting  their  location.  The 
lymphocytes,  so  called,  being  the  youngest  of  the  white  corpuscles,  show  it  less  than  the 
older  forms.     The  eosinophile  cells  are  less  al)le  to  manifest  the  peculiar  activities  of 

*  See  paper  by  the  author,  New  York  Medical  Journal,  August  16,  1884. 


riiYsKM.  I'h'oj'inrr/h-s  of  77/ a'  LiAKocvrEfi 


41 


(he  olhcr  forms.  It  is  parliciilarlv  llic  iiioiiomiclcar  and  polymiclcar  coriJiisclcs  wliicli 
art-  ciKlowcd  willi  iik.sI  |)r(.ii(.un(c(l  adivilv.  'I'lusc  liavc  ("lie  power,  like  the  aiiichii 
aiiioiiji;  the  lowest  Umws  of  life,  to  ii(»t  only  spread  llieiiiselves  around  inert  bodies,  like 
{2;raiiiiles  ofeannine  or  other  particles  used  for  experiment,  or  the  particles  of  eoal-dnst 
found  in  certain  conditions  in  the  hiiinan  body,  hut  they  also  have  the  power  to  eiif^dohe 
inany  liviiifj:  or<ranisms,  for  the  main  part  veo(.t;d)le  (hacteriaj.  I'lider  the  inicroscoj)e 
it  is  possible  to  see  livin<j  bacilli,  performing;  active  movements,  altliou<,di  enclosed  in  the 
nutritive  vacuoles  of  the  leukocytes,  in  some  of  the  lower  animals.  This  (uiirhoid  j)ower 
possessed  by  these  cells  of  thus  attacking  and  <lisposinor  of  foreign  bodies  or  irritants 
has  boon  demonstrated  and  proved,  especially  by  I\I(>tchnikofi",  and  has  been  called 
by  him  p/iagori/tosis.  His  views  wore  for  a  long' time  disputed,  and  are  i)erhaj)s  not 
yet  absolutely  and  generally  accepted.  Nevertheless,  they  lulfil  every  demand  made 
upon  them  for  explanation,  and  are  suscej)til)Ie  of  such  demonstration  iinder  the  micro- 
scope that  wo  now  have  practically  a  new  and  ap|)arentlv  a  correct  theory  of  the 
inflaTiimatory  jirocess.  (See  Chai)t('r  III.)  Any  cell  which 'has  this  property  is  known 
as  a  pJiar/ori/fr.  It  is  shan-d  by  some  of  the  leukocytes  with  certain  other'cells  to  be 
spoken  of  later  (wandering  tissue  cells).     Colls  whicli  possess  this  jiower  do  not  attract 

Fio.  3 


Phagocytosis  in  anthrax  pustule.     (Gaylord.) 

all  microbes  indiscriminately,  and  it  is  often  the  case  that  the  leukocytes  of  an  animal 
peculiarly  susceptible  to  a  certain  kind  of  bacteria  do  not  attract  them  at  all,  even  thouo-h 
they  are  directly  in  contact.  It  is  plausible  that  an  explanation  of  the  peculiar  suscep- 
tibility of  certain  animals  to  certain  diseases  is  furnished  by  this  fact  (Fig.  3). 

On  the  other  hand,  leukocytes  may  and  do  englobe  virulent  microbes.  In  man 
the  mononuclear  forms  do  not  take  up  either  the  streptococcus  of  erysipelas  or  the 
gonococcus;  whereas  these  two  organisms  are  readily  attracted  by  the  polyiuiclear 
neutrophile  cells.  The  bacillus  of  leprosy,  on  the  other  hand,  is  never  attacked  by  the 
polynuclear  forms,  but  is  speedily  devoured  by  the  mononuclear  cells.  This  shows  that 
the  various  leukocytes  may  exercise  a  marked  selective  ability.  This  inclusion  of 
minute  bodies  within  ameboid  cells  seems  to  be  an  evidence  of  a  peculiar  tactile  sensi- 
bility upon  the  part  of  the  latter.  In  fact,  this  is  clearly  established,  and  seems  to  be 
inseparable  from  the  peculiar  attraction  between  leukocyte  and  bacterium,  to  wliich 
the  name  rhemofa.vis  has  been  given,  and  which  is  described  in  an  ensuing  cha])ter. 
If  the  included  organism  is,  as  is  usually  the  case,  killed,  it  is  disposed  of  by  a  true 
process  of  intracellular  digestion  in  a  neutral  or  alkaline  protoi^lasmic  medium,  and  its 
inert  portions  are  again  extruded.      On  the  other  hand,  if   the  leukocyte  is  poisoned 


42  SURGICAL  PATHOLOGY 

or  (lie  in  this  j)liago('vtic  attempt,  it  j)rc.s(Mits  usually  as  a  so-callrd  pii.s  ceU  ov  cor-p^iscle, 
and  the  soHd  |)art  of  pus  is  made  up  in  hirge  measure  ol"  cells  which  have  perished  in 
this  way.     (See  Inflammation  and  Suppuration.) 

To  regard  pliayorijto.si.s-  a-v  an  ajjair  mostly  of  certain  tissue  cells  and  iniiadincj  bacteria 
would  bo  altogether  too  narrow  a  view  to  take  of  it.  It  is  really  a  process  of  the  greatest 
importance  and  of  constant  performance  in  our  systems.  By  virtue  of  it  disinte- 
grated muscle  fibers  and  other  tissue  cells  arc  disposed  of,  sloughs  are  separated,  certain 
absorbable  foreign  bodies  (catgut,  etc.)  taken  away — i.  e.,  absorbed — cellular  tissue 
reduced  in  innnerical  strength  (progressive  atrophy),  and  a  great  variety  of  changes, 
either  normal,  as  those  pertaining  to  health  and  advancing  years,  or  abnormal,  like 
those  incid(Mit  to  many  diseases,  are  actually  the  ])roduct  of  this  kind  of  ])hagocytic 
activity.  The  protective  ])ower,  then,  which  tlie  ))hag()(ytes  exert  as  against  bacteria 
is  only  one  part  of  their  normal  functions,  by  virtue  of  which  they  become,  in  effect, 
perhaps  the  most  important  cells  within  our  bodies.  Their  ])owers  are  limited,  however, 
as  will  be  seen  when  describing  pus,  for  the  so-called  pus  corpuscle  is  nothing  but  a 
phagocyte  which  has  perished  in  its  self-assumed  task.  It  is  known  also  that  in 
certain  instances  phagocytes,  which  are  incapable  of  defence  as  against  the  mature 
bacterial  organism,  are  nevertheless  capable  of  englobing  its  spores  and  preventing 
their  development.  This  is  true,  for  instance,  in  case  of  anthrax  in  animals  ordinarily 
immune,  as,  for  instance,  the  frog  and  fowl.  If,  however,  in  these  very  animals  the 
vitality  of  the  phagocytes  be  affected — as  by  cooling  in  fowls  or  heating  in  frogs — 
phagocytosis  is  so  far  interfered  with  that  the  spores  germinate  within  the  enfeebled 
leukocytes  and  the  entire  organism  is  infected. 


CHAPTER   III. 

INFLAMMATION. 

InfJammation  if  an  rxprrs'sion  of  flic  rfjorf  madr  by  a  givrn  nrgani.s'm  to  rid  itNrlf 
of  or  irndi'T  inert  noxious  irriiant.s^  arisinc/  from  ivitjiin  or  infrodurrd  from  iriflionl 
(Sutton,  modifiod). 

After  liaviufi;  duly  coiisidoird  liyjx'iviniii  us  ti  j)liciioincn()ii  liaviuif  an  identity  and 
termination  of  its  own,  wo  are  prepared  to  study  the  more  eomplex  processes  included 
under  the  term  infiamviation ,  the  first  of  which  is  the  hyperemia  already  considered. 
'IMie  characteristic  of  the  truly  inflammatory  process  is  that  it  does  not  stop  witli 
mere  conifestion  nor  with  any  of  its  previously  mentioned  terminations,  hut  (^oes 
on  to  sometliing  more  complex.  It  must  hv  understood,  thercfon',  in  this 
consideration  that  hy|)eremia  is  the  first  act  of  the  vessels,  resultinij  from  peculiar 
stinuili  which  will  shortly  he  considered.  Even  the  hyperemia  seems  to  he  now  more 
distinct  than  under  other  circumstances,  and,  along  with  the  dilatation  of  vessels 
and  the  stagnation  of  blood  current,  the  capillary  vessels  seem  crowded  with  blood 
corpuscles  to  an  abnormal  degree,  the  rapidity  of  their  motion  is  checked,  and  there 
occurs  accumulation  of  blood  cells  along  the  walls  of  the  small  veins,  to  which  they 
seem  to  adhere  as  if  by  some  new  cohesive  property.  The  result  is  that  before  long 
the  vessel  wall  ajipcars  to  have  received  a  new  coating  of  white  corpuscles,  this  being 
more  marked  in  the  veins  than  in  the  arterioles,  while  in  the  latter  the  red  are  more 
numerously  mingled  with  the  white  than  in  the  veins,  in  which  the  distinction  between 
the  two  classes  of  cells  is  better  maintained. 

Next  comes  the  phenomenon  whose  clear  recognition  and  description  is  inseparably 
connected  with  Cohnheim's  name.  This  is  known  under  different  names  as  711  ig ration 
or  diapedesift  of  the  leukocytes.  The  program  is  about  as  follows:  A  little  protrusion 
of  the  vascular  wall,  a  marked  alteration  in  the  shape  of  a  leukocyte,  which  yet  adheres 
to  this  point  of  its  lumen,  and  then  the  curious  fact  so  often  seen  under  the  microscope 
— the  gradual  passage  of  this  cell  through  the  vascular  wall,  from  its  inner  to  its  outer 
side,  by  what  is  generally  known  as  its  ameboid  movement.  This  migration  of  the 
leukocyte  is  not  confined  to  its  mere  escape  from  the  restriction  of  the  vessel  lumen,  but 
goes  on  to  an  indeterminate  extent  after  it  has  detached  itself  from  the  outer  surface 
of  the  vessel.  This  seems  to  occur  by  virtue  of  the  same  ameboid  characteristic  which 
it  exhibited  in  passing  through  between  the  cells  of  the  vessel  itself.  If  this  occurs  at 
one  point,  it  occurs  at  innumerable  points,  in  consequence  of  which  a  large  number 
of  leukocytes  escape  into  the  tissues  of  the  part  involved.  This  diapedesis  occurs 
most  markedly  from  the  smaller  veins,  to  a  less  extent  from  the  capillaries.  The  cells 
which  escape  from  the  latter  are  usually  accomjianied  by  red  cells,  the  consequence 
being  that  the  exudate  which  necessarily  occurs  at  the  same  time  is  more  or  less  tinged 
with  the  coloring  matter  of  the  blood,  and  is  known  as  a  hemorrhagic  exudate. 

The  above  phenomenon,  described  in  so  few  words,  is  in  its  minutifie  a  really  complex 
one,  depending  on  a  variety  of  causes  not  easily  appreciated;  but  it  is  at  least  positive 
and  well  known,  because  it  can  be  observed  at  will  in  the  mesentery  or  web  or  tongue 
of  certain  animals  which  can  be  confined  upon  the  stage  of  the  microscope.  The 
phenomena  of  inflammation,  therefore,  comprise,  first,  hyperemia,  and  then  escape 
from  the  bloodvessels  of  the  corpuscular  and  fluid  elements  of  the  blood.  The  former 
may  be  due,  as  already  seen,  to  various  irritations  of  a  non-specific  character;  while, 
as  we  shall  learn,  the  latter  practically  never  take  place  save  when  the  irritation  has 
been,  as  pathologists  say,  specific  or  infectious. 

The  phenomena  of  true  inflammation  comprise  practically  the  roles  plaved  by  the 

three  elements  which  conspire  to  produce  those  changes — namely,  the  tissues,  the 

blood,  and  the  fspecifie  irritants  which  are  the  primary  cause  of  the  entire  lesion.      Each 

of  these  should  be  considered  separately. 

^  •'  ( 43 ) 


44  SURGICAL  PATHOLOGY 

All  observers  agree  that  in  aetively  inflamed  tissues  the  number  of  cells  is  very  greatly 
increased.  A  certain  increase  may  be  accounted  for  by  that  which  has  already  been 
described — namely,  the  escape  into  the  tissues  of  the  wandering  cells  fn^n  the  blood- 
vessels. But  neither  this  alone  nor  the  products  of  their  ra{)id  j)r(jliferati(jn  are  suffi- 
cient to  account  for  all  the  cells  found  in  the  truly  inflammatory  condition.  It  is  now 
well  established  that  in  connective  tissue  there  are  two  varieties  of  cells — the  fixed 
and  the  wandering  —the  former  concealed  in  the  trabecuhe  of  the  intercellular  substance, 
while  the  latter  are  small,  ordinarily  round  in  shape,  much  resembling  the  white  cor- 
puscles, possessed  of  ameboid  characteristics,  and  having  the  power  of  changing  posi- 
tion. These  are  known  as  the  wandering  cells,  which  meander  through  the  lymph 
spaces  of  the  tissues  or  back  and  forth  into  and  out  of  the  blood-vascular  system, 
their  migration  being  regulated  by  causes  not  yet  known.  Under  natural  conditions 
their  number  is  relatively  small.  Once  given  a  true  inflammatory  disturbance  they 
are  reproduced  with  amazing  rapidity;  and  their  numbers,  added  to  those  pro- 
duced by  diapedesis  of  leukocytes,  with  the  combined  proliferative  activity  of  both 
forms,  .serve  to  account  for  the  new  cells  whose  presence  characterizes  phlegmonous 
and  other  similar  disturbances.  That  these  Avandering  connective-tissue  cells  have 
much  to  do  with  these  changes  is  shown  by  the  unmistakable  evidences  of  excessive 
activity  known  as  karyokiiiesis  (i.  e.,  nuclear  acthiiij). 

Karyokinesis  is  common  not  only  in  inflammatory  disturbances,  but  in  new-growi;hs 
of  rapid  formation,  especially  sarcomas,  which  are  formed  from  mesobla.stic  cells, 
the  same  which  have  to  do  with  connective  tissue.  Endothelial  cells  also  undergo  the 
same  changes. 

The  peculiar  characteristics  of  the  leukocytes  have  already  been  described  at  con- 
siderable length  in  the  preceding  chapter.  It  must  suffice,  then,  here  to  say  that  during 
the  mflammafori/  attack  the  leukocAi;es  are  increased  in  nuviher,  i.  e.,  there  is  a  tempo- 
rary leukocytosis  which  is  the  usual  accompaniment  of  suppuration.  For  instance, 
this  is  regularly  present  in  purulent,  but  not  in  catarrhal,  forms  of  appendicitis.  The 
recognition  of  this  fact  may  be  of  great  value  in  diagnosis.  For  instance,  leukocytosis 
is  rarely  pre.sent  in  tuberculous  disease  unless  suppuration  complicates  the  case.  It 
is  met  with  in  suppurative  osteomyelitis  and  in  all  cases  of  pocketing  of  pus.  More- 
over, when  leukocytosis  is  present  coagulability  of  the  blood  is  increased.  Of  the 
various  leukocytes,  it  is  the  mononuclear  and  polynuclear  forms  (see  Chapter  II) 
which  are  endowed  with  the  most  pronounced  activity  and  which  play  the  principal 
role  among  the  blood  cells  or  phagocytes.  That  phagocytosis  plays  a  most  important 
part  in  the  inflammatory  process  is  a  matter  to  be  emphasized  in  more  than  one  way 
and  in  more  than  one  place.  The  account  of  the  process  already  given  should  suffice  for 
descriptive  purposes;  the  importance  of  the  act,  however,  .should  be  made  most  promi- 
nent in  considering  inflammation  and  suppuration.  That  the  phagocytic  properties  of 
these  cells  are  limited  will  be  remembered  when  we  recall  that  in  certain  instances 
phagocytes,  which  are  incapable  of  defence  as  against  the  mature  bacterial  organism, 
are  yet  capable  of  englobing  the  spores  and  preventing  their  development.  Never- 
theless, the  activities  of  even  the  most  lively  phagocytes  are  capable  of  being  influenced 
and  repressed  by  extremes  of  heat  and  cold  to  which  patients  may  be  exposed,  either 
locally  or  generally. 

CHEMOTAXIS  AND  OPSONINS. 

Having  considered  briefly  the  cells  which  take  prominent  part  in  the  inflammatory 
process,  and  the  escape  along  with  them  of  the  fluid  portions  of  the  blood,  whether 
these  coagulate  or  not,  it  is  necessary  before  referring  to  specific  factors  to  discuss  that 
which  induces  the  above  cells  to  act  in  this  way.  That  there  is  a  peculiar,  even  a 
mysterious,  attraction  which  brings  specific  irritant  and  phagocyte  together  has  been 
for  some  time  recognized,  but  it  remained  for  Pfeffer  to  study  it  carefully  and  to  give  it 
the  name  by  which  it  now  passes,  i.  e.,  chemotaxis,  while  others  have  widened  our 
knowledge  of  it,  especially  by  a  recognition  of  the  opsonins  or  material  which 
"prepares  food,"  i.e.,  prepare  microbes  for  ingestion  by  the  phagocytes. 

Chemotaxis  is  a  term  implying  a  peculiar  property  of  altraction  and  rejyuhion  between 
cells,  both  animal  and  vegetable.  It  mainly  pertains  to  vegetable  cells  alone,  and 
has  been  offered  as  the  explanation  of  the  sporulation  of  ferns,  for  example;  but  as  it 


HPKCiriC   lUUITASTS 


45 


interests  us  most  in  this  place  it  is  manifested  between  the  animal  cells  of  the  human 
body  and  the  bacteria,  which  are  vegetable  cells.  As  a  result  the  former,  i.  c..,  the 
phaj^ocvtes,  having;  power  of  miifratioii,  are  drawn  toward  the  latter.  'Vo  l)c  more 
accurate,  this  mutual  or  peculiar  attraction  is  known  as  pofiitivr  cJinnotaxu,  it  being 
also  known  tliat  exactly  the  reverse  prevails  under  certain  circumstances,  and  that 
mobile  cells  will  move  away  as  rapidly  as  possible  from  certain  organisms  or  sub- 
stances for  which  they  seem  to  have  a  repugnance,  this  being  known  as  negative 
chcmotaxis. 

SPECIFIC  IRRITANTS. 

These  are  essentially  living  organisms,  bacteria,  fungi,  and  the  protozoa,  (he  first 
named  being  by  far  the  most  frecpient.  Before  a  lesion  can  assume  the  ty|H'  of 
inHamnuition  as  here  understood  some  one  or  more  of  these  organisms  must  have 
secured  an  entrance  into  the  tissues,  the  circumstances  determining  such  invasion 
being  considered  a  little  farther  on.  It  is  these  living  organisms  which,  having 
once  invaded  the  tissues,  determine  that  most  active  congregation  and  f)roliferation 
of  certain  cells  which  we  have  just  described  under  the  head  of  Phagocytosis. 
When  once  the  irritants  are  present  there  begins  that  very  active  conflict  which 
Virehow  has  so  graphically  alluded  to  as  the  battle  of  the  cells.  Now^  the  mysterious 
chemotactic  pro})erties  of  the  component  substances  manifest  themselves,  and  now 
phagocyte  is  drawn  toward  bacterium,  or  the  reverse,  while  the  tiny  war  goes 
on  with  sometimes  varying  results,  it  being  a  question  which  can  prove  victor 
in  the  conquest.  This  is  no  fiction  of  the  imagination,  but  is  a  contest  which  may 
be  seen  under  the  microscope  in  certain  of  the  lower  animals,  while  its  results 
may  be  seen  in  the  examination  of  pus  from  any  human  source.  In  another  place 
I  have  also  likened  this  conflict  to  that  in  which  certain  of  the  enemy  resort  to 
poisoned  weapons,  because  modern  biological  chemistry  has  now  shown  very  evidently 
that  it  is  a  part  of  the  life  history  of  many  of  these  microorganisms  to  produce,  prob- 
ably as  excretory  products,  albuminoid  or  other  substances  having  sometimes  extremely 
toxic  properties.  And  so  it  comes  about  that  in  many  of  the  surgical  infections,  while 
the  local  destruction  is  produced  by  the  actual  death  of  tissues  which  have  been  invaded 
by  microorganisms,  the  general  or  systemic  symptoms,  generally  referred  to  as  the 
toxic  symptoms,  are  literally  due  to  poisons  generated  in  the  infected  area,  dispersed 
throughout  the  system,  and  often  proving  fatal. 

The  local  effect  of  these  specific  irritants,  when  they  are  not  promptly  attacked, 
devoured,  and  removed  by  phagocytes,  is  pus,  which  means  cellular  death,  or  gangrene, 
which  is  death  of  masses  of  cells  which  have  not  had  time  to  separate  from  each  other. 
Pus,  then,  is  the  ordinary  consecjuence  of  the  contest  above  alluded  to,  and  eacJi  pus 
cell  represents  the  dead  body  of  a  pharjocyte  which  has  perished  in  the  attempt  to  protect 
the  parent  organism  from  harm.  That  it  has  died  valiantly  can  almost  invariably 
be  determined,  because  within  its  dead  body  may  be  seen  one  or  more  of  the  minute 
invaders  which  it  has  attacked.  This,  then,  is  the  light  in  which  inflammation  and 
infection  should  be  viewed. 

In  other  words,  we  may  have  escape  of  fluid  portions  of  the  blood,  which  may  or 
may  not  coagulate;  we  may  even  have  some  escape  of  corpuscular  elements  with  some 
activity  in  the  extravascular  cells,  which  shall  lead  to  temporary  or  even  permanent 
enlargement  of  a  part;  all  of  which  may  be  provoked  by  injury  or  by  the  presence  of  cer- 
tain chemical  irritants  within  the  blood  or  tissues;  for  example,  alcohol,  uric  acid,  etc. 
But  the  factors  which  provoke  the  greatest  activity  on  the  part  of  intravascular  and 
extravascular  cells,  and  which  determine  the  richness  in  albumin  of  fluid  exudates,  or 
their  prom])t  coagulation  as  soon  as  blood  serum  has  escaped  from  the  vessels,  and 
which  particularly  determine  the  furious  rush  of  phagocytes  and  that  kind  of  intercellular 
conflict  which  leads  many  of  the  contestants  on  both  sides  to  death,  are  living  organ- 
isms which  are  introduced  from  without,  whose  presence  at  the  point  of  inflammation 
is  abnormal  and  injurious,  which  are  offending  sub.stances  in  every  respect,  while  the 
whole  phenomenon  of  inflammation  is  an  expression  of  an  effort  to  rid  the  system 
thereof.  Taking  this  view  of  the  subject,  there  is  an  important  distinction  between 
hyperemia  and  its  consequences,  which  is  absolutely  a  non-infectious  condition,  and 


46  SURGICAL  PATHOLOGY 

inflammation  with  its  consequences,  which  is  always  an  infection  and  is  always  followed 
bv  more  or  less  death  of  cells,  the  same  being  often  extruded  in  a  semifluid  mass  known 
as  pu6". 

CIRCUMSTANCES  WHICH  FAVOR  INFECTION. 

1 .  The  Virulence  of  the  Infecting  Organisms  and  the  Amount  Introduced.  — 

There  is  the  widest  diti'eri'uce  bclween  various  h^ruis  of  uiicnjori^anisins  in  the  matter 
of  virulence;  and  it  is  true  that  there  are  very  great  diflerences  between  the  same  species 
under  ditt'erent  circumstances,  these  differences  depending  on  conditions  as  yet  abso- 
lutelv  unknown.  With  certain  organisms  it  is  enough  to  infect  an  animal  with  one 
alone  in  order  to  bring  about  a  fatal  result,  this  meaning  that  the  organism  itself  is 
extremely  virulent  and  the  animal  extremely  susceptible. 

In  a  guinea-pig,  for  instance,  a  single  virulent  anthrax  bacillus  will  produce  death, 
whereas  in  a  more  resistant  animal  many  are  required,  and  in  still  others  there  is 
absolute  immunity  against  the  disease.  Man  is  much  more  susceptible  to  the  pyogenic 
organisms  than  most  of  the  lower  animals,  which  is  one  reason  why  wrong  deductions 
have  been  drawn  from  many  experiments,  and  why  veterinary  surgeons,  who  are  so 
careless  of  all  antiseptic  precautions,  as  a  rule  have  good  results  in  work  which,  done 
after  the  same  fashion  on  the  human  being,  would  be  inevitably  fatal.  It  is  one  reason 
also  why  one  may  draw  false  inferences  from  experimental  work,  for  instance,  upon 
dogs,  which  survive  many  an  operation  which  can  scarcely  be  successfully  repeated 
upon  a  human  being.  The  influences  which  affect  the  vitality  and  virulence  of  micro- 
organisms are  most  numerous  and  widespread.  Temperature,  sunlight,  moisture  or 
dryness,  association  with  other  bacteria,  are  but  a  few  of  the  conditions  known  to  be 
more  or  less  operative.  Inoculation  with  a  small  number  of  certain  bacteria  may  be 
harmless;  up  to  a  certain  number  it  may  produce  only  a  local  disturbance,  like  abscess, 
while  a  still  larger  dosage  may  produce  fatal  results.  This  is  not  the  case  with  all, 
however,  but  only  with  some  organisms.  Bacteria  which  have  been  repeatedly  passed 
through  the  animal  body  become  more  virulent  than  those  cultivated  for  many  genera- 
tions in  test-tubes  in  the  laboratory.  This  variable  virulence  is  especially  character- 
istic of  the  colon  bacillus,  the  anthrax  bacillus,  and  the  micrococcus  of  erysipelas. 
Nor  does  it  always  follow  that  the  most  virulent  organism  is  necessarily  cultivated 
from  the  most  toxic  or  serous  manifestation  of  its  activity. 

2.  Association. — Bacteria  are  seldom  found  in  pure  cultures  under  natural  con- 
ditions. By  mutual  association  remarkable  changes  are  produced,  sometimes  in  the 
direction  of  enhanced  virulence,  sometimes  in  the  direction  of  attenuation  of  effect. 
Certain  organisms,  extremely  dangerous  alone,  lose  their  power  when  combined  with 
others,  while  still  others  have  their  virulence  increased  to  a  rapidly  fatal  degree.  In 
fact,  these  effects  are  so  strange  and  so  contradictory  that  no  law  governing  them  has 
yet  been  formulated,  it  l)eing  necessary  to  establish  each  case  by  experimental  investi- 
gation. The  virulence  of  the  anthrax  bacillus  under  ordinary  circumstances  is  well 
known,  as  is  also  that  of  the  streptococcus  of  erysipelas  in  man.  Yet,  when  these  two 
organisms  are  introduced  sinuiltaneously,  the  mixture  is  apparently  wellnigh  harm- 
less. On  the  other  hand,  the  simultaneous  inoculation  of  certain  other  species  greatly 
increases  the  danger  from  either  alone.  The  diplococcus  pneumonic'e  when  combined 
with  the  anthrax  I)acillus  seems  to  have  a  greatly  augmented  power. 

3.  Hereditary  Influences. — The  fact  that  immunity  against  certain  infections 
and  susceptibility  to  other  conditions  are  transmitted  from  parent  to  offspring  is  one 
which  admits  of  no  dispute.  The  explanation,  however,  is  almost  as  remote  from  us 
today  as  it  ever  was.  But  the  recognition  of  the  fact  is  of  the  greatest  importance  to 
all  practising  surgeons.  That  bacteria  frequently  enter  through  wounds  and  bruises 
is  self-evident,  but  we  all  know  that  such  wounds  are  more  likely  to  suppurate  in  some 
than  in  others,  and  the  causes  of  infection  in  some  are,  to  a  certain  extent,  connected 
with  the  hereditary  habit  of  tissues.  The  same  causes  influence  not  merely  liability  to 
infection,  but  its  severity  and  character.  There  are  undoubtedly  also  local  as  well 
as  general  variations,  and  it  is  very  certain  that  among  these  the  results  of  bruising 
or  contusion  are  by  far  the  most  prominent.  There  is  also  undoubted  experimental 
evidence  that  under  certain  circumstances  bacteria  produce  only  local  lesions,  whereas 
under  others  they  produce  general  and  even  fatal  infection. 


circi'msta.\('j:s  which  f.wou  isfkction  47 

4.  Local  Predisposition.  Local  predisposition  is  a  factor  of  almost  cfjnal  impor- 
tance. (  )iice  «fiveii  a  (listiiic!  infection,  and  liyj)cremia  is  sometimes  a  contrihiilinfr 
cause  of  inflammation.  I'cr  contra,  anemia  of  tissues  s(>ems  to  be  also  a  favoring 
condition,  in  parts  involved  in  chronie  congestion  the  Mood  Hows  more  slowlv,  while 
the  vessels  are  dilated  and  ap|)arently  susceptihilit y  is  increased.  Infection  here 
produces  a  type  of  disea.se  mentioned  as  ///y/>o,s7r///f  hijlmiiiniilion .  C'ons|)ienous 
(>xception  as  to  the  occasional  value  of  an  artificial  passive  hvperemia  is  .seen, 
however,  in  the  so-called  congestion  trealment  (Hier's)  of  luhercnious  joints,  where 
the  more  or  less  constant  flooding  of  the  tissues  with  VfMions  blood  seems  to  render 
them  iminhabitable  for  living  bacilli,  which  apparently  die  and  disappear  (by  phago- 
cytosis), thus  jKM-mitting  a  slow  return  to  the  normal  condition.  (General  anemia, 
again,  is  a  ])re(lisposing  cause,  while  toxemias,  including  diabetes,  etc.,  are  still  more 
so.  The  liability  of  diabetic  patients  to  sui)purative  and  even  gangrenous  infection 
is  proverl)ial.  The  ])re.sence  of  foreign  bodies  has  much  to  do  also,  and,  infection  once 
having  occurred  along  with  its  introduction,  the  j)re,scnce  of  a  foreign  body  will  nearly 
always  exc-ite  suppuration;  ()thcrwi.se  it  will  ordinarily  remain  inert.  The  withdrawal 
of  trophic  nerve  influences  also  appaivntly  permits  infection,  as  is  instanced  bv  the 
ease  with  which  bed-sores  form  in  paralytic  patients.  Obstruction  to  the  circulation 
or  to  escaj)e  of  .secretions  more  easily  j)ermits  infection;  for  example,  in  the  appendix, 
in  the  kidney,  in  the  gall-bladder,  the  .salivary  glands,  etc.  Furthermore,  one  may 
fornuilate  a  quite  comprehensive  statement  and  say  that  all  such  lesions  as  solutions 
of  continuity,  hemorrhages,  degenerations,  vascular  stasis  produced  by  strangulation, 
etc.,  and  all  perforations,  increase  more  or  less  the  lial)ility  to  infection. 

5.  Pre-existing  Disease. — Here  are  reckoned,  first,  previou.f  and  long  existent 
toxemias,  e.  g.,  syphilis,  diabetes,  scurvy,  etc.  Other  conditions,  like  lithemia,  cholemia, 
acetonemia,  and  the  various  conditions  represented  l)y  oxaluria,  or  in  which  acetone, 
peptone,  and  excess  of  uric  acid  are  found  in  the  urine,  also  come  under  this  head. 
One  need  never  be  surprised  to  find  suppuration  occurring  in  those  cases  in  spite  of 
due  observance  of  all  ordinary  precautions,  since  by  their  existence  immunity  is  destroyed 
and  vulnerability  increased.     (See  chapter  on  Auto-infections.) 

Recent  toxemias  also  have  important  bearing  in  this  same  respect.  For  instance, 
after  typhoid  fever  and  other  acute  wasting  diseases,  including  the  exanthemas, 
surgical  operations  are  sometimes  followed  by  failure,  and  should  always  be  postponed 
until  complete  recovery,  except  in  cases  of  emergency.  The  condition  to  be  hereafter 
described  as  eiiterosepsis,  and  which  has  previously  been  known  imder  many  different 
names,  as  fecal  anemia,  stercoremia,  etc.,  is  one  which  makes  the  performance  of 
all  operations  dangerous,  and  which  certainly  predisposes  to  septic  disturbances 
of  all  kinds.  The  postpuerperal  state  is  also  one  in  which  operations  are  to  be  avoided 
if  possible. 

Certain  anatomical  changes  peculiar  to  the  various  ages  also  belong  in  this  category. 
Old  age,  with  its  accompanying  arterial  sclerosis,  its  cardiac  debility,  and  other  well- 
known  tissue  alterations,  favors  sluggishness  of  wound  repair  and  leads  not  infrequently 
to  sloughing  or  to  bed-sores.  Amyloid  changes  betoken  impaired  vitality.  Children 
are  much  more  liable  to  acute  osteomyelitis  than  adults.  Nursing  infants  arc  apparently 
exempt  from  many  of  the  infectious  diseases,  but  possess  relatively  small  power  of 
vital  resistance  to  surgical  operations.  General  anemia  and  impaired  nutrition  of 
the  body  predispose  to  most  infections  and  to  acute  starvation. 

6.  Personal  Habits  and  Environment. — Diet  has  much  to  do  with  tissue  resistance. 

Rats  fed  on  bread  are  more  susceptible  to  anthrax  than  those  fed  on  meat.  Hunger 
makes  pigeons  highly  susceptible  to  the  same  disea.se,  and  artificial  immunity  induced 
in  various  animals  is  quickly  destroyed  by  starvation.  Prolonged  thirst  seems  to 
have  the  same  result.  Excessive  fatigue  generally  reduces  immunity,  as  already  men- 
tioned. The  various  drugs  which  destroy  red  corpuscles  impair  immunity,  and  even 
by  injection  of  water  into  the  circulation  the  bactericidal  power  of  the  blood  is  reduced. 
White  mice  fed  with  phloridzin,  which  produces  artificial  diabetes,  become  highly 
susceptible  to  glanders,  from  which  they  are  ordinarily  exempt.  In  this  connection 
may  also  be  mentioned  the  various  toxemias  alluded  to  under  the  previous  heading, 
which  may  proceed  from  the  intestine,  from  the  genito-urinary  tract,  and  probably 
also  from  other  sources.  Climate  has  more  or  less  to  do,  as  also  extremes  of  weather, 
with  power  to  resist  infection  or  to  survive  .serious  operations.     Dark  habitations, 


48  SURGICAL  PATHOLOGY 

poorly  vmtilatcfl,  constitute  .surroundings  wliicli  nianifcstly  f)rcflisposo  to  infection 
of  all  kinds.  Rabbits  inocvilated  with  tuberculosis  and  confined  within  a  dark  cell, 
badly  ventilated,  become  rapidly  diseased,  while  others  similarly  inoculated,  but  allowed 
to  nnim  at  large,  present  but  slight  evidences  of  the  affection.  Certain  occupations 
predispose  to  certain  diseases.  This  is  pre-eminently  the  case,  for  example,  with 
workers  in  mother-of-pearl,  who  are  exceedingly  liable  to  a  particular  form  of  osteo- 
myelitis; and  with  those  who  make  phosphorus  matches,  who  are  prone  to  suffer  from 
a  peculiar  necrosis  of  the  lower  jaw.  Prolonged  supjniration  may  ])roduce  such 
changes  in  the  blood  and  tissues  that  vital  processes  of  repair,  cell  resistance,  and 
chemotaxis  may  be  so  far  interfered  with  as  to  facilitate  subse([uent  infection. 

Finally,  the  injiuence  of  local  injurij  to  tissues,  j)articularly  of  contusions  which  cause 
tissues  to  lose  their  vitality,  is  strenuously  insisted  upon  by  all,  and  is  spoken  of  repeat- 
edly in  other  places  in  this  work.  Many  tissues  will  succumb  to  inoculation  after 
bruising,  ligature  en  masse,  etc.,  which  before  such  injury  are  not  in  the  least  disturbed. 

7.  Fetal  Infection. — It  is  only  in  a  very  limited  class  of  cases  that  infection  can  be 
transmitted  from  mother  to  fetus,  but  there  are  instances  of  this  kind  in  which  the 
surgeon  is  deeply  concerned.  As  Welch  has  stated,  syphilis  is  the  only  infection 
capable  of  direct  transmission  through  the  ovum  or  spermatozoon;  but  intra-uterine 
infection  may  occur  in  many  ways,  and  many  diseases  may  be  thus  transmitted.  The 
placenta  is  usually  regarded  as  a  perfect  filter;  nevertheless,  it  is  occasionally  passable 
to  microorganisms.  These  may  be  caused  by  preexisting  lesions  in  the  placenta 
or  by  the  virulence  and  activity  of  bacteria.  It  is  known  that  in  animals  the  bacilli 
of  chicken  cholera  (inoculated  into  the  mammalia),  of  sym])tomatic  anthrax,  and  the 
pyogenic  cocci,  frequently  traverse  this  barrier.  In  mankind  infection  m  utero  has 
been  observed  in  smallpox,  measles,  scarlatina,  relapsing  fever,  syphilis,  tuberculosis, 
croupous  pneumonia,  typhoid  fever,  anthrax,  and  surgical  sepsis. 

SOURCES  OF  INFECTION. 

That  the  effects  of  bacterial  invasion  may  be  anticipated  and  guarded  against  most 
eiTectually  it  is  necessary  that  the  practitioner  should  be  thoroughly  familiar  with  the 
sources  from  wdiich  they  come,  and  the  localities  in  and  about  the  body  which  they  most 
commonly  inhal)it  or  where  they  are  met  with  in  largest  numbers. 

Skin  and  Mucous  Membranes. — Of  all  possible  sources  of  infection,  the  skin  itself 
is  probably  the  most  fertile.  It  is  exposed  to  contamination  by  air  and  by  everything 
which  may  come  in  contact  with  the  body,  and  there  is  ])erhaps  no  organism  met 
with  in  disease  which  may  not  be  found  upon  its  surface  or  within  its  recesses.  In 
fact,  these  recesses,  such  as  the  crevices  beneath  the  nails,  the  spaces  between  the 
toes,  and  the  various  pockets  like  the  tonsils,  the  axillse,  etc.,  are  those  most  commonly 
inhabited  by  microorganisms. 

Bacteria  may  penetrate  the  skin  by  means  of  three  different  routes,  namely,  the 
sw^eat  glands,  the  hair  follicles,  and  the  sebaceous  glands,  by  means  of  their  regular 
openings.  The  hairy  appendages  of  the  skin  are  even  greater  sources  of  danger  than 
the  skin  itself,  since  a  direct  path  of  infection  into  the  depths  of  the  skin  is  afforded  by 
their  follicles.  Experimentally  it  has  been  shown  that  when  bacteria  are  rubbed  into 
the  skin  where  there  are  no  follicles,  there  is  freedom  from  infection,  whereas  the 
reverse  is  equally  true,  and  it  is  clinically  generally  recognized  that  furuncles  and 
carbuncles  form  almost  exclusively  in  those  parts  provided  with  hair  and  sebaceous 
glands. 

The  mucous  membranes  are  in  constant  contact  with  microorganisms  and  furnish 
conditions  in  many  respects  favorable  for  their  rapid  development.  Nevertheless, 
the  latter  is  interfered  with  and  often  inhibited  by  certain  mechanical  and  chemical 
influences  which  afford  protection.  The  conjimctiva  is  an  extremely  exposed  mem- 
brane, which  harbors,  however,  but  a  relatively  small  number  of  bacteria  under  ordinary 
circumstances.  The  tears  before  escaping  from  the  conjiuictival  sac  are  sterile,  and 
are  probably  saline  enough  to  act  as  an  antiseptic  bath  for  the  cornea.  Moreover, 
by  free  escape  of  secretion  through  the  nasal  duct  the  conjunctival  sac  is  kept  constantly 
irrigated,  to  which  is  mainly  due  its  ordinary  healthy  condition,  as  it  is  well  known 
how  commonly  lesions  follow  obstruction  to  the  lacrymal  duct.     The  horrible  results 


PLATE  III 


FIG.  2 


Artificial  Dental  Caries  in  Cross-section. 
Tubules  Filled  with  Bacteria.     (Miller.) 

FIG.  3 


Dental  Caries.     Disappearance  of  Dental  Tissues 
as  Result  of  Presence  of  Bacteria.     (Miller.) 

FIG.  5 


^^:%M  V 


Dental  Caries.      X  500.     (Miller.) 


Putrid  Tooth  Pulp.     Infection  of  Dental 
Tissue.   X  1000.     (Miller.) 


FIG.  4 


'^ 


»^ 


Dental  Caries.     Tubule  Filled  with  Cocci. 
(Miller.) 

FIG.  6 


Dental  Caries.     Tubules  Plugged  with 
Cocci.      X  500.     (Miller.) 


SOi'RCKS  OF   ISI-LCTIOS  49 

of  I^fiyptian  oplitlialniia,  /.  c,  tlu-  pyogenic  form  of  coiijuiK-tiviiis,  arc  familiar  to 
travellers  in  Kjr.v])t.  Howe  and  others  have  shown  that  this  disturhancc  is  due  to 
flies,  which  are  carriers  of  infection,  and  are  attracted  toward  the  eyes  of  infants, 
while  the  siijierstitious  notions  of  the  parents  restrain  their  children  from  instinctive 
protection  of  the  eyes  when  thus  irritated.  There  is  prohahly  no  greater  common 
carrier  of  jjyogenic  infection  than  the  common  house-fly,  and  nowhere  is  this  ageiicv 
nmrc  d(■Inl•^-^tr;l^(•^l  lli.iii  in  the  hot  climates  of  the  ( )ricnt. 

Upper  Respiratory  Tract.— The  oral  cavity  and  pharynx  are  seldom  free  from  bac- 
teria. Miller  has  studied  over  one  hundred  species  that  he  has  found  under  various 
circumstances  in  the  human  mouth.  Some  of  these  are  j)athogenic;  others  are  ap|)ar- 
ently  absolutely  innocent.  Many  of  the  forms  which  grow  in  saliva  will  not  grow  in 
ordinary  media.  (See  Plate  III,  illustrating  infection  of  the  teeth.)  Miller  has  also 
shown  that  many  forms  of  dental  caries  are  but  ex])re.ssions  of  bacterial  invasion  even 
of  those  aj>jxirently  most  solid  structures,  the  teeth;  an<l  of  late  we  have  been  taught 
more  fully  that  such  invasion  may  extend  far  beyond  the  confines  of  the  teeth  alone, 
and  may  spread  to  various,  even  to  distant  j)arts,  and  produce  [)Ossibly  fatal  mischief. 
Absces.ses  in  the  brain  and  extensive  septic  infections  have  been  traced  to  invasion 
along  the  line  of  the  dental  tubules.  One  of  the  most  virulent  of  all  the  common 
inhabitants  of  the  mouth  is  the  pneumococcus  of  P'rankel,  known  also  as  the  micrococcus 
lanceolatus  of  Stebernrg.  In  virulence  it  is  a  variable  organism,  but  it  is  present 
in  a  virulent  state  in  only  12  or  15  per  cent,  of  ca.ses  of  infection  due  to  it.  This  is  the 
organism  which  is  the  cause  of  lobar  pneumonia,  and  frequently  of  bronchopneumonia, 
as  well  as  of  numerous  phlegmons  and  otiier  inflammations  of  the  throat,  and  which, 
getting  into  the  general  circulation  through  the  tonsils  or  other  possible  ports  of  entry 
about  the  mouth,  causes  serious  septic  and  inflammatory  disturbances  in  widely  distant 
regions.  Aside  from  dental  caries,  a  widely  opened  port  of  entry  is  often  aftorded  by 
those  ulcerations  around  the  margins  of  the  gums  which  are  produced  by  accumulations 
of  tartar.  Disease  in  the  antnmi  of  Highmore,  for  instance,  and  many  other  local 
destructions,  are  frequently  caused  in  this  way. 

The  next  most  common  port  of  entry  is  the  tonsils,  faucial,  lingual,  and  pharyngeal, 
which  contain  a  variety  of  crypts  which  are  often  filled  with  .secretions  or  retentions 
loaded  with  bacteria.  One  of  the  most  common  sources  of  an  involvement  of  the 
cervical  lymph  nodes  in  tuberculous  di.sease  is  an  infection  springing  first  from  the 
tonsils  or  the  teeth. 

In  spite  of  the  fact  that  myriads  of  bacteria  are  swept  into  the  nasal  cavities  with  the 
air  we  breathe,  few  are  seen  in  the  nose.  A  peculiar  capsule  bacillus,  closely  alliefl  to 
that  described  by  Friedlander,  has  been  found  in  a  number  of  cases  of  ozena,  while 
the  pneumococciis  of  Frankel  is  also  often  found  there,  and  is  known  to  produce 
abscesses  of  the  brain.  C)ne  specific  organism — namely,  that  of  rhinosderoma — 
concerns  the  nose  almost  solely,  its  first  ravages  being  met  with  in  this  location. 

Alimentary  Canal. — Probably  more  microorganisms  enter  the  alimentary  canal 
than  gain  accos  in  any  other  way,  these  coming  both  from  food  and  drink  as  well  as 
air.  Once  within  its  confines,  few  of  them  are  capable  of  prolonged  existence.  ^^  elch 
states  that  the  meconium  of  newborn  infants  is  sterile,  but  that  within  twenty-four 
hours  it  usually  contains  abundant  bacteria.  That  bacterial  infection  through  this 
passage-way  is  a  fertile  source  of  non-surgical  lesions  is  well  known.  The  possibility 
of  surgical  infections  being  produced  in  the  same  way  is  both  more  remote  and  less 
demonstrable.  Naturally,  anaerobic  organisms  find  here  more  favorable  conditions, 
and  even  extremely  acid  or  extremely  alkaline  conditions  do  not  .serve  to  destroy  all 
such  life.  Pyogenic  cocci  are  often  "present  and  are  frequently  found  in  peritoneal 
exudates.  In  the  intestines  of  herbivorous  animals  the  tetanus  bacilli  and  those  of 
malignant  edema  are  regularly  found.  The  fungus  of  actinomyco.sis  also  finds  its 
way  into  the  bowel  along  with  ingested  food.  Under  ordinary  conditions  the  bde  in 
its  natural  reservoirs  is  free  from  bacteria,  but  the  colon  bacilli  and  pyogenic  cocci 
often   invade  these  precincts. 

GenitO-urinary  Tract.— Even  the  healthy  urethra  may  contain  bacteria,  ^^hlle 
these  may  wander  upward  to  an  indefinite  extent,  it  is  believed  that  the  urine  contamed 
within  the  bladder  in  a  condition  of  perfect  health  is  free  from  bacteria,  and  that  if 
such  gain  entrance  they  do  not  long  remain.  The  same  is  true  of  the  female  bladder  and 
urethra.  The  vagina  contains  organisms  of  manv  species,  some  of  which  do  not  grow 
4 


50  SUIiCUCAL   IWTlloLOdY 

on  ordinary  culture  media,  hut  are  to  he  recoj^nized  hy  tlie  microscope.  While  it  is 
generally  acknowledged  that  the  vaginal  secretion  is,  as  a  rule,  possessed  of  hactericidal 
properties,  there  is  as  yet  no  satisfactory  nor  comprehensive  explanation  of  this  fact, 
its  nonnai  acidity  not  heing  sulHcient  to  account  for  the  fact. 

The  Milk  in  the  Lacteal  Ducts.-  In  a  condition  of  |)erfcct  health  milk  secreted 
from  tile  ideal  maiuniaiy  gland  is  sterile,  but  may  easily  become  coutandnated  upon 
its  exit  from  the  ni|)ple.  Conversely,  under  many  favoring  ccjiiditions  orgaiusms 
may  travel  into  the  lacteal  ducts  from  the  skin  without,  and  thus  contaminate  the  nnlk  , 
In  all  probability  the  breast  corresponds  in  behavior  to  other  glands  whoso  ducts 
open  upon  the  surface,  and,  while  such  openings  invite  entrance  of  bacteria,  their 
migrations  do  not  extend  far  from  the  surface  unless  some  of  the  other  conditions  already 
mentioned  predis))ose  to  further  infection  or  extension. 

In  sunnnarizing  the  general  topic  of  possible  sources  and  jmtlis  oj  infection  bacteria 
may  enter  and  exert  deleterious  action: 

A.  From  wifliin  the  system;  and 

B.  From  without. 

A.  From  witliin  they  may  enter  the  tissues  either  through  the  inspired  air,  through 
food  and  drink,  i.  e.,  ingesta,  or  by  means  of  more  direct  inoculation,  e.  rj.,  by  foreign 
bodies  or  by  venereal  contact.  The  danger  through  infection  by  inspired  air  is  very 
small,  and  concerns  probably  a  limited  nund)er  of  organisms,  of  which  the  tubercle 
bacillus  is  the  most  important.  Foul  air  and  air  which  emanates  from  sewers,  cess- 
pools, etc.,  while  most  uni)leasant  to  breathe  and  deleterious  in  many  other  ways, 
do  not  necessarily  contain  any  microorganisms  which  can  be  injurious.  This  fact, 
in  oi)position  to  general  belief,  is,  nevertheless,  proved  by  recent  investigations.  The 
ino-esta  furnish  the  most  fertile  source  of  contagion  from  within,  but  the  diseases 
thereby  produced  fall  for  the  most  part  into  the  domain  of  medicine  rather  than  that 
of  surgery. 

B.  Injection  from  ivithout  the  body  may  come  by  actual  contact  with  previous  skin 
or  mucous  lesions,  and  particularly  from  noxious  insects  anfl  certain  parasites.  Among 
surgeons  the  princi{)al  sources  of  contact  infection  to  be  enumerated  and  guarded 
against  are: 

1.  Skin  and  hair; 

2.  Instruments; 

3.  Sponges  or  their  substitutes; 

4.  Suture  materials; 

5.  The  hands  of  the  surgeon  and  his  assistants; 

6.  Drainage  materials; 

7.  Dressing  materials; 

8.  From  miscellaneous  sources,  e.  q.,  drops  of  perspiration,  unclean  irrigator  nozzle, 

a  contaminated  nail-brush,  the  clothing  of  the  operator,  etc. 

While  insisting  here  upon  the  recognition  of  these  sources  of  danger,  the  precautions 
to  be  taken  against  them  are  to  be  considered  under  another  heading,  to  which  the  reader 
is  referred. 

One  of  the  greatest  sources  of  possible  infection  has  of  late  been  shown  to  be  the 
presence  of  flies  and  other  noxious  insects,  which  act  as  carriers  of  infection.  The 
Egyptian  ophthalmia,  which  ruins  the  sight  of  30  per  cent,  of  the  inhabitants  of  Egypt, 
has  been  shown  by  Howe  and  others  to  be  due  to  infection  by  this  mechanism;  and  a 
simple  bacteriological  ex])eriment  will  suffice  to  show  that  the  foot-tracks  of  a  single 
fly  across  a  wound  furnish  abundant  opportunities  for  infection  with  organisms  which 
are  presumably  virulent.  In  fact,  the  danger  of  carriage  of  infection  by  this  means  is 
greater  than  from  almost  all  other  sources,  except  the  use  of  improper  materials  during 
surgical  operations. 

CLASSIFICATION  OF  INFECTIONS. 

We  speak  of  infections  as  primari/,  serondori/,  and  mixed;  and  it  is  necessary,  for 
purposes  of  accuracy  at  least,  to  make  a  reasonably  clear  distinction  betw^een  them. 

Primary  Infection. —  By  primary  infection  is  meant  infection  with  a  single  form 
of  oro-anism  whose  effects  are  prompt  and  speedy.  Of  this,  erysipelas  or  syphilis  may 
serve  as  illustrations.     Most  of  the  acute  infections  belong  to  the  primary  type. 


ii.\("ri:in.\  of  its  foumat/ox 


51 


Secondary  Infection.  -  Sccoiidiuv  intVciion  incaiis  that  after  certain  (listurhai.ces 
due  to  a  priiiiaiv  iiileetioii,  t.  c,  one  of  a  j,'iven  type,  there  oeeiirs  at  some  later  period 
iind  from  a  distinct  soiiree  anotlier  infection  whose  results  may  he  more  or  less  disas- 
trous, and  cause  the  ease,  at  least  for  the  time  l)ein<j,  to  assume  a  different  aspect. 
We  have  an  illustration  of  this  in  the  case,  for  example,  of  |)rinuirv  tuherculosis  with 
distinct  infection  of  a  number  of  lymj)h  nodes,  which,  actin<;  as  filters,  have  caufjht  in 
their  tissue  net  a  large  numher  of  tubercle  bacilli  that,  lodfjiiifj  there,  have  produced 
the  usual  well-known  results  and  have  j)ractically  converted  the  infected  nodes  into 
•jranulomata.  In  these  infected  masses  well-known  clian<,'es,  such  as  those  which 
follow  tuberculous  infection — atrophy,  caseation,  calcification,  etc. — maybe  occurrirm, 
when  suddenly  there  comes  infection  of  a  pijofjniir  tyj)e  from  another  source,  and 
su|)puration  of  the  ojranuloma  is  the  result.  It  is  possible  even  to  have  a  tertiary 
injection,  of  which  the  following  may  be  a  hypothetical  instance:  Primary  infection 
with  scarlatina  or  measles,  by  which  vital  susceptibility  is  in  some  instances  lowered; 
as  the  result  of  this,  secondary  tuberculous  infection  in  an  individual  previously  resistant; 
and,  third,  a  siij^purative  infection,  as  above  described. 

In  contradistinction  to  these  distinct  events,  separated  by  an  appreciable,  sometimes 
a  considerable,  length  of  time,  we  recognize  a  mixed  injection,  where  two  or  more  organ- 
isms are  implanted  at  or  about  the  same  time.  An  illustration  of  this  is  seen  in  most 
cases  of  gonorrhea  in  which  there  is  a  synchronous  attack  made  by  the  gonococcus, 
which  is  a  s|)ecific  microorganism,  accompanied  by  staphylococci  or  streptococci, 
whose  effect  will  complicate  the  case  and  make  it  assume  a  less  particulate  type  of 
infection.  Mixed  infections  may  often  occur  in  other  ways,  as  syphilis  and  chancroid, 
chancroid  and  gonorrhea,  etc.  ISIost  cases  of  mixed  infection  belong  rather  to  surgery 
than  to  general  medicine,  and  constitute  an  apparent  \iolation  of  the  rule  to  which 
physicians  often  point — that  two  distinct  infectious  diseases  are  seldom  communi- 
cated or  acquired  at  the  same  time.     Nevertheless,  the  facts  remain  as  above. 

Terminal  Infections. — Terminal  infections  constitute  an  apparent  paradox,  per- 
haps oftener  in  medical  than  in  surgical  cases.  Few  people,  as  Osier  has  shown, 
die  of  the  diseases  from  which  they  suffer.  The  final  exitus  is  due  to  a  more  or  less 
rapid  infection  which  terminates  life.  These  terminal  infections  are  mainly  due  to  a 
few  well-known  microbes,  such  as  the  streptococcus,  staphylococcus  aureus,  pneumo- 
eoccus,  bacillus  proteus,  gonococcus,  bacillus  pyocyaneus,  and  the  gas  bacillus.  In 
surgery  such  infections  are,  perhaps,  most  often  seen  in  mahgnant  lymphoma,  diabetes, 
tuberculosis,  syphilis,  cancer,  and  in  the  so-called  surgical  kidney. 

BACTERIA  OF  PUS  FORMATION. 

Bacteria  which  act  as  agents  in  the  formation  of  pus  are  collectively  known  as 
pyogenic  organisms.     These  are  divided  into  two  groups: 

A.  The  Obligate;  and 

B.  The  Facultative. 

Obligate  pyogenic  organisms  are  those  whose  activity  is  manifested  in  the  direction 
of  pus  formation,  which  seem  to  produce  it  if  they  produce  any  unpleasant  action  what- 
ever. On  the  other  hand,  the  jacultative  organisms  are  those  which  are  known  occa- 
sionally to  be  active  in  this  direction,  and  yet  which  are  not  always  nor  necessarily 
so.  The  members  of  group  A  are  fairly  well  known  and  catalogued,  and  are  not 
numerous.  On  the  other  hand,  there  is  reason  to  believe  that  many  organisms  may 
have  the  occasional  effect  of  producing  pus,  as  it  were,  by  accident  or  at  least  in  a  way 
not  absolutely  natural  or  peculiar  to  themselves,  but  still  are  frequently  found  when 
there  is  no  pus  present.  A  suitable  list  of  the  facultative  organisms,  therefore,  can 
hardly  be  made,  and  will  not  be  here  attempted,  the  effort  being  only  to  mention  the 
more  common  organisms  which  play  this  facultative  role.  It  may  be  mentioned 
also  that  even  the  adjectives  "obligate"  and  "facultative"  are  to  be  accepted  with 
some  mental  reservation,  since  staphylococci,  for  instance,  may  be  met  with  even  in  the 
absence  of  pus,  although  nearly  all  that  we  know  about  these  organisms  implies  that 
pus  would  be  the  result  of  their  presence.  Furthermore,  there  are  certain  other  organ- 
isms, not,  strictly  speaking,  bacteria,  which  also  have  the  power  of  producing  either 
pus  or  pyoid  material.  These  also  will  be  mentioned  in  their  place.  Some  of  them 
belong  not  only  to  the  vegetable,  but  also  to  the  animal  kingdom. 


52 


SURGIC.  [L  PA  TIIOLOG  Y 


Obligate  Pyogenic  Organisms.  A.  The  Staphylococcus  Pyogenes  Aureus,  Albus, 
Citreus,  the  Staphylococcus  Epidermidis,  etc. — One  of  the  characU'ristitvs  of  the 
staphylococei  as  a  trroup  is  the  powerful  peptonizing  aetion  whieh  they  exert.  More- 
over, the  chemieal  ])roducts  of  their  life  ehanges  seem  to  be  more  potent  in  a  local 
than  a  general  way,  leading  to  greater  destruction  of  tissue  in  their  immediate  vicinity, 
with  greater  iiiliihition  .of  the  chemotactic  powers  of  the  leukocytes;  that  is,  with 
more  interference  with  phagocytosis,  by  which  their  |)rogress  would  be  interfered  with. 
Their  presence  is  recognized  by  a  peculiar  odor,  as  of  sour  paste,  which  should  lead  to 
a  prom[)t  cliangi>  of  dressings  and  disinfection  of  the  wound  (by  irrigation,  spraying  with 
hydrogen  dioxide,  etc.). 

B.  Streptococcus  Pyogenes  and  Streptococcus  Erysipelatis. — These  two  organisms 
do  not  diifcrin  morphology  nor  characteristics,  and,  while  for  some  time  considered  as 
distinct  from  each  other,  are  now  by  most  observers  regarded  as  identical.  The  strep- 
tococci grow  in  chains  of  variable  length,  and  individual  cocci  vary  in  size.  They 
grow  -with  and  without  oxygen,  in  all  media,  at  ordinary  temperatures,  do  not  liquefy 
gelatin,  stain  readily,  sometimes  but  not  invariably  coagulate  milk,  and  vary  in  lon- 
gevity. They  differ  extraordinarily  in  virulence  according  to  their  sources. 
^  There  are  many  streptococci  not  included  under  the  al)ove  head  which  are  indis- 
tinguishable mor))hologicalIy  aiul  in  other  respects,  and  yet  which  are  partly  or  entirely 
free  from  pathogenic  activity  in  man.     A  biological  study  reveals  remarkable  and  unex- 

FiG.  5 


Staphylococci  in  pus.       ■.  1000. 
Pfeiffer.) 


(Friinkel  and 


Streptococci  in  pus.     X  1000.     (Frankel  and 
Pfeiffer.) 


plainable  transformation  between  the  different  members  of  this  species,  a  part  of  which 
may  be  referable  to  conditions  pertaniing  to  the  organisms  infected,  hut  part  of  which 
apparently  pertains  to  tin  bacteria.  It  is  held  by  some  that  scarlatina  is  an  invasion  by 
certain  organisms  of  this  class;  this,  however,  is  not  yet  definitely  established.  When 
found  in  the  stools  of  children  with  summer  diarrheas  they  are  regarded  as  indicating 
ulceration  of  the  intestinal  mucosa. 

In  contradistinction  to  the  staphylococci,  the  streptococci  manifest  a  predilection  for 
lymph  vessels  and  lymph  sjoaces,  along  which  they  extend  with  great  rapidity.  They 
have  less  pei)tonizing  power  than  the  staphylococci  (except  in  the  absence  of  oxyo-en)- 
hence  streptococcus  infection  assumes  usually  the  type  of  widespread  infiltration  rather 
than  of  circumscribed  and  distinct  edema.  One  .s(>es  remarka})le  instance's  of  this  in 
cases  of  phlegmonous  erysij^elas.  It  is  suggc-sted  also  that  the  peculiar  manner  of  o-rowth 
of  the  streptococci,  in  long  chains  which  may  coil  up  and  entangle  blood  corpuscles  has 
much  to  do  with  the  formation  of  fat  emboli  and  with  pyemic  disturbances.  ' 

Both  these  bacterial  forms  have  the  power  of  producing  lactic  fermentation  in  milk- 
and  lactic-acid  formation  sometimes  takes  place  with  suppuration  in  the  human  tissues' 
causing  acidity  of  discharge,  sour  odor,  and  watery  pus.  It  appears  also  that  these 
two  pyogenic  forms  have  less  power  of  ptomain  or  toxin  formation  than  manv  others 
and,  consequently,  that  the  pyrexia  attending  suppuration  or  purulent  infiltration  is 
not  always  to  be  ascribed  to  this  cause  alone,  for  fever  may  in  some  measure  be  due  to 


BACTERIA    OF  PUS  FORM ATlOS 


53 


tissue  metal)oli.sm  attcndiiiii:  their  (growth,  (he  nietahoHc  pnxhirts  heiiifj  pyretic.  This 
is  in  a  measure  substantiated  by  the  fever  atteiuiinf,'  trichinosis,  where  the  question  of 
ptoniain  |)()is()iiiui;  has  not  yet  h(>en  raised. 

C.  Micrococcus  Lanceolatus.— Micrococcus  lanccohitus  is  also  known  as  the  diplo- 
coccHs  punnuou'ur  or  the  jjucuniococcus  of  Friinkel  and  Weichselhauin,  and  as  the 
micrococcu.s'  of  .s-piitiim  srptironia  of  Pasteur  and  of  Sternberg;.  It  is  of  interest  to  sur- 
fjcons  because  it  causes  many  loc-aH/,ed  inflam- 
mations and  is  a  frecjuent  factor  in  eausiu}]; 
septicemia;  it  is  often  present  in  the  mouths 
of  heahhy  individuals.  It  may  produce  the 
various  forms  of  exudates  as  the  result  of  con- 
gestion set  uj)  by  its  presence;  also  otitis  media, 
menini;itis,  osteomyelitis,  and  suj)purative  dis- 
turltance  in  the  periosteum,  the  salivary  o;lands, 
the  thyroid,  the  kidney,  tlx-  endocardium,  etc. 

I).  The  Micrococcus  Tetragenus. — Suj)|)ura- 
tions  produced  by  tlicse  orfjanisms  arc  ])ro- 
longed,  mild  in  character,  not  j)ainful,  but 
accompanied  by  much  brawny  iiuhiration  of 
tissues. 

E.  The  Micrococcus  Gonorrhoeae. — The  micro- 
coccus ^onorrluea-,  or  gonnrocciis,  is  found  con- 
stantlv  in  the   pus  of  true  gonorrhea,  in  manv        ,,.  ,  .,,,., 

•  .  ,'     .  ^       ,  ■       i>    ,1  •  "  I'lplococcus  pneumoniae  of  Friinkel.     (Karcr 

cases  the  pus  bemo;  a  pure  culture  ot  this  or-  and  Schmori.) 

ganism.      These    cocci    are    generally    seen    in 

pairs  (biscuit-shaped),  while  their  inclusion  within  the  leukocyti's  or  their  attachment 
in  or  to  epithelial  cells  is  characteristic.  Unlike  other  pyogenic  cocci,  they  do  not 
stain  by  Gram's  method,  being  decolorized  by  iodine,  by  which  fact  tiiey  may  be  dis- 
tinguished. They  are  cultivated  with  difficulty,  and  are  known  rather  by  their  clinical 
effects  than  by  their  laboratory  characteristics;  are  human  parasites,  other  animals,  so 
far  as  known,  being  practically  immune.  The  gonococcus  may  also  produce  abscesses, 
and  may  be  carried  to  distant  parts  of  the  body,  where  its  effects  are  commonly  noted  as 
pyarthrosis,  athough  endocanlitis,  pericarditis,  pleurisy,  etc.,  are  known  to  l)e  due  to  it, 
and  fatal  pyemia  has  been  produced  in  consequence.  In  some  way  it  is  probal)lv 
the  ex])lanation  of  the  post  gonorrheal  arthritis,  wrongly  spoken  of  as  gonorrheal 
rheumatism. 

F.  The  Bacillus  Coli  Communis  or  Colon  Bacillus. — This  is  an  inhabitant  of  the 
intestinal  canal;  varies  extremely  in  virulence  and  somewhat  in  morpliological  appear- 
ances; coagulates  milk;  is  often  associated  with  other  organisms;  migrates  easily  both 
along  the  alimentary  canal  and  from  it  into  the  surrounding  tissues  or  channels.  It 
is  a  disturbing  element  in  the  production  of  kidney  and  hepatic  disease,  also  in  the 
production  of  appendicitis  and  peritonitis.  Ordinarily  its  pyogenic  properties  are  not 
virulent;  occasionally,  however,  it  becomes  extremely  virulent. 

G.  The  Bacillus  Pyocyaneus. — The  bacillus  pyocyaneus,  a  widely  distributed  organ- 
ism, often  observed  in  the  skin  and  outside  of  the  body;  a  motile,  liquefying  l)acillus, 
growing  at  ordinary  temperatures,  seldom  .seen  alone,  but  occasionally  producing  pus 
without  association  with  other  organisms;  it  stains  the  discharges  and  dressings  a  bluish- 
green  and  imparts  sometimes  an  offensive  odor.  Suppuration  caused  by  this  bacillus  is 
usually  prolonged,  but  characterized  l)y  little  constitutional  disturbance. 

Facultative  Pyogenic  Organisms — /.  e.,  those  which  have  the  power  of  provoking 
suppuration,  but  v^■hich  have  other  and  more  distinct  pathogenic  activities  as  well. 

A.  Bacillus  Typhi  Abdominalis. — This  is  found  in  many  ])us  foci,  developing  during 
or  after  typhoid  fever.  It  is  occasionally  met  with  alone,  though  most  of  these  abscesses 
are  really  mixed  infections.  It  is  generally  found  in  the  bone  or  beneath  the  periosteum. 
Such  abscesses  are  frequently  seen  in  the  ribs,  and  may  not  be  noticed  until  months  after 
convalescence  from  the  fever.  The  pus  contained  within  them  is  not  always  typical  in 
appearance,  but  may  be  unduly  thin  or  unduly  thick. 

B.  Bacillus  Proteus. — Under  this  name  are  included  three  distinct  forms,  which  were 
originally  descril)ed  by  Hauser  as  distinct  species,  but  which  are  now  regarded  as  pleo- 
morphic forms  of  the  same  organism.     It  is  a  motile  bacillus,  met  with  in  decomposing 


54  Sl'h'<;iCAL   PATIKiLOaV 

animal  and  vcgetahlr  material,  and  oc-casionally  found  in  (lie  alimentary  canal.  It 
has  been  known  to  produce  |)u.s,  especially  in  the  peritoneal  cavity  and  about  the  appen- 
dix.    It  may  even  cause  <reiieral  infection  and  peritonitis. 

C.  Bacillus  Diphtheriae.  A  uoii-motile  bacillus,  varvinj^;  considcral)!}'  in  size  and 
shape,  chan<i;in<f  tiic  reaction  in  sweet  bouillon  from  acid  to  alkaline;  produces  a  danger- 
ous infective  inflannnation  of  exposed  surfaces,  with  tenacious  exudate  amounting  to 
a  distinct  membrane.  As  a  j)art  of  its  life  history  it  also  ])roduces  a  toxalbumin,  which 
is  one  of  the  most  powerful  cell  ])oisons  known,  the  disintegration  of  the  cell  constituents 
due  to  its  action  being  rapid  and  pronounced.  This  accomits  for  the  heart  failures 
which  are  often  re|)orted  in  connection  with  the  disease. 

D.  Bacillus  Tetani. — More  will  be  said  about  this  organism  when  considering  tetanus, 
and  to  that  subject  the  reader  is  referred.  The  tetanus  bacillus  is  occasionally  found  in 
pus  which  comes  from  the  area  through  which  the  original  infection  was  produced. 
But  these  bacilli  do  not  travel  to  any  distance  in  the  human  body,  and  are  seldom  found 
away  from  the  area  involved.  Under  most  circumstances  the  pus  is  the  product  of  a 
mixed  infection. 

E.  Bacillus  (Edematis  Maligni. —  This  organism  will  be  more  fully  considered  under  a 
different  heading.  (See  Malignant  Edema.)  It  is  a  long,  anaerobic  bacillus,  widely 
distributed  in  the  soil  and  the  feces  of  animals.  It  is  believed  that  this,  like  the  tetanus 
bacillus,  may  occasionally  lead  to  formation  of  pus. 

F.  Bacillus  Tuberculosis. — This  organism  likewise  will  receive  fuller  description  in  an 
ensuing  chapter.  (See  Tuberculosis.)  The  pus  of  old  cold  abscesses  in  which  the 
more  obligate  pyogenic  organisms  have  long  since  died  usually  contains  this  organism 
in  mildly  virulent  form.  On  the  other  hand,  fresh  suppurations  occurring  in  connection 
with  tuberculous  disease  are  mixetl  infections.  There  is  reason  to  believe,  however, 
that  this  organism  is  capable  of  producing  pus  even  when  none  of  these  are  present; 
for  example,  in  that  form  of  acute  miliary  tuberculosis  which  is  occasionally  met  with 
as  bone  abscess  it  may  be  found. 

G.  Bacillus  Anthracis. — This  is  one  of  the  most  malignant  and  resistant  organisms 
known,  being  in  the  highest  degree  poisonous  for  the  smaller  animals,  man  being  less 
susceptible.  One  of  its  characteristic  lesions  in  the  human  body  is  a  form  of  pustule 
commonly  known  as  malignant  'pustule,  the  pus  in  which  is  usually  a  pure  culture  of 
this  organism.     (See  Anthrax.) 

H.  Bacillus  Mallei. — This  is  the  organism  which  produces  glanders  in  the  lower 
animals  and  in  man.  That  form  of  the  disease  known  as  farcy,  in  which  the  infected 
nodules  rapidly  l)reak  down,  is  likely  to  contain  pus  which  will  be  more  or  less  a  pure 
culture  of  this  organism. 

I.  Bacillus  Leprae. — This  is  the  microorganism  which  produces  leprosy,  closely 
resembling  the  tubercle  bacillus.  It  is  constantly  and  exclusively  present  in  the  lesions 
of  leprosy,  which  are  often  of  the  su])purativ(>  ty]X',  the  bacilli  being  enclosed  within 
pus  cells;  it  is  also  found  in  the  fluid  surrounding  them.  Although  suppuration  in 
these  cases  may  be  in  a  large  measure  due  to  secondary  infection,  it  is  positive  that  the 
leprous  bacilli  deserve  to  })e  grouped  in  this  place. 

J.  The  Bacillus  Pneumoniae  of  Friedlander. — The  bacillus  pneumonia^  of  Fried- 
lander  was  at  one  time  regardetl  as  the  cause  of  croupous  j)neumonia,  which  is  now  known 
to  be  due  to  the  micrococcus  lanceolatus.  The  Friedlandei  bacillus,  however,  is 
capable  of  producing  bronchopneumonia,  and  is  occasionally  met  with  in  empyema, 
suppurative  meningitis,  and  inflammations  about  the  nasopharyngeal  cavity,  of  which 
it  is  known  to  be  an  occasional  inhabitant. 

K.  The  Bacillus  of  Rhinoscleroma. — A  distinctive  organism  has  Ikhmi  described  for 
this  disease  and  given  this  name.  It  has  such  wide  morphological  ditt'erences,  however, 
that  it  is  possible  that  it  is  only  the  bacillus  of  Fricdli'inder  abov(>  mentioned.  At  all 
events,  an  organism  of  this  general  character  is  constantly  found  in  this  disease  in  the 
thickened  tissues  from  the  nose  (Fig.  S). 

L.  The  Bacillus  of  Bubonic  Plague. — This  was  recently  discovered  by  Kitasato, 
and,  in  view  of  the  recent  ravages  of  the  disease  in  the  Orient,  has  assumed  considerable 
importance.  It  grows  upon  most  media,  and  is  found  in  th(>  blood,  in  buboes,  and  in 
all  internal  organs  of  pateints  suffering  from  this  disease.  The  smaller  animals  are 
susceptible  upon  inoculation.  Animals  fe<l  with  inoculated  foods  die  also,  showing 
the  possibility  of  infection   through   the   intestine.     When   exjiosed   to  direct  sunlight 


FUNGI 


55 


for  a  tVw  hours  tlic  hacilliis  dies.  'V\h-  ovncral  syinploiiis  of  the  dis.'asc  arc  those  <.f 
heiiioiTlia^ic   septicemia    and    ils    coiisc(|iiciiccs. 

M.  The  Bacillus  of  Rauschbrand.  This  is  seldom,  if  ever,  seen  in  this  eonntrv. 
It  is  known  in  Kn^land  as  "the  hhick-lcn;"  <,r  "(|nartcr-<-viL"  It  is  an  anacrohic  or^ranisiii^ 
fiT(|Ucntl.v  met  with  in  cattle,  which  causes  a  peculiar  empiiyseina  of  suhcntaneous 
tissue,  spreads  deeply,  and  is  followed  hy  a  copious  exuchitc  of  dark  scrum  with  j;as 
formation.  The  smaller  animals  are  not  ordinarily  inoculahie;  hut  if  to  the  culture 
niJiterial  there  is  added  L'O  j)er  cent,  of  lactic  acid,  their  insusce|)tihility  is  overcome  and 
they  siiccumh  to  the  (hsease.  So,  also,  as  in  the  case  of  the  tetanus  haCillus,  hy  a<lrliti()n 
of  the  l)acilius  prodi<,nosus  or  of  proteus  vul<faris  the  disease  may  he  |)roduced  in  other- 
wise insusceptihlc  animals. 

.\.  The  Bacillus  Aerogenes  Capsulatus.  'I'h<-  hacilhis  ai'ro^fcncs  capsulatus  seems 
capable  sometimes  of  caiisin<j  pyotrenic  and  even  fatal  infection.  Its  presence  is  a.sso- 
ciated  with  <xas  formation.      It  ffrows  as  an  aiiaj'rohc. 

().  The  Bacillus  of  Chancroid,— The  bacillus  of  chancroid  identified  hv  Ducrev,  and 
briefly  tlescribed  in  (he  chapter  on  tliat  subject. 


Fin.  7 


Fio.  8 


Rhinoscleroma :  infiltration  of  tissues  about  the  no.se. 
(Case  reported  by  Dr.  Wende,  Buffalo.) 


Bacilli  of  rhino.^cleroui: 


Pfeiffer.) 


YEASTS. 

Busse  was  the  first  to  call  attention  of  clinicians  and  patholofiists  to  the  role  played 
by  yeasts  in  certain  infections.  Since  the  original  observations  of  Bus.se  in  a  case  in 
which  the  organism  produced  a  general  infection,  the  lesions  of  which  were  a  combina- 
tion of  tumor  and  abscess  formation,  various  observers  have  noted  the  presence  of  patho- 
genic yeasts,  usually  in  skin  lesions.  Gilchrist  and  Stokes  were  the  first  in  this  country 
to  determine  the  nature  of  these  organisms,  and  their  observations  have  been  followed 
by  the  detection  of  a  large  number  of  similar  cases.  In  the  skin  lesions  the  organisms 
are  found  in  minute  abscesses;  in  the  subcutaneous  ti.ssue  and  in  the  infcctif)ns  similar 
to  tho.se  of  Bu.s.se  large  absces.ses  surrounded  by  extensive  ma.s.ses  of  granulation  tissue 
characterize  the  infection.  The  organisms  can  be  detected  in  the  pus  by  means  of 
an  examination  of  the  fresh  unstained  fluid  (Fig.  9). 


FUNGI. 


Besides  the  micro-organisms  ever\^vhere  grouped  as  bacteria,  there  are  other  minute 
organisms  which  have  also  the  power  of  engendering  pus.  One  of  th(>sc  is  the  ray 
fungus,  known  as  the  acHnomycis ,  which  causes  the  disease  known  as  lumpy  jaw  {)r 
actinomycosis.  Suppuration  i.s  always  a  concomitant  of  the  advanced  lesions  ot  this 
disease,  and,  while  it  may  be  in  many  instances  a  mixed  infection,  it  is  not  necessarily 


56 


SURGICAL  PATHOLOGY 


so.  Moreover,  the  pus  producetl  under  these  (inuiiistances  contains  minute  calcareous 
particles  which  are  pathognomonic,  by  which  a  diagnosis  can  sometimes  be  made 
off-hand. 

Besides  these  fungi,  others,  belonging  rather  to  the  class  of  vegetable  molds,  which 
are  yet  pathogenic  for  human  beings,  may  be  occasionally  met  with  under  these  circum- 
stances— e.  g.,  ilir  fiingns  of  Mcuhtra  foot,  the  Icptothrix,  and  other  molds  from  the 
mouth,  while  the  different  varieties  of  aspi'ujilln.s  may  be  found  in  pus  about  the  ear  or 
even  in  that  from  the  brain. 


PROTOZOA. 

The  protozoa  have  the  power  of  producing,  if  not  absolute  ideal  pus,  something  so 
nearly  resembling  it  that  we  may  include  them  among  the  facultative  pyogenic  organisms. 
The  best  known  of  these  protozoa  are  the  amrlxr.  which  are  met  with  in  the  intestinal 
canal  in  some  countries,  occasionally  in  the  I 'nited  .States,  especially  as  the  exciting  cau.ses 
of  a  peculiar  type  of  dysentery  often  accompanied  by  abscess  of  the  liver.  In  these 
abscesses  the  amebje  are  found,  and  no  other  organisms.     Another  group  of  the  protozoa. 

Fig.  9 


-b(? 


Blastomycetic  pus  (fresh;. 


1000.      KJaylord.) 


known  to  biologists  as  the  coccidia,  are  also  capable  of  causing  pus  formation,  more 
particularly  in  some  of  the  lower  animals.  Numerous  other  parasites,  belonging  higher 
in  the  animal  kingdom,  are  undoubted  exciters  of  pus  formation,  though  it  is  not  neces- 
sary to  lengthen  the  li.st  beyond  those  already  mentioned. 

Protozoa  have  recently  been  established  as  the  active  agents  in  the  production  of  small- 
pox and  probably  also  of  scarlatina.  They  have  been  .seen  so  generally  in  and  around 
cancer  cells  as  to  make  it  extremely  probable  that  cancer  is  a  protozoan  infection.  In 
syphilis  also  they  are  found  as  the  spirochrto',  now  n^garded  as  its  cause. 

Protozoa  are  as  ubiquitous  as  bacteria,  but  their  recognition  is  as  yet  more  difficult, 
as  but  little  is  known  of  them.  The  numerous  stages  through  which  they  pass  in 
completing  their  life  cycles  only  complicate  the  subject,  while  the  difficulties  encountered 
in  cultivating  them  are  still  to  be  overcome.  As  we  become  more  familiar  with  them 
we  shall  more  frequently  find  them  lo  be  pathogenic  organisms. 


SUPPURATION  57 

CLINICAL  CHARACTERISTICS  OF  PUS  FROM  DIFFERENT  AGENCIES. 

Staph ijlococcus. — Dirty  white,  niodcratciy  tliick,  with  .sour-puslc  odor. 

SircptorocruJi. — Thin,  white,  often  with  shreds  of  tissue. 

Colon  Bacillius. — Tliiek,  brownisli,  with  fetid  odor,  or  thin,  dirty  white,  with  thicker 
raas.ses. 

M icrorncnts  Lanrrohitu.s . — Thin,  watery,  greenisli,  often  copiotis. 

Bacillus  Pi/<)ri/a)i(it.s-. —  Distinctly  green  or  l)lue  in  tint. 

Bacillus  Tuhcrculo.s-i.s. — Thick,  cnrdy,  wiiite  j)iistc,  or  thin,  <;reenish,  with  small, 
cheesy  lumps  or  even  with  bone  sj)iciiles. 

Actinoiiii/cis. — Thick,  brownish  white,  with  small,  firm,  gritty  or  chalky  nodules  of 
yellow  color. 

Ameba  Coli. — Thick,  l)rownish  red. 


BACTERIAL  DETERMINATION  AS  AN  INDICATION  IN  TREATMENT. 

There  is  a  ])ractical  side  of  great  importance  pertaining  to  the  recognition  ot  the  nature 
of  the  infectious  organism  in  many  cases  of  suppuration  and  abscess.  For  instance, 
pus  which  is  due  to  streptococcus  invasion  indicates  a  collection  which  shouhl  be  freely 
evacuated  and  carefully  drained.  This  is  also  true  in  essential  resjx'cts  of  staphylo- 
coccus pus,  particularly  that  due  to  the  streptococcus  aureus.  Putrid  pus  from  any 
source  requires  disinfection  and  free  drainage,  the  former  preferably  perhaps  by  hydrogen 
dioxide.  Pus  which  is  due  to  the  colon  bacillus  is  not  often  extremely  virulent,  which 
accounts  for  so  many  cases  of  appendicitis  recovering  with  or  without  operation. 
A  collection  of  this  pus  needs  little  more  than  mere  drainage  and  opportunity  for  escape. 
Pus  from  a  recognizable  tuberculous  source  may  .still  contain  living  tubercle  bacilli. 
This  means  either  that  the  cavity  whence  it  came  should  be  completely  destroyed  and 
eradicated,  or  else  that  the  margins  of  the  incision  or  opening  through  which  it  has 
escaped  should  be  .so  cauterized  that  infection  of  a  fresh  surface  is  impossible.  The 
same  is  true  of  absce.s.ses  due  to  glanders  bacilli  and  to  certain  ca.ses  of  suppurating  bubo 
following  chancroid,  where  the  whole  course  of  events  shows  the  virulent  character  of 
the  organisms  at  fault. 

SUPPURATION. 

Although  it  may  be  possible  to  produce  in  certain  laboratory  experiments  metamor- 
phosed material  which  very  closely  simulates  pus,  or,  in  fact,  by  injection  of  chemical 
irritants,  to  sometimes  imitate  the  suppurative  processes,  nevertheless,  the  student 
should  be  brought  face  to  face  with  the  statement,  to  which  for  surgical  purposes  there 
is  no  practical  exception,  that  suppuration ,  i.  e.,  jorviation  of  pus,  is  due  to  the  presence 
in  the  tissues  of  the  specific  irritants  already  catalogued  and  described,  and  of  the  penihar 
peptonizing  or  other  biochemical  changes  which  bacteria  exert  upon  Inking  animal  cells. 

Coagulation  Necrosis. — Coagulation  necrosis  is  the  term  applied  to  the  characteri.stic 
changes  occurring  in  the  tissue  cells  when  thus  attacked,  which  may  be  summarized 
as  a  fading  away  of  cell  outlines,  diminution  in  reaction  to  reagents,  and  a  merging 
of  cells  and  intercellular  substance.  Coagulation  necrosis  is  not  the  only  result  of  bac- 
terial activity,  but  may  be  produced  by  other  cau.ses.  Nevertheless,  pyogenic  bacteria 
do  not  exert  their  deleterious  action  upon  the  tissues  without  occasioning  changes 
included  under  this  term.  In  an  area  thus  infected,  as  already  described,  leukocytes, 
i.  €.,  phagoc\-tes,  are  present  in  increa.sed  number  for  purposes  already  mentioned. 
As  we  approach  the  centre  of  activity  phagocytes  are  more  numerous  than  cells,  and 
intercellular  barriers  completely  break  down.  When  bacteria  are  found  in  greatest 
number,  there  also  occurs  the  greatest  phagocytic  activity,  and  there  also  will  be  found 
the  evidence  of  suppuration,  i.  e.,  pus.  As  already  indicated,  the  polynvclear  leuko- 
cytes are  most  active  in  the  process  of  defence.  Where  coagulation  necrosis  is  most 
marked  there  has  been  the  greatest  activity  of  conflict  with  the  greatest  death  of  cells. 
Around  these  areas  bacteria  and  cells  are  found  in  indiscriminate  arrangement.  Ti.s.sue 
vitality  is  impaired  by  intoxication  of  the  cells  by  the  excretory  products  of  the  bacteria, 


58  SURGICAL  PATHOLOGY 

i.  e.,  the  so-callod  ptorniiins,  toxins,  etc.,  unci  their  |)()\\cr  of  rt'.si.stuncc  is  thus  weakened. 
From  the  nieehanieul  results  of  pressure  tension  around  the  centre  of  activity  is  increased, 
by  which  tension  vitality  is  still  more  impaired  and  more  rapid  tissue  death  occurs. 
Thus  there  occurs  mifrration  or  hiiiiowing  of  })us;  or,  to  state  it  more  clearly,  the  tissues 
break  down  in  front  of  the  advan(in<^  destruction,  and  in  the  direction  of  least  resistance. 
This  is  known  as  the  poinfitu/  of  pii.s,  which  brings  it  many  times  to  the  surface,  and 
often  in  other  and  less  desirable  directions. 

Abscess. — An  abscess  is  a  circumscribed  collection  of  pus.  The  tei-m  is  used  in  con- 
tradistinction to  purulent  injiliration,  in  which  the  collection  is  not  circumscribed,  but 
is  exceedingly  diifuse  and  extends  itself  in  various  directions,  the  amount  at  any  spot 
being  almost  inapprecial)le.  Purulent  infiltration  is  regarded  as  the  more  serious  of  the 
two  conditions,  as  it  is  more  difficult  for  pus  to  escape  under  these  circumstances  than 
when  it  can  be  evacuated  through  a  single  opening.  The  term  phlegmon  is  one  now 
generally  used  to  indicate  a  suppurative  process,  usually  of  the  general  character  of  puru- 
lent infiltration  rather  than  of  abrupt  abscess,  but  generally  employed  to  include  both 
conditions.  The  adjective  phlegmonous  is  coupled  with  the  names  of  other  surgical 
infectious  diseases  to  indicate  that  it  is  complicated  by  suppuration,  e.  g.,  phlegmonous 
erysipelas.  Pus  is  a  product  of  bacterial  activity  usually  formed  rapidly  rather  than 
otherwise,  and  abscess  formation  or  phlegmonous  activity  of  any  kind  is  a  question  of 
but  a  few  days.     Empijema  means  a  collection  of  pus  in  a  preexisting  cavity. 

The  significance  of  this  condition  is  well  described  in  the  story  of  inflammation  and 
suppuration,  to  paraphrase  Sutton,  read  zoologically,  as  though  it  were  the  story  of  a 
battle:  The  leukocytes  (phagocytes)  are  the  defending  army,  the  vessels  its  lines  of 
communication,  the  leukocytes  being,  in  effect,  the  standing  army  maintained  by  every 
composite  organism.  When  this  body  is  invaded  by  bacteria  or  other  irritants,  informa- 
tion of  the  invasion  is  telegraphed  by  means  of  the  vasomotor  nerves,  and  leukocytes 
are  pushed  to  the  front,  reinforcements  being  rapidly  furnished,  so  that  the  standing 
army  of  white  corj^uscles  may  be  increased  to  thirty  or  forty  times  the  normal  standard. 
In  this  conflict  cells  die,  and  often  are  eaten  by  their  companions.  Frequently  the 
slaughter  is  so  great  that  the  tissues  become  burdened  by  the  dead  bodies  of  the  soldiers 
in  the  form  of  pus,  the  activity  of  the  cells  being  proved  by  the  fact  that  their  protoplasm 
often  contains  bacilli  in  various  stages  of  destruction.  These  dead  cells,  like  the  corpses 
of  soldiers  who  fall  in  battle,  later  become  hurtful  to  the  organism  which,  during  their 
lives,  it  was  their  duty  to  protect,  for  they  are  fertile  sources  of  septicemia  and  pyemia. 
This  illustration  may  seem  romantic,  but  is  warranted  by  the  facts. 

Around  the  margin  of  the  site  of  an  acute  abscess  a  barrier  is  formed  by  condensation 
and  cell  infiltration  of  the  surrounding  tissues.  This  is  not  a  distinct  wall  nor  membrane, 
yet,  nevertheless,  serves  as  a  sanitary  cordon  to  confine  the  mimic  conflict  within  reason- 
able bounds.  This  is  the  zone  of  real  inflammation;  within  it  there  are  tissue  destruction 
and  coagulation  necrosis.  By  virtue  of  the  peptonizing  power  of  the  pyogenic  organisms 
the  parts  involved  in  this  necrosis  gradually  litjuefy  the  intercellular  substance  dissolving 
first.  It  is  this  which  in  the  main  forms  the  fluid  portion  of  the  pus.  Various  tissues 
show  widely  differing  resistance  to  this  softening  process.  In  true  glands  the  inter- 
lobular septa  seem  to  break  down  first,  and  in  this  way  suppuration  extends  around  the 
acini  or  gland  lobules,  and  thus  pus  may  contain  masses  of  easily  recognizable  size. 
These  masses  are  ordinarily  known  as  sloughs. 

It  is  by  virtue  of  the  so-called  lym|)hoid  cells,  which  are  those  principally  involved  in 
producing  the  barrier  or  boundary  of  the  acute  abscess  as  above  described,  that  granu- 
lation tissue  is  formed,  which  takes  up  the  effort  of  repair  as  soon  as  pus  is  evacuated. 
This  boundary  has  no  sharp  limit,  but  shades  off  into  healthy  surrounding  tissues. 

Under  the  term  "abscess"  is  meant  that  which  is  described  as  acute  abscess.  Under 
certain  circumstances,  especially  when  they  are  produced  by  the  facultative  pyogenic 
organisms  rather  than  the  obligate,  abscesses  form  more  slowly,  and  may  be  spoken  of 
as  subacute.  These  are  terms  used  in  contradistinction  to  the  so-called  cold  absces.ses, 
which,  although  clinically  bearing  a  certain  resemblance  to  the  acute,  are  in  almost  every 
pathological  respect  different  from  it.  Cold  abscesses  will  be  considered  under  the  head 
of  Tuberculosis.  It  is  possible  to  have  an  acute  pyogenic  infection  of  a  cold  abscess; 
in  such  case  we  have  acute  manifestations.  Graintation  abscesses  are  those  where  pus 
forming  in  one  part  tends  to  migrate,  usually  in  the  direction  in  which  gravity  would 
take  it,  extending  into  portions  deeper  or  lower.     Perhaps  the  best  illustration  of  this  is 


SUPPURA  Tins  59 

the  ji()iiitin<]f  of  a  psoas  abscess  helow  Poupart's  lifjainent.  Mrta.s-taiir  abscesses  are  ihoae 
w  liicli  are  t'onued  as  the  result  of  embolic  processes,  each  one  being  in  miniature  a  repe- 
tition of  a  lesion  which  has  occurred  at  some  other  |)art  of  the  body.  Tlie  underlyinj; 
fact  concerning  metastatic  abscesses  is  that  the  primary  j)rocess  has  occurred  in  some 
other  j)ortion  of  the  body,  whence  it  has  been  distributed  as  above.  These  will  be  con- 
sidered in  the  chapter  treating  of  Pyemia. 

The  jiroduct  of  all  acute  suppurative  lesions  is  pu^t.  This  is  an  o])a(|ue  fluid  of  creamy 
consistence  and  whitisli  or  grayish  appearance,  varying  in  density,  met  with  in  amounts 
from  a  minute  drop  to  half  a  gallon  or  more.  Under  ordinary  circumstances  it  is  odor- 
less, and  its  reaction,  either  acid  or  alkaline,  is  very  faint.  It  is,  like  the  blood,  composed 
of  a  fluid  and  a  solid  portion.  The  solid  portion  consists  of  so-called  jms  corpuscles 
and  other  debris  of  tissue,  which  vary  with  the  site  of  the  disease  and  the  parts  involved. 
The  source  of  the  pus  corjnisdes  has  been  cited  and  the  statement  made  that  they  are 
in  effect  the  bodies  of  j)hagocytes  which  have  perished  in  the  biochemical  fight  for 
existence  of  the  ])arent  organism.  Cocci  or  bacilli  are  found  in  pus  corpuscles  and 
also  in  the  surrounding  fluid. 

Pus  should  be  without  odor,  but  under  certain  circumstances  it  po.s.scs.ses  an  odor 
^vhich  will  vary  in  character  accortling  to  the  source  of  the  pus  or  the  nature  of  its  prin- 
cipal bacterial  excitant.  Pus  from  the  upper  end  of  the  alimentary  canal  frequently 
has  the  sour  smell  of  gastric  contents;  that  from  the  neighborhood  of  the  lower  end,  the 
fetid  odor  which  is  for  the  most  part  due  to  the  action  of  the  colon  bacillus.  Inasmuch 
as  colon  bacilli  are  found  in  widely  distant  parts  of  the  body,  they  may  also  give  an 
impleasant  odor  to  pus  even  from  a  brain  abscess.  When  the  pus  has  become  contaminated 
with  the  ordinary  saprophytic  organisms,  it  may  smell  like  any  other  decomposing  mate- 
rial. The  older  writers  called  it  icJwrous  pus,  ^vhile  sa?iious  pus  was  suppo.sed  to  be  that 
more  or  less  mixed  with  blood,  undergoing  ammoniacal  decomposition  or  else  strongly 
acid.  Pus  sometimes  has  a  well-marked  blue  or  bluish-green  tint.  This  is  due  to  the 
presence  of  the  bacillus  pyoci/aneus,  already  descriljed.  An  orange  tint  is  sometimes 
given  by  the  presence  of  hematoidin  crystals,  due  to  the  original  hemorrhagic  character 
of  the  infected  exudate.  The  former  appearance  indicates  usually  a  slow  course  to  the 
suppurative  lesion,  while  the  latter  has  been  regarded  by  some  as  affortling  an  unfavor- 
able prognosis.  Distinctly  red  pus,  who.se  tint  is  due  to  the  presence  of  a  bacillus  giving 
bright-red  cultures  on  blood  serum,  has  been  noted  in  other  instances.  This  can  readily 
be  distinguished  from  blood,  because  ujjon  dressings  it  does  not  change  color. 

Pus  may  form  superficially,  when  it  is  called  subcutaneous  suppuration,  in  which- 
case  there  is  a  minimum  of  pain,  becau.se  tension  is  not  great  and  the  distance  to  the 
surface  is  short.  Collections  which  form  beneath  the  fasciae,  especially  the  deej^er 
fascije  of  the  limbs  and  trunk,  give  ri.se  to  much  more  extensive  disturbance,  both  locally 
and  generally,  and  frequently  do  not  point  for  many  days;  or,  instead  of  pointing,  burrow 
deeply  and  find  their  outlet  at  some  undesirable  point.  These  are  known  as  subfascial 
collections.  Subperiosteal  ab.sces.ses  give  ri.se  to  still  more  pain,  becau.se  of  the  unyielding 
character  of  their  limiting  structures,  and  the  symptoms  caused  by  them  are  acute  and 
distressing. 

An  illustration  of  the  pain  which  may  follow  deep  suppuration  may  also  be  seen  in 
the  ordinary  panaritium,  or  bone  felon,  where  the  path  of  infection  is  from  without,  but 
the  destructive  lesion  is  confined  within  absolutely  unyielding  ti.ssues,  at  least  at  fir.st. 
Along  certain  tissues  infection  spreads  with  rapidity.  This  is  particularly  true  of  the 
delicate  areolar  tissue  seen  between  tendons  and  tendon  sheaths,  and  the  infectious 
process  may  follow  this  tissue  wherever  it  shall  lead,  even  along  complex  courses. 

The  question  often  arises.  Can  pus  be  resorbedf  There  is  no  question  but  that  small 
amounts  of  pus  are  disposed  of  by  phagocytic  activity,  and  the  disappearance  of  purulent 
infiltration,  under  the  influence  of  favoring  remedies,  or  even  when  let  alone,  is  not 
infrequently  noted.  True  pus  resorption  is  a  question  of  phagocytic  possibilities,  and 
can  occur  only  in  very  limited  degree,  as  a  result  upon  which  it  is  not  safe  to  count,  and 
which  is  capable  of  enouragement  only  up  to  a  certain  point. 

One  inevitable  law  seems  to  govern  collections  of  pus,  that  when  they  advance  or 
migrate  in  any  direction  it  is  in  that  of  least  resistance.  This  causes  them  to  take  peculiar 
and  sometimes  disastrous  courses,  but  it  is  a  law  which  is  never  violated.  It  leads  to 
the  bursting  of  absce.s.ses  into  the  brain,  into  the  pleural  cavity,  into  the  peritoneal  cavity, 
the  bowel,  and  elsewhere;  it  leads  to  a  condition  where  pus  may  travel  along  a  path  even 


60  SURGICAL  PATHOLOGY 

a  foot  or  more  in  length,  rather  than  come  to  the  surface,  a  distance  of  perhaps  an  inch, 
and  affords  one  of  the  best  reasons  for  early  operative  interference  so  that  the  disastrous 
effects  of  burrowing  may  be  obviated.  When  the  pus  is  limited  to  a  droj)  or  fraction 
thereof  the  abscess  is  called  a  furuncle,  especially  when  in  the  skin.  The  average 
"boil"  of  the  layman  is  a  subcutaneous  or  subfascial  abscess.  When  the  infiltration 
is  pronounced,  and  when  there  has  been  more  or  less  extensive  destruction  of  tissue, 
with  perhajis  formation  of  numerous  outlets  for  the  escape  of  pus  and  detritus,  it 
is  known  as  a  carbuncle.  (See  Cliaj)ter  XXVI.)  In  certain  conditions  small  superficial 
furuncles  or  boils  form,  sometimes  in  great  number  aiul  almost  synchronously,  or,  as 
it  were,  in  cro|)s.     This  conflition  is  known  as  general  jurunculo.tis. 

Signs  and  Symptoms  of  Abscesses. — The  apjx^iranees  by  which  pus  may  be 
suspected  or  delected  are  those  ol"  congestion  and  hyperemia,  more  or  less  abruptly  cir- 
cumscribed and  markedly  accentuated.  Along  with  these  there  is  more  or  less  edema  or 
edematous  infiltration  of  the  skin  and  overlying  tissue,  which  jx^rmits  of  that  peculiar 
appearance  known  as  "pitting  on  pressure."  Often,  too,  there  is  a  distinctly  edematous 
swelling  of  the  parts,  especially  around  the  margin,  with  brawny  infiltration  of  the  centre 
of  the  infected  area.  Numerous  vesicles  occasionally  are  noted  upon  the  skin,  which 
may  be  filled  with  reddish  serum.  When  softening  and  pus  formation  occur,  there  is 
a  condition  which  to  the  palpating  fingers  gives  the  characteristic  sensation  known  as 
fluctuation.  Fluctuation  simply  points  out  the  presence  of  fluid  beneath;  but  when  in 
an  area  marked  as  thus  described  fluctuation  is  noted,  it  means  the  presence  of  pus. 
It  is  detected  by  manipulating  in  a  direction  parallel  to  and  concentric  with  the 
axis  of  the  limb  or  part.  The  pain  is  also  in  most  instances  significant;  patients 
speak  of  it  as  having  an  intense  and  throbbing  character.  With  these  local  signs  occur 
symptoms  indicating  some  degree  of  sejitic  intoxication,  i.  e.,  pyrexia,  chills,  malai.se, 
.sweats,  etc.,  which  are  corroborative  indications,  their  intensity  being  a  rea.sonably 
correct  index  of  the  severity  and  gravity  of  the  local  infection. 

When  a  deep-seated  abscess  is  suspected  a  careful  blood  count  will  often  permit  a 
diagnosis  to  be  made.  This  is  conspicuously  true  of  cases  of  appendicitis.  If  leuko- 
cyto-sis  is  established  there  should  be  immediate  operation.     (See  Chapter  II.) 

It  is  seldom  that  a  superficial  collection  of  pus  can  be  mistaken  for  anything  else.  In 
small  and  superficial  abscesses  (boils,  furuncles)  as  pus  approaches  the  superficial  layer 
(epidermis)  of  the  skin  it  may  be  discovered  through  its  thin  covering.  In  deep  lesions 
there  is  often  a  doubt,  even  on  the  part  of  the  most  experienced.  The  measure  now 
usually  re-sorted  to  for  purposes  of  diagnosis  and  exact  recognition  is  the  exploring  or 
aspirating  needle.  The  old  exploring  needle  was  one  of  good  size,  having  a  groove 
along  which,  after  introduction,  pus  might  pass.  Since  the  almost  universal  useof  the 
hypodermic  syringe,  a  small  aspirating  needle  attached  to  the  ordinary  syringe  is  the  meas- 
ure commonly  adopted.  Such  a  needle  may  be  introduced  into  the  brain,  into  the  liver, 
or  into  almo.st  any  and  every  soft  tissue  without  danger,  and  if  properly  manipulated 
is  almost  sure  to  facilitate  detection  of  pus.  Exploration  done  with  either  of  these  means 
and  for  this  purpose  should  always  be  conducted  as  an  aseptic,  even  if  a  minor  operation, 
in  order  that  no  extra  infection  may  be  added  from  without.  The  skin  should  be  care- 
fully washed,  the  needle  sterilized,  etc. 

It  is  good  surgery  to  resort  to  the  knife  either  for  the  above  purpose  or  in  order  that 
by  a  longer  incision  or  by  opening  the  cavity  deep  exploration  may  be  made.  Such 
explorations  are  of  b'^nefit  even  though  a  circumscril)cd  collection  of  pus  is  not  found, 
since  by  relief  of  tension  and  local  abstraction  of  blood  they  act  in  a  revulsive  wav  and 
do  much  goofl.  Acting  upon  the  same  principle  the  trephine  or  the  bone  chisel  may 
be  used  for  the  purpose  of  opening  the  cranium  and  exploring  for  pus,  or  of  op)ening 
into  the  medullary  canal  of  the  long  bones  and  hunting  there  for  that  which  is 
suspected. 

Treatment. — As  soon  as  suppuration  threatens  speedy  measures  should  be  aflopted, 
either  for  the  purpose  of  bringing  about  resorption,  or  of  favoring  and  hastening  suppu- 
ration. In  theory  antiseptic  applications  are  demanded;  in  practice  they  are  sometimes 
of  benefit.  These  may  consist  of  mere  soothing  applications,  as  a  lead  and  opium 
wash,  or  some  other  wet  or  dry  astringent  applied  upon  the  surface;  or  they  may  consist 
of  cold  applications,  which  by  their  astringent  action  will  limit  the  amount  of  exudate 
and  prevent  its  further  infection.  Or  advantage  may  be  taken  of  the  properties  of  moist 
heat,  and  the  application  of  hot  poultices  or  fomentations  may  encourage  exudation, 


sum' RATION  (51 

l)ut  particularly  (|tiick('ii  superficial  hrcakiiifj  down,  and  thus  hasten  the  time  when  the 
phleifiHon  shall  point,  or  come  sudicieiitly  close  to  the  surface  to  show  that  its  contents 
arc  j)us  and  jK'rniit  of  evacuation.  Such  local  a])plications,  therefore,  {;ive  relief 
from  pain  and  hasten  favorably  the  suppurative  process.  In  eases  of  phlegmonous 
infiltration,  the  aj^plication  of  an  ointment  e()m|)o.sed  of  resorcin  5,  iehthyol  1(),  mercu- 
rial ointment  35,  and  lanolin  50  j)arts,  or  el.se  the  Cred^*  silver  ointment,  is  heiieficial. 
I'nder  the  influi'iice  of  the.se  antiseptic  and  sorhefaeient  prej)arati()ns,  and  of  moist  heat, 
many  phlegmonous  infiltrations  assume  a  kindlier  tyiM-,  and  may  secure  the  actual 
resorption  of  pus. 

Finally  in  almost  every  ca.se  pus  must  he  evacuated.  Here  the  universal  rule  mav  he 
ai)plicd,  to  which  there  are  practically  no  exceptions,  and  which  should  he  stamped  on  the 
mind  of  every  student  and  young  practitioner.  It  is — that  'jrus  left  io  ii.sr/j  trill  do  more 
harm  than  will  fhc  knife  of  tlw  surgeon  if  judiciously  used  for  its  evacvalion.  Action 
taken  in  accordance  with  this  rule  may  be  considered  WM.se  and  timely.  The  operation 
of  evacuation  may  at  one  time  be  a  mere  puncture,  or  possibly  the  aspirating  needle  alone 
will  be  enough;  at  other  times  it  requires  extensive  and  careful  dissection  and  entail.s 
no  little  responsibility.  This  is  particularly  true  in  sucii  deep-seated  suppurations  as 
tho.se  around  the  appendix  and  in  the  brain,  while  in  the  deep-seated  bone  lesions  of 
this  character  the  u.se  of  the  bone  chi.sel  or  the  cutting  forceps  may  be  of  use.  But  the 
rule  holds  good,  no  matter  where  the  pus  may  be,  and  as  long  as  good  judgment  is  shown 
in  the  operative  procedure  nothing  but  good  can  come  from  recognition  of  this  law. 
After  the  evacuation  of  pus  the  cavity  should  be  cleansed  and  disinfected  with  hydrogen 
dioxide,  |)erhaps  even  with  caustic  pyrozone,  or,  if  these  are  not  at  hand,  with  other 
suitable  antiseptic  .solutions. 

Ordinary  judgment  should  be  exercised  in  evacuating  every  abscess,  in  order  that 
opening  be  made  at  that  point  which  in  the  common  position  of  the  body  shall  be  most 
favorable  to  drainage  by  mere  gravity  alone.  If  circumstances  compel  opening  when 
advantage  cannot  be  taken  of  gravity,  then  one  or  more  cminterofwninrjs  should  be  made 
at  points  .selected  where  tirainage  may  be  best  effected,  and  where  anatomical  conditions 
do  not  make  it  injudicious  to  incise.  Drainage  should  be  favored  by  the  introduction 
of  a  drainage  tube  or  of  other  aids,  such  as  gauze,  strands  of  catgut,  bundles  of  horse- 
hair, etc.  Finally,  a  dressing  should  be  applied  which  is  both  protective  and  absorbent, 
and  in  quantity  sufficient  to  make  compression  of  the  walls  of  the  abscess  cavity — not 
sufficient  to  obstruct  drainage,  but  enough  to  favor  prompt  adhesion  of  surfaces,  which 
by  s})eedy  granulation  shall  ensure  prompt  healing. 

Abscesses  are  found  in  proximity  to  large  vessels  or  dangerous  anatomical  regions, 
when  care  must  be  exercised  in  opening  them.  Here  careful  dissection  should  be 
made  under  an  anesthetic.  This  is  true  of  ab.scesses  in  the  neck  and  of  tho.se  around 
the  appendix,  for  example,  where  the  general  peritoneal  cavity  is  shut  of?  only  by  more 
or  less  delicate  adhesions,  and  where  the  surgeon  must  literally  feel  his  way  with  great 
precaution  le.st  adhesions  be  torn  and  the  previously  protected  cavity  infected.  At  other 
times,  especially  in  abdominal  abscesses,  it  is  necessary  to  pack  sponges  or  absorbent 
gauze  in  and  about  the  parts,  so  that  any  fluid  which  may  escape  may  be  absorbed  by 
these  dressings. 

Accompanying  Disturbances.— The  disturbance  of  function  which  accompanies 
ail  congestion  and  exudation,  whether  provoked  by  specific  irritants  or  not,  has  been 
alluded  to;  but  in  cases  of  surgical  infections,  especially  tho.se  which  produce  local  suppu- 
ration, di.sturbance  of  function  is  much  greater,  while  there  are  other  di.sturbances  which 
sometimes  constitute  the  worst  feature  of  these  ca.ses.  The  presence  of  pus  is  often  indi- 
cated, especially  w'hen  deeply  seated,  by  one  or  more  chills,  and  the  occurrence  of  a  chill 
is  ahvays  marked  to  varying  degree  by  pyrexia.  It  is  conceded  that  the  chill  is  an 
expression  of  a  general  septic  disturbance;  but  it  is  necessary  also  not  to  forget  that 
general  septic  disturbance  is  a  frecjuent  accompaniment  of  pus  which  is  not  evacuated 
as  soon  as  formed.  Moreover  in  certain  cases  suppuration  and  septic  infection  seem 
to  occur  synchronou.sly,  one  being  local,  the  other  general. 

Pus  may  also  be  suspected  beneath  a  surface  which  is  red,  tender,  swollen,  edema- 
tous, and  pitting  on  pressure.  When  fluctuation  is  added  to  these  indications  any 
element  of  floubf  is  thereby  dissipated. 

Other  indications  of  the  presence  of  pus  are  a  w^ell-marked  leukocx-tosis,  coupled  wuth 
the  iodine  reaction  indicating  the  existence  of  glycogen  in  the  blood,  the  presence  of 


62  SURGICAL   PATHOLOGY 

indican  in  the  urine,  und  the  positive  results  frequently  ohtained  hy  niakinfj  cultures 
from  the  blood.  When  pyogenic  bacteria  are  found  in  the  blood  the  inference  is  very 
plain,  and  both  treatment  and  prognosis  are  influenced.  In  such  a  case  the  introduction 
into  the  blood  of  an  antiseptic  such  as  Crede's  soluble  metallic  silver  or  of  the  antistrep- 
tococcus  serum,  is  plainly  indic-ated.  The  absence  of  bacteria  from  the  blood,  under 
these  circumstances,  does  not  disprove  the  jiresence  of  pus,  but  their  presence  gives  a 
very  serious  character  to  the  disease,  and  should  lead  to  a  most  guarded  prognosis. 
Invasion  of  the  blood  by  staphylococci  is  nearly  twice  as  serious  as  when  streptococci 
gain  entrance.  Suppuration  of  the  bones  and  of  the  tendon  sheaths  is  liable  to  produce 
such  invasion. 

The  other  disturbance  with  which  suppuration  is  so  often  complicated  is  .septic 
infection.  In  fact  it  may  be  questioned  whether  pyrexia  is  not  an  expression  of  this  con- 
dition. Any  collection  of  pus,  no  matter  how  small,  may  show  signs  of  septic  infection; 
and,  on  the  other  hand,  large  collections  may  be  formed  without  serious  septic  symptoms 
— in  other  words,  suppuration  and  expressions  of  septic  infection  may  be  blended  in 
almost  every  conceivable  way.  Sepsis  as  a  distinct  condition  will  be  described  in  another 
chapter. 

It  is  important  to  summarize  what  may  become  of  pus  when  once  it  has  formed  and 
is  not  promptly  evacuated.     Pus  when  long  present  may  be — 

A.  Ah.sorhed; 

B.  Encapsulated ;  and 

C.  Undergo  various  degenerations  or  chemical  alterations. 

A.  The  possibility  of  the  ahmrption  of  pus,  or,  what  is  equivalent  to  it,  its  spontaneous 
disappearance,  has  been  mentioned.  While  it  does  not  usually  take  this  course,  it  may 
thus  disappear;  as,  for  instance,  in  the  anterior  chamber  of  the  eye  in  cases  of  liypopyon, 
or  in  various  other  localities,  particularly  when  present  only  in  small  amounts.  The 
absorption  of  pus  is  purely  a  matter,  as  far  as  we  know,  of  phagocytic  activity  plus  the 
powder  of  the  tissues  to  take  up  various  fluids. 

B.  Encapsulation. — This  occurs  only  when  pus  has  been  present  for  some  time  and 
when  the  virulence  of  the  pyogenic  organisms  is  not  intense.  We  may  get  encapsulation 
of  pus  in  any  part  of  the  body,  the  most  typical  illustration  naturally  being  within  the 
bones.  Around  the  purulent  focus,  as  around  any  other  irritating  foreign  body,  the 
capsule  is  formed  by  condensation  of  surrounding  tissue.  This  is  the  way  in  which  most 
cold  abscesses  with  their  limiting  membranes  are  produced,  those  produced  by  tubercle 
bacilli  having  slight  irritating  properties.  Inasmuch,  then,  as  the  biological  activity 
in  such  a  focus  is  small,  there  is  time  for  such  encapsulation;  while  by  the  membrane 
thus  formed,  or  the  sanitary  cordon,  already  referred  to,  protection  is  afforded  to  the 
surrounding  tissues.  In  such  a  collection  fresh  infection  may  incite  acute  disturbances 
again,  and  many  abscesses  which  thus  lie  latent  for  a  considerable  length  of  time  are 
fanned,  as  it  were,  into  a  conflagration,  when  a  new  and  acute  inflammation  is 
produced. 

C.  Of  the  various  metamorphoses  and  chemical  changes  that  occur  in  that  which 
was  originally  pus,  the  caseous  and  the  calcific  are  the  most  common.  These  also  are 
connected  largely  with  the  tuberculous  process,  although  calcareous  particles  are  found 
in  the  pus  of  actinomycosis.  Under  their  respective  heads  these  degenerations  will  be 
more  particularly  described. 

Certain  names  have  been  given  to  collections  of  pus  in  different  localities  or  under 
peculiar  circumstances.  A  collection  of  pus  in  the  anterior  chamber  of  the  eye  is  known 
as  hypopyon;  when  in  any  preexisting  cavity,  it  is  known  as  empyema  of  that  cavity, 
the  distinction  Ijetwee?!  empyema  and  ahsce.ss  being  that  "abscess"  means  a  circumscribed 
collection  where  previously  there  was  no  cavity,  while  "empyema"  implies  a  normal 
cavity,  without  respect  to  size  or  location,  filled  with  this  abnormal  fluid.  The  term 
empyema,  when  not  used  in  connection  with  some  particular  cavity,  is  understood  to  refer 
to  a  collection  of  pus  in  the  pleural  cavity.  Other  names  also  are  used  which  are 
particulate  and  distinctive;  in  these  the  prefix  pyo  is  used  while  the  suflrix  indicates  the 
part  involved;  thus  we  have  pyothorax,  pyopericardimn,  pyarthrosis,  etc. 


SINUS  AM)  riSTCLA  53 

SINUS  AND   FISTULA. 

These  are  terms  apj)lie(l  to  more  or  less  tuhular  <liannrl.s  ahnnnnalh/  rrmvrrfivrf  rnrions 
parts  of  ilic  hodij,  or  ronticrdng  .some  carilif  with  the  surjnrc  0/  the  Ixxtij  in  a  irai/  ana- 
toinicalhj  fjititr  ahnorvKil.  Or  tliey  may  he  ref^arded  as  tubular  itlrcrs,  or  ulcerated 
tunnels,  eouneetin*;  as  al)ove.  A  more  exact  distinction  heween  the  two  terms  would 
imply  that  a  siniLs  connects  the  surface  with  some  dee|H'r  j)ortioii  where  a  cavitv  is  not 
normally  ])resent — i.  e.,  with  a  focus  of  disease — whereas  a  fistula  |»rojw'rlv  refers  to  a 
tubular  passajje  connecting;  natural  or  j)re(-.\istin<;  cavities  in  an  abnormal  manner. 
Tiius  we  s])eak  of  buccal,  rectal,  vesicova<;inal  fistulas,  etc.,  whereas  a  passage  leading; 
down  to  an  old  absces.s  or  to  a  focus  of  disease  in  bone,  for  instance,  is  properlv  referred  to 
as  a  sinus.  It  is  possible  for  the  margins  of  a  fistula  to  become  more  or  less  cicatrized 
and  cease  to  be  ulcerous,  whereas  the  entire  track  of  a  sinus  is  practically  a  continuous 
ulcer,  only  tubular  in  arrangement. 

Causes.  A.  Congenital. — There  are  numerous  points  about  the  body  where,  as  the 
result  of  arrest  of  (Icvclopnieiit  or  failure  to  grow,  fistulous  passages  which  are  c(Miij)rised 
within  the  normal  fetal  arrangements,  but  which  should  close  later,  either  before  or  at 
birth,  fail  to  do  so.  Thus  we  have  congenital  fistulas  of  the  neck,  pTsistent  urachus, 
persistent  omphalomesenteric  duct,  etc.  These  are  in  no  sense  primarily  connected 
with  diseased  conditions,  but  may  bt-come  so  secondarily. 

B.  Pre-existing  Abscess  with  Unhealed  Channel  of  Escape — e.  g.,  rectal,  fecal,  and 
other  fistulas  and  sinuses  which  connect  with  tuberculous  foci  in  any  part  of  the  body. 

C.  Previous  Traumatic  or  other  Destruction  of  Normal  Tissues — e.  g.,  vesicovaginal 
fistulas  due  to  tissue  death  from  pressure,  buccal  fistulas  from  gangrene  of  the  cheek, 
as  in  noma. 

D.  Foreign  Bodies — bullets,  ligatures,  etc. — which  prove  irritating  or  infectious 
enough  to  prevent  absolute  healing.  More  or  less  tortuous  sinuses  will  generally  be 
found  leading  down  to  the  irritating  material. 

E.  The  Presence  of  Necrosed  or  Necrotic  Material — e.  g.,  a  sequestrum  in  bone, 
which  is  usually  evidenced  by  the  presence  of  one  or  more  sinuses. 

Treatment. — If  the  determining  cause  is  still  acting,  the  treatment  is  to  remove  the 
cause.  Consequently,  when  the  sinus  leads  down  to  diseased  bone  or  other  dead  or 
dying  tissue,  the  complete  evacuation  of  the  cavity  is  necessary  before  the  sinus  may 
heal.     If  the  cause  is  a  foreign  body,  its  removal  should  be  at  once  insisted  upon. 

An  excellent  suggestion  is  to  stain  all  fistulous  tracks  with  methylene-blue;  the  blue 
trail  after  doing  this  may  be  followed,  no  matter  how  irregular  its  course  (Fergusson). 
If  the  color  is  mixed  with  a  little  hydrogen  dioxide,  and  this  forced  into  a  sinus 
mouth  or  a  fistulous  opening,  it  will  carry  the  dye  to  all  parts  of  the  cavity.  This  may 
be  used  even  in  dealing  with  fecal  fistulas  or  those  extending  deeply  into  the  interior 
of  the  body  or  among  the  viscera. 

Fistulas  of  congenital  origin  and  those  which  connect  two  normal  cavities  of  the  human 
body  are  usually  due  to  a  cause  which  has  ceased  to  act.  Consequently  we  should 
endeavor  solely  to  atone  for  the  result.  The  direction  and  the  course  of  a  sinus  may 
be  learned  by  the  use  of  a  probe  curved  to  suit  and  manipulated  by  a  gentle  hand, 
force  never  being  required.  Or  sometimes,  when  the  silver  instrument  fails  to  pass,  a 
flexible  bougie  or  catheter  may  be  introduced.  The  character  of  the  passage  can  be 
judged  for  the  most  part  by  the  appearance  of  the  discharges.  "With  simises  of  recent 
origin  leading  down  to  recent  suppurative  foci  it  may  be  sufficient  to  enlarge  the  open- 
ing and  to  wash  the  cavity  thoroughly.  If  a  particle  of  gauze,  tube,  or  sponge  has  been 
left  therein,  its  removal  is  necessary  to  secure  prompt  healing.  In  cases  of  long  stand- 
ing antiseptic  and  stimulating  substances  should  be  injected  or  the  interior  should  be 
cauterized  with  strong  solutions  of  zinc  chloride  or  silver  nitrate,  or  with  these  melted  upon 
the  end  of  a  probe.  The  chronic  sinus,  as  well  as  the  chronic  rectal  fistula,  is  usually 
an  expression  of  local  tuberculons  disease  Accordingly  these  passages  may  be  found 
lined  with  the  same  dense,  fungating  membrane  which  lines  a  cold  aljscess  cavity — the 
membrane,  protective  in  its  purpose,  to  which  I  have  given  the  name  pjjophjj lactic. 
Whenever  such  tissue  and  such  membrane  are  met  with  they  should  l)oth  be  extirpated 
thoroughly,  since  in  this  way  only  can  absolute  eradication  of  the  tuberculous  infection 
be  relied  upon.     After  such  complete  excision — which  means  usually  laying  open  the 


64  SURGICAL  I'ArilOUXiY 

entire  sinus — the  parts  may  be  brought  together  with  sutures  (this,  at  least,  is  usually 
possible  about  the  rectum)  to  secure  jirimary  union;  otherwise,  the  whole  sinus,  as  well 
as  the  cavity  to  which  it  has  led,  must  heal  by  the  (jranulatinj;  process,  both  being  kept 
packed  with  gauze  or  some  other  desirable  foreign  body  acting  as  an  irritant,  thereby  pro- 
voking more  rapid  formation  of  granuhition  tissue.  When  it  is  necessary  thus  to  pack  a 
cavity,  or  when  it  is  desired  to  keep  its  uj)per  exh  open  lest  it  heal  Ijcfore  the  lower  part, 
ordinary  white  beeswax,  as  suggested  by  Gunn,  makes  a  serviceable  material.  This 
can  be  inolded  in  hot  water  to  fit  the  cavity;  can  be  tunnelled  or  bored  for  drainage;  can 
be  diminished  in  size  as  the  c-avity  heals,  and  is  absolutely  non-absorbent. 

Finally  there  are  numerous  plastic  methods  which  have  been  resorted  to  in  various 
parts  of  the  body,  most  of  which  are  made  to  comprise,  first,  the  absolute  eradication  of 
the  diseased  tract,  and,  later,  the  closure  of  the  wound  thus  made  by  transplantation 
or  sliding  of  flaps,  or  any  other  plastic  ex])edient  which  may  be  considered  best.  These, 
as  well  as  the  special  treatment  made  necessary  for  particular  forms  of  sinus  and  fistula, 
will  be  dealt  with  under  their  proper  headings. 


CHAPTER    TV. 
ULCER  AND  ULCERATION. 

The  term  ukrr  pertains  to  surfaees,  and  should  be  defined  as  a  aurjace  which  is  or 
ought  to  be  yranuhituig,  i.  c,  healing. 

While  an  ulcer  may  be  the  result  of  ulceration,  it  is  not  necessarily  so,  the  term  ulcera- 
tion being  one  of  very  loose  sifjnificance  and  applied  to  many  different  j)rocesses.  The 
idea  underlying;  ulceration  is  injection,  and,  when  limited  to  its  proper  significance,  the 
term  should  never  be  used  for  a  process  in  which  infection  and  consccjuent  breaking 
down  of  tissue  do  not  virtually  comprise  the  whole  process.  Therefore,  it  is  to  be 
distinguished  from  certain  disaj)j)earances  of  tissue  alluded  to  under  the  head  of 
Atrophy  or  Interstitial  Absorption.  It  is  not  correct  to  say  that  the  sternum  ulcerates 
away,  making  room  for  a  growing  aortic  aneurysm,  the  question  of  infection  here  not 
being  raised.  These  distinctions  should  be  accurately  maintained  and  constantly  borne 
in  mind. 

ULCERS. 

The  causes  of  ulcers  may  be — 

A.  Traumatic; 

B.  Local;  or, 

C.  Con.stitufionaL 

A.  Traumatic. — This  includes  all  surfaces  which  are  granulating  and  healing  more 
or  less  raj)idly,  or  are  displaying  a  disposition  toward  healing,  and  which  may  have 
been  produced  by  wounds,  burns,  frostbites,  etc.  These  include  also  ulcers  due  to  pres- 
sure, as  from  splints,  bandages,  orthopedic  apparatus,  or  from  exter7mi  friction.  Ulcers 
which  form  around  foreign  bodies  may  also  be  included  under  this  head,  their  essential 
cause  being  traumatic.  It  should  include  also  destruction  of  the  surface  by  various 
chemical  agencies,  such  as  strong  caustics,  and  the  consequences  of  intense  heat  or  cold, 
including  burns  and  frostbites. 

B.  Local. — 1.  Among  local  causes  may  be  mentioned  local  infections,  with  tissue  death 
in  consequence,  such  as  occur  in  tuberculous,  cancerous,  leprous,  syphilitic,  and  other 
specific  manifestations  where  surfaces  are  involved. 

2.  Tumors,  either  benign  or  malignant,  whose  blood  supply  is  cut  off  and  whose 
surface  is  thereby  predisposed  to  infection. 

3.  Perverted  surface  nutrition,  for  example,  in  connection  with  varicose  veins  of  the 
extremities,  where,  aside  from  any  perverted  trophoneurotic  influence,  there  is  stagnation 
of  blood,  saturation  of  tissues  with  serum,  and  final  leakage  of  the  same,  even  to  the 
surface.  Varicose  veins  of  the  leg  which  lie  near  or  underlie  ulcerating  surfaces  become 
thrombosed  and  obliterated,  so  that  such  ulcers  rarely  bleed.  On  the  other  hand,  a 
passive  hyperemia  here  leads  to  edema,  perversion  of  nutrition,  failure  to  repair  trifling 
surface  injury,  and  a  surface  is  left  which  of  itself  rarely,  if  ever,  heals. 

4.  So-called  pressure  sores  or  bed-sores,  which  in  some  cases  may  be  regarded  as  having 
a  traumatic  origin,  but  which,  nevertheless,  would  not  occur  from  purely  traumatic 
influences  without  predisposing  tissue  changes.  The  bed-sore  is  probably  the  best 
illustration  of  this.  Simple  ulcer  is  known  as  bed-sore,  while  a  sloughing  ulcer  of  this 
kind  is  frequently  alluded  to  as  decubitus.  Such  ulcers  are  usually  found  over  those 
regions  of  the  body  made  most  prominent  by  bony  projections,  ujwn  which  undue  pres- 
sure is  made  when  debilitated  patients  have  lain  for  a  long  time  in  bed. 

5.  Ulcer  is  the  frequent  result  of  numerous  skin  diseases,  into  whose  etiology  as  yet 
bacteria  have  not  been  introduced — e.  g.,  pemphigus,  eczema,  etc. 

6.  Ulcer  is  the  occasional  result  of  embolic  or  other  disturbance  of  the  principal  artery 
of  the  part,  by  which  nutrition  is  cut  off  and  tissue  death  results. 

5  (65) 


QQ  SVHGICAL   I  ATIIULOGY 

7.  Bites  of  inserts  or  other  parasites  or  of  noxious  animals  frcqiKMitly  lead  to  ulceration. 

8.  Certain  more  s|)eeiHe  forms  of  uleer  are  described  by  .some  writers,  a|)])arently 
with  more  or  less  reason,  amonfij  them  being  chanrroid,  perforating  nicer  of  the  foot, 
etc.  (Chancroid  is  described  in  Chapter  X.)  Trophic  ulcers  ()f  the  fingers  or  hand 
are  also  seen,  particularly  after  injury  to  or  division  of  nerve  trunks  in  the  arm  or  forearm. 
Perforating  ulcer  of  the  foot  is  a  circumscribed  circular  ulcer  with  thickened  edges, 
often  nearly  concealed  by  overhanging  skin.  It  may  be  found  in  any  j)art  of  the  sole 
of  the  foot,  but  is  most  "common  near  the  first  joint  of  the  great  toe.  The  borders 
of  the  ulcer  are  usually  anesthetic.  It  is  frequently  .seen  in  diabetics.  By  some 
it  is  associated  with  trophic  nerve  disturbance;  by  others  it  is  regarded  as  having  a 
specific  etiology  of  its  own.  The  ])robability,  however,  is  that  it  is  simply  a  subvariety  of 
pressure  sore. 

\).  Since  the  introduction  of  the  Rontcjen  or  x-rays  into  surgical  therapeutics  a  new 
local  cause  of  painful  and  intractable  ulcers  should  be  enumerated.  A  too  prolonged 
or  injudicious  exposure  of  a  part  to  this  ])eculiar  influence  induces  first  a  dermatitis, 
which  is  not  always  imm(Mliate,  but  may  be  tardy  in  a])pearance,  and  which  may  be 
followed  by  desciuamation  or  exfoliaticn  that  may  proceed  to  absolute  surface  destruc- 
tion and  sloughing.  These  lesions  are  popularly  spoken  of  as  a--ru})  hurns.^  The  super- 
ficial ulcers  thus  produced  ma^  be  extensive  and  are  nearly  always  excessively  sensitive 
and  painful.  The  very  structure  of  the  surface  vessels  is  affected  and  they  undergo  a 
species  of  sclerosis.  A  strong  preparation  of  radium  has  been  known  to  produce  a 
similar  effect. 

C.  Constitutional. — 1.  Ulcers  are  frequently  met  with  in  certain  constitutional  con- 
ditions which  are  characterized  by  tendency  to  local  manif(>station  at  points  of  least 
resistance.     Among  these  may  be  mentioned  scurvy. 

2.  There  are  ulcers  of  api)arently  distinctive  trophoneurotic  origin,  of  which  that 
mentioiied  above  as  B,  8 — perforating  ulcer  of  the  foot — may  possilily  be  one.  These 
accompany  certain  nervous  disorders  of  central  origin,  prominent  among  which  are 
locomotor  ataxia  and  tabetic  disease  of  all  forms. 

3.  Ulcers  are  produced  sometimes  as  the  result  of  specific  or  selective  action  of  certain 
drugs,  among  them  mercury  and  phosphorus  being  the  most  prominent.  These  mani- 
festations are  usually  perceived  in  the  mouth,  and  may  be  regarded  as  infections  at  points 
of  least  resistance.  Nevertheless,  they  are  commonly  associated  with  the  tendency  of 
the.se  drugs. 

4.  There  are  many  constitutional  conditions  in  which  vitality  is  so  lowered  that  a 
special  lialnlity  to  ulcer — i.  e.,  infection  and  ])roduction  of  ulcer  at  many  points — is  noted. 
It  is  well,  however,  to  mention  that  the  common  diseases  in  which  this  tendency  is  most 
often  noted  are  typhoid,  diphtheria,  diabetes,  and  syphilis. 

With  this  summary  of  the  conunon  causes  of  ulcer  it  is  again  stated  that  ulcers  may 
be  due  to  direct  consequence  of  traumatic  loss  of  substance  or  to  the  process  of  ulceration 
— i.  e.,  as  a  consequence  of  previous  infection,  or  as  permitted  by  trophoneurotic 
disturbance  and  ischemia.  Ulceration  is  a  process  of  molecular  death,  in  which  cells 
die  successively  and  more  slowly,  as  di^stingui.shed  from  gangrene,  in  which  there  is 
simultaneous  death  of  large  agg'-egations  of  cells,  by  which  a  slough  or  its  equivalent 
is  produced. 

Ulcers  are  referred  to  as  healthy  when  the  process  of  granulation  is  proceeding  with 
average  rapidity;  indolent,  when  the  reverse  prevails;  sloughing,  when  there  is  actual 
visible  tissue  death  in  connection  with  the  ulcerative  process;  phagedenic,  when  the 
gangrenous  tendency  is  well  marked  and  the  process  exceedingly  rapid;  irritable  or 
eretlmtic,  when  the  surface  is  exquisitely  sensitive;  hemorrhagic,  when  bleeding  easily; 
fungous  or  fungoi^l,  when  the  granulations  have  risen  above  the  surface  and  are  increasing 
at  too  rapid  a  rate.  There  is  a  peculiar  form  of  ulcer,  .seen  mostly  upon  the  face,  to  which 
the  name  rodent  ulcer  (also  lupus  exedens)  has  been  given.  This  is  now  know^n  to  be 
a  slowly  growing  form  of  epithelioma,  and  is  described  in  Chapter  XXV. 

The  best  examples  of  the  indolent  ulcer  are  seen  in  coimection  with  varicose  veins  of 
the  extremities;  of  the  phagedenic  ulcer,  in  certain  cases  of  chancroid;  of  the  irritable 
ulcer,  in  ulceration  of  the  cornea,  when  the  pain  and  photophobia  are  intense;  or  in 
fissured  ulcer  of  the  anus,  where  the  pain  and  sphincter  spasm  are  sometimes  agonizing. 

Ulcers  are  described  according  to  their  shape  as  regular  or  irregular;  as  fissured, 
when  they  extend  more  or  less  deeply  and  abruptly  into  the  surface  involved;  as  fistulous 


PROCKSSES  OF  REP  MR  67 

whoii  tlicy  have  a  tul)ular  arraiij^ciiiciit ;  as  rodent,  when  tluy  spare  iiotliiii;;  in  tlieir 
course. 

The  borders  of  ulcers  are  descrihed  as  hrd/fln/,  indiircilcd,  finiiid,  cdtiiKiloii.s,  under- 
mined, lirid,  nijidiiied,  etc.,  tliese  adjectives  e.\])lainiii<f  tlieiuselves. 

The  ftiirfaces  of  ulcers  are  described  as  hcd/t/ii/  w  lieu  tliev  have  normal  color  and 
ap|)earance,  in/ldiiird,  crcdrntrd,  rorrrrd  irifh  .v/oz/r/Z/.v,  cd/loii.s,  etc.  The  cdl/oiis  ulcer  i.s 
one  which  exhibits  little  chaujje  from  mouth  to  month;  its  surface  is  dirty,  and  its  secre- 
tion thin  and  mucopurulent.  It  is  usually  sunk  cousiderahly  helow  the  surroundiuj^; 
level,  while  its  border  is  firm  and  nodular.  The  best  examples  of  this  form  are  tho.se 
accompanying  varieo.se  veins. 

In  size  or  area  ulcers  may  vary  from  the  sliglitest  local  destruction  of  tissue  to  an 
area  covering  an  entire  limb  or  a  large  part  of  the  trunk.  In  depth  they  vary  within 
le.sser  limits;  while  an  external  ulcer  may  connect  with  some  deej)  lesion  by  means 
of  a  tubular  passage  or  sinus.  It  thus  appears  that  the  term  ulcer  may  be  applied  to 
the  result  of  a  natural  effort  to  repair  loss  of  substance  without  introducing  the  element 
of  disease,  or  that  it  may  be  the  c()nse(|ucnce  of  local  infection  with  local  tissue  disaster. 

The  character  of  the  material  discharged  from  an  ulcer  will  vary  according  to  the  cate- 
gory iu  which  it  belongs.  Tiie  healthy,  healing,  or  granulating  surface,  often  sj)oken  of 
as  ulcer,  discharges  a  material  in  gross  apjiearanee  much  resembling  pus  from  an  acute 
abscess;  in  consistency,  color,  and  other  apj)earanees  it  is  the  same.  Nevertheless, 
its  origin  is  essentially  distinct.  This  material  represents  simply  the  waste  of  reparative 
material,  .sent  up  to  the  surface  for  the  pur]X)se  of  hurrying  the  process.  Its  fluid,  like 
that  of  pus,  comes  from  the  .serum  of  the  blood;  its  corpuscular  elements,  like  tho.se  of 
pus,  are  leukoc}1;es  or  wandering  tissue  cells,  which  have  been  furnished  in  great  numbers 
— in  fact,  in  excess.  As  it  comes  to  the  surface — or  as,  rather,  it  is  rejected  from  the 
surface,  being  superfluous  in  amount — it  is  likely  to  become  contaminated  with  bacteria 
by  contact  infection,  and  consequently  may  be  seen  under  the  microscope  to  contain 
various  microorganisms.  This  contamination,  however,  has  been  final,  accidental,  and 
irrelevant.  This  material  is  not  pus;  has  no  infectious  properties,  except  those  which 
may  accidentally  be  conveyed  to  it ;  represents  no  warfare  of  cells,  only  excess  of  supply 
or  overdemand;  and  should  be  spoken  of  as  pi/oid  or  pvruloid  material,  and  never  con- 
fu.sed  with  pus.  In  amount  it  will  vary  according  to  the  activity  of  the  reparative 
endeavor,  and  somewhat  according  to  the  amount  of  irritation  of  the  surface  by  dress- 
ings which  may  be  applied.  If  a  granulating  surface  is  absolutely  protected  from 
possibility  of  contact  infection,  it  will  never  contain  microorganisms;  while  this  pyoid, 
if  allowed  to  remain  too  long,  especially  when  infection  is  permitted,  may  decompose  and 
become  irritating,  and  is  a  material  to  be  gently  dislodged  by  a  spray  or  an  irrigating 
stream  with  each  dressing,  which  dressing  should  be  made  once  in  twenty-four  to  sixty 
hours. 

PROCESSES    OF    REPAIR. 

An  ulcer  having  been  defined  as  a  surface  which  is  or  ought  to  be  granulating,  it 
becomes  necessary  to  define  the  granulation  process  and  to  show  how  healing  is  thereby 
achieved.  Granulation  tissue  is  a  name  applied  to  a  new  and  temporary  tissue  of 
embryonic  type,  which  acts  as  a  scaffolding  or  temporary  structure,  permitting  the  con- 
struction of  more  permanent  tissue.  It  is  produced  entirely  by  the  activity  of  cells, 
which  are  the  mononuclear  and  polynuclear  leukocytes  and  the  wandering  cells  already 
mentioned.  They  are  frequently  known  as  embryonal  cells  when  performing  this  func- 
tion; sometimes  as  formative  cells.  They  have  a  distinct  nucleus,  which  stains  readily, 
and,  having  this  resemblance  to  epithelial  cells,  they  are  often  referred  to  as  epithelioid 
cells — sometimes  as  fibroblasts,  because  they  may  later  assume  the  dignity  of  connective- 
tissue  cells.  They  assume  a  multitude  of  shapes.  Between  these  cells  a.s  they  are  drawn 
toward  the  point  at  which  they  are  mo.st  needed,  perhaps  by  chemotactic  activity,  there 
is  an  intercellular  substance  which  later  becomes  fibrillated.  As  these  fibers  develop 
the  remaining  cells  become  entangled  between  them,  and  in  this  way  a  new  connective 
tissue  is  formed  of  cells  of  originally  mesobla.stic  origin.  Of  such  tissue  the  solid  part 
of  granulation  ti.ssue  is  built.  This  tissue  is  es.sentially  different  from  the  epithelium 
which  it  is  expected  will  sub.sequently  cover  it.  If  a  normal  granulating  surface  is 
scanned  with  a  magnifying  glass  of  small  magnifying  power,  it  will  be  seen  to  consist 


68  SURGICAL  PATHOLOGY      ' 

of  numerous  minute  projections,  each  of  which  is  known  as  a  granulation,  consisting  of 
the  tissue  above  descril)efl,  formed  as  a  minute  eminence  around  a  budding  capillary 
bloodvessel,  from  which  a  projection  has  arisen  u])on  the  exposed  surface.  This  ca|)il- 
lary  bud  is  the  result  of  karyokinetic  activity  on  the  part  of  the  endothelium — namely, 
the  hypoblastic  cells  of  which  it  is  essentially  composed.  In  each  of  these  cells,  under 
certain  circumstances,  the  karyokin(>tic  threads  already  mentioned  develop  and  become 
loosely  coiled,  while  the  chromatin  in  the  nucleus  increases  in  amount  and  the  nucleolus 
disappears.  The  chromatin  threads  become  thicker,  arrange  themselves  equatorially 
around  the  poles  of  the  nucleus,  and  gradually  turn  so  as  to  point  toward  it,  while  a  new 
membrane  forms  around  each  separate  coil,  and  two  nuclei  arc  thus  made  out  of  one. 
While  this  is  taking  place  within  the  nucleus  the  cell  protoplasm  undergoes  active  rotary 
motion,  is  finally  segmentated,  and  by  the  time  the  nucleus  is  divided  is  nearly  ready 
for  complete  division  of  the  cell.  While  nuclear  division  is  usually  bipolar,  it  may  be 
multipolar;  if  a  rearrangement  of  the  protoplasm  is  delayed,  the  result  becomes  a  multi- 
nuclear  cell,  known  as  a  qlant  cell. 

The  consequence  of  this  endothelial  activity  is  new  cell  formation  and  the  construction 
of  a  projection  from  the  capillary  which  soon  attains  the  dignity  of  its  parent  vessel, 
and,  as  connective-tissue  cells  form  around  it,  soon  becomes  a  granulation  by  itself, 
each  granulation  being  marked  by  a  capillary  loop  of  its  own.  Healing  by  granulation 
or  the  granulation  process,  no  matter  how  set  up  or  caused,  is  essentially  the  formation 
of  hundreds  or  thousands  of  these  tiny  structures,  a  new  one  being  formed  on  top  of  those 
which  precede  it,  while  those  first  formed  and  deeper  down  undergo  condensation  and 
metamorphosis  of  tissues,  by  which  they  are  converted  into  something  higher  in  the 
tissue  scale.  Under  ideal  conditions  true  granulation  building  proceeds  'pari  passu 
with  epithelial  reproduction  around  the  margin  of  the  granulating  surface,  so  that  by  the 
time  granulation  tissue  has  completely  filled  the  defect,  no  matter  how  caused,  epithelial 
covering  has  been  completely  constructed  and  the  healing  process  thus  completed. 
These  two  processes,  however,  do  not  necessarily  keep  pace  with  each  other.  Should 
surface  repair  take  place  relatively  early,  we  may  have  a  depressed  scar;  while,  on  the 
other  hand,  should  it  not  proceed  rapidly  enough,  or,  to  state  it  in  another  way,  should 
the  granulating  process  be  too  rapid,  we  have  such  excess  of  granulations  as  shall  rise 
considerably  above  the  surrounding  level,  and  may,  under  certain  circumstances,  become 
so  exuberant  that  nutritive  material  cannot  be  formed  rapidly  enough,  and  those  granu- 
lations farthest  away  from  the  centre  of  supply  may  die.  Such  exuberant  granulation 
.is  often  spoken  of  as  fungoid,  and  constitutes  that  great  bugbear  in  the  eyes  of  the  laity 
which  is  termed  by  them  proud  flesh.  It  has  no  further  significance  than  that  the  supply 
has  exceeded  the  demand  and  that  the  granulating  process  has  been  overdone.  Such 
luxuriant  granulations  may  be  cut  away  with  scissors  or  knife,  may  be  burned  away 
with  caustic  agents  or  the  actual  cautery,  or  may  be  disposed  of  in  any  other  manner 
without  harm  and  only  with  benefit;  in  fact,  it  is  often  necessary  to  suppress  this  exu- 
berant tendency  by  caustics  and  pressure,  in  order  that  the  desired  epithelial  covering 
may  be  properly  formed. 

Epithelium,  being  an  e])iblastic  structure  and  capable  of  no  other  origin  save  from 
its  kind,  can  only  be  supplied  from  those  regions  where  it  has  jjreexisted.  Consequently, 
ulcers  involving  the  external  surface  of  the  body  demand  a  lively  epithelial  reproduction 
in  order  that  they  may  have  a  normal  covering.  Epithelial  activity  sometimes  becomes 
retarded,  and  is  much  slower  toward  the  termination  of  the  liealing  process  than  at  the 
beginning.  The  epithelial  covering  of  a  healing  ulcer  is  always  marked  by  a  delicate 
whitish  or  pinkish  film,  which  proceeds  from  the  periphery  as  well  as  from  any  little 
island  of  original  epithelial  structure  left.  It  is  well  known  that  after  a  certain  amount 
of  this  repair  the  process  sometimes  comes  to  a  complete  halt,  and  the  various  expedients 
for  stimulating  and  promoting  it,  as  sponge  grafting  and  the  different  methods  of  skin 
grafting,  have  been  devised  solely  to  atone  for  such  sluggishness  or  inability. 

Ulcers  of  small  size,  which  are  more  or  less  exposed  to  the  air  in  healthy  individuals, 
while  also  exposed  to  possibility  of  infection,  nevertheless  seem  to  escape  it,  owing  to 
the  defensive  power  of  the  blood  serum  and  the  active  cells.  Such  discharge  as  naturally 
comes  from  them,  when  not  excessive,  undergoes  evaporation  until  a  point  is  reached 
where  a  dry  crust  or  scab  is  formed.  Under  this  scab  granulation  proceeds  to  a  point 
where  the  pressure  of  the  scab  itself,  presumably  on  the  level  of  the  surrounding  parts, 
checks  its  activity,  while  at  the  same  time  epithelial  reproduction  goes  on  until  it  has 


PROCESSES  OF   R  IIP  MR 


69 


been  complotod.     Then  the  seal),  hciiifj^  no  l(tiiif(  r  of  use,  drops  ofT  or  is  dctiichrd  hy 
slitjlit  friction. 

Such  U  granulation  tissue:  at  first  a  mere  trelliswork  of  temporary  and  delicate  cell 
structure,  traced  in  a  certain  amount  of  intercellular,  honio<jeiieous  substance,  into 
which  the  buddiiijjj  vessels  j)roject,  the  whole  mouiitinir,  nearer  an<l  nearer  to  the 
surfaci',  day  by  day,  with  variable  rapidity,  diininisliiiif^  in  this  rciijard  as  the  days  j^o 
by,  so  that  frc(|ucntly  tiie  fjranulation  proc-css  comes  to  an  ap|)arcnt  hah  before  enoujjh 
new  tissue  has  be(>n  formed.  While  the  superficial  (granulations  preserve  the  characteri.s- 
tics  above  noted,  those  deeper  down  under<i^o  firmer  an<l  more  c()m[iletc  or<rariization, 
and  the  delicate  embryonic  structures  show  the  same  tendency  wliich  they  do  in  the 
growing  embryo,  by  virtue  of  what  Virchow  has  called  v^rtapla.tia,  to  become  converted 
into  something  higher  and  more  dignified  in  the  tissue  scale.  The.se  cells  do  not  special- 
ize themselves  to  the  extent  of  permitting  complete  repair  of  organs  of  special  sen.se. 
Thus,  while  a  wound  in  the  cornea  or  retina  may  be  completely  healed,  it  heals  by  cica- 
tricial tissue,  and  not  by  repair  of  the  special  structures  involved.     On  the  other  liand, 


Fig.  10 


Fir;,  n 


Cicatricial  deformity  following  bum.    (Original.; 


Cicatricial  tleformity  fdl    -  ii„ 
same  case. 


le  view  of 


tissues  of  more  common  connective  type — fibrous,  bone,  cartilage,  etc. — are  capable  of 
regeneration ;  and  it  seems  to  be  a  part  of  the  privilege  of  these  new  granulations  to  merge 
themselves  into  that  kind  of  tissue  necessary  for  filling  the  gap.  Nevertheless  the 
most  common  result  of  granulation  is  its  metablastic  conversion  into  fibrous  tissue,  which 
has  the  special  characteristic  of  contractility  without  elasticity.  As  a  result  the  scars 
contract,  in  consequence  of  which  disfiguring  results  are  sometimes  the  almost  inevitable 
consequence  of  healing  of  extensive  losses  of  substance.  In  certain  instances  it  is  pos- 
sible by  constant  effort  to  overcome  the  unpleasant  effect  of  this  cicatricial  contraction. 
For  example,  after  extensive  burn  of  the  anterior  part  of  the  arm,  the  forearm  will  be 
gradually  and  permanently  flexed  upon  the  arm  by  virtue  of  contraction  of  the  scar  in 
front  of  the  elbow  unless  some  forcible  means  is  practised  for  maintaining  extension  of 
the  limb  for  at  least  a  part  of  the  time.  So  with  many  other  injuries  and  the  various 
mechanical  or  other  expedients  required  to  prevent  the  untoward  result.  Nowhere 
are  the  after-effects  more  disfiguring  or  serious  than  about  the  face,  where  the  eyelids 
are  drawn  out  of  shape,  the  contour  of  the  mouth  altered,  and  where,  sometimes, 
there  are  other  extensive  manifestations  (Figs.  10  and  11). 

As  a  result  of  healing  of  the  granulating  surface  there  is  what  is  known  as  a  cicatrix 
or  scar.  This  is  composed  of  fibrous  tissue,  probably  more  or  less  distorted  by  virtue 
of  its  contractility,  and  of  epithelial  covering  furnished  from  the  margin  of  the  original 
ulcer,  constituting  a  thin,  glistening  membrane,  applied  clo.sely  to  the  scar  tissue  beneath, 
without  intervening  fat  or  tissue  which  permits  of  the  play  of  the  one  upon  the  other. 
When  this  epithelial  surface  is  abraded  it  is  repaired  with  difficulty,  and  a  raw  or  ulcer- 


70 


S URGICA  L  P.  \  TIIOLOa  Y 


or  even  mutilating  opt^rations  in 


l^IG.    12 


ating  scar  is  difficult  to  heal.  Manifestation  of  perverted  ej)itlu'lial  outgrowth  is  fre- 
quently provoked  at  these  points  by  the  action  of  continuous  irritation.  In  con.sequence 
there  is  what  is  generally  recognized  as  the  transfonnaiinn  of  a  chronic  ulcer,  or  the  site 
of  one,  into  an  cpiiJidioind,  or  j)ossil)ly,  by  similar  irritation  of  the  connective-tissue 
elements,  into  a  sarcoma.  This  is  the  so-called  cancerous  degeneration  of  previous 
ulcers,  and  is  noted  occasionally.     The  lesion  is  one  which  often  rcciuircs  disfiguring, 

order  to  get  rid  of  the  malignant  disease  (Fig.  12.) 
All  the  scars  thus  resulting  are  liable  to  undergo 
a  fibrous  and  degenerative  change  to  which  is 
given  the  name  cicairicial  keloid.  It  is  marked  by 
increase  in  size  and  density,  by  reddening  which 
denotes  increased  vascularity,  and  extension  into 
surrounding  previously  healthy  tissue.  By  these 
changes  a  given  scar  is  made  much  more  prominent 
and  disfiguring.  It  cannot  be  prevented  by  any 
ordinary  treatment,  and  is  often  the  hcte  noir  of 
surgeons.  (See  also  under  Fibroma,  and  chapter 
on  Diseases  of  the  Skin.) 

The  surface  of  a  superficial  scar  while  thus 
covered  with  epithelium  shows  a  complete  lack  of 
all  the  other  skin  elements.  No  hair  grows  upon 
such  a  surface,  because  the  original  hair  follicles 
are  destroyed ;  neither  is  it  moistened  l)y  perspiration 
nor  anointed  by  sebaceous  material,  because  the 
secretory  glands  have  also  disapj^eared.  It  is  a 
surface  which  often  needs  more  or  less  protection, 
especially  when  in  exposed  situations. 

Treatment. — Here,  as  in  all  other  instances, 
the  first  effort  of  the  siu'geon  should  be  to  remove 
the  cause.  This  may  be  done  by  local,  or  may 
require  constitutional  measures.  If  a  definite  local 
cause  can  be  established,  its  removal  may  be  a 
slight  or  may  entail  a  more  or  less  serious  sur- 
gical operation.  Aside  from  this  disposal  of  the 
exciting  agent,  treatment  should  be  divided  into 
the  general  and  the  local.  General  treatment  is 
scarcely  called  for  when  dealing  with  healthy  ulcers; 
but  in  all  those  instances  where  the  constitutional 
condition  of  the  patient  is  below  par,  or  where  there  is  a  general  poisoning  or  infection 
underlying  the  ulcer  itself,  prompt  and  energetic  constitutional  treatment  should  be 
at  once  instituted.  In  scurvy,  for  instance,  the  diet  and  hygienic  surroundings  of  the 
patient  should  be  rectified  immediately.  In  syphilis  no  lasting  nor  deep  impression 
can  be  made  on  local  manifestations  without  general  constitutional  treatment.  In 
tuberculosis  and  the  other  surgical  infections  much  will  be  accomplished  by  internal 
medication,  by  pro{Der  hygiene,  as  well  as  by  local  applications  or  operation.  The 
importance  of  these  general  measures  is  likely  to  be  underestimated,  and  many  fail 
to  realize  the  advantage  of  combining  suitable  internal  and  external  therapeutic 
measures. 

Local  Treatment. — First  of  all  may  be  mentioned  the  insistence  upon  repose  which 
induces  phii-stological  rest.  The  ulcer  may  then  show  a  tendency  to  heal.  This  may 
necessitate  wearing  a  splint  or  restraining  apparatus,  or  confinement  in  bed,  depending 
upon  the  location  of  the  ulcer.  Physiological  rest  will  be  enforced  sometimes  by  stretch- 
ing a  sphincter  in  order  to  temporarily  paralyze  it  in  cases  of  irritable  rectal  ulcer,  where 
the  principal  pain  is  produced  by  the  reflex  spasm  of  its  fibers.  Again,  the  eye  with 
irritable  ulcer  of  the  cornea  is  sometimes  kept  so  tightly  closed  by  the  same  kind  of 
spasm  there  that  it  may  be  neces.sarv  to  divide  the  lids,  or  the  orbicularis  muscle  at  the 
angle  of  the  lids,  in  order  to  make  access  to  the  part.  This  is  carrying  out  the  principle 
of  physiological  rest,  because  it  permits  proper  exposure  and  treatment. 

The  healthy  and  healing  ulcer  needs  no  treatment  except  protection.  Epithelial 
covering  will  probably  keep  pace  with  filling  of  the  depression  by  granulations,  and 


Epitheliomatous  degeneration  of  chronic 
ulcer,  necessitating  amputation.  (Original.) 


PROCESSES  OF  REPAIR  7I 

all  that  is  nocessarv  to  do  is  to  jirrvcnt  external  irritation.  Should  there  he  excess  of 
discharge,  the  siin|)lest  absorbent  dressing,  with  enough  antiseptic  material  to  prevent 
putn*faction  bv  contamination  with  the  bacteria  of  the  surrounding  air,  should  be  em- 
ployed. The  ulcer  which  is  becoming  tardy  in  its  repair  may  be  stimulated  by  silver 
nitrate,  zinc  chloride,  or  other  caustic  ap|)lications,  which  act  as  a  sj)ur  to  the  sluggish 
grainilations,  «lestroying  those  with  which  it  comes  in  contact,  but  stimulating  those 
below  to  do  their  duty   more   jjromptjy. 

The  conventional  applications  to  ulcers  fall  usually  under  two  categories — the  watcri/ 
solutinn.s  and  the  iiiu/iirnts. 

Investigations  in  the  laboratory  have  led  to  the  employment  of  peptonized  j)repa- 
rations,  among  which  are  peptonized  cod-liver  oil  and  some  of  the  partially  or  predi- 
gested  foods,  such  as  hoxnmne,  etc.  These  appear  to  have  the  power  of  digesting  sloughs 
and  of  causing  a  s|xx'dy  separation  or  disposal  of  ever^-thing  necessary  in  the  endeav(jr 
to  secure  a  healthy  condition  of  the  ulcerating  surface  and  give  most  satisfactory  results. 
When  sloughs  are  j)resent  it  is  an  advantage  to  dust  over 
them  papoid,  caroid,  etc.,  which  have  the  power  of  cata- 
lytic disposition  of  decomj)osing  material  without  reference 
to  the  action  of  bacteria.  I'nder  their  use  there  seems  to 
be  a  solution  and  disj)()sition  of  these  dead  products.  With 
a  foul  ulcer — one  from  which  the  discharge  is  more  or 
less  offensive,  due  usually  to  decomposition  of  sloughing 
masses,  not  yet  separated — the  method  of  ronfinuoiis  im- 
mersion in  hot  water,  when  it  can  be  performed,  is  always 
valuable.  But  nothing  seems  to  equal  brewers'  yeast  for 
this  purj)osc.  It  may  be  applied  on  absorbent  cotton 
(which  should  be  soaked  in  it)  and  covered  with  oiled 
silk.     Its  curative  propertv  mav  be  ascribed  to  the  nuclein        Cicatricial  deformity  following 

,  .    .     .,  ^    .         .^       I         "  •  Ti.        -11         U         f        U  specific  ulcer.      (Original.) 

which  it  contains  in  a  nascent  state.     It  will,  when  iresh, 
clean  off  a  sloughing  surface  better  than  anything  I  ever  used. 

Many  ulcers  are  surrounded  with  such  firm,  indurated  borders  that  it  seems  impossible 
that  any  active  regenerative  process  can  arise  from  such  source.  Hence,  incisions  have 
been  practised  for  centuries.  These  have  been  made  radially  from  the  centre  or  have 
been  made  parallel  to  the  margin  of  the  ulcer,  or  sometimes  the  firm,  dense  tissues 
have  been  minced  or  chopped  by  a  series  of  cross-cut  stabs  or  incisions;  as  the  result 
of  which  renewed  activity  has  arisen,  and  an  impetus  given  to  the  healing  process. 
These  methods,  however,  have  yielded  to  that  alluded  to  above.  The  ulcer  in  which 
granulation  has  come  to  a  standstill  is  often  treated  with  the  sharp  spoon  or  curette.  The 
result  of  this  has  been  to  provoke  again  a  speedy  renewal  of  granulation  efforts,  and 
treatment  by  curetting  is  standard  and  often  useful.  Actual  cauterization  of  the  ulcer 
with  a  view  to  such  complete  destruction  of  its  covering  and  border  as  shall  lead  to  their 
separation  by  the  sloughing  process  is  occasionally  practised.  This  is  perhaps  best 
perfonned  with  the  actual  cautery.  It  lacks,  however,  the  valuable  features  of  the  opera- 
tive method,  to  be  described  below.  Modern  methods  have  made  it  plain  that  it  is  often 
an  absolute  waste  of  valuable  time  to  resort  to  the  older  expedients  of  stimulation,  incising 
the  edges,  etc.,  and  that  one  can  accomplish  by  an  operation  in  perhaps  three  weeks 
what  ten  times  that  length  of  time  would  fail  to  do  by  older  methods.  The  most  effective 
method,  therefore,  in  dealing  with  old  and  chronic  ulcers  is  to  anesthetize  the  patient,  to 
excise  the  entire  affected  area — i.  e.,  the  surface  which  ought  to  be  granulating  and  the 
firm  border  and  tissue  in  its  neighborhood — and  then  to  cover  the  surface  either  with 
skin  grafts,  pared  off  with  a  razor  according  to  the  Thiersch  method,  or  with  a  strip  of 
skin  whose  full  thickness  is  raised,  which  is  taken  from  surrounding  parts  by  some 
autoplastic  or  heteroplastic  method.  This  line  of  treatment  is  so  far  preferable  to  all 
others  that,  except  in  case  of  refusal  of  the  patient  to  submit  to  it,  it  is  the  one  which 
must  hereafter  commend  itself.  It  may  afford  opportunity  for  extensive  plastic  opera- 
tions or  for  the  exercise  of  the  best  discretion  and  knowledge  of  experienced  men;  yet 
ca.ses  are  rare  in  which  it  cannot  be  successfully  performed.  These  methods  of  skin 
grafting  have  so  far  supplanted  the  older  method  of  sponge  grafting  that  the  latter  is 
now  .seldom  practised.  It  may  possibly  have  a  sphere  of  u.sefulness  in  certain  ulcer- 
ated cavities,  but  under  all  other  circumstances  it  must  take  a  position  far  below  the 
plastic  methods  in   practical   value. 


72  SURGICAL  PATHOLOGY 

Finally,  ulcers  of  specific  type— syphilitic,  tuberculous,  leprous,  glanderous,  etc. — 
need  methods  in  which  the  first  effort  should  Ije  not  so  much  to  arrange  for  healing  as  to 
dispose  of  infectious  material.  The  knife,  the  scissors,  the  sharp  spoon  come  first  into 
use  here,  the  surgeon  Ix-aring  in  mind  that  almost  all  this  material  is  more  or  less  infec- 
tious, and  that  inoculation  of  his  own  hands  Ls  jjossible  as  the  result  of  carelessness. 
After  taking  away  with  instruments  all  the  granulation  tissue,  with  its  surroundings, 
which  seems  to  expose  to  danger,  it  is  well  to  cauterize  the  part  with  the  actual  cautery, 
nitric  acid,  bromine,  or  zinc  chloride. 

The  markedly  hemorrhagic  ulcer,  whose  surface  bleeds  on  the  slightest  contact  or 
disturbance,  is  often  a  cancerous  ulcer,  though  not  necessarily  so.  This  ready  bleeding 
is  usually  the  effect  of  the  fragility  of  the  walls  of  the  new-formed  bloodvessels.  In  many 
mstances  it  Is  sufficient  to  scrape  until  harder  or  more  resisting  tissue  is  encountered. 
Hemorrhage  may  be  profuse  for  the  moment,  but  it  is  easily  controlled.  Caustic-s  may 
then  \ye  applied  or  not,  according  to  the  judgment  of  the  surgeon. 

Another  method  is  to  treat  such  a  surface  with  the  actual  cautery-.  Another  is  to 
operate,  even  in  the  presence  of  incurahde  disease,  in  order  to  check  a  tendency  to 
fatal  hemorrhage  before  the  disease  has  expended  itself.  In  a  general  way,  in  regard 
to  small,  ulcerating,  cancerous  surfaces,  it  may  l>e  said  that  if  they  bleed  excessively  or 
are  unduly  irritable,  it  is  preferable  to  attack  them  by  operative  measures  in  spite  of 
the  impossibility  of  effecting  a  cure. 

There  are  other  methods  of  treating  ulcers,  but  they  have  mainly  been  abandoned 
for  those  mentioned. 


CHAPTER   V. 

gangrp:ne. 

Gangrene  is  known  also  as  necrosis,  although  this  term  is  usually  limited  to  gangrene 
of  bone.  It  is  known  also  as  mortification,  and  to  the  older  writers,  especiallv  when 
soft  ))arts  die  and  se|)arate  in  sloughs,  as  sp/iacclus.  (lanf/rrnr  means  death  of  tissue 
in  v'isihle  and  more  or  less  circuniscrihrd  inasses.  It  is  distinguished  from  ulceration 
not  on  account  of  molecular  disintegration,  particle  by  j)article,  but  because  of  death  in 
toto  and  sijnclironously  of  a  large,  perha])s  innumerable,  number  of  cells.  Gangrene 
is  described  as  due  to  causes  which  may  be: 

A.  Traumatic,  inchuling  the  so-called  thermal  causes  as  essentially  mechanical 
injuries.  Umler  this  head  are  included  cases  where  injury  is  the  primary  cause,  whether 
this  injury  is  the  crushing  of  a  limb,  the  separation  or  occlusion  of  its  main  bloodvessels, 
the  division  of  its  main  nerves,  or  the  crushing  or  pulpefying  of  its  entire  structure  by 
machinery  or  accident;  also  those  so-called  thcrvial  cases  which  are  due  to  intense 
heat  or  intense  cold.  To  these  might  be  added  the  citenrical  causes,  comj)rising  injuries 
by  powerful  caustics,  alkalies,  or  acids,  which  are  known  to  cause  speedy  death  of  every 
living  tissue  with  which  they  come  in  contact. 

Gangrene  from  frostbite  is  often  of  the  moist  type.  There  is  scarcely  a  limit  to  its 
extent,  either  in  area  or  depth.  It  is  due  primarily  to  thrombosis,  which  is  followed 
by  a  purplish  color  of  the  skin,  by  loss  of  local  warmth,  and  numbness.  Naturally 
it  involves  the  ears,  nose,  fingers,  and  toes.  But  after  alcoholism  and  exposure  one  or 
more  entire  limbs  may  be  involved.  With  moist  gangrene  there  is  danger  of  septic 
infection  (q.  v.).  After  formation  of  a  line  of  demarcation  the  line  of  amputation  may 
be  made  to  follow  it  closely,  but  the  best  results  are  obtained  by  higher  division,  at  points 
of  election,  where  tissues  are  less  sensitive  and  less  infiltrated. 

B.  Local  Causes. — These  are  largely  connected  with  ischemia,  (langrene  from 
edema — itself  the  result  of  passive  hyperemia  and  exudation — is  not  infrecjuent,  the 
most  common  expression  of  this  condition  being  seen  perhaps  in  the  external  genitals 
of  the  male.  Embolism  due  to  valvular  heart  disease,  throvibosis  due  usually  to  a  pre- 
ceding phlebitis,  but  possibly  to  marasmic  origin,  especially  met  with  after  confinement, 
with  disturbance  in  the  uterine  sinuses,  shutting  off  the  circulation  by  endarteritis, 
which  thus  assumes  the  form  obliterayis,  are  some  of  the  local  causes  which  concern 
the  bloodvessels  alone.  In  fact,  the  majority  of  cases  of  spontaneous  gangrene  are 
probably  due  to  changes  in  the  vessels,  endarteritis  being  the  cause  of  a  condition  known 
as  atheroma  of  vessels,  in  which  fungoid  outgrowths,  or,  rather,  ingrowths  into  the 
vessel  lumen,  are  common.  Any  one  of  these,  if  detached,  may  serve  as  an  embolus. 
The  degenerative  excavations  in  the  thickened  walls  of  the  bloodvessels,  which  discharge 
more  or  less  cholesterin  and  other  debris,  and  which  have  been  known  as  atheromatous 
abscesses  (misnomer),  are  frequently  the  precursors  of  the  disease  under  consideration. 
As  the  result  of  these  changes  alone,  without  reference  to  formation  of  emboli,  ve.s.sels 
may  become  completely  occluded,  especially  when  slightly  injured. * 

Extravasation  of  blood  is  another  cause  connected  with  the  bloodvessels,  this  coming 
usually  from  traumatic  rupture,  possibly  from  idiojiathic  causes.  At  any  rate,  the 
tension  in  the  part  may  threaten  its  life  because  of  the  pressure  which  overcomes  the 
circulation  of  blood.  Lir/ation  of  the  main  trunk  of  an  artery  is  sometimes  followed 
by  gangrene,  no  matter  how  carefully  done,  collateral  circulation  being  insufficient  to 

'  Intermittent  claudication,  when  recognized,  may  be  regarded  as  a  precursor  of  that  arteriosclerosis  which 
may  proceed  to  gangrene.  The  term  implies  temporary  anemia  of  one  or  more  of  the  extremities,  with 
numbness,  burning,  or  prickling  sensations  in  the  skin,  occasional  cramps  in  the  muscles,  with  loss  of  power, 
tenderness  of  the  ners-e  trunks,  weakening  or  loss  of  pulse  in  the  affected  part,  ^^'hen  these  symptoms  occur  in 
the  feet  they  are  not  infrequently  followed  by  terminal  gangrene  or  other  evidences  of  angioneurotic  necrosis, 
including  even  those  forms  known  as  erythromelalgia  and  Raynaud's  disease.  Its  treatment,  of  cour.se,  is 
relaxation  of  vasomotor  spasm,  best  accomplished  by  the  use  of  the  nitrites,  among  which  nitroglycerin  is 
iserhaps  most  valuable. 

(73) 


74 


SURGICAL  PATHOLOGY 


sustain  the  nourishment  of  the  part.  In  certain  fractures,  simple  as  well  as  compound, 
the  blood  sup{)l_v  of  a  part  is  rudely  broken  off  by  injury  to  a  bloodvessel  in  such  a  way 
as  to  cause  local  or  general  death,  either  of  a  bone  or  of  the  entire  limb.  Flaps  made 
for  plastic  purj)oses,  arranged  without  sufficient  regard  to  their  projXT  blood  supply, 
or  so  dre-ssed  after  o}>eration  as  to  sustain  undue  pressure,  are  often  .so  shut  off  from  the 
heart  as  to  die  for  want  of  blood.  Finally,  gangrene  may  be  the  result  of  pressure 
either  from  splints,  bandages,  etc.,  or  from  iumors  increasing  in  size,  or  po.ssibly,  as  in 
certain  pressure  .sores,  etc.,  from  the  mere  weight  (jf  the  body.  Here,  too,  chemical 
agents  must  l)e  mentioned,  referring  now  to  the  peculiar  action  of  certain  joods  or  drugs, 
particularly  ergot.  Thus  antiseptic  solutions,  particularly  carbolic  acid,  may  be  made 
strong  enough  to  destroy  the  vitality  of  certain  tissues.  Carbolic  gangrene  (Warren) 
is  a  po.ssibility  not  to  be  forgotten. 

Extravasation  of  urine,  unless  promptly  recognized  and  appropriately  treated, 
or  especially  as  occurring  when  the  urine  is  peculiarly  to.xic  fammfjuiacal)  and  the 
patient's  vitality  reduced,  as  in  confirmed  alcoholics,  is  almost  sure  to  produce  gangrene 
which  inav  easilv  terminate  fatallv. 


Fig.   14 


Fig.    l; 


Uaj-naud's  disea-se:  digit!  monui.     (Original.) 


Raynaud's  disease:  perforating  ulcer  of  foot.     (Original.) 


C.  Constitutional  Causes. — Among  these  are  to  be  mentioned  particularly  that 
symptom-comj^lcx  ordinarily  known  as  diabetes  or  glycosuria.  This  means  a  depraved 
condition  of  the  system  in  which  gangrene  is  threatened  or  permitted  under  circumstances 
which  otherwise  would  have  little  or  no  disastrous  effect.  Thus  diabetic  gangrene  has 
come  to  be  one  of  the  recognized  manifestations  of  the  general  di.sea.se.  That  the 
trophic  nerves  have  a  more  or  less  pronounced  effect  in  determining  gangrene  in  certain 
ca.ses  seems  to  be  now  quite  well  established.  It  is  well  known  how  quickly  bed-sores 
form  after  injuries  to  the  spine,  while  in  certain  nervous  affections  a  minimum  of  friction 
of  the  skin  may  determine  its  death,  particularly  about  the  labia  or  scrotum.  It  is 
said  that  the  insane,  when  made  to  sleep  by  chloral,  may  develoj)  decubitus  from  pressure 
in  a  single  night.  There  is  also  a  well-known  form  of  symmetrical  gangrene,  known 
sometimes  as  Raynaud's  disea-se,  which  is  characterized  by  s\Tnmetrv  of  lesions  and 
absence  of  definite  pathological  changes  (Figs.  14  and  15).  The  so-called  digiti  mortui, 
or  dead  fingers,  and  erythromelalgia  are  examples  of  this  character.  A  condition  almo.st 
leading  up  to  gangrene,  but  perhaps  not  absolutely  terminating  in  such  a  way,  has  been 
known  as  local  asphyxia,  which  seems  to  be  a  condition  of  arterial  spasm  with  venous 
congestion  and  slight  edema.  "While  the  aged  will  often  recover  from  a  legitimate  surgical 
operation  without  disturbance,  it  is,  nevertheless,  true  that  senile  gangrene  commencing 
in  the  toes  has  for  its  cause  some  very  trifling  injury  or  lesion,  such,  e.  g.,  as  paring  of 
a  corn,  or  the  like.  This  .shows  a  weakened  local  and  general  resistance,  as  well  as  the 
wisdom  of  redoubling  aseptic  precautions  in  operations  upon  such  patients. 


GANGRENE 


75 


As  constiliitioual  causes  also  should  he  iiiclmlcd  I  he  (Iclclcrioiis  effects  of  (•crlaiii  drills, 
particularly  «'ri;ot,  incrciirv,  and  |)lios|)lioiii.s. 

1 ).  Infectious  Causes.  In  the  instances  already  n)cnl  ioncd  reference  to  the  infectious 
microorganisms  has  been  avoided.  There  remain  to  he  considered  ty|x\s  of  fjanjijrcne 
due  to  the  activity  of  certain  microorganisms—  lio.spital  (/anffrrnr,  ph/cfjiiionoii.s  rrtj- 
sipelus,  iii(ili(/n(nit  rdciiKi,  (i<ui(/rtn<)ii.s  riiij)lii/.snna,  noma,  ainliiim,  etc. 

Gaiifjrene  as  the  result  of  infectious  processes  is  seen  in  |)hlef;monous  ervsi|)elas,  where 
death  of  tissue  seems  to  be  ilue  to  the  combined  influence  of  the  invarhnjr  ori^aiiisnis  and 
of  mechanical  agencies — i.  c,  tension  ])r<)duced  by  stasis  and  exudation,  with  such  stretch- 
ing of  ti.ssues  or  overcrowding  with  inilammatory  jiroducts  as  to  virtuallv  strangle 
them,  in  consequence  of  all  of  which  they  die.  (jangrene  of  an  entire  hand  may  thus 
result,  or,  more  commonly,  the  gangrene  is  limited  in  extent  to  the  more  superficial 
parts,  so  that  sloughs  separate.  A  specific  form  of  gangrenous  inflammation  known 
as  malignant  edema,  due  to  a  peculiar  anaerobic  bacillus,  will  be  treated  of  separatelv 
under  a  distinct  heading,  (-^uite  like  it  in  several  res])ects  is  the  gangrenous  eni[)hvscina 
of  certain  writers,  known  also  as  the  fulminating  form,  or,  as  the  French  call  it,  tlie  "  f/an- 
grcne  foudroi/antc."  More  or  less  emphysematous  condition  may  accompany  malignant 
edema;  yet  that  we  do  iiave  gaseous  forms  of  gangrene  without  the  sjM-cific  bacillus  of 
malignant  edema  is  estal)lished.  At  least  sixteen  cases  of  so-called  gaseous  gangrene 
due  to  infection  by  the  haciUus  acrogencs  capsulatufi  are  on  record,  of  which  twelve  were 
fatal.     IMost  of  them  followed  surgical  injuries — e.  g.,  compound  fracture. 


Fio.   16 


Noma.     (Original.) 

Hospital  gangrene,  so  called,  has  been  in  years  past  the  terror  of  military  surgeons 
and  camp  hospitals.  As  a  type  it  has  almost  completely  disappeared  from  observation, 
and,  in  its  old  manifestations  at  least,  is  now  practically  never  seen. 

Noma,  known  also  as  gangrenous  stomatitis,  eancrum  oris,  and  gangra^na  oris,  is  a 
term  applied  to  a  form  of  tissue  necrosis  affecting  the  cheeks  or  parts  about  the  face  of 
young  children,  occurring  frequently  as  a  complication  of  the  exanthemata.  A  similar 
condition  occasionally  involves  the  external  genitals.  From  the  fact  that  it  seldom  passes 
across  the  middle  line,  it  has  been  regarded  by  some  as  of  neurotic  origin.  Naturally 
bacteria  are  always  found  in  the  decomposing  tissues;  but  whether  there  as  cause  or 
as  result  is  not  yet  established.  The  probability  is,  however,  that  we  have  to  deal  with 
a  specific  form  of  infection.  The  loss  of  substance  is  usually  so  great  as  to  determine 
complete  perforation  of  the  cheek,  so  that  the  jaw  bones  may  be  laid  bare.  The  gums 
and  alveolar  processes  also  frequently  .share  in  the  process,  and  the  teeth  occasionally 
drop  out.  Death  of  tissue  is  rapid,  and  septic  infection  may  accompany  it  to  such  an 
extent  as  to  cause  the  death  of  the  patient  in  a  few^  days.  While  most  vigorous 
measures  are  necessary  for  combating  it,  the  patients  are  often  so  reduced  as  to  preclude 
the  possibility  of  doing  much,  and  death  is  the  termination  of  noma.  Free  incision, 
even  complete  excision,  is  called  for,  perhaps  with  combined  resort  to  the  actual  cautery 
or  such  remedies  as  bromine  (strong  or  diluted).     Antistreptococcic  serum  has  also  been 


76  SURGICAL  PATHOLOGY 

used  with  success.     Obviously  it  must  he  used  early  if  success  is  expected.     Should 
patients  recover,  there  is  extensive  defonnity  as  the  result  of  cicatricial  contraction. 

Alonf^  the  coast  of  Africa  and  in  the  West  Indies  there  occurs  anionfj  the  negroes  a 
j)eculiar  gangrenous  affection  of  the  toes  known  as  ainlium.  This  may  assume  either 
the  moist  or  the  dry  ty])e  of  gangrene,  hut  the  result  is  gradual  sc])aration  of  the  ])art, 
usually  by  the  dry  ])rocess,  as  if  it  had  been  strangulated  by  a  ligature.  The  disease 
is  slow  and  may  extend  over  ten  years.     The  cause  is  unknown. 

Finally,  gangrene  is  the  termination  of  the  infectious  process  in  several  other  zymotic 
diseases,  among  the  best  illustrations  being  that  afforded  by  diphtheria.  The  formation 
of  diphtheritic  ulcers  in  the  mouth  and  the  vulva,  about  the  eyes  and  elsewhere,  as  the 
result  of  separation  of  sloughs,  is  too  frequent  to  pass  unnoticed,  yet  at  the  same  time 
docs  not  essentially  differ  from  the  separation  of  sloughs  due  to  any  other  specific  cause. 
All  these  acute  zymotic  diseases,  therefore,  need  to  be  regarded  as  among  the  possible 
causes  of  gangrene  by  infection  of  tissues. 

The  sijmmefrical  ganc/irnc,  often  paroxysmal,  affecting  the  fingers  and  toes,  described 
by  Raynaud  and  often  called  by  his  name,  is  due  to  vasomotor  spasm,  and  is  accompanied 
by  neuralgia  and  sensory  disturbances,  with  coldness  of  the  part  and  discoloration 
suggestive  of  impending  gangrene.     (See  above.) 

Billroth  and  others  have  also  described  a  sfontaneous  or  angioyicurotic  gangrene  of 
the  extremities,  occurring  during  youth,  in  abrupt  distinction  to  senile  gangrene,  whose 
course  is  tedious  and  painful,  which  will  usually  necessitate  amputation.  The  cause 
of  this  condition  has  been  found  to  be  a  well-marked  arteriosclerosis  and  thrombosis, 
both  in  the  arteries  and  veins.  This  form  of  gangrene  occurs  most  often  in  the  frigid 
zone — e.  g.,  in  Northern  Russia. 

•  There  are  also  forms  of  visreral  gangrene,  traumatic  and  non-traumatic,  which  often 
constitute  fatal  maladies.  The  latter  are  mainly  due  to  thromlmtic  or  embolic  lesions,  for 
example,  the  gangrene  of  the  mesentery,  already  alluded  to  when  discussing  thrombosis 
(q.  v.),  clinically  described  under  Surgical  Diseases  of  the  INIesentery. 

Gross  Appearances. — In  a  general  way  tissue  death,  known  as  gangrene,  assumes 
two  opposite  types — the  moist  and  the  dry.  In  "moist  gangrene,  aside  from  those  appear- 
ances which  indicate  commencing  putrefaction  of  tissues,  and  the  loss  of  heat  due  to 
stoppage  of  the  blood  supply,  one  of  the  most  characteristic  features  is  the  formation 
of  a  so-called  tine  of  demarcation,  i.  e.,  a  line  which  separates  the  dead  from  the  living 
tissues.  While  this  is  usually  plainly  indicated  by  a  red  line  which  abruptly  separates 
the  discolored,  usually  dark,  dead  portion  from  the  briglit  red,  congested  appearance 
of  the  living  tissues,  it  is  noted  that  this  area  of  redness  shades  out  into  a  more  and  more 
natural  appearance  as  we  pass  upward,  while  below  the  line  is  seen  a  surface,  usually 
covered  with  blisters,  from  which  exudes  a  foul-smelling,  altered  .serum,  while  the  gan- 
grenous portion  assumes  a  dark,  finally  an  almost  black  a})pearance,  retaining  only 
the  crude  outlines  of  its  original  shape.  Along  with  this  the  objective  evidences  of 
putrefaction  are  unmistakable,  appearances  and  odor  being  characteristic.  W^ith  all 
there  are  more  or  less  constitutional  disturbances,  and  a  recognizable,  often  a  profound, 
condition  of  septic  infection,  due  to  the  fact  that  along  the  line  of  demarcation  absorbents 
are  still  active  and  that  the  poisonous  products  of  putrefaction  are  being  absorbed  into 
the  general  system.  Consequently  collapse,  profuse  perspiration,  septic  diarrhea,  etc., 
are  noted.  In  gangrene  from  frostbite  the  process  is  .slower  than  in  the  traumatic 
forms.  In  gangrene  from  e.rtrarasation  of  vrine  the  .separation  of  sloughs  is  extensive, 
and  sloughing  of  the  scrotum  with  exposure  of  the  testicles  is  a  frequent  result. 
In  decubitus,  or  bed-sore,  the  process  is  still  more  slow,  but  always  of  the  moist  typ)e. 
After  a  variable  length  of  time  there  is  separation  of  slough  and  a  resulting  large, 
often  foul,  ulcer. 

Drg  or  senile  gangrene  presents  a  very  distinct  contrast  to  the  moist  type.  It  occurs 
generally  in  patients  over  fifty,  often  as  the  result  of  causes  which  are  .slow  of  action. 
As  a  result  of  the  shrinking  and  corrugation  of  the  tissues,  with  the  dryness  of  the  same 
by  evaporation,  there  is  a  peculiar  a])jx»arance  known  as  mummification,  the  foot,  for 
instance — the  feet  are  usually  first  involved — resembling  the  foot  of  a  person  who 
has  been  embalmed,  except  that  it  is  discolored.  It  is  possible  .sometimes  to  have  a 
combination  of  moist  and  senile  gangrene,  especially  when  there  has  been  infection 
by  which  putrefaction  is  permitted.  When  from  the  outset  putrefactive  processes  are 
prevented,  the  gangrene  of  this  type  is  almost  invariably  dry.     In  j)raetically  all  of  the 


GAXGRENE  '  77 

cast's  of  this  cliaractcr  there  will  he  found  cvidciiccs  of  vascular  disease,  usually  in  the 
femoral  artery  and  its  branches.  (Janjfreiie  of  the  foot  alone  is  most  commonly  due  to 
endarteritis,  while  gangrene  of  the  foot  and  leg  together  are  usually  due  to  eniholism 
or  thrombosis. 

While  disease  of  the  vessel  walls  is  usually  of  the  type  either  of  endarteritis  or  arterial 
scK'rosis,  peculiar  to  the  closing  years  of  life,  and  commonly  affecting  the  lower  extremi- 
ties, gangrene  due  to  embolism  of  arti'Hes  or  thrombosis,  or  both,  may  occur  in  the  young, 
and  in  the  U|)pcr  extremities  as  well,  in  the  latter  case  the  cnd)oli  being  detached  from 
the  heart,  while  thrombosis  may  be  caused  by  a  tight  s])liiit  or  bandage,  or  even  the 
use  of  crutches.  I  have  repeatedly  amputated  the  arm  as  well  as  the  leg  for  gangrene 
of  this  type. 

Signs  and  Symptoms. — The  appearance  and  the  odor  of  a  part  will  indicate  impend- 
ing or  actual  traumatic  gangrene.  The  pallor,  the  coldness,  the  dryness  of  senile 
gangrene  are  also  characteristic.  In  the  latter  form  constitutional  symptoms  are  not 
indicative  nor  essentially  of  septic  type.  As  soon,  however,  as  a  process  of  spontaneous 
sejxiration  begins  j)utrefacti()n  is  inevitable  and  sepsis  unavoidable.  In  moist  gangrene 
there  is  seldom  acute  pain.  This  is  one  of  the  predominating  subjective  features  of 
the  senile  form.  Hemorrhages  occur,  sometimes  terminating  fatally,  in  the  moist  forms 
when  large  vessels  are  eroded.  This  is  particularly  true  of  the  pharfcdrnir  f)r  liospihd 
form.  A  recognition  of  their  possibility  may  enable  us  to  avoid  sudden  death  from 
this  source. 

Treatment. —  Thrcaicning  (jancjrcnc  should  be  attacked  and  the  cause  removed. 
Threatening  bed-sores  may  be  avoided  by  equalizing  surface  pressure,  which  can 
be  done  with  the  water-bed;  by  protecting  the  skin  or  by  stimulating  and  toughening 
it  with  alcoholic  and  astringent  lotions;  by  frequent  changes  of  position;  by  attention 
to  the  heart,  which  should  be  stimulated  to  a  point  that  may  make  it  capable  of  forcing 
or  distributing  blood  ecjually  over  the  entire  body.  So,  too,  with  limbs  which  are 
enveloped  in  dressings  or  sjilints;  it  is  well  to  leave  exposed  the  tips  of  the  toes  or  fingers 
in  order  that  discoloration  of  the  same  may  be  recognized  and  the  threatening  disasters 
averted.  Local  gangrene  as  the  result  of  pressure  by  tumors,  aneurysms,  etc.,  cannot 
always  be  averted. 

For  gangrene  there  is  but  one  relief,  the  removal  of  the  dead  and  dying  tissue.  The 
method  and  location  of  the  operation  must  be  determined  by  the  general  character  of 
the  cause.  For  a  case  of  acute  traumatic  gangrene  amputation  at  the  nearest  point  of 
election  above  the  injury  will  often  suffice.  In  case  of  gangrene  from  frostbite  the  tissues 
in  the  neighborhood  of  the  line  of  demarcation  are  so  affected  or  their  vitality  so  com- 
promised that  to  separate  the  tissues  along  the  lines  at  which  nature  is  endeavoring  to 
remove  them  is  not  enough,  and  to  go  an  inch  or  so  above  this  line  is  to  operate  in 
tissues  which  bleed  readily  and  heal  badly.  Consequently  it  is  often  advisable  to  select 
a  point  at  some  distance  above.  It  is  especially  in  diabetic  and  senile  gangrene  that 
surgeons  have  laid  down  the  rule  that  if  amjndation  is  done  at  all  it  must  be  high.  For 
gangrene  of  the  toe,  as  the  result  of  disease  of  the  vessels,  it  is  best  to  amputate  above 
the  ankle;  whereas  if  any  greater  portion  of  the  foot  is  threatened,  amputation  should 
take  place  above  the  knee.  The  tibial  arteries  have  been  found  so  brittle  as  to  snap 
under  a  ligature,  and  the  femorals  so  disorganized  as  to  require  handling  and  ligating 
with  the  greatest  caution.  These  high  amputations  are  therefore  necessitated  by  the 
condition  of  the  vessel  walls.  While  amputation  for  traumatic  and  acute  cases  is,  in 
the  majority  of  instances,  if  not  too  long  delayed,  successful  in  saving  life,  in  the  senile 
and  particularly  in  the  diabetic  forms  it  is,  in  the  majority  of  cases,  a  disappointment. 


PART   II. 
SURGICAL   DISEASES 


CHAPTER    VI. 

AUTO-INFECTION,  ESPECIALLY  IN  SURGICAL  PATIENTS. 

One  of  the  greatest  lulvaiKes  made  in  pathology  has  been  the  estahh.sliinent  of  the 
fact  that  a  great  many  of  the  morbid  conditions  from  which  the  human  race  suffer  are 
those  (hie  to  causes  arising  entirely  from  within  their  own  systems  and  in  consequence 
of  deficiencies  of  elimination  or  of  perverted  })hysiological  processes  wliich,  in  large 
degree,  are  themselves  the  result  of  errors  and  indiscretions  in  diet,  in  manner  of  life, 
in  habits,  etc.  That  these  general  facts  have  been  recognized  for  centuries  is  [)erhaps 
a  credit  to  the  powers  of  observation  of  practitioners  of  past  generations.  Exact  knowl- 
edge, however,  has  come  only  with  exact  laboratory  methods  of  research  and  most 
painstaking  study  of  the  secretions  and  excretions,  both  under  normal  and  morbid 
conditions.  The  subject  of  auto-intoxication  has  been  too  commonly  relegated  to  the 
domain  of  internal  medicine,  and  has  been  supposed  to  be  one  in  which  the  surgeon 
need  take  only  passing  interest. 

The  alkaloids  are  by  no  means  the  only  poisonous  products  which  the  human  body 
may  produce  and  retain.  That  most  important  excrementitious  material  of  all — i.  i\, 
carbon  dioxide — could  not  be  retained  in  the  organism  for  more  than  a  few  moments 
without  death  as  the  inevitable  consequence.  The  various  soluble  Jentwnts  elaborated 
by  certain  glands  may  exert  deleterious  influence,  both  local  and  general;  and  in  the 
saliva  are  also  found  protlucts  which  are  not  ferments.  The  biliary  acids  also,  if  they 
do  not  find  free  escape,  may  produce  fatal  poisoning.  So  also  leucin,  tyrosin,  and  all 
the  excrementitious  products  which  arise  from  insufficient  liver  activity,  are  caf)al)le 
of  producing  forms  of  intoxication — such,  for  example,  as  eclampsia,  etc.  The  charac- 
ter of  the  solvent  has  much  to  do  with  toxicity.  Thus  aqueous  extract  of  putrid  matter 
is  more  poisonous  than  that  of  fecal  matter,  while  alcoholic  extract  of  fecal  material  is 
more  toxic  than  that  of  putrid.  All  the  alkaloids  produced  within  the  body  are  not 
poisonous.  Some  are  found  in  the  normal  tissues,  and  they  are,  perhaps,  only  one  of 
the  results  of  the  disassimilation  of  animal  cells.  Nor  are  all  these  poisons  of  bacterial 
origin,  although  many  are  formed  only  in  the  presence  of  microbes. 

From  these  constantly  menacing  sources  of  intoxication  man  escapes  by  virtue  of 
his  intestinal,  cutaneous,  pulmonary,  and  renal  emunctories.  For  instance,  the  use- 
fulness of  the  perspiration  is  shown  by  the  odor  which  it  assumes  under  the  influence 
of  certain  disorders.  Among  hypochondriacs  and  the  inactive  fatty  acids  are  elimi- 
nated by  the  skin.  Hence  the  odors  of  hospital  wards,  asylums,  prisons,  etc.  So,  too, 
in  the  case  of  many  who  suffer  from  deep-seated,  indolent  ulcers,  the  odor  of  the  skin 
is  suggestive  of  the  presence  of  pus.  During  twenty-four  hours  there  is  eliminated  from 
the  lungs  1100  grams  of  carbon  dioxide,  water,  etc.,  which  sometimes  contain  ammonia 
and  various  volatile  fatty  acids;  all  of  which  will  explain  fetor  of  breath  when  it  is  the 
result  of  incomplete  nutrition  and  destruction  of  food.  Of  the  organs  of  elimination, 
the  most  important  is  the  kidney,  which  does  not  reabsorb  a  part  of  its  own  products, 
as  does  the  intestine.  The  kidneys  eliminate  fluids  and  solids,  not  gases.  The  most 
important  of  the  toxic  principles  contained  in  the  urine  are : 

(79) 


80  SURGICAL  DISEASES 

1.  Urea,  whifh  plays  an  iinportuiit  and  iisrful  role  in  the  economy,  since  it  possesses 
the  property  of  forcing  the  renal  barrier  and  reniovin<j  alon<^  with  itself  the  water  in  which 
it  is  dissolved  and  other  toxic  matters.  Urea  is  toxic,  hut  only  in  the  sense  that  any 
other  substance,  even  water,  may  be — i.  c,  it  is  toxic  only  in  large  doses,  less  than  sugar, 
and  no  more  than  the  most  inoffensive  salts.  This  is  contrary  to  generally  received 
views,  but  is  established  by  the  researches  of  Bouchard. 

2.  A  narcoiic  substance,  and 

3.  A  sialarjogiie  sul)stance,  whose  composition  is  unknown ; 

4.  5.  Two  substances  having  the  property  of  causing  ronriilsion.'i.  one  having  the  power 
of  contract! II cj  tlic  pupils.     The  composition  of  both  is  unknown. 

6.  A  substance  which  produces  Jicut  by  diminishing  heat  production — possibly  a 
coloring  matter.  That  coloring  matters  are  al)sorl)cd  by  charc(jal  and  that  in-ine  thus 
decolorized  is  rendered  less  toxic  are  no  })roof  that  the  coloring  matters  themselves  are 
responsible  for  this  toxic  action.  There  is  no  doubt  that  numerous  alkaloidal  bodies 
possessing  a  high  molecular  weight  are  precijjitated  by  means  of  carbon  or  charcoal, 
and  to  these  bodies  may  be  attributed  a  portion  of  that  toxic  action  previously  con- 
sidered as  due  to  coloring  matters. 

7.  Potassium  salts,  which  are  really  convulsing  agencies,  are  the  most  toxic  perhaps 
of  any  of  the  poisons  contained  in  the  urine.  Chloride  of  potassium,  for  instance,  is 
toxic  at  IS  Gm.  for  every  kilo  of  animal. 

Salivation  and  mijosis,  as  well  as  diarrhea,  are  often  noticed  in  so-called  uremia. 
In  that  form  known  as  hepatic  uremia,  when  the  liver  no  longer  forms  urea,  the  kidneys 
scarcely  act.  In  other  words,  if  urea  is  no  longer  present  in  the  body,  the  kidneys  are 
deprived  of  their  principal  stimulation  to  physiological  activity.  Consequently  urea, 
for  so  long  a  time  the  l^ugbear  of  physicians,  is  shown  to  be  most  dangerous  when  absent. 
When  urea  is  deficient,  blood  serum  or  water  in  which  the  other  toxic  substances  are 
dissolved  should  be  withdrawn.  This  is  best  done  by  venesection,  whose  value  in 
so-called  uremia  experience  amply  corroborates.  When  kidney  activity  ceases,  intoxi- 
cation is  likely  to  be  produced  by  potassium  salts.  Ptomains,  amido  bases,  etc.,  are 
proved  to  be  present  in  normal  urine  and  are  known  to  produce  toxic  efTect.  These 
ptomains  increase  enormously  in  pathological  urines,  and  to  this  increase,  rather  than 
to  that  of  potassium  and  coloring  matters  (which  remain  fairly  constant),  may  be  attrib- 
uted the  higher  toxicity  of  pathological  urine.  In  certain  cases,  however,  as  in  that 
of  jaundice,  the  toxicity  of  the  urine  is  partly  due  to  decomposition  of  tissue  cells,  whereby 
potassium  salts  and  organic  decomposition  products  are  liberated  and  excreted  in  the 
urine.  The  toxicity  of  the  urine  also  increases  with  the  increase  of  indican,  which  is 
indirectly  a  product  of  intestinal  fermentation. 

The  osmotic  pressure  of  the  blood  has  much  to  do  with  the  general  subject  of  auto- 
intoxication, since  it  surrounds  and  permeates  all  the  organs  of  the  body,  which  are 
necessarily  in  equilibrium  with  it.  Their  individual  cells  functionate,  then,  in  accord- 
ance with  it,  and  variations  in  such  pressure  must  affect  their  activities.  It  is  a  special 
function  of  the  kidneys  to  eliminate  enough  of  the  accumulat(^d  metabolic  products  in 
the  blood  to  keep  this  osmotic  pressure  at  its  normal.  Should  investigation  or  symptoms 
of  disease  show  a  wide  divergence  from  this  standard,  the  inference  is  plain,  i.  e.,  that 
there  is  renal  insufficiency  from  impairment. 

This  test  may  be  made  with  a  small  amount  of  blood  by  cryoscopy  (determination  of 
freezing  point).  So,  too,  a  determination  of  electrical  conductiiniy,  may,  in  a  similar  way 
and  for  a  similar  purpose,  be  made  of  clinical  value.  Unfortunately,  these  investiga- 
tions are  not  exactly  simple  in  character,  and  are  not  available  outside  of  well-equipped 
hospitals. 

Correct  performance  of  hepatic  jiinction  is  also  necessary  that  siu'gical  cases  may 
progress  without  disturbance.  Bile  escapes  direct  absorption  by  the  blood,  but  not 
all  contact  with  it,  since  in  the  intestine  it  is  in  contact  with  mesenteric  capillaries,  but 
must  pass  again  through  the  liver,  which  takes  it  up  again  and  pours  it  once  more  into 
the  intestine. 

Bile  in  the  blood  is  always  dangerous,  although  its  toxicity  is  much  smaller  than  has 
been  supposed.  Of  all  the  bile  thrown  out  into  the  duodenum,  we  are  only  able  to 
account  for  about  one-half.  Its  coloring  matter  and  biliary  salts  are  metamorphosed. 
Yet  in  certain  morbid  conditions  bile,  as  such,  may  be  reabsorbed  in  the  liver  along 
the  margin  of  the  hepatic  cells.     In  these  cases,  if  the  kidneys  remain  permeable,  auto- 


AUTO-IXFKCTIOX,   KSl'llCl MJ.Y   IS   SVIidlCM.   PATIKXTS  ,si 

intoxication  is  simply  tlin-atciKMl ;  if  tiicv  liavi-  ceased  to  Ite  perini-ahle,  actual  auto-iiiloxi- 
catioii  is  tiic  result. 

Pntre  fart  ion  of  iutc.sliiiul  contcnt.s  afVords  anotlier  source  of  auto-intoxicatioii.  This 
comes  both  from  imperfect  nietam()rj)liosis  of  food  and  from  bacterial  infection.  Here 
the  contlitions  are  most  favorable.  Nitrofjenous  substances  become  jx'ptonized,  and 
peptones  form  the  best  culture  media  for  microbes.  Water  is  present  in  suflicient 
quantities,  and  a  constant  temj)erature  of  37°  C.  is  maintained.  The  digestive  tube 
is  always  oj)en,  and  invaded  at  frcnpient  intervals.  By  such  mechanism  are  formed 
tiio.se  produc-ts  whose  effects  are  revealed  in  the  so-called  putrid  frrrr  of  da.sjjard. 
Briefjer  has  shown  that  alkaloids  are  developed  during  the  act  of  peptonization.  Fecal 
matter  contains  also  cxcrctin,  whose  toxicity  has  been  amply  proved,  and  several  other 
alkaloidal  substances,  soluble  in  various  media,  varying  in  toxicity.  The  potassium 
and  ammonium  salts  contribute  largely  to  the  toxicity  of  feces;  bile  also,  but  in  lesser 
degree.  It  has  been  shown  that  the  aqueous  extract  of  putrid  matter  is  very  toxic, 
while  that  of  fecal  matter  is  otherwise. 

The  most  serious  features  of  the  conditions  grouped  under  the  heading  of  Iirif/ht\s- 
disease  are  their  so-called  vremic  features.  These  happen  at  th(>  period  wlien  retention 
of  toxic  products  is  peculiarly  harmful.  As  long  as  the  urine  is  amf)le  in  amount  and 
density — i.  e.,  containing  enough  toxic  materials  in  .solution-^there  is  no  danger  of 
intoxication.  But  when  it  no  longer  eliminates  in  twenty-four  hours  what  it  should, 
then  we  see  the  chronic  and  paroxysmal  nervous  accidents,  the  edemas,  fluctuations  of 
temperature,  etc.  Oliguria  with  urine  of  increasing  density  and  general  edema  of  the 
tissues  may  be  noticed,  although  the  other  secretions  continue  natural  and  the  tongue 
moist.  As  long  as  the  normal  amount  of  solids  is  eliminated,  this  form  of  "  uremia"  may 
be  due  to  mere  accumulation  of  water  and  may  not  be  serious.  Ordinarily,  vremic 
patients  are  those  whose  urine  has  lost  its  toxicity.  Usually  on  the  day  in  which  so-called 
uremic  accidents  happen  the  urine  quite  ceases  to  be  toxic  and  is  scarcely  more  so  than 
distilled  water.  Urea  alone  is  not  to  be  held  guilty  for  this  condition.  In  order  to  kill 
a  man  with  urea  it  would  require  the  cjuantity  which  he  makes  in  sixteen  days.  Never- 
theless, it  may  become  harmful  after  undergoing  transformation  into  ammonium  car- 
bonate or  other  substances. 

Among  the  most  poisonous  substances  in  the  urine  are  the  extractive  and  coloring 
materials.  Normal  urine  loses  one-half  of  its  toxicity  by  decoloration;  bile  acts  in  the 
same  way.  Urea  alone  represents  about  one-eighth  of  the  total  toxicity  of  urine.  x4m- 
monia  is  toxic,  but  present  in  small  amounts.  The  coloring  matters  of  the  urine  cause 
two-thirds  of  its  toxicity,  the  remainder  of  which  is  to  be  ascribed  to  its  mineral  salts, 
which  it  contains  in  the  following  proportion :  A  liter  of  urine  ordinarily  contains  44  Gm. 
of  solid  matter,  of  which  32  are  organic,  12  mineral.  Of  the  latter,  potassium  salts 
constitute  3  Gm.,  sodium  salts  7.5  Gm.,  and  other  earthy  salts  constitute  the  remainder. 

In  these  conditions  physicians  have  relied  largely  upon  purgatives,  hoping  thereby 
to  remove  urea  from  the  blood.  But  intestinal  elimination  has  no  elective  affinity  for 
it,  and  removes  it  only  in  its  normal  proportion  with  the  balance  of  the  blood.  Purga- 
tives, however,  help,  first,  by  dehydrating  the  tissues — i.  e.,  removing  water  with  toxic 
material  in  solution.  But  they  should  be  followed  by  restoring  to  the  tissues  pure  water. 
By  bleeding  more  extractives  are  removed  than  by  any  other  channel,  excej)t  by  the 
kidneys.  A  bleeding  of  32  Gm.  removes  from  the  body  as  much  toxic  matter  as  would 
280  Gm.  of  a  liquid  diarrhea  or  100  liters  of  perspiration.  This  much  may  be  removed 
by  two  leeches.  It  is  especially  in  i\\e  subacute  nephritis  of  scarlatina,  etc.,  that  bleeding 
finds  its  greatest  indication.  If  the  kidneys  are  chronically  diseased,  the  utility  of 
bleeding  is  doubtful.  Between  the  arterial  capillaries  of  the  bowels,  however,  and  the 
liver  is  found  a  mass  of  blood  accumulated  in  the  portal  vessels.  This  may  be  regarded 
as  a  reserve  which  can  be  thrown  into  the  general  circulation  when  needed,  in  order  that 
thereby  arterial  tension  may  be  augmented  and  the  function  of  the  kidney  increased. 
Cold  injections  into  the  bowels  will  often  accomplish  this,  and  serious  anuria  frequently 
disappears  after  their  use.  It  is  advisable,  also,  to  make  use  of  urea  by  subcutaneous 
administration,  as  the  most  powerful  diuretic  known,  surface  friction,  caffeine,  digitalis, 
etc.,  being  far  behind  it  in  efficiency.  In  the  form  of  intoxication  noted  in  the 
eclampsia  of  puerperal  patients  inhalations  of  chloroform  are  valuable.  Potassium 
salts  should,  under  these  circumstances,  never  be  employed.  An  exposure  of  urine  in 
compressed  air  will  diminish  its  toxicity,  on  account  of  contact  with  the  oxygen;  the 
6 


82  SURGICAL  DISEASES 

most  toxic  bacteria  are  those  which  jfrow  without  oxygen.  Consequently  patients 
inhaUng  this  gas  may  overcome  this  k'unl  of  auto-intoxication. 

The  value  of  an  active  liver  is  not  appreciated  by  most  surgeons  to  the  full  extent. 
The  blood  of  the  portal  vein  is  so  much  more  toxic  than  that  of  the  hepatic  vein  that  it 
is  evident  that  the  function  of  the  liver  is  to  purify  and  remove  the  toxic  material  from  the 
blood  that  comes  from  the  intestines.  This  has  been  called  by  Flint  and  others  the 
depurative  action  of  the  liver.  The  activity  of  the  liver  also  may  be  proved  by  grinding 
uj)  a  freshly  removed  liver  with  alkaloids,  whereby  the  latter  are  chemically  changed. 

That  the  facts  above  stated,  or  others  related  thereto,  have  not  been  lost  sight  of  by 
surgeons  is  shown  by  such  expressions  as  .septic  enteritis,  cnterosep.sis,  etc.,  which  are  used 
by  various  writers.  In  previous  publications  the  writer  has  made  a  separate  topic  of 
so-called  intestinal  toxemia,  which  he  has  preferred  to  introduce  here  as  one  of  the  many 
possible  auto-intoxications.  It  is  a  condition  not  always  permitting  of  exact  definition, 
nor,  still  less,  can  the  exact  toxic  agency  be  indicated  in  a  given  case.  Nevertheless, 
it  has  been  made  plain  that  there  is  perhaps  no  condition  which  so  predisposes  to 
sapremia,  septicemia,  or  even  pyemia  as  this  vague  condition  of  intestinal  toxemia, 
which,  notwithstanding,  is  so  often  present.  Many  surgical  patients  present  forms 
of  blood  poisoning  in  which  the  poison  has  not  proceeded  from  the  wound,  for  which 
the  surgeon  is  not  responsible,  except  that  he  may  have  neglected  to  avail  himself  of 
certain  precautions. 

The  auto-intoxications,  then,  which  have  peculiar  interest  for  the  surgeon  may  be 
conveniently  classified  as  follows: 

1.  Those  caused  by  failure  in  the  function  of  particular  organs;  e.  g.,  myxedema, 
cretinism,  and  cachexia  strumipriva  from  thyroidal  failure;  pancreatic  diabetes,  where 
the  islands  of  Langerhans  are  invaded  (interstitial  pancreatitis,  q.  v.);  Addison's  disease 
from  adrenal  failure  (this  being  at  present  the  prevailing  belief). 

2.  Those  caused  by  general  disturbance  of  metabolism,  where  its  incomplete  or 
abnormal  products  reach  the  general  circulation,  e.  g.,  oxaluria,  gout,  diabetes.  (See 
Diabetic  Gangrene.) 

3.  Those  caused  by  retention  in  particular  organs  or  tissues  of  disturbed  metabolic 
products,  e.  g.,  the  toxemias  following  serious  burns  and  many  septic  conditions. 

4.  Those  due  to  excessive  formation  of  more  or  less  normal  products,  e.  g.: 

(a)  Hijdrothionemia,  i.  c.,  the  presence  of  hydrogen  sulphide  in  the  blood.  This 
results  from  one  form  of  gastro-intestinal  putrefaction  and  causes  violent  symptoms 
with  evidences  of  hydrogen  sulphide  poisoning.  It  is  seen  in  some  cases  of  gastric  dila- 
tation, especially  those  caused  by  pyloric  obstruction  {q.  v^. 

(b)  Acetonuria  and  Acetonemia. — The  former  sometimes  follows  chloroform  anesthesia, 
and  occurs  especially  in  diabetes  (particularly  after  removal  of  the  pancreas  in  experi- 
mental animals).  Acetone  per  se  is  nearly  or  quite  harmless,  but  its  congeners,  diacetic 
and  beta-oxybutyric  acids,  are  very  toxic.  The  danger  in  so-called  acetonuria  is  from 
acid  intoxication  by  these  acids,  which  has  been  described  as  "excessive  acidosis,"  and 
its  co-existence  with  glycosuria  makes  diabetes  certain,  while  prognosis  is  grave  in  pro- 
portion to  its  presence.  Prominent  among  the  s_\Tnptoms  produced  by  it  are  delirium 
and  coma. 

When  either  or  all  of  these  three  substances  are  present  in  the  blood  its  alkalinity  is 
reduced  and  its  ability  to  absorb  carbon  dioxide  impaired ;  hence,  acetonemia  is  evidenced 
by  carbon  dioxide  poisoning.  To  the  l)rain  symptoms  above  noted  is  added  a  peculiar 
odor  in  the  breath — sweetish  or  ethereal.  This  has  been  noted  in  pyemia.  This 
condition  may  set  in  after  various  operations,  but  whether  due  to  disease,  the  traumatism 
itself,  or  to  chloroform  may  not  always  be  determined.^ 

(c)  Cystinuria. 

(d)  Coma  of  cancerous  cachexia  (coma  carcinomatosum). 

(e)  Exophthalmic  goitre,  from  excess  of  thyroidal  activity  (thyroidism). 

Besides  the  above  there  is  auto-intoxication  proceeding  especially  from  the  gastro- 
intestinal and  hepatic  systems.  Of  the  former,  the  best  surgical  examples  are  seen  in 
the  tetany  which  occasionally  takes  its  rise  from  a  dilated  stomach,  and  which  may 
be  cured  by  a  pyloroplasty  or  a  gastro-enterostomy;  in  the  nephritis  which  follows 
stercoremia  of  intestinal  obstruction;  and  in  oxaluria,  with  its  painful,  serious,  and  often 

■  See  paper  by  Brewer,  Annals  of  Surgery,  1902,  vol.  xxxvi.  No.  4,  p.  481. 


Al'ro-IXFh'CTIOX,   ESPECIALLV   IX  SURdlCAL   l'.\TI i:\TS  83 

tlff<)riiiiii<;  or  (  rippliii;,'  j"'"'  aiVcctioiis.  ( )f  tlu'  latter  \vc  liavc  cxitiiiitlcs  in  the  cliolcinia 
of  aciitr  atropliy  or  ot"  l>iliary  ohstnictioii,  and  in  the  uremia  of  hepatic  origin  which 
occasionally   terminates   a   surgical   case. 

In  addition  to  the  ahove  there  should  also  he  mentioned  the  auto-intoxications  of 
pregnancy,  with  the  consequent  salivation,  perijjherul  neuritis,  piguientations  of  the 
skin,  icterus,  and  pruritus,  which  are  mainly  attributed  to  jxirverted  action  of  the  liver 
or  kiilneys. 

The  practice  of  preparing  patients  for  operation  hy  a  course  of  purgatives,  emetics, 
etc.,  is  based  upon  the  recognition  of  certain  principles.  The  general  symj)toms  included 
under  the  name  cnicrosvp.sis,  sirrrornitia,  coprrmia,  are  dut.^  to  the  activity  of  tlie  colon 
bacillus,  which  .seems  to  be  made  more  virulent  by  certain  conditions  of  diet  or  retained 
fecal  excretions,  and  to  such  an  extent  that  it  wanck'rs  widely  from  its  normal  habitat 
and  may  be  found  in  distant  j)arts  of  the  body.  Enirro.srp.fi. f  viajj  hr  mi.stakryi  for  .<f«r- 
gical  frvrr,  and  is  to  be  distinguished  from  it,  perhaps,  only  by  the  .study  of  the  excretions 
of  a  case  and  establishing  the  fact  that  they  are  free,  and  that  con.sequently  pyrexia, 
etc.,  cannot  be  due  to  diminished  elimination.  Aside  from  the  migrations  of  the  colon 
bacillus,  it  is  also  possible  for  auto-intoxication  to  occur.  Thus  tiiat  which  is  stcr- 
coremia  one  day  may  later  become  a  genuine  .septicemia,  vital  resistance  being  so  lowered 
as  to  permit  of  local  infection.  The  various  conditions  are  .so  often  merged  that  it  is  diffi- 
cult to  separate  and  identify  them.  Xevcrthcless,  cntcrosepsis  differs  from  sapremia 
in  that  in  the  one  instance  the  putrefying  material  is  contained  within  a  normal  cavity, 
whereas  in  sapremia  it  is  contained  within  an  alinormal  cavity,  in  either  ca.se  corresj)ond- 
ing  to  a  .frpfic  .luppo.s-itory,  varying,  however,  in  tlie  place  of  insertion,  also  in  the  nature 
of  the  surrounding  tissues,  which  in  the  latter  case  are  more  capable  of  absorption  and 
of  becoming  infected  than  in  the  former. 

A  determination  of  indol  and  indican  is  often  of  the  greatest  value,  both  in  determining 
the  extent  of  infection  and  the  presence  of  pus.  Indol  is  set  free  under  the  following 
circumstances:  (a)  Suppuration  in  a  closed  cavity.  (6)  Continued  suppuration  in 
a  cavity  with  an  outlet,  (c)  Ulceration  or  necrosis  of  tissue.  The  degree  of  indicanuria 
will  depend  on  the  length  of  time  pus  has  been  present,  the  possibility  of  absorption 
from  the  tissues  surrounding  it,  and  its  degree.  When  pus  is  fully  formed  in  a  serous 
sac  the  indican  reaction  becomes  intense  according  to  the  length  of  time  pus  has  been 
present.  This  is  particularly  true  in  the  empyemas  of  childhood.  In  continued  suppu- 
ration with  a  free  outlet  the  production  of  indol  will  be  great;  but  the  amount  finally 
eliminated  will  depend  upon  the  character  of  the  surrounding  tissue.  When  solid  ti.s.sue, 
like  bone,  becomes  affected,  the  elimination  of  indol  is  inten.se.  Rapid  biogenic  degener- 
ation of  ti.ssue  causes  an  increased  amount  of  indol  to  be  deposited  in  the  liver,  and  it  is 
possible  at  postmortem,  by  simple  extraction  with  absolute  alcohol,  to  take  from  the 
liver  this  excess  deposit  in  the  shape  of  its  oxidation  product,  indigo  blue.  Lardaceous 
degeneration  is  characterized  by  marked  and  persistent  elimination  of  indol,  which 
seems  to  be  a  product  of  tyrosin.  It  occurs  frequently  in  the  liver,  in  which  indol  is 
notably  deposited.  Its  primary  factor  is  deposited  by  the  blood,  in  which  latter  indol 
circulates  and  is  oxidized.  Lardaceous  material  gives  a  red  or  blue  color  with  oxidizing 
agents,  which  latter  yield  with  indol  an  indigo  red  or  blue. 

The  practical  outcome  of  such  a  chapter  as  this  is,  then,  to  insist  as  strongly  as 
possible  on  the  preparation  of  patients,  whenever  this  is  feasible,  for  an  ordeal  which 
comprises  the  combined  effect  of  anesthesia  and  con.sequent  disturbance  of  secretion 
and  elimination,  with  loss  of  blood  and  of  .strength,  and  sub-sequent  confinement  in  bed, 
wnth,  moreover,  all  that  this  entails  in  further  impairment  of  activities  of  important 
organs.  It  is  not  always  possible,  practically  rarely  so  in  emergency  cases,  to  adopt  these 
precautions ;  in  which  cases  they  must  be  atoned  for,  as  far  as  possible,  by  extra  atten- 
tion in  the  same  directions  after  the  emergency  is  pas.sed  or  has  been  met.  In  the 
former  case,  however,  the  functions  of  the  skin,  the  kidneys,  and  the  abdominal  viscera 
should  be  regulated,  the  first  by  hot-air  baths;  the  .second  by  this  same  measure  in  con- 
junction with  copious  draughts  of  pure  water,  the  correction  of  hyperacidity  of  the 
urine,  and  the  administration  of  whatever  drugs  may  be  of  benefit  as  diuretics,  etc.; 
and  the  third  by  a  course,  perhaps  covering  several  days,  of  gentle  or  active  purgation, 
by  which  the  alimentary  canal  will  be  entirely  emptied  of  all  that  may  sers-e  to  act  as 
a  source  of  poisoning.  In  addition  to  this,  in  certain  ca.ses  careful  massage  will  dislodge 
from  the  muscles  and  other  tissues  material  which  they  ought  not  to  retain,  and  which 


84  SURGICAL  DISEASES 

will  be  washed  away,  as  it  were,  by  the  extra  ainoiitit  of  fluid  which  tliis  preparation, 
necessitates.  Again,  the  activity  of  the  heart  should  be  stimulated,  perhaps  by  difjitalis, 
but  preferably  by  that  best  of  all  tonics,  strychnine,  which  is  to  be  administered 
hypodermicaliy  in  average  doses  of  a  thirtieth  or  twenty-fifth  of  a  grain,  morning 
and  night.  When  these  precautions  are  taken,  patients  will  succe.ssfully  pass  through 
trying  ordeals  without  anything  which  may  give  rise  to  alarm.  When  they  are  not 
possible,  the  risk  of  ojx-rating,  even  in  a  small  way,  is  materially  enhanced.  So,  too, 
after  operations  when  these  y)rec-autions  have  not  been  taken,  it  is  necessary  to  give 
careful  attention  to  atoning  for  their  lack  by  such  active  purgation  as  a  now  reduced 
patient  may  bear — by  hot-air  baths,  if  feasible,  and  by  the  administration  of  such 
intestinal  antiseptics  as  charcoal,  naj)l)thulin,  corrosive  sublimate,  bismuth  salicylate, 
salol,  etc.,  for  the  purpose  of  reducing  to  the  lowest  possible  minimum  the  opportunity 
for  formation  of  jxnsons  which  will  disturb  the  proper  repair  of  injury. 


CHAPTER    VII. 

THE  SURGICAL  FEVERS  AND  SEPTIC  INFECTIONS. 

SURGICAL  FEVER,  KNOWN  ALSO  AS  TRAUMATIC  FEVER,  OR  ASEPTIC 

WOUND  FEVER. 

Formerly  the  surt^^ical  fevers  were  all  i2;r()ii])e(l  tocrctlier,  and  a  certain  amount  of 
febrile  disturhance  was  looked  for  after  any  injury.  But  with  the  introduction  of  anti- 
septic methods  and  the  healing  of  wounds  by  primary  union,  with  absence  of  all  septic 
phenomena,  and  the  use  of  the  clinical  thermometer,  it  is  noted  that  there  is  a  certain 
rise  of  temperature  more  or  less  quickly  after  an  operation  or  reception  of  a  wound, 
with  fever  of  mild  grade,  persisting  for  several  hours  or  two  or  three  days,  and  with  other 
accompaniments.  This  j)henomenon  has  been  carefully  studied,  and  .so  .se])arated 
from  tile  septic  fevers  as  to  deserve  a  distinct  recognition  under  the  names  above  given, 
of  which  the  most  common  in  this  country  is  surgical  fcirr. 

As  long  as  this  fever  is  free  from  indications  of  .septic  character  it  is  M'ithout  significance 
and  needs  only  symptomatic  treatment.  It  begins  usually  within  the  first  twenty-four 
or  thirty-six  hours,  after  which  the  temperature  may  rise,  progressively  or  with  a  morning 
remission,  to  a  height  of  102°  or  possibly  103°.  In  children  we  are  more  likely  to  get 
extremes  in  this  regard  than  in  healthy  adults.  It  will  l>e  followed  by  some  disturbance 
of  alimentary  function,  glazing  or  drying  of  the  tongue,  deficiency  in  urinary  .secretion, 
and  subside  generally  spontaneously — invariably  so  if  cathartics,  diuretics,  cool  sjionge 
baths,  etc.,  are  used.  It  is  usually  due  to  the  retention  of  blood  clot,  ligatures,  etc., 
or  tissues  which  have  been  ligated  and  whose  stumps  remain;  in  all  instances  there  is 
some  foreign  material  to  be  removed.  This  means  unusual  phagocytic  activity,  perhaps 
temporary  leukocytosis,  with  active  metamorphosis  of  clot  and  other  material,  of  all  of 
which  the  elevated  temperature  is  an  accompaniment  and  expression.  It  is  not  unlikely 
that  the  antiseptic  materials  used  may  sometimes  occasion  this  pyrexia. 

Iodoform  and  carbolic  acid  are  among  the  drugs  in  common  use  which  are  known 
to  be  irritating  and  capable  of  producing  toxic  symptoms.  Often  after  the  use  of  the 
latter  the  urine  will  be  discolored  and  will  furnish  the  clue  to  the  fever.  In  young  chil- 
dren particularly,  and  not  infrequently  in  adults,  mental  disturbance,  even  active  delirium, 
may  characterize  the  case.  This  is  not  always  to  be  explained  by  cerebral  anemia  due 
to  loss  of  blood  during  the  operation  or  accident,  but  is  probably  due  to  drug  toxemia  or 
to  intoxication  from  materials  furnished  by  the  altered  tissues. 

Surgical  fever  of  strict  type  may  merge  into  a  more  or  less  continuous  fever  as  the  result 
of  intestinal  toxemia  permitted  by  failure  to  evacuate  the  bowels,  and  this  intestinal 
toxemia  may  he  a  p-edisposing  cause  of  genuine  septic  infection.  Consequently  a  sur- 
gical fever  which  does  not  disappear  within  two  days  is  to  be  viewed  with  suspicion, 
especially  if  it  does  not  subside  after  the  administration  of  cathartics. 

Some  surgical  fevers  are  accompanied  by  eruptions,  a  number  of  which  may  be  due 
to  drugs  and  some  to  intrinsic  poisons.  Thus  carbolic  acid  and  iodoform  give  rise 
occasionally  to  erjihematous  eruptions,  and  the  concomitant  administration  of  drugs 
like  potassium  iodide,  quinine,  antipyrine,  and  copaiba  may  produce  urticarial  or 
other  manifestations.  Again,  it  is  known  that  certain  toxins — produced,  e.  g.,  by 
the  bacillus  pyocyaneus— are  capable  of  causing  dilatation  of  the  superficial  vessels 
and  various  flushes  or  eruptions.  To  one  of  these,  which  dilates  the  capillaries, 
Bouchard  has  given  the  name  of  ectasine.  Consequently  it  by  no  means  follows  that 
every  eruption  or  rash  following  operations  or  injuries  is  of  a  specific  character.  On 
the  other  hand  it  seems  to  be  established  by  numerous  observers — among  whom  Paget 
is  perhaps  the  most  prominent— that  surgical  patients,  particularly  the  young,  are 
particularly  liable  to  infection  by  scarlatina;  and  in  the  experience  of  Thomas  Smith, 
of  fortv-three  children  whom  he  cut  for  stone,  ten  had  scarlet  fever.     Therefore,  in  spite 

(85) 


86  SURGICAL  DISEASES 

of  the  fact  that  a  certain  miniher  of  cases  of  erujition  may  have  been  mistaken  for  scarlet 
fever,  it  is  undoubtedly  true  that  in  surgical  and  puerj)eral  cases  patients  are  more  than 
usually  liable  to  this  invasion.  The  use  of  antitoxins  or  serums  is  also  occasionally 
followed  by  intense  urticaria. 

The  subject  of  surgical  fever  may  then  be  epitomized  as  consisting  of  elevation  of 
temperature  with  certain  accompanying  disturbances,  which  appear  to  be  essentially 
due  to  the  results  of  tissue  metabolism,  including  also  metabolism  of  l)]()()d  clot,  ligatures, 
etc.  It  is  not  a  necessary  nor  conspicuous  accompaniment  of  all  surgical  cases,  and 
in  some  individuals,  even  after  grave  operations,  it  will  scarcely  be  noted.  It  is  more 
likely  to  be  extreme  in  children  than  in  adults.  As  a  result  of  excessive  loss  of  blood 
it  may  be  postponed.  It  may  be  com{)licated  and  prolonged  by  any  one  of  the  auto- 
infections,  particularly  that  already  mentioned  in  the  preceding  chapter  as  intestinal 
toxemia,  as  a  result  of  which  septic  infection  may  ensue,  and  that  which  was  at  first 
a  legitimate  surgical  fever  may  thus  become  merged  into  a  septic  condition.  In  the 
absence  of  auto-infection,  and  with  appropriate  treatment,  surgical  fever  should  quickly 
subside  until  it  becomes  indistinguishable  about  the  second  or  third  day. 

Proceeding  then  in  the  order  of  pathological  complexities,  the  first  of  the  surgical 
infectious  fevers  to  be  considered  is  sapremia. 

SAPREMIA. 

The  term  sapremia  will  be  used  here  as  indicating  a  condition  which  is  often  likened 
to  an  into.ricafion  produced  by  a  supposititious  septic  suppository.  The  term  was  first 
used  by  Duncan,  and  was  largely  confined  to  puerperal  cases.  Some  of  the  most  ideal 
cases  of  sapremia  are  those  of  puerperal  origin. 

In  each  of  the  three  conditions  comprised  under  the  general  term  of  septic  infection  it 
is  not  now  a  question  of  particular  organisms,  but  of  intoxication  by  products  which  are 
more  or  less  common  to  at  least  several  of  them.  In  a  general  way,  they  are  mainly 
due  to  the  activity  of  the  organisms  already  grouped  as  pyogenic.  Those  which  produce 
pus  are  capable  of  causing  septic  infection.  In  addition  to  these,  it  is  probable  that 
certain  of  the  saprophytes  or  ordinary  putrefactive  organisms  may  produce  the  same 
effect. 

Symptoms. — In  sapremia  the  symptoms  begin  promptly,  depend  for  their  intensity 
upon  the  dosage  of  poison,  and  recede  quickly  as  soon  as  the  source  of  poisoning  is 
removed  or  its  activity  subdued.  An  instance  of  the  possible  causes  of  sapremia  will 
perhaps  best  illustrate  its  pathology.  Take,  for  example,  the  act  of  delivery  of  the  full- 
term  fetus.  At  the  completion  of  this  operation  there  is  left  a  fresh,  bleeding  wound 
of  large  area  which  is  more  or  less  exposed  to  putrefactive  agencies.  This  is  reduced 
with  the  contraction  of  the  uterine  walls  to  a  comparatively  small  cavity  containing 
more  or  less  freshly  coagulated  blood.  As  long  as  this  clot  does  not  putrefy  it  is 
disintegrated  inoffensively,  to  be  discharged  in  large  part  with  the  lochia.  If  germs 
of  putrefaction  enter,  either  during  the  act  of  labor  or  afterward,  and  linger,  putre- 
factive processes  are  set  up  in  the  clot  with  the  prompt  production  of  certain  toxins  and 
ptomains.  There  is  here  then  a  septic  suppository  with  conditions  favorable  for  absorption 
by  the  containing  tissues.  How  quickly  the  poisoning  may  show  itself,  and  how  soon 
it  may  subside  after  removal  of  the  putrefying  clot,  daily  experience  may  tell. 

Sapremia  then  is  intoxicatio7i  produced  by  absorption  of  the  results  of  putrefaction  of 
a  contained  material  loithin  a  more  or  less  closed  cavity,  whose  walls  are  capable  of  absorp- 
tion of  noxious  products  as  they  form.  As  long  as  putrefaction  i?  essentially  limited 
to  the  contained  mass,  and  does  not  spread  to  and  involve  the  containing  or  surrounding 
tissues  the  case  is  one  of  sapremia.  As  soo7i  as  the  processs  preads  from  the  cojitaining 
tissues  the  case  merges  from  one  of  sapremia  into  one  of  septicemia.  That  this  may 
occur  in  any  case  without  prompt  intervention  will  be  readily  understood.  Sometimes 
patients  may  die  of  sapremia,  though  rarely,  and  in  such  case  ordinarily  as  the  result  of 
gross  neglect.  Once  the  septicemic  process  is  begun,  however,  its  spread  cannot  always 
be  checked,  and  the  case  which  one  day  is  sapremic  and  redeemable  may  later  become 
septicemic  and  practically  lost. 

The  symptoms  of  sapremia  are  not  essentially  different  from  those  common  to  septic 
infection,  save  that  ordinarily  they  are,  at  least  at  first,  milder.     There  are  fiushing  of 


SKl'TJCKMIA  S7 

the  face,  dry  tongue,  nu'iital  disturhaiicc,  pyrexia,  while  iisiiaHy  all  the  symptoms  are 
ushere<l  in  by  a  chill,  whieh  may  have  been  precedeil  only  by  siifjht  mafaise.  These 
are  followed  by  nausea  and  vomiting,  with  headache,  and  often,  later,  by  diarrhea  or 
active  |)urgiiig.  Later  delirium  may  occur,  possibly  even  fatal  eoina.  On  postmortem 
examination  there  are  few  changes  revealed;  alterations  in  the  blood,  a  failure  to  coagu- 
hite,  and  some  softening  of  the  spleen  and  liver  would  ])rol)ably  be  the  onlv  ones. 

Treatment. — 'I'he  treatment  should  be  |)romj)t  and  the  cause  removed.  In  puer- 
peral sa|)rcniia  the  uterus  should  be  emptied,  antiseptic  douches  given,  irrigating  as  often 
as  necessary  to  prcvcMit  offensiv<>  odor  to  the  discharge,  and  combating  general  signs 
of  poisoning  by  |)lainly  indicated  measures.  Heart  depression  should  be  overcome  by 
diffusible  stiumlants  and  hypodermic  injections  of  .strychnine  in  do.se.s  of  ^t^  grain  or 
more.  The  bowels  should  he  unloaded  by  a  mercurial  followed  l)y  a  saline  cathartic; 
suppression  of  urine  treated  by  venesection  and  hot-air  baths  or  sweats;  diuretics  shouUl 
aLso  be  prescribed,  and  fluids  administered  copiously.  If  the  patient  is  restless,  an 
opiate  should  be  given;  if  delirious,  necessary  restraint  should  be  resorted  to. 

E.s.sentially  the  same  measures  should  be  y)ursued  in  a  surgical  wound  or  in  a  case  of 
compound  fracture,  or  any  injury  where  retained  material  may  be  undergoing  changes 
already  alluded  to.  General  measures  should  be  the  same.  Purgatives  are  advisable 
in  these  cases. 

Chronic  Sapremia.— Chronic  sapremia  is  a  better  name  for  what  used  to  be  known 
as  heetic  fever.  It  is  characterized  by  rapid,  feeble  pulse,  a  temperature  but  little 
elevated  in  the  morning  and  rising  to  102°  or  103°  in  the  latter  part  of  the  day,  with 
profu.se  perspiration,  or  sometimes  colliquative  sweats  that  leave  patients  exhausted. 
There  is  usually  a  distinctive  flushing  of  the  cheeks.  Emaciation  is  a  marked  feature 
in  most  instances.  Hectic  means  simply  habitual  fever.  It  is  met  with  particularly 
in  tuberculous  ca.ses,  whether  of  lungs  or  bones  or  joints,  in  empyema,  p.soas  abscess,  and 
most  all  chronic  pyogenic  infections.  It  is  frequently  followed  by  or  associated  with 
amyloid  or  waxy  degeneration  of  the  liver,  kidneys,  and  spleen.  This  process  commences 
in  the  walls  of  the  bloodvessels  and  by  its  spread  to  the  surrounding  connective  tissue 
leads  to  notable  enlargement  of  these  organs,  with  albuminuria,  edema,  ascites,  and 
the  usual  associated  phenomena. 

Treatment. — Treatment,  in  addition  to  that  already  indicated  above,  should  be 
addressed  to  removal  of  the  cause.  In  all  instances  it  should  comprise  attention  to 
elimination,  digestion,  nutrition,  and  fresh  air.  By  such  measures  even  distinct  amyloid 
changes  may  be  arrested,  or  possibly  improved. 

Cryptogenetic  or  Spontaneous  Septicemia.— Crypt ogenetic  or  spontaneous  septi- 
cemia is  a  term  applied  to  those  cases  in  which  the  port  of  entry  of  the  germs  is  no  longer 
visible — e.  g.,  a  hypodermic  puncture — or  cannot  be  positively  determined.  On  careful 
study  this  may  be  found  to  consist  of  a  small  focus  where  pus  is  forming  wuthin  narrow 
confines  and  under  great  pressure.  Under  the.se  circumstances,  as  Kocher  has  shown, 
toxic  virulence  is  rapidly  augmented.  This  is  doubtless  one  reason  why  the  septic 
features  of  many  cases  of  osteomyelitis  and  appendicitis  are  so  pronounced. 

SEPTICEMIA. 

According  to  the  view^s  thus  enunciated,  the  difference  between  sapremia  and  septi- 
cemia is  not  one  of  character  as  much  as  of  location,  hi  septicemia  the  'putrefactive 
axiiion  is  no  longer  confined  to  material  enclosed  by  (yet  not  of)  the  tissues  themselves,  Imt 
has  spread  from  this  to  the  surrounding  living  cells,  which  are  being  attacked  by  bacterial 
enemies;  in  other  words,  we  deal  with  infection  of  litying  tissues  rather  than  with  mere 
intoxication.  This  is  a  progressive  iyivasion  of  tissues  by  continuity,  with  a  constantly 
proceeding  systemic  into.xication  by  poisons  produced  in  larger  quantities.  So  rapid 
may  this  action  be— as  may  be  .seen  in  malignant  diphtheria— that  the  individual  speedily 
succumbs  before  evidences  of  abscess  or  local  gangrene  appear.  On  the  other  hand, 
providing  that  the  toxic  action  is  less  pronounced  or  the  patient's  vitality  more  enduring, 
— i.  e.,  his  ti-ssues  more  resistant — abscess,  phlegmon,  or  local  gangrene  may  result 
the  destruction  of  ti,ssue  being  limited  to  the  environs  of  the  parts  first  involved.  Bac- 
teria are  also  found  in  the  blood. 

While  septicemia  then  may  be  a  direct  continuance  of  an  original  sapremia,  it  is  not 


88  SURGICAL  DISEASES 

intended  to  intimate  that  it  may  not  originate  de  novo;  that  is,  viany  cases  may  begin  as 
a  pronounced  septicemia  jrom  a  local  injection.  This  is  the  case,  for  instance,  with  the 
maiority  of  (Hssecting  woinids,  etc. 

Symptoms. — In  septicemia  there  is  a  period  of  incubation,  usually  two  or  three  days, 
often  longer.  If  this  follows  an  o|x»ration,  the  mild  fever  which  would  indicate  the 
slumbering  fire  is  usually  regarded  as  surgical  fever.  But  when  this  rises  and  is  followed 
bv  prostration,  with  alimentary  disturbance,  loss  of  aj^jx-tite,  headache,  etc.,  followed 
by  typhoidal  .symptoms,  the  alarm  is  .sounded  and  should  Ije  quickly  heeded.  Usually, 
but  not  always,  there  is  a  preliminary  or  premonitory  chill,  after  which  prostration  will 
be  more  marked  than  before.  The  severity  of  the  .symptoms  cannot  be  foretold  from 
the  size,  location,  or  character  of  the  wound.  The  character  of  the  fever  is  essentially 
continued,  usually  with  morning  remissions.  Gu.ssenbauer  has  called  attention  to  a 
class  of  cases  in  which  subnormal  tem]>erature  is  cau-sed  by  the  absorption  of  ammonia 
compounds.  To  these  he  has  given  the  name  ammoniemia.  This  condition  may  be 
seen  in  connection  with  gangrenous  hernia,  and  has  even  been  mistaken  for  shock 
(Warren).     (.See  also  acetonemia,  in  previous  chapter.) 

In  septicemia  from  infection  of  a  visible  portion  of  the  body  there  are  usually  seen 
CA'idences  of  lymphangitis  and  perilymphangitis  of  .septic  character.  These  will  be 
evidenced  by  tender  and  purplish  lines,  extending  subcutaneously  along  the  course  of 
the  known  lymphatics  or  in  connection  with  the  more  prominent  subcutaneous  veins. 
The  lymph  nodes,  into  which  these  visible  ves.sels  as  well  as  the  deeper  ones  empty, 
become  enlarged  and  tender;  the  whole  lymphatic  system  panicipates;  the  spleen  in  aggra- 
vated cases  becomes  notaljly  enlarged,  and  even  the  bone-marrow  more  or  less  involved. 
Diarrhea  is  commonly  an  early  but  controllable  symptom.  A  hematogenous  icterus 
of  mild  degree  is  another  frequent  accompaniment.  The  conjunctiva  becomes  discolored 
and  the  skin  slightly  so.  Should  the  blood  be  examined  marked  leukocytosis  will  be 
noted,  and  should  cultures  be  made  from  it,  in  many  instances  at  least,  the  organisms 
at  fault  can  be  detected  and  recovered  from  it.  The  vigor  of  the  heart  muscle  is. seriously 
impaired;  the  pulse  becomes  rapid  and  iceak.  In  scarcely  any  form  of  septic  infection 
is  this  more  prominent  than  in  diphtheria;  and  microscopic  examination  shows  the  rapid 
disintegration  of  the  cells  of  the  heart  muscle,  as  well  as  those  of  other  parts  of  the 
body,  even  to  the  almost  complete  molecular  disintegration  of  the  nuclei.  Ervthematoid, 
pustular,  and  even  hemorrhagic  eruptions  are  met  with  upon  the  skin,  some  of  which  are 
probably  to  l>e  explained  by  thrombosis  of  the  dermal  capillaries.  Certain  compli- 
cations are  not  infrequent,  among  which  inflammations  of  the  pericardium  and  endo- 
cardium— e.  g.,  ulcerative  endocarditis — are  frequent.  As  the  case  becomes  aggravated 
the  temperature  rises  irregularly;  the  hot,  dry  skin  becomes  cold  and  clammy;  prostra- 
tion and  indifference  more  marked;  diarrhea  more  colliquative;  icterus  more  pronounced; 
urine  more  reduced  in  quantity  or  suppressed;  and  these  .s\Tnptoms  are  succeeded  by 
indifference,  mental  apathy,  stupor  or  delirium,  and  finally  death,  the  patients  being 
comatose  and  collapsed. 

While  these  are  the  general  indications  of  septicemia,  the  wound  or  site  of  injury 
has  undergone  changes  which  are  also  characteristic  They  comprise  the  edema  and 
redness  of  wound  margins,  which  may  be  seen  even  in  sapremia,  followed  by  increasing 
tumefaction,  esca|)e  of  foul-smelhng  discharge,  and  finally  by  sloughing  and  gangrene 
of  the  parts  involved.  On  microscopic  examination  the  capillaries  are  filled  with 
infective  thrombi  and  vessel  walls  infiltrated  with  microorganisms,  which  abound  also 
in  the  lymph  spaces.  Bacterial  infection  can  be  traced  in  microscopic  sections  from 
the  infected  area,  from  the  point  in  the  neighborhood  of  the  wound  where  microbes 
infest  the  tissues  to  points  remote  from  it,  where  they  are  sparsely  found,  if  at  all.  The 
same  evidences  of  infection  may  be  traced  along  the  lymphatic  vessels,  and  often  the 
veins. 

Postmortem  Evidences. — The  postmortem  evidences  of  septicemia  are  indicative 
on  first  sight:  the  blood  is  of  the  consistency  of  tar  and  does  not  coagulate;  evidences 
of  putrefaction  are  plain  to  sight  and  smell;  the  .serous  membranes,  particularly  the  pia 
mater,  are  often  extra vasated ;  the  muscles  are  discolored  and  of  a  darker  hue  than  natural, 
edema  of  the  lung  is  frequent;  the  intestines  reveal  a  gastro-intestinal  catarrh,  the  duo- 
denum and  rectum  .showing  punctate  hemorrhages;  the  spleen  is  darkened,  enlarged, 
and  softened;  the  liver  shows  similar  signs,  less  marked,  and  at  times  an  emphysematous 
condition  due  to  putrefactive  gases.     Cultures  can  be  made  from  the  fluids  and  tissues 


SI'PTICKMIA 


SI) 


of  orj^ans  finis  afTcclod.  It  is  also  of  iinportaiuc  to  cinphasizc  that  such  material  is 
poirrr/iil/i/  and  often  fatally  nijrriious;  some  of  the  worst  forms  of  disseetiii^  wounds 
and  instances  of  jntiil  iiifrclioii  have  come  from  carelessness  in  makini^  these  postmortem 
examinafion.'i. 

Sofar  as  eoneern.s  the  character  of  the  wound,  which  is  most  likely  to  he  followed  by 
septicemia,  there  is  but  little  to  be  said.  Wounds  made  by  infected  tools,  the  butcher's 
knife,  the  anatomist's  scalpel,  etc.,  are  the  most  dangerous.  All  forms  of  pIile<fmonous 
erysii)elas,  many  cases  of  fi^anfj^rene  followintr  frostbite,  nearly  all  instances  of  tranmatic 
j!;an<jren(\  most  cases  of  carbuncle,  and,  in  fact,  all  similar  lesions,  are  likely  to  be  followed 
by  septicemia.  The  so-called  sj)ontaneous  cases  have  an  e(|ually  infectious  origin, 
though  one  which  is  concealed.  In  unreco<:jnized  instances  of  ap|)cndicilis,  for  instance, 
and  in  many  other  conditions,  althouj;h  the  path  of  infection  may  not  be  easily  traced, 
it  is,  nevertheless,  always  j)resent,  and  can  be  found  if  dili<^ent  search  is  made.  The 
nasal  cavity,  the  tonsils,  the  teeth,  the  middle  ear,  the  deep  urethra,  and  the  rectum 
are  often  overlooked  as  ottering  possibilities  for  septic  infection  which  may  follow  this 
general  type. 

Treatment. — This  should  be  both  local  and  general.  Local  treatment  should  consist 
in  complete  and  absolute  removal  of  the  active  cause.  'J'his  comjtrises  the  reopening 
of  wounds,  evacuation  of  clot,  cutting  or  scraping  away  of  sloughs  and  gangrenous 
tissue,  with  cauterization  of  the  exposed  living  tissue,  in  order  that  aljsorjjtion  may  be 
prevented,  and  will  often  inchuh^  am])utation  or  extir|)ation  of  a  part.  For  tissues 
which  are  not  too  completely  riddled  by  disease,  and  lost  beyond  })(wsibility  of  redemption, 
continuous  immersion  in  hot  water  offers  the  best  possible  prospect.  By  it  putrefac- 
tion .seems  checked,  the  separation  of  dead  from  living  tissues  is  accelerated,  relief  of 
pain  or  discomfort  is  att'orded,  and  disinfection  of  material  which  is  foul  and  infectious 
is  guaranteed.  An  excellent  local  application  is  the  mixture  of  resorcin  .5  parts,  ichthvol 
10  parts,  ung.  hydrarg.  40  parts,  and  lanolin  45  parts,  already  mentioned  in  Chaj)ter 
IV,  or  the  application  of  hreurrs'  yeast.  (See  chapter  on  Ulcers.)  Of  great  value  also 
will  be  found  the  silver  ointment  of  Crede  (Unguentum  Crede).  This  permits  of 
absorption  of  silver  through  the  unl)roken  skin  (as  in  the  case  of  ung.  hydrarg.),  and  the 
dis.semination  throughout  the  .system  of  the  antiseptic  virtues  of  the  silver  itself.  To 
ensure  its  greatest  efficiency  this  ointment  should  be  thoroughly  rubbed  in,  especially 
over  parts  which  are  not  too  tender.  Many  cases  of  septic  infection  promptly  yield 
under  the  influence  of  the  argentine  preparations  which  Crede  has  lately  introduced. 

In  suitable  cases  also  the  subcutaneous  injections  of  antistrepfocorcic  serum  will  be 
followed  by  beneficial  effects.  The  earlier  the  injection  is  given  the  better  the  j)rospec"t 
of  benefit.  Evidence  is  strongly  in  favor  of  this  serum  as  a  pro])hylactic  measure, 
especially  before  operations,  when  septic  pneumonia  or  other  septic  accidents  are  feared. 

Another  measure  of  great  utility  in  selected  cases  is  the  intravenous  infusion  of  a  solu- 
tion of  Crede's  soluble  silver,  made  with  1  gram  of  silver  in  1000  Cc.  of  sterilized  water 
at  a  temperature  of  105°  to  110°.  In  cases  of  profound  toxemia  a  small  amount  of  blood 
may  be  withdrawn  (50  to  400  Cc),  for  reasons  stated  in  Chapter  VI.  No  hesitation 
need  be  felt  in  introducing  500  Cc.  or  even  1000  Cc.  of  this  solution.  It  is  the  ideal  way 
of  bringing  a  powerful  non-toxic  antiseptic  into  immediate  contact  with  pathogenic 
microbes. 

There  have  been  recent  suggestions  as  to  the  intravenous  injection  of  very  dilute 
formalin  solution,  in  order  to  take  advantage  of  its  remarkable  germicidal  activity; 
it  has  been  employed  in  a  few  cases,  especially  of  puerperal  sepsis,  with  success, 
1  Cc.  of  standard  formalin  solution  is  mixed  with  800  Cc.  of  sterilized  salt  solution. 
It  has  been  shown  that  if  50  Cc.  of  this  is  thrown  into  the  veins  of  an  average  adult  it 
will  form  with  the  5000  Cc.  of  blood  a  mixture  of  1  to  200,000,  in  which  strength  it 
may  be  expected  to  prove  an  efficient  bactericidal  agent.  Indeed,  a  smaller  amount  or 
a  weaker  preparation  would  probably  suffice.  Barrows  has  reported  success  following 
two  infusions,  two  days  apart,  of  first  .500  Cc,  then  750  Cc.  of  a  1  to  5000  formalin 
solution.  Still,  these  injections  may  be  followed  by  cramps  in  the  arms,  cardiac 
discomfort  or  distress,  and  blood  (or  blood  cells)  in  the  urine.  It  would  probably  be 
well  to  limit  this  use  of  formalin  to  those  cases  at  least  in  which  the  presence  of  cocci  in 
the  blood  can  be  demonstrated  by  culture  or  other  method. 

An  excellent  method  in  the  local  treatment  of  parts  which  admit  of  it  (hands  and 
feet)  is  their  exposure  to  dry  hot  air  in  the  Kelly  heater  or  some  similar  apparatus.     Hot 


90  SURGICAL  DISEASES 

air  will  be  home  at  a  temperature  of  210°  to  220°,  which  may  he  destructive  to  germs 
while  still  tolerable  for  a  short  tiuie  by  the  tissues.  Clintou,  of  Bufi'alf),  with  whom  this 
method  is  original,  reports  that  the  teinj)erature  within  the  tissues  thus  treated  is  raised 
to  about  107°,  which  is  above  the  thermal  death  point  of  the  ordinary  pyogenic  organ- 
isms, and  that  this  method  gives  better  results  than  any  other  of  treatment  of  septic 
infection  of  those  parts  which  can  be  subjected  to  it. 

The  general  treatment  of  septicemia  is,  in  the  main,  stimulant  and  tonic.  Fever  is 
not  to  be  treated  with  arterial  sedatives  nor  often  with  antipyretics.  It  is  a  symptom 
of  poisoning,  and  its  too  prom|)t  suj^pression  prevents  both  the  recognition  of  the  intoxi- 
cation and  tile  measure  of  its  degree.  Pyrexia  then  is  best  combated  with  cool  sponge 
baths  and  stimulant  measures  of  a  general  character.  The  principal  reliance  nuist  be 
upon  nutrition  and  stimulants.  Assimilation  may  be  impaired  when  gastro-intestinal 
catarrh  is  as  prominent  a  feature  as  it  is  in  many  of  these  cases.  Consequently  the 
simplest  and  most  assimilable  food,  often  that  wliich  is  predigested,  should  be  adminis- 
tered. Milk,  eggs,  beef  peptonoids,  and  fruits  are  among  the  most  appropriate.  The 
best  stimulants  and  tonics  are  alcohol  and  strychnine.  Strychnine  is  preferably  adminis- 
tered hypodermically  in  doses  of  ^-^  grain  from  two  to  four  times  a  day.  Heart  depression 
is  best  combated  by  this  measure,  or  by  quinine  in  large  doses,  while  digitalis  and  atro- 
pine may  be  added.  For  internal  use  alcohol  is,  par  excellence,  the  remedy.  This  is 
administered  in  doses  only  to  be  measured  by  their  effect.  In  fact,  the  administration 
of  alcohol  in  these  cases  is  a  matter  of  effect,  and  not  of  dosage.  Aside  from  these  meas- 
ures the  intestinal  antiseptics  should  be  administered,  among  these  being  corrosive 
sublimate,  y^^  grain,  every  three  or  four  hours,  salol  in  large  doses,  bismuth  salicylate, 
or  naphthalin — any  or  all  of  these  in  connection  with  powdered  charcoal.  Intestinal 
pain  and  frequency  of  stool  can  be  more  or  less  controlled  by  opium,  while  disinfection 
of  the  alimentary  canal  is  only  to  be  accomplished  by  the  above  remedies,  in  connection 
with  flushing  of  the  colon  with  saturated  boric  acid  solution  or  something  of  that  kind. 
Pain  is  to  be  controlled  by  morphine  administered  subcutaneously. 

No  special  attention  need  be  given  to  the  so-called  septicopyemia.  It  represents 
a  mixed  condition  of  septic  intoxication,  local  infection,  and  destruction,  with  metastatic 
abscess,  and  is  a  term  appropriately  applied  to  cases  which  combine  the  significant 
features  of  each  type. 

PYEMIA. 

The  derivation  of  the  term  pyemia,  which  came  into  general  use  in  1828,  is  misleading. 
Although  septic  fever  always  accompanies  suppuration,  it  is  not  certain  that  pus  as 
such  circulates  in  the  blood,  as  the  term  pyemia  implies,  the  error  having  arisen  origin- 
ally from  mistaking  the  contents  of  breaking-down  thrombi  for  pus  from  ordinary  sources. 
While  a  recognition  of  the  etiology  of  the  disease  is  new,  the  disease  itself  has  been 
recognized  for  many  centuries. 

Pyemia  is  only  met  with  in  connection  with  suppuration,  as  far  as  known,  never  with- 
out it.  In  those  cases  which  appear  to  be  free  from  suppuration  pus  will  be  found. 
Pyemia  may  be  described  as  septicemia  plus  thrombotic  and  evibolic  accidents,  which 
lead  to  distribution  of  infectious  material  to  all  parts  of  the  body.  This  distril)ution  is 
made  by  the  bloodvessels,  although  to  some  extent  the  lymphatics  undoubtedly  partici- 
pate. When  pyogenic  organisms  reach  bloodvessel  walls  they  tend  to  set  up  a  mycotic 
phlebitis,  which,  by  virtue  of  the  coagulating  blood,  becomes  soon  what  is  known  as 
thrombophlebitis.  Infection  proceeding  through  the  vessel  walls,  the  endothelial  lining 
is  loosened,  while  to  these  rotting  spots  leukocytes  adhere  and  coalesce  into  a  more  or 
less  homogeneous  mass.  This  so-called  white  thrombus  becomes  also  infected  with 
bacteria;  portions  of  it,  loosened  and  dislodged,  are  carried  by  the  returning  blood  stream 
to  the  right  side  of  the  heart,  whence  they  are  distributed  through  the  lungs.  Dislodge- 
ment  may  be  made  by  mere  force  of  the  blood  stream,  or  may  be  assisted  by  movements 
of  the  part  or  handling  of  the  same.  These  particles  of  thrombi  are  loaded  with  the 
infectious  organisms  which  began  the  disease,  and  wherever  one  settles  a  reproduction 
of  the  original  thrombophlebitis  is  rapidly  produced.  In  this  way  numerous  infected 
thrombi  are  formed  within  the  vessels  of  the  lungs,  which,  again,  loosen,  and  are  now 
swept  into  the  left  side  of  the  heart,  whence  they  are  distributed  with  arterial  blood  in 
all  directions.     While  it  is  true  that  they  are  equably  distributed,  it  is  also  positive  that 


PYKMJA  91 

certain  tissues  seem  more  eapal)l(>  of  Indirinjr  and  I)einir  attacked  l)v  tlie  contained 
orjjanisnis  than  arc  others.  Wlien  it  is  once  appreciated  that  each  |)arti{le  of  infected 
clot  is  capahle  of  scttiiifi:  np,  cither  in  the  hnij^s  or  in  the  other  tissues,  upon  the  second 
(listril)Ution,  otlier  al)sccss  formations  aiiaio^'ous  in  etioh)<jy  to  that  from  whicii  came 
the  first  distnrhance,  then  the  fundamental  idea  of  mcfa.s-tafir  ahscesK  is  fully  impressed. 
The  term  mctasia.sis  may  he  rejjarded  as  sifiionifuiou.'i  irifli  iransporiaiion,  and  metas- 
tatic abscesses  are  those  produced  hy  transj)()rtation  of  infected  j«irticlcs  from  one  part 
of  the  body  to  another.  Wherever  they  lodge  similar  trouble  will  result.  Contiguous 
minute  metastatic  abscesses  quickly  cuak'.srr,  and  in  this  way  large  collections  of  |)us 
are  formed.  The  blood  also  contains  organisms  not  attached  to  thrombi,  and  from 
the  blood  of  the  jncmic  patient  cultures  can  at  almost  any  time  be  made.  I'ntil  this  is 
done  it  will  be  virtually  imj)ossible  to  incriminate  any  |)articular  organism  as  the  one  at 
fault.  Tliroml)()-arin-Uis  is  the  e(|uivalent  in  the  arteries  of  thrombophlebitis  in  the 
veins,  and  is  accompanied  by  the  same  tlctachmcnt  of  endothelium,  adliesion  of  leuko- 
C}'tes,  etc.  Whenever  such  a  lesion  occurs  in  artery  or  vein,  coagulation  necrosis  takes 
place  and  suppuration  occurs  around  it.  The  metastatic  abscess  is  thus  the  result 
of  breaking  down  of  this  affected  tissue,  and  is  often  called  miliar]/  abscess.  Particles 
of  infective  thrombi  cling  also  to  the  valves  of  the  heart  and  a  septic  endocarditis  may 
result. 

The  possibility  of  so-called  spontaneous  or  idiopathic  pyemia  is  occasionallv  discussed. 
This  means  a  pyemia  whose  cause  is  concealed.  The  explanation  will  be  found  some- 
times in  an  acute  infectious  osteomyelitis,  sometimes  in  ulcerative  endocarditis,  or 
inflauKMl  apjXMidix  or  other  portion  of  the  peritoneal  cavity.  Again,  it  may  j)roceed  from 
middle-ear  iliseasc,  in  which  there  is  so  little  discharge  as  scarcely  to  attract  attention. 
Thus  causes  which  predispose  to  suppuration  (see  Chapter  III)  come  into  play  here, 
and  the  influence  of  exposure,  fatigue,  starvation,  etc.,  is  not  to  be  ignored  in  furnishing 
an  explanation  for  the  so-called  idiopathic  cases. 

In  the  majority  of  instances,  however,  pyemia  follows  surgical  operations  and  injuries, 
among  which  are  compound  fractures,  deep  injuries  with  small  superficial  evidence 
thereof,  compound  injuries  of  the  skull,  and  injuries  by  which  veins  are  exposed.  Inas- 
much as  the  typical  pyemic  manifestations  recjuire  a  certain  length  of  time  for  their 
development,  the  onset  of  this  disease  is  more  delayed  than  in  the  case  of  septicemia. 
While  the  case  may  be  manifestly  one  of  septic  infection  of  unrecognizable  type,  the 
characteristic  indications  of  pyemia  seldom  appear  in  less  than  ten  days,  and  frequently 
not  for  several  days  longer. 

Symptoms. — The  s}Tiiptoms  of  pyemia  do  not  essentially  differ  from  those  of  other 
septic  infections.  The  principal  difference  is  in  the  frequency  of  chill  and  range  of  tem- 
perature. Chills  are  more  common  at  the  inception  of  the  condition,  and  more  frequent 
throughout  its  continuance  than  in  other  septic  conditions.  The  chill  may  be  slight 
or  assume  the  proportions  of  a  rigor,  and  each  chill  is  followed  by  colliquative  sweat  and 
exhaustion.  In  other  w^ords,  chills  which  are  infrequent  in  septicemia  are  common  in 
pyemia.  There  is  reason  to  believe  that  with  each  fresh  distribution  of  emboli  we  have 
one  or  more  chills  as  the  objective  evidence  thereof.  Distinctive  also  of  pyemia  is  the 
temperature  curve,  which  much  resembles  that  of  intermittent  fever,  without  the  regu- 
larity of  change  characteristic  of  malarial  fevers.  It  is  without  regular  remissions,  and 
has  been  referred  to  as  irregularly  intermittent.  The  first  rise  is  abrupt  and  usually 
excessive,  while  with  each  fresh  chill  or  series  of  chills  similar  abrupt  alterations  will 
be  noted.  These  occur  so  frequently  and  fluctuate  so  irregularly  that  in  order  to  note 
them  accurately  the  temperature  should  be  taken  at  least  every  two  hours.  The  tem- 
perature seldom  drops  to  normal. 

As  the  lungs  fill  with  the  first  crop  of  infected  emboli,  and  the  first  series  of  metas- 
tatic abscesses  form  there,  there  is  more  or  less  dyspnea  and  sense  of  oppression;  there 
may  be  also  pidmonary  complications — pleurisy,  bronchitis,  etc.,  even  pulmonary  edema. 
Frequently  there  is  expectoration  of  frothy  and  discolored  sputum;  occasionally  there 
is  blood  in  the  sputum.  A  peculiar  sweetish  odor  of  the  breath  has  been  noted  by  many 
observers  in  this  disease,  and  is  supposed  to  be  idiopathic  and  characteristic.  (See 
acetonemia  in  previous  chapter.)  With  the  dispersion  of  the  second  crop  of  emboli  from 
the  lungs  there  is  apt  to  be  icterus,  with  evidence  of  metastatic  abscess  in  the  liver,  and 
collection  of  pus  as  the  result  of  coalescence  of  small  abscesses.  The  sensorium  is 
not  so  afifected  in  pyemia  as  in  septicemia,  and  in  the  former  disease  patients  are  more 


92  SURGICAL  DISEASES 

likely  to  be  alert  and  active  in  mind.  General  hi/pcresthcsia  and  restlessness  are  common. 
CoUifiuative  sweats  are  also  a  feature  of  pyemia.  There  is  the  same  liability  to  erup- 
tions, etc.,  which  may  mislead  or  complicate  the  diafjnosis.  A  dermatitis  is  seen  some- 
times in  pyemia,  the  lesions  assuming;  a  papular  or  pustular  form,  due  to  local  infections 
of  the  skin.  Purpuric  spots  are  also  seen,  and  vesication  is  not  infrequent.  Within 
the  mouth  sordes  collect  upon  the  teeth  or  gums;  the  tongue  becomes  dry  and  brown 
and  heavily  coated.  Diarrhea  is  less  common  in  pyemia.  The  urine  is  usually  scanty 
and  high  colored,  containing  solids  in  excess;  albumin  is  sometimes  found  therein,  as 
well  as  peptone.  The  presence  of  peptone  in  the  urine  is  probably  an  indication  of 
the  breaking  down  of  pus  corpuscles  in  various  parts  of  the  tissues. 

A  significant  objective  evidence  of  pyemia  is  met  with  in  the  metastatic  collections 
of  pus  within  the  joints,  which  occur  relatively  early,  and  which,  if  multiple,  may 
lead  to  a  correct  diagnosis.  One  of  the  earliest  joints  to  be  involved  is  the  sterno- 
clavicular, although  none  of  the  joints  are  free  from  the  possibility  of  invasion.  The 
articular  serous  membranes  seem  to  have  the  property  of  carrying  and  holding  the 
infective  thrombi  better  than  any  other  tissue  in  the  body.  The  pyarthrosis  of  pyemia 
is  for  the  most  part  painless,  yet  implies  loss  of  function  of  the  affected  joints.  The  dis- 
tention of  these  is  usually  evident  to  the  eye,  the  fluctuation  pronounced,  tenderness 
not  extreme,  but  the  swollen  part  merges  into  tissues  which  are  edematous  and  reddened. 
When  pain  in  the  limb  is  extreme,  it  is  usually  because  of  metastatic  abscess  within  the 
bone-marrow  cavity.     In  other  words,  we  now  have  a  metastatic  osteomyelitis. 

In  all  cases  of  pyemia  prostration  is  marked,  yet  the  pulse  is  seldom  weak,  at  least 
until  toward  the  close  of  life.  As  cases  progress  from  bad  to  worse  subsultus  tendinum 
is  often  noted 

The  appearance  of  the  wmmd  or  site  of  operation  does  not  differ  essentially  from 
that  already  described  under  Septicemia.  There  is  usually,  however,  less  discharge, 
granulations  are  smoother  and  dryer,  and  if  tissues  are  gangrenous  they  are  not  as  wet 
and  nauseous  as  in  the  other  case.  Evidences  of  thrombophlebitis  and  lymphangitis 
will  proceed  from  the  wound  toward  the  body,  as  in  other  instances  of  septic  infection. 

Prognosis. — Prognosis  is  usually  had.  "While  recovery  may  follow  where  metastatic 
infiltration  has  not  been  too  general,  the  ordinary  case  of  pyemia  will  die  within  twelve 
to  fourteen  days  after  diagnosis.  Sometimes  the  entire  process  is  much  slower,  and 
isolated  cases  occur  which  can  be  designated  as  so-called  clironir  pyemia,  which  differs 
but  little  from  the  acute  form.  A  case  of  pyemia  should  not  fail  of  recognition  because 
there  is  no  evidence  of  infection  from  without.  A  fatal  case  of  pyemia  has  been  known 
to  occur  from  a  suppurating  soft  corn  which  was  not  discovered  during  life;  also  from 
peridental  abscess,  etc.,  which  had  been  overlooked.  Death  is  the  result  of  tissue 
destruction   and  septic  intoxication. 

Postmortem  Appearances. — In  the  vessels  these  consist  essentially  of  throinbosis, 
examj)les  of  which  may  be  seen,  for  instance,  in  the  cranial  sinuses  and  in  the  large 
veins.  Aside  from  these,  with  the  enlargement  and  softening  of  the  spleen,  the  liver, 
and  lymphatic  structures,  already  described  under  Septicemia,  the  principal  objective 
evidences  consist  in  the  discovery  of  metastatic  abscesses  in  many  or  all  parts  of  the 
body.  As  stated  above,  there  is  no  tissue  or  organ  in  which  they  may  not  be  found. 
The  mechanism  of  their  production  has  lieen  already  described.  Infarcts  may  also 
be  met  with,  in  the  kidneys  especially,  the  liver  and  spleen  as  well,  and  indicate  areas 
already  cut  off  from  blood  supply  by  thrombo-arteritis,  in  which  abscess  formation 
would  have  occurred  had  time  been  given.  In  the  liver  large  abscesses  may  be  found; 
joint  cavities  may  be  filled  with  pus;  the  lungs  are  usually  the  site  of  innumerable  small 
abscesses.  The  other  postmortem  changes  commonly  noted  are  not  difficult  of  explana- 
tion, but  are  not  so  characteristic  or  pathognomonic  as  to  call  for  funher  mention.  In 
a  joint  which  has  become  filled  with  pus  there  usually  has  been  loosening  of  the  cartilage 
and  more  or  less  disorganization  of  all  the  joint  structures,  which  appear  to  have  under- 
gone rapid  ulcerative  destruction  and  putrefaction. 

Treatment. — Treatment  of  pyemia  is  in  large  degree  unsatisfactory.  That  which 
used  to  be  the  terror  of  surgeons  in  the  pre-antiseptic  era  is  now,  thanks  to  Lister  and 
others,  almost  abolished.  Pyemia  is  a  rare  disease  in  modern  surgical  practice.  Its 
possibility  should  be  borne  constantly  in  mind,  however,  and  the  necessity  for  careful 
antiseptic  or  for  a  rigid  aseptic  technique  is  in  large  degree  based  upon  fear  of  pyemic 
consequences. 


ERYSIPELAS  93 

When  once  cstalilislicd,  the  disease  is  to  ht-  (reati-d  on  lines  iiearlv  similar  to  those 
laid  tlowii  for  se])tieeniia,  ineludiiiij  resort  to  the  ielithyol  or  silver  ointments,  and  to 
intravencnis  infusion  of  silver  solution.  (Sei-  p.  SU.)  Amputation  or  extirpation  of 
the  part  from  which  infection  has  first  proceeded  may  be  of  avail.  Anionj;  the  most 
successful  measures  for  surgical  treatment  of  this  disease  is  to  expose  the  infected  area, 
open  the  involved  veins,  and  either  excise  them  or  scraiK'  them  out  and  disinfect  them. 
This  treatment  has  been  successful  in  cases  of  cranial  infection  following;  middlcH-ar 
disease,  etc.     (See  chapter  on   Cranial   Sur<jerv.) 

Disinfection  of  the  infected  area  and  immersion  in  hot  water  should  he  praciised. 
Metastatic  abscesses  should  be  opened  and  drained,  and  every  accessible  collection  of 
pus  evacuated,  either  by  the  knife  or  asj)irator  needl(> — r.  r/.,  in  the  liver. 

The  medicinal  treatment  is  ])ractically  the  same  as  in  .septicemia,  while  the  surgeon's 
mainstays  are  alcohol  and  strychnine.  These,  with  cathartics  and  intestinal  antise[)tics, 
will  practically  sum  up  the  drug  treatment,  the  surgeon  meantime  not  neglecting  the 
matter  of  nutrition,  crowding  it  in  every  assimilable  form. 


ERYSIPELAS. 

Erysipehis  is  an  anitc  injeciions  disease  characterized  hy  its  tendency  tn  inroire  the 
skin  and  cellular  structures,  tn  extend  along  the  lyinpliatic  vessels,  to  involve  wounds  and 
injuries  binder  certain  conditions,  accompanied  hy  more  or  less  fever  of  septic  type,  leading 
frequently  to  septic  disturbances  of  profoundest  character,  yet  tending  in  the  majority  of 
instances  to  spontaneous  recovery.  It  has  been  observed  probably  from  j)rehistoric 
times,  but  has  not  found  a  proper  description  nor  appreciation  until  perhaps  within  the 
past  century.  It  occurs  in  so-called  traumatic  and  idiopathic  form — which  latter  means 
that  the  site  of  infection  is  not  discovered — and  also  in  a  virulent  and  contagious  type, 
which  leads  to  the  apj^earance  of  a  number  of  cases  over  a  large  territory ;  it  often  appears 
in  the  epidemic  form.  On  account  of  the  reddening  of  the  skin  it  goes  by  the  name 
of  the  rose  among  the  German  laity.  It  may  assume  the  type  of  an  infectious  derma- 
titis, subsiding  without  suppuration,  or  a  similar  lesion  of  exposed  mucous  membrane 
may  be  noted,  or,  occasionally,  its  virulence  seeming  greater,  its  lesions  are  met  with  in 
more  deeply  seated  parts,  accompanied  by  suppuration  or  even  gangrene,  and  it  is  then 
called  phlegmonous.  In  a  small  proportion  of  cases  the  infectious  organism  appears 
to  be  transported  from  one  part  of  the  body  to  another,  and  thus  we  have  metastatic 
expressions  of  this  disease.  The  most  common  examples  of  this  are  seen  in  ery- 
sipelatous meningitis  after  erysipelas  of  the  face  or  scalp,  and  erysipelatous  peritonitis 
after  the  disease  has  manifested  itself  on  the  truncal  surface.  It  is  of  a  type  which 
makes  itself  almost  interchangeable  with  puerperal  fever;  and  when  epidemics  of  ery- 
sipelas have  involved  certain  states  or  areas,  it  has  been  noted  also  that  nearly  every 
obstetrical  case  developed  puerperal  septicemia. 

Etiology. — There  is  more  than  passing  interest  connected  with  this  last  statement. 
It  is  now  definitely  established  that  the  infectious  organism  is  a  streptococcus  which  is 
allied  to,  if  not  identical  with,  the  streptococcus  pyogenes,  the  ordinary  pyogenic  organism 
of  this  form.  This  specific  organism  has  been  separated,  studied,  and  its  role  assigned 
by  Fehleisen,  and  the  organism  is  frequently  called  Fehleisens  coccus.  Preserving 
always  its  morphological  characteristics,  it  acts,  as  do  many  other  pathogenic  organisms, 
within  wide  limist  in  virulence.  Cultivated  from  some  cases,  it  scarcely  seems  infectious, 
while  from  others  it  is  fatal. 

Pathology. — The  disease  manifests  a  tendency  to  travel  via  lymphatic  routes.  As 
long  as  it  is  confined  to  the  skin  and  superficial  tissues  it  has  the  appearance  of  an  acute 
dermatitis.  When  it  migrates  deeper  it  generally  leads  to  suppuration,  another  reason 
for  believing  that  the  streptococci  of  erysipelas  and  of  pus  production  are  the  same.  In 
the  affected  and  infected  area  the  minute  l\Tnphatics  will  be  found  crowded  with  the 
cocci,  which  are  seen  much  less  often  in  the  small  bloodvessels;  also  in  the  tissues  beyond 
the  apparently  infected  area  they  may  be  found  dispersed  less  freely.  The  bacterial 
activity  seems  most  active  along  the  advancing  border  of  the  superficial  lesion.  Here 
the  phenomena  of  hyperemia  and  phagocytosis  are  most  active.  Even  in  the  vesicles 
that  are  characteristic  of  the  disease  the  organisms  may  be  found. 

The   discharges   from  this   region  are   infectious,  and   caution   should  be  observed 


94  SURGICAL  DISEASES 

in  dressing  such  cases.  A  finger  pricked  by  a  pin  from  a  dressing  may  subject  the 
individual  to  loss  of  life.  The  dressings  containing  the  discharges  should  be  burned 
immediately. 

The  path  of  infection  is  usually  through  a  wound,  and  as  soon  as  discovered  a  case 
of  ervsipelas  should  be  separated  from  all  surgical  cases,  or  if  the  ervsijX'latous  patient 
cannot  be  isolated,  he  should  be  removed  from  proximity  of  other  wounded  individuals. 

Erysipelas  which  follows  injury,  however  slight,  is  termed  traumatic.  The  terms 
"idiopathic"  or  "spontaneous"  should  be  restricted  to  those  cases  in  which  the  path 
of  iiifccticjii  is  not  discovered. 

Sjnnptoms. — With  the  exception  of  the  local  appearances,  they  are  essentially  the 
same  in  both  of  the  above-mentioned  forms.  The  characteristic  feature  of  the  disease 
is  a  dermatitis  with  its  peculiar  roseate  hue,  which  it  is  im|x)ssible  to  describe  in  words. 
In  tint  it  differs  slightly  from  that  noted  in  certain  cases  of  er^-thema.  It  is,  however, 
accompanied  by  an  infiltration  of  the  structures  of  the  skin,  .so  that  the  area  which  is 
reddened  is  at  the  same  time  elevated  above  the  surrounding  surface.  Its  edges  are 
often  irregular.  As  exudate  takes  the  place  of  blood  in  the  tissues,  the  red  tint  merges  into 
a  vellow.  At  this  time  there  is  more  induration  of  the  skin  and  tendency  to  pit  on  pres- 
sure. Vesication  of  this  involved  area  is  now  frequent,  the  vesicles  often  coalescing  and 
forming  large  blebs  and  bullse,  which  fill  with  serum  that  may  become  discolored  or 
purulent.  AVhen  exposed  to  the  air,  unless  the  tissues  become  gangrenous,  this  serum 
usuallv  evaporates  and  forms  scabs.  This  disturbance  of  the  skin  is  always  followed 
after  a  number  of  days  by  desquamation.  This  infectious  dermatitis  shows  a  constant 
tendency  to  spread  in  all  directions.  Its  most  characteristic  apjX'arances  are  limited 
to  the  margin  of  the  enlarging  zone,  while  in  its  centre  there  may  be  evidences  of  recession 
of  the  disease.  If  it  commences  in  the  vicinity  of  a  wound  it  will  probably  spread  in 
all  directions  from  it.  Beginning  in  the  face,  it  usually  spreads  upward;  in  the  trunk, 
in  all  directions;  if  on  the  extremities  it  tends  to  migrate  toward  the  trunk.  Wanderiiig 
erysipelas  is  a  term  often  applied  to  these  phenomena.  The  metastatic  expressions  of 
the  disease  have  been  described. 

When  this  affection  attacks  a  recent  wDund  the  local  appearances  are  not  essentially 
distinct  from  those  mentioned  under  Septicemia.  The  Avound  margins  separate  to 
a  greater  or  less  extent,  the  surfaces  slough,  and  a  characteristic  seroptirtilent  discharge 
occurs.  Granulating  surfaces  usually  become  glazed — often  covered  with  a  membrane 
resembling  that  of  diphtheria;  deep  sloughs  may  occur,  undermining  of  wound  edges, 
even  hemorrhages  from  destruction  of  vessel  walls.  In  rare  instances,  however,  under 
the  influence  of  the  microbic  stimulation  granulations  proceed  faster  than  normal. 

Whether  the  disease  proceeds  from  an  injury  or  not,  the  constitutional  s^inptoms 
varv  but  little.  There  is  usually  a  period  of  malaise  with  nausea,  followed  by  alimentary 
disturbance,  coating  of  the  tongue,  elevation  of  temperature,  sometimes  with  occurrence 
of  chill.  Complaint  of  pain  or  unpleasant  sensation  will  lead  to  examination  of  the  area 
involved,  when  the  above  symptoms  will  be  noted,  with  evidences  of  li/mphangitis  and 
enlargement  of  lymph  nodes.  When  chill  occurs  it  is  followed  by  pyrexia.  Tem|X'ra- 
ture  fluctuates,  with  a  tendency  to  assimie  the  remittent  type.  When  the  disease 
subsides  spontaneously  it  is  by  a  gradual  process  of  Ix^ttemient  and  subsidence  of 
temperature.  In  other  instances  the  constitutional  s^Tuptoms  assimie  more  or  less  of 
the  septicemic  or  typhoid  type,  and  it  is  seen  that  the  patient's  condition  is  practically 
one  of  mild  septicemia,  which  often  proves  fatal. 

When  the  disease  assumes  the  phlegmonous  tN'pe  the  constitutional  SATnptoms  become 
more  and  more  typhoidal  and  the  septicemia  becomes  most  pronounced.  Locally 
exudation  goes  on  to  the  point  of  threatening,  even  of  actual,  gangrene,  unless  tension 
is  relieved  by  incisions.  Pain  is  usually  intense,  partly  because  of  confined  exudates 
beneath  resisting  structures.  More  or  less  rapidly  the  local  and  constitutional  signs 
of  pus  formation  are  noted,  and  unless  these  are  obsened  and  acted  upon  early  there 
will  not  only  be  suppuration,  but  more  or  less  actual  gangrene,  so  that  not  only  pus, 
but  sloughs  of  tissue  will  Ix'  discharged  through  the  incision,  or  will,  when  this  is  delayed, 
make  their  escape  by  death  of  overlying  textures. 

In  all  phlegmonous  cases  there  is  practically  coincidence  of  septicemia,  already  de- 
scribed, and  of  the  local  appearances  above  noted.  In  proportion  to  the  extent  of  the 
lesion  in  these  phlegmonous  cases,  and  failure  to  afford  relief,  will  be  the  opportunity 
for  septic  intoxication. 


h'ln  SII'KLAS  f)5 

TIk-  imifoiis  iiiciiil)niii('  (Iocs  lud  always  cscaiH',  and  even  in  tiie  nose,  the  |)liarvn.\, 
the  vufijina,  and  the  rectmii  a  distinctive  ei ysipclatons  lesion  may  In-  t'oinid.  The  disease 
may  travel  from  the  j)harynx  throu<;li  the  nose  and  involve  the  face,  or  tliroii<^h  the 
Eustaehian  tube  to  the  ear  and  thence  to  the  scalp,  or  rirr  versa.  Kri/.s-ijtc/ithiii.s  /(iri/n- 
(/iti-K  is  to  be  feared  on  account  of  edema  of  the  <flottis,  which  would  soon  be  fatal 
unless  overcome  by  intubation  or  tracheotomy.  An  infectious  exudation  into  the  lunjjs 
is  also  known  to  follow  i-rysipclas,  and  has  been  considered  an  rrif.siprlnfoit.s  jmrumoiiia. 
The  cellular  tissue  of  the  orbits  may  also  be  involved,  when  abscesses  will  occur,  which 
should  be  opened  early;  the  ])aroti<l  and  other  salivary  fjlands  may  become  involved, 
usually  in  suj)puration. 

Many  cases  are  accompanied  by  much  (jnstric  irritation,  which  it  is  difficult  to 
explain.  Ulcers  are  sometimes  found  in  the  intestines,  as  after  burns.  These  usually 
give  rise  to  l)loody  diarrhea.  'I'he  cerebral  symj)toms  may  be  simply  those  of  delirium 
from  irritation  or  of  meningitis  from  inf(>ction.  Strange  phenomena  have  followed 
the  disease  in  certain  instances — cessation  of  neuralgic  and  of  vague,  unexplainablc  pain, 
improvement  in  deranged  mental  condition,  spontaneous  disappearance  of  tumors, 
etc.     Ailvantage  has  l)een  taken  of  this  last  in  the  treatment  of  these  eases.     (See  Cancer.) 

It  is  quite  likely  that  some  of  the  worst  forms  of  phlegmonous  erysipelas  are  due  to 
mixed  infection.  To  inject  the  bacillus  prodigiosus  together  with  the  streptococcus  of 
erysijH'las  will  greatly  enhance  the  virulence  of  the  latter,  so  that  reaction  may  proceed 
even  to  gangrene. 

Postmortem  Appearances. — These  are  not  distinctive,  but  are  a  combination  of 
local  evidences  of  suj)puruti()n  and  gangrene,  with  the  deterioration  of  the  blood,  the 
softening  of  the  s})leen,  etc.,  which  are  characteristic  of  septic  poisoning.  Only  in  the 
skin,  and  then  under  microscopic  examination,  can  any  pathognomonic  appearance 
be  discovered.  This  will  consist  in  the  crowding  of  the  lymphatic  vessels  and  con- 
nective-tissue spaces  with  cocci,  in  the  evidences  of  rapid  cell  proliferation,  in  the  quantity 
of  exudate,  in  vesication,  sloughs,  etc. 

Diagnosis. — Diagnosis  of  erysipelas  should  be  made  mainly  from  various  forms 
of  erythema,  from  certain  drug  eruptions,  and  from  other  forms  of  septic  infection 
which  do  not  assume  the  clinical  type  of  erysipelas.  The  gastric  symptoms  of  this 
disease  are  sometimes  produced  by  certain  poisonous  foods  or  the  distress  which  is 
produced  liy  medicines,  such  as  quinine,  antipyrine,  etc. 

Prognosis. — The  majority  of  instances  of  idiopathic  erysipelas  run  a  certain  limited 
course,  although  the  eruption  may  spread  to  almost  any  distance  upon  the  body.  When 
the  disease  attacks  surgical  cases,  and  especially  w^hen  it  involves  wound  areas,  the 
prognosis  is  not  so  good.  When  the  disease  assumes  an  epidemic  type  and  involves 
cases  of  all  kinds,  it  will  be  found  to  have  a  virulence  that  may  make  it  a  most  serious 
affair.  In  proportion  to  the  extent  to  which  it  assumes  the  phlegmonous  type  it  will 
be  found  locally,  if  not  generally,  destructive.  The  ordinary  case  of  facial  erysi})elas 
will  recover  with  almost  any  treatment.  Nevertheless  meningitis  may  develop,  and 
even  a  mild  case  is  to  be  treated  with  care  and  caution. 

Treatment. — Danger  comes  from  two  sources — .septic  intoxication  and  local  phleg- 
mons or  gangrenous  destruction.  Each  is  therefore  to  be  combated.  Treatment 
should  consist  of  isolation.  There  is  no  specific  internal  treatment  for  this  disease. 
Tincture  of  iron,  which  w^as  long  vaunted  as  such,  has  proved  unsatisfactory,  and  is 
of  benefit  only  as  a  supporting  measure  in  a  limited  class  of  cases.  Constitutional 
measures  should  be  employed:  First,  for  the  purpose  of  maintaining  free  excretion 
by  bowels  and  kidneys;  second,  for  the  purpose  of  supporting  and  maintaining  strength; 
third,  for  tonic  and  stimulant  measures  in  prostrated  and  debilitated  patients;  and, 
fourth,  for  the  purpose  of  combating  intestinal  sepsis  or  intoxication  from  any  other 
source.  The  robust  patients  with  this  disease  need  no  particular  tonic.  The  aged, 
the  enfeebled,  the  dissipated,  the  prostrated  individuals,  and  the  confirmed  alcoholics 
are  those  who  need  vigorous  stimulation,  partly  by  alcohol  and  quinine,  and  })artly  by 
strychnine,  preferably  given  hypodermically,  and  by  the  other  diffusible  stimulants 
by  which  they  may  be  kept  alive.  Pilocarpine,  given  subcutaneously  and  pushed  to 
the  physiological  limit,  has  been  praised  by  some.  If  along  wnth  prostration  there  occur 
restlessness  and  delirium,  then  anodynes  and  hypnotics  are  serviceable,  and  should  be 
administered  to  meet  the  indication — morphine  hypodermically  and  any  of  the  agents 
which  produce   sleep  are  now   most  beneficial.      Finally,  if  there  is  any  drug  which 


9()  SURGICAL  DISEASES 

can  Ik-  adiniiiistcR-d  in  doses  sufficient  to  saturate  tfie  system  with  an  antiseptic  which 
shall  at  the  same  time  not  jjrove  fatal  because  of  toxicity,  this  is  the  ideal  medicament 
for  constitutional  use  only.  Such  a  dru*;  is  not  known,  but  it  will  be  well  to  give  some  near 
approach  to  it  internally,  as  by  administering  corrosive  sublimate,  salol,  naphthalin, 
or  something  else  of  this  character  in  doses  as  large  as  can  be  tolerated. 

Should  patients  become  violent  it  may  be  necessary  to  resort  to  mechanical  restraint — 
a  strait-jacket,  a  restraining  sheet,  a  camisole,  etc. 

Nourishment  must  be  kept  up  by  the  administration  of  the  easily  assimilable  and  pre- 
digested  foods. 

Locally  the  number  of  remedies  that  have  been  resorted  to  is  legion.  In  a  mild 
case  of  spontaneous  ervsijx-las — i.  r.,  where  no  infection  can  be  traced — it  will  sometimes 
be  sufficient  to  put  on  a  soothing  application,  like  a  lead-and-opium  wash.  It  often  gives 
relief  to  have  the  jxirt  protected  from  air  contact,  which  may  be  done  by  a  soothing 
ointment  or  by  dusting  the  part  with  a  y)owder,  such  as  })ismuth  oleate  or  subnitrate, 
zinc  oxide,  etc.,  these  being  rubbed  up  with  powdered  starch;  or  by  a  film  of  rubber 
tissue  or  of  oiled  silk.  Brewers'  yeast  applied  on  compresses  and  covered  with  oiled 
silk  is  efficacious. 

Even  before  the  bacterial  origin  of  the  disease  was  accepted  it  had  been  suggested 
to  use  antiseptic  applications,  either  in  watery  solution  or  combined  with  oil  or  some 
unguent ;  this  is  now  the  ideal  method  of  local  treatment,  the  difficulty  being  only  to  find 
that  which  shall  be  efficacious  as  an  antiseptic,  yet  not  injurious  in  other  ways.  Com- 
presses wrung  in  solutions  of  various  antiseptics  are  often  serviceable.  The  following 
preparation  has  given  satisfaction:  Resorcin  (or  naphthalin)  5,  ichthyol  5,  mercurial 
ointment  40,  lanolin  50.  The  proportions  of  these  ingredients  may  be  varied,  and 
the  amount  of  ichthyol  sometimes  increased,  especially  when  the  skin  is  not  too  tender. 
The  affected  parts  are  anointed  with  this,  and  then  covered  with  oiled  silk  or  other 
impermeable  material,  simply  to  prevent  its  absorption  by  the  dressings ;  the  parts  are  then 
enveloped  in  a  light  dressing  and  bandaged.  Crede's  silver  ointment  has  also  proved 
useful.  As  the  disease  becomes  mitigated  the  ointment  may  be  reduced  with  simple 
lard,  and  discontinued  when  local  signs  have  disappeared.  Absorption  of  any  of  these 
preparations  may  be  hastened  by  scratches  over  the  affected  area  with  the  sharp  point 
of  a  knife. 

Treatment  of  threatening  phlegmon,  or  phlegmonous  erysipelas,  must  be  more  radical, 
and  consists  of  free  incision  down  to  the  depth  of  the  deepest  tissues  involved.  In 
treating  dissecting  and  other  septic  wounds  of  the  fingers  incision  should  be  made  to 
the  tendon  sheaths,  even  to  the  bone.  It  is  only  by  such  radical  measures  that  worse 
disaster  may  be  avoided.  Some  aggravated  local  cases  are  treated  by  a  series  of  deep 
incisions  with  the  use  of  the  curette,  the  surface  after  careful  clearing  being  kept  buried 
under  an  antiseptic  solution  (silver  lactate  1  to  500)  or  ointment. 

RELATION  OF  LYMPH  NODES  AND  GRANULATION   TISSUE  TO  INFECTION. 

In  connection  with  ervsipclas  and  the  rule  of  the  lymj)liatics,  it  is  advisable  to  consider 
the  relation  and  behavior  of  the  lymph  nodes  and  granulation  tissue  to  infecting  agents. 
Depending  on  the  virulence  of  the  infectious  material,  the  site  of  infection,  and  the  variety 
of  the  microbe  will  be  its  arrival  in  these  protective  filters.  Then  follows  a  series  of 
cycles  of  maximum  and  minimum  activity  in  the  nodes,  during  the  former  the  bacteria 
almost  disappearing.  The  more  jnithogenic  the  microorganism  the  more  certain  the 
destruction  of  the  lymph  node,  or  perhaps  of  the  individual.  The  well-known  enlarge- 
ment of  the  nodes  is  due  almost  solely  to  an  increase  in  their  lATnphoid  elements.  Halban, 
who  demonstrated  these  cyclic  variations  in  the  contents  of  the  lymph  nodes,  is  inclined 
to  insist  on  an  intimate  relation  between  them  and  the  temperature  variations  noted  in 
cases  of  septic  infection. 

When  granulations  are  present  the  lymph  sacs  are  closed,  as  by  a  sanitary  cordon. 
Unless  this  tissue  is  broken  they  are  proof  against  ordinary  infection.  It  is  well  known 
that  erysipelas  Avill  appear  about  an  old  wound  or  sinus  that  has  been  rudely  probed. 
Even  virulent  organisms  spread  upon  healthy  granulating  surfaces  fail  to  infect.  Strong 
carbolic  and  other  toxic  agents  can  be  used  in  and  about  such  granulating  cavities  with 
an  exemption  from  poisoning  that  otherwise  would  produce  dangerous  effects. 


CHAPTER    VIII. 

SURGICAL  DISE^VSES  COMMON  TO  MAX  AM)  1)(  )MESTIC  ANIMALS. 

TETANUS. 

SjTioiiynis:    Trismus,  Lockjaw. 

Tetanus  is  an  acute  infccfious  disease,  of  ri-lativcly  infrequent  oecurrenco,  invarinhly 
of  tuicrohic  origin,  characterized  hij  more  or  Ics.s  tonic  musclr  spasm  with  chniic  r.racer- 
batioiis,  whieh,  for  the  most  ])art,  oeeurs  first  in  tiie  nuiscles  of  tiie  jaw  and  neek,  involving 
progressively,  in  fatal  cases,  nearly  the  entire  musculature  of  the  body.  Certain  races 
of  peoj^le  seem  predisposed,  and  in  certain  climates  and  geograj)hical  areas  the  disease 
is  exceedingly  prevalent.  Negroes,  Hindoos,  and  many  of  the  South  Sea  Islanders 
show  a  |x^culiar  racial  predisposition,  and,  in  a  general  way,  inhabitants  of  warm  countries 
are  less  resistant.  This  is  shown  partly  by  the  fact  that  in  various  European  wars  the 
Italians  and  French  have  suffered  more  than  the  soldiers  of  more  northern  climes. 
Tetanus  is  by  no  means  confined  to  adult  life,  since  infants  are  far  from  exempt,  and 
in  the  tropics  the  trismus  of  tJie  newborn  is  the  cause  of  a  high  mortality  rate.  In 
Jamaica  one-fourth  of  the  newborn  negroes  succumb  within  eight  days  after  birth,  and  in 
various  other  hot  countries  the  proportion  is  at  times  equally  great.  One  plantation 
owner  states  that  fully  three-fourths  of  the  colored  children  born  upon  his  plantation 
succum})cd  to  the  disease.  The  peculiar  reason  for  this  infection  will  aj>pear  later  when 
speaking  of  tetanus  nconatoruvi.  ISIen  seem  more  commonly  affecteil  than  women, 
probal)ly  because  of  their  occupations,  by  which  they  are  more  exj)osed.  ^Military 
surgeons  have  had  to  contend  with  the  disease  in  its  most  virulent  form,  and  it  has  been 
noted  that  soldiers  when  worn  out  by  fatigue  or  suffering  from  the  disaster  of  defeat 
seemed  more  liable  to  the  disease.  Li  LSI 3  the  English  soldiers  in  Spain  suffered  from 
tetanus  in  the  proportion  of  1  case  to  SO  wounded  men.  In  the  East  Indies,  in  1782, 
this  proportion  was  doubled.  Quick  variations  of  heat  and  cold,  such  as  warm  days 
and  cold  nights,  coupled  with  the  other  exposures  incidental  to  military  life,  seem  to 
exert  a  great  effect.  Curiously  enough,  the  wounded  in  many  campaigns  who  have 
been  cared  for  in  churches  have  suffered  more  from  the  disease  than  those  cared  for  in 
any  other  way.  Tetanus,  however,  is  by  no  means  necessarily  confinetl  to  any  one 
clime  or  race,  but  may  be  met  with  anywhere,  at  any  time,  providing  only  that  infection 
has  occurred.  A  celebrated  Belgian  surgeon  lost  by  tetanus  ten  cases  of  major  opera- 
tions before  he  discovered  that  the  source  of  the  infection  was  his  hemostatic  forceps. 
As  soon  as  these  were  thoroughly  sterilized  by  heat  he  had  no  further  undesirable 
complications.  If  the  disease  can  be  conveyed  by  the  instruments  of  a  careful  surgeon, 
how  much  more  so  by  the  dirty  scissors  of  a  careless  midwife,  etc. 

It  is  true,  also,  that  the  popular  notions  of  the  laity  concerning  the  liability  to  tetanus 
after  certain  forms  of  injury  are  not  ill-founded.  Small,  ragged  wounds  of  the  hands 
and  feet  are  those  which  ordinarily  receive  little  or  no  attention,  and  are  among  those 
most  likely  to  be  followed  by  this  disease.  The  toy  pistol,  which,  a  few  years  ago,  was 
such  a  prevalent  and  widely  sold  children's  toy,  was  the  cause  of  many  a  small  laceration 
of  the  hand,  due  to  careless  handling  and  the  peculiar  injury  produced  by  the  explosion 
of  a  small  charge  of  fulminating  powder  in  a  paper  or  other  cap.  It  was  not  the  character 
of  the  laceration  or  injury  thereby  produced,  but  the  fact  that  such  injuries  occurred  in 
the  dirty  hands  of  dirty  children,  which  were  most  likely  to  become  infected,  that  has 
caused  the  so-called  toy-pistol  tetanus  to  be  raised  almost  to  the  dignity  of  a  special 
form  of  this  disea.se.  During  the  month  of  July,  18S1,  in  Chicago  alone,  there  were 
over  60  deaths  from  tetanus  among  children  who  had  been  injured  in  this  way  by  these 
little  toys.     This  led  to  their  sale  being  suppressed  by  law^ 

Etiology. — Two  theories  have  had  strong  advocates,  one  being  that  which  would 
account  for  the  disease  by  irritation  of  nerves;  while  the  second,  the  humoral,  would 
7  *  (97 ) 


98  SURGICAL  Dl SILASES 

explain  the  disease  by  alterations  in  the  blood.  Each  has  had  its  most  ardent  defenders, 
but  both  have  now  completely  yielded  to  the  investif^ations  of  a  few  observers,  among 
whom  Kitasato  and  Nicolaier  are  the  most  prominent.  These  ardent  workers  were, 
in  1.S85,  able  to  clearly  establish  the  'parasitic  nature  of  this  disease,  and  to  isolate  and 
investigate  the  or<;anisms  by  which  it  is  ])r()duced. 

The  bacillus  of  tetanus  is  a  somewhat  slender,  rod-shaped  orf>;anism,  with  a  peculiar 
tendency  to  spore  formation  at  one  end,  which  gives  it  a  drumstick  appearance.  It  is 
essentially  an  anaerobic  organism,  and  can  never  be  cultivated  in  contact  with  the  air. 
In  laboratory  experiments  it  is  grown  in  the  depths  of  a  solid  culture  medium  or  else 
in  fluids  and  on  surfaces  in  an  atmosphere  of  hydrogen  gas.  It  is  one  of  the  apparent 
contradictions  of  bacteriology  that  this  organism,  which  can  only  be  grown  as  an  anaerobe, 
nevertheless  abounds  in  earth,  particularly  the  rich,  black  loam  which  best  supports 
luxuriant  vegetal)le  life,  and  that  it  practically  inhabits  the  upper  layers  of  the  soil, 
which  accounts  for  the  fact  that  so  many  contaminations  and  infections  have  occurred 
from  step]>ing  upon  planks  or  boards  with  nails  [)rojecting,  or  from  introduction  of 
splinters,  or  from  lacerations  of  the  hands  and  feet  which  are  so  often  followed  by  con- 
tact with  such  materials.  There  is  nothing  about  a  rusty  nail  wound  wliicli,  by  itself, 
predisposes  to  tetanus,  but  the  rusty  nail  upon  which  a  person  steps  is  either  itself  in- 
fected or  leaves  a  rent  or  wound  which  may  become  infected  within  the  next  few  moments, 

and  which   is  not  likely  to  receive  the  careful 

^""•-  i'^'  attention  v.hich  it  should.     Verneuil  has  of  late 

^— '"  laid  stress  upon  the  fact  that  in  localities  where 

horses  are  kept  tetanus  is  more  prevalent,  and 
that  the  infectious  organism  abounds  in  and  upon 
stable  floors,  about  barn-yards,  and  wherever  the 
excretions  of  a  horse  may  be  found.  Bacteriolo- 
gists are  aware  that  in  the  intestines  of  herbiv- 
orous animals  the  bacilli  (anaerobic)  of  tetanus 
and  malignant  edema  are  often  found.  Verneuil 
has  further  shown  that  almost  the  only  instances 
of  tetanus  which  occur  on  shipboard  are  upon 
those  ships  which  are  used  for  transportation  of 
horses  and  cattle.  His  statements  are  at  least 
interesting,  if  not  absolutely  well-founded.  At 
all  events,  tetanus  is  certainly  of  telluric  origin. 

A    French    veterinary    surgeon   of   twenty-five 

Tetanus  bacilli,  .bowing  spore  formation.         J^^rs'  experience  had  uot  Seen  a  single  case  of 
(Kitasato.)  tetanus  until  1884,  when  he  "removed  a  tumefied 

testicle  from  a  horse,  with  the  ecraseur,  and  it 
died  of  tetanus;  in  the  following  six  months  he  castrated  five,  and  all  died;  another 
castrated  fifteen  in  one  day,  and  all  died  but  one;  another  in  ten  days  castrated  six 
bulls  and  operated  on  three  fillies  for  umbilical  hernia,  when  five  of  the  bulls  and  one 
of  the  fillies  died."  This  will  illustrate  how  the  infectious  agent  may  be  conveyed  by 
instruments,  etc. 

The  tetanus  bacillus  manifests  other  peculiar  properties,  for  some  of  which  it  is  mo.st 
difficult  to  account.  Upon  susceptible  animals  it  is  violently  infectious,  but  is  rarely 
found  at  any  distance  from  the  tissues  in  which  it  has  first  lodged.  In  laboratory  in- 
vestigations the  period  of  incubation  is  seldom  longer  than  forty-eight  hours.  Another 
peculiarity  of  the  organism  is  that  it  generates  certain  poisons  of  active  properties  which 
may  be  separated  from  pure  cultures,  by  whose  injection  the  peculiar  spasms  of  the 
disea.se  itself  may  be  reproduced.  The.se  have  been  isolated,  especially  by  Brieger,  who 
has  given  to  them  the  names  of  tetanin,  ietanoioxin,  .spasmotoxin,  etc.  It  has  been 
estimated  that  about  ^]-^^  Gm.  of  the  pure  toxin  of  tetaiuis  would  be  a  fatal  do.se  for  a 
man.  This  toxm  .seems  to  have  a  specific  affinity  for  the  ganglion  cells  of  the  anterior 
horn  of  the  spinal  cord,  with  which  it  unites  with  great  force.  Herein  lies  the  secret  of 
its  disturbing  power. 

It  is  peculiar  that  some  time  may  elapse  after  its  injection  before  the  appearance  of 
the  first  symptoms.  Diphtheria  toxins  appear  to  be  prompt  in  their  action,  and  thus 
display  quite  opposite  characteristics.  Experiment  would  .seem  to  show,  moreover, 
that  the  tetanus  toxins  do  not  reach  the  cord  through  the  blood  stream,  but  appear  to 


TKTAXUS  99 

slowly  pass  aloii;;  (lie  axis  cyliiidiTs.  Sensory  iicrvt-s  do  not  (ransj)ort  the  (oxins  to  the 
cord.  'V\\v  toxin  enters  the  nerve  termination,  first  of  all,  at  (lie  site  of  the  infection, 
where  it  is  most  concentrated,  which  will  explain  why  the  spasms  most  fre(|nently  hetrin 
in  the  vicinity  of  the  infection,  or  are  the  most  marked  there.  Most  of  the  toxin  is  taken 
up  by  till'  l)lood  and  lymph  and  distributed  all  over  the  body,  and  then  passing  alonj^ 
the  motor  fibers  it  enters  the  cord  and  leads  to  fijeneral  convulsion.  When  the  toxin  is 
injec-ted  directly  into  the  cord  the  symptoms  be<,'in  at  once,  'riicrefore,  for  protective 
purj)oses,  much  may  be  expected  from  the  administration  of  the  antitoxin  in  cases  of 
suspicious  injury  or  those  where  experiment  hiis  shown  there  Ls  rea.son  to  fear  the 
development  of  tetanus.  There  does  not  appear  to  be  on  record  a  single  instance  in 
which  a  |X'rson  who  had  been  given  antitoxin  soon  after  receiving  such  a  wound  has 
developed  tetanus,  nor  does  the  antitoxin  by  itself  seem  to  have  done  any  harm.  Ob- 
viously, tlu-n,  the  earlier  antitoxin  is  used  in  the  case  the  better.  It  may  be  recalled  that 
there  are  no  diagnostic  symptoms  of  tetanus  until  the  first  spasm  develops,  usualh  after 
the  exi)iration  of  from  five  to  twelve  days.  By  this  time  the  nerve  cells  are  thoroughly 
saturatetl  with  the  poison  and  considerable  time  may  elapse  before  the  antitoxin  can 
reach  these  cells  t)y  a  more  indirect  route. 

Tetanus  Neonatorum. — Tetanus  neonatorum,  or  ietamis  of  ihe  newborn,  a  condition 
already  alluded  to,  is  a  remarkably  fatal  afiection,  very  prevalent  among  the  negro  race, 
esjx'cially  in  hot  climates.  It  nowise  differs  from  traumatic  tetanus,  but  is  such  in  effect, 
since  the  infection  in  these  instances  always  follows  the  division  of  iJic  umhilical  cord, 
which  is  usually  eficcted  with  dirty  scissors  in  the  hands  of  a  dirty  midwife,  while  the 
thread  with  which  the  cord  is  tied  is  itself  a  possible  source  of  infection,  as  well  as  the 
rags  which  are  used  to  cover  the  umbilicus  in  the  first  dressing.  It  is  generally  fatal, 
because  of  the  weakness  and  lack  of  resistance  of  these  little  patients.  It  occurs 
usually  within  a  week  after  birth,  if  at  all. 

Tetanus  Cephalicus.^ — Tetanus  cephalicus,  called  also  tetanus  hydrophohicus  and 
head  tetanus,  is  only  a  peculiar  manifestation  of  this  same  afTection,  confined  mainly 
to  the  head  and  usually  following  injuries  to  this  region.  The  muscle  spasms  are 
mostly  confined  to  the  facial,  pharyngeal,  and  cervical  muscles,  sometimes  extending 
to  the  abdominal.  These  manifestations  may  be  reproduced  in  animals  by  inocu- 
lating them  on  the  head  rather  than  upon  the  extremities.  It  is  the  least  fatal  form 
of  the  disease. 

Sjnnptoms. — There  is  always  a  period  of  incubation,  usually  three  or  four  days, 
occasionally  a  week  in  length,  but  rarely  longer. 

It  is  generally  held  that  the  longer  the  period  of  incubation  the  more  hopeful  the 
prognosis.  AVhile  for  the  great  part  the  disease  assumes  an  acute  type,  a  chronic 
tetanus  is  described  and  occasionally  seen.  The  first  warning  of  the  disease  usually 
comes  as  more  or  less  stiffness  of  the  cervical  and  maxillary  muscles,  which  is  likely  to 
be  referred  to  by  the  patient  as  a  "sore  throat,"  because  of  the  consequent  difficulty  in 
deglutition.  A  complaint  to  this  effect  should  be  regarded  as  a  warning,  especially 
if  on  inspection  no  visible  reason  for  it  can  be  detected  in  the  pharynx.  This  com- 
plaint is  usually  made  in  the  morning  after  an  ordinary  night's  rest.  This  muscle 
stiffness  will  be  followed  by  increasing  tonic  spasm  in  the  muscles  of  the  jaw,  making  it 
difficult  to  open  the  mouth,  while  the  head  and  neck  gradually  become  stiffened  and 
fixed  by  spasm  of  the  cervical  muscles.  These  muscles  may  now  be  felt  more  or  less 
rigidly  contracted,  as  if  by  voluntary  eflFort,  and  the  condition,  which  is  at  first  not  painful, 
becomes  after  some  hours  a  source  of  discomfort,  perhaps  of  actual  pain,  to  the  patient. 
If  the  disease  pursues  the  usual  course,  the  other  muscles  of  the  body  become  gradually 
affected,  usually  in  the  order  of  their  proximity,  but  not  necessarily  so.  The  abdominal 
muscles  are  firm  and  board-like,  and  the  dorsal  muscles  more  or  less  contracted,  some- 
times to  an  extent  which  causes  arching  of  the  spine.  Should  the  original  wound  or 
port  of  entry  for  infectious  germs  have  been  in  the  hand  or  foot,  the  muscles  of  this  liinb 
become  contracted,  more  or  less  rigidly,  holding  it  in  a  position  which  is  not  easily 
changed,  even  by  efforts  of  the  attendant.  Sensation  is  also  often  more  or  less  perverted. 
In  this  condition  of  tonic  rigidity  the  muscles  remain,  to  relax  usually  only  with  death. 

The  most  characteristic  features  of  the  disease,  however,  are  the  peculiar  clonic 
exacerbations,  which  convert  spastic  rigiflity  into  violent  and  conxndsivc  muscle  activity, 
so  that  the  limbs  and  even  the  frame  of  the  patient  are  more  or  less  contorted,  the 
muscle  exertion  being  sometimes  painful  to  witness.     Notable  effects  are  thus  produced; 


100  SURGICAL  DISEASES 

the  month  is  peculiarly  puckori-d,  and  its  corners  drawn  upward  and  backward  by  the 
risorius  muscles,  ^ivin<i  to  the  face  that  peculiar  expression  known  as  the  ''.sardonic 
grin."  When  the  abdominal  and  flexor  muscles  of  the  tlii<jhs  are  involved,  and  the 
body  is  more  or  less  curved  forward,  this  condition  is  known  as  empro.stliutonu.s;  when 
the  muscles  of  the  back  especially  are  involved,  with  the  extensor  muscles  of  the  thighs, 
as  opiiiJwionos;  and  when  the  body  is  bent  to  one  side  or  to  the  other  it  is  called 
pkurosthotonos.  It  is  said  that  opisthotonic  convulsions  occur  to  such  an  extent  in 
some  instances  that  the  heels  touch  the  head.  At  all  events,  the  patient's  body  Ls 
fretjuently  raised  from  the  bed,  so  that  he  rests  upon  the  head  and  feet. 

Another  characteristic  feature  of  the  disease  is  the  reflex  irrifabilifij,  or  hyperesthesia,  by 
which  these  convulsive  attacks  apparently  are  produced.  Into  this  condition  the  patient 
falls  more  or  less  rapidly  within  the  first  day  after  the  inception  of  the  disease,  and  to 
such  a  height  may  it  be  augmented  that  the  slightest  movement  in  the  room,  jarring 
of  the  bed,  or  displacement  of  clothing,  even  noise  or  a  flash  of  light,  may  immediately 
bring  on  a  convulsion.  Rupture  of  muscles  has  been  reported  during  some  of  these 
violent  convulsions. 

During  the  course  of  this  disease  the  jaws  are  so  fixed  that  patients  speak  with  extreme 
difficulty  and  the  tongue  cannot  be  protruded.  The  mind  is  clear  until  the  end.  The 
pain  is  rather  the  acute  soreness  due  to  intense  muscle  strain.  There  is  spasm  of  the 
sphincters,  by  which  urine  and  feces  are  often  retained.  There  is  nothing  characteristic 
about  the  temperature,  which  is  seldom  much  augmented.     Attempts  to  swallow  give 

Fig.  18 


Characteristic  tetanic  spasm  in  a  rabbit  twenty-six  hours  after  inoculation  with  pure  culture  of  tetanus 

bacilli.    (Tizzoni  and  Cattani.) 

pain,  and  are  resisted  because  of  the  renewed  muscle  spasm  which  is  likely  to  follow 
the  irritation  inseparable  from  the  act  itself.  As  the  result  of  spasm  of  the  glottis 
peculiar  respiratory  sounds  may  be  noted. 

Until  the  last  only  the  voluntary  muscles  are  involved.  Finally,  however,  there  are 
spasms  of  the  accessory  respiratory  muscles  and  of  the  diaphragm.  Death  is  usually 
produced  by  involvement  of  these  muscles  analogous  to  those  of  the  others,  and  results 
usually  from  apnea  or  sujjoraiion.  During  the  last  hour  or  two  perspiration  may  be 
copious  and  the  temperature  may  rise. 

Chronic  tetanus  is  characterized  throughout  by  a  milder  and  much  more  prolonged 
series  of  symptoms.  The  period  of  incubation  is  much  longer,  and,  while  the  general 
program  of  the  acute  form  is  adhered  to,  it  is  of  less  severe  degree  and  is  spread  over  a 
longer  time ;  in  fact,  cases  covering  two  months  or  more  are  reported.  In  chronic  tetanus 
the  prognosis  is  much  more  hopeful  than  in  the  acute  form. 

The  wound  is  but  slightly,  if  at  all,  affected.  In  some  cases  it  will  be  found  to  have 
healed  before  the  onset  of  the  disease.  If  suppurating  or  open,  its  evidences  of  repair 
will  be  found  unsatisfactory  and  some  indications  of  septic  infection  may  be  noted. 
Pricking  or  needle  sensations  may  be  subjective  phenomena. 

Prognosis. — Prognosis  is  almost  invariably  bad;  if  patients  live  more  than  five  or 
six  days  it  is  thereby  improved. 

Postmortem  Appearances. — These  are  rarely  distinctive.  In  most  instances  there 
are  e^^dences  at  least  of  hyperemia,  if  not  of  more  active  changes,  in  the  upper  portions 
of  the  cord.  Less  often  slight  changes  have  been  noted  in  the  brain,  consisting,  in 
some  measure,  of  disintegration  and  softening.  Evidences  of  ascending  neuritis  in  the 
nerve  trunks  leading  to  the  injured  area  have  been  claimed  in  some  instances.  Few  if 
any  distinctive  postmortem  changes  can  be  described  as  due  to  this  disease. 


THTASUS  101 

Diagnosis.  'I'licdiaf^nosis  .slidiild  l»c  iiiadc  ;is  hclwccii  siri/rlininr  jioi.sdiiinr/,  In/filiriu, 
lii/(ln)/)li(il/i(i,  tctdiii/,  ;iii(l,  ill  the  iM'tfiiiiiiii^,  I'roiii  |)liarviij;iti.s,  loiisilliiis,  etc.  Wlicii  llu- 
disease  is  fully  devel(»|)e<l  it  is  not  likely  to  he  inislakeii  tor  anything  else. 

Tetaiuis  may  he  siiimlated  hy  lii/slrrid,  hut  in  this  event  the  phenomena  will  he  so 
uneerlain,  and  the  evidenees  of  or<;anie  disease  so  essentially  laekinj^,  that  it  is  not  likely 
that  mistake  eun  oecur. 

Treatment. — If  any  ease  can  he  ima(];ine(I  in  whieh  efheiei.t  treatment  is  most  urjrently 
demanded  it  is  one  of  tetanus.  In  scarcely  any  disease,  however,  is  (hni^  treatment  so 
unsatisfactt)ry.  In  the  rare  instances  in  which  |)atients  have  recovered  it  is  (juestiotiahle 
whether  it  is  not  due  to  individual  resistanc(!  rather  than  to  medication.  'J''realnient  may 
he  sulxlivided  into  loail,  ron.st it ut tonal,  and  .s-prrijir.  If  there  is  still  an  opni  .sitpyiinttitiq 
or  discJiarijiiKj  wound,  it  is,  of  course,  essential  to  cleanse  this  out,  hasin^f  this  advice 
in  some  nu-asure  upon  <fencral  principles — larj^cly  upon  the  fact,  already  state*!,  that 
ordinarily  only  the  immediate  surroundiu<is  of  such  a  wound  are  found  infected  hy  the 
bacilli  them.selves.  Consequently  thorough  scraping,  excising,  and  cauterizaiion , 
either  with  j)owerful  cau.stics  or  the  actual  cautery,  arc  indicated.  Since  the  sjx'cific 
germ  is  an  anaerobe,  hydrogen  dioxide  may  be  u.sed  locally  with  great  advantage,  mainly 
becau.se  it  oxidizes  the  albuminous  material  uj)on  which  the  bacilli  thrive.  If  it  is  in  a 
finger  or  toe,  anii)utation  may  be  the  simplest  method  of  eradicating  the  local  lesions. 

Constihitioiial  treatment  may  be  divided  into  )iutrition  and  medication.  The  tendencv 
too  often  in  these  ca.ses  is  to  be  careless  or  indefinite  with  regard  to  the  excretions  and 
the  nutrition  of  the  patient.  If,  for  instance,  each  attem])t  at  catheterization  throws 
him  into  convulsions,  the  bladder  may  become  overdistended  and  burst.  So,  too, 
there  is  apprehension  usually  in  regard  to  fecal  evacuations.  At  the  same  time 
these  patients  are  allowed  to  almost  starve  because  of  the  difficulty  of  feeding  them. 
It  is  advisable  to  resort  to  chloroform  to  permit  the  introduction  of  the  stomach  tul)e — 
through  the  nostrils,  if  necessary — by  which  nutrition  may  be  introduced  into  the 
stomach  without  causing  the  violent  convulsions  that  would  occur  without  an  anesthetic. 
At  the  same  time  the  catheter  may  be  used. 

In  the  way  of  active  medication  there  is  no  agent  so  efficacious  for  controlling  the 
tetanic  spasms  as  chloroform,  which  may  be  administered  occasionally,  or  more  or  less 
continuously,  according  to  the  wishes  of  the  attendant.  By  its  use  the  severest  si)asms 
can  be  kept  in  abeyance,  and  the  horrible  character  of  the  disease  somewhat  mitigated. 
Of  the  other  medicaments  used,  most  of  them  are  of  the  nature  of  nerve  sedatives, 
such  as  chloral,  the  bromides.  Calabar  bean,  cannabis  indica,  opium,  etc.  Hot-air  baths 
or  diaphoretics,  by  which  copious  perspiration  may  be  induced,  have  yielded  good 
results. 

Specific  treatment  means  in  these  instances  taking  advantage  of  the  well-known 
properties  which  the  blood  serum  of  an  animal  artificiulli/  immunized  against  the 
disea.se  po.s.se.sses.  This  is  in  accordance  with  experimental  labors  with  a  number  of 
diflferent  diseases,  of  which  tetanus  is  one.  It  is,  in  efifect,  similar  to  the  serum  therapy 
of  diphtheria. 

The  most  hopeful  of  remedies  is  antitoxin.  More  lives  can  be  saved  by  this  prepara- 
tion, if  used  early  and  freely,  than  by  any  other  known  remedy.  Moschcowitz,  in  1900, 
collected  .338  cases,  with  a  mortality  of  40  per  cent.  In  many  of  the.se  cases  it  was  not 
u.sed  early.  It  is  of  importance,  however,  to  use  it  at  the  very  out.set,  and  to  repeat  its 
u.se  as  soon  or  as  often  as  may  be  indicated  by  any  exacerbation  of  symptoms.  In  one 
instance  under  my  observation  twenty-three  phials  of  antitoxin  were  used  before  mu.scle 
rigidity  subsided;  in  another  ca.se  double  this  amount  was  u.sed.  Without  quoting 
figures  it  is  safe  to  say  that  the  former  great  mortality  rate  of  tetanus  has  been  reduced 
at  least  50  per  cent,  by  its  use,  and  that  further  reduction  can  be  eflfected  by  its  early 
and  prolonged  use. 

The  use  of  antitoxin  nowise  takes  away  the  necessity  for  proper  physical  care  of  the 
laceration  or  the  wound.  Every  particle  of  affected  tissue  should  be  cut  away,  all  the 
principles  of  physical  cleanliness  adhered  to,  and  proper  antiseptics  used. 

When  the  antitoxin  is  used  in  the  presence  of  the  disea.se  it  should  be  injected  into 
the  spinal  canal,  as  it  is  known  that  the  cerebrospinal  fluid  may  contain  a  consider- 
able amount  of  the  toxin  and  is  of  itself  highly  poi.sonous.  Therefore  after  in.serting 
the  needle  into  the  canal  it  is  well  to  withdraw  a  considerable  amount  of  the  fluid  before 
injecting  the  antitoxin.     If  this  method  is  pursued  the  material  is  brought  into  more 


102  SURGICAL  DISEASES 

immediate  contact  with  the  anterior  horns  of  (he  cord  than  conld  he  eU'ected  in  any  other 
way.  After  withdrawing  all  the  Hiiid  that  will  run  throujfh  the  needle  without  applying 
the  syringe — probably  150  to  200  (Jm.  10  to  15  Cc.  of  the  antitoxin  may  be  slowly 
injected,  the  process  consuming  from  three  to  five  minutes.  Then  a  further  injection 
should  be  made  along  some  of  the  large  nerve  trunks,  preferably  those  leading  to  the  part 
involved.  This  injection  should  be  made  with  a  finer  needle,  such  as  that  with  which 
cocaine  solution  is  injected  during  anesthesia  for  the  ])revention  of  shock.  This  is  a 
more  effective  and  less  serious  matter  than  trephining  the  skull  for  the  injection  of  fluid 
upon  the  surface  of  the  brain,  "^riiis  may  be  done  while  the  patient  is  under  the  influence 
of  the  anesthetic  administered  for  the  purpo.se  of  giving  proper  attention  to  the  wound. 
The  antitoxin  should  be  injected  into  the  nerve  trunks  after  their  ex|)osure.  At  the 
same  time  it  is  well  to  make  intravenous  saline  injections  at  more  than  one  point. 
After  from  twelve  to  fifteen  hours  the  injection  of  antitoxin  and  perhaps  of  saline  solu- 
tion should  be  repeated,  if  necessary,  under  such  light  anesthesia  as  can  be  produced 
by  ethyl  chloride.  Recently  a  substitute  for  antitoxin  has  been  suggested  in  an  emulsion 
of  brain  tissue  which  has  been  shown  to  have  a  specific  affinity  for  the  tetanus  toxin.  It 
has  been  seen  that  when  these  two  substances  have  been  thoroughly  shaken  together  the 
toxin  is  removed  from  the  fluid  and  confined  in  harmless  form  within  the  brain-tissue  cells. 

In  injecting  the  antitoxin  into  the  spinal  canal  no  harm  will  ensue  if  a  little  blood 
flow  through  the  needle,  showing  that  the  cord  itself  has  been  touched. 

When  there  is  need  to  employ  this  material  the  brain  of  a  freshly  killed  small  animal 
should  be  removed  under  antiseptic  precautions.  10  Om.  or  15  Gm.  should  be  emulsi- 
fied in  about  30  Cc.  of  sterile  salt  solution,  which  should  then  be  strained  through  a  sterile 
cloth  under  light  pressure.  This  is  then  injected  as  near  the  wounfl  as  possible  and  the 
procedure  repeated  every  day  as  long  as  indicated.  This  method  can  only  be  expected 
to  neutralize  toxin  that  has  not  yet  entered  the  nerve  cells.  Nevertheless,  Russian 
observers  have  reported  thirteen  recoveries  out  of  sixteen  instances  in  which  the 
method  was  practised. 

When  no  other  means  are  at  hand  a  1  per  cent,  carbolic  acid  solution  may  l)e  injected 
after  the  same  fashion,  using  such  an  nmount  that  about  five  grains  are  administered 
during  twenty-four  hours  to  an  adult.  This  is  the  method  especially  favored  by  the 
Italians,  and  is  due  especially  to  Baccelli. 

Matthews  has  devised  a  method  which  seems  quite  effective  in  experimental  animals. 
It  consists  of  the  use  of  a  solution  of  the  following:  Sodium  chloride  4  Gm.,  sodium 
sulphate  10  Gm.,  sodium  nitrate  3  Gm.,  calcium  chloride  14  Cgm.,  water 
1000  Cc.  This  is  intended  for  intravenous  injection,  and  must  be  introduced  very 
slowly.  The  performance  should  be  repeated  twice  during  the  first  twenty-four  hours 
and  once  each  succeedng  twenty-four  hours.  It  produces  profountl  diuresis,  i.  e.,  a 
washing  out  of  tissue  cells,  as  he  calls  it. 


HYDROPHOBIA. 

Hydrophobia  is  an  acute  specific  or  infectious-  disease,  as  far  as  known  never  originating 
in  man,  Imt  transmitted  to  him,  usually  through  the  bite  or  by  inoculation  from  the  saliva 
of  a  rabid  animal — in  this  country  usually  the  dog,  although  the  wolf,  the  cat,  the  skunk, 
and  even  certain  of  the  domestic  poultry,  are  capable  of  conveying  the  disease.  Chickens 
are  said  to  be  immune  save  when  their  vital  resistance  is  lowered  by  starvation.  Chicken 
blood  injected  into  other  animals  seems  to  antidote  the  virulence  of  the  virus.  It  can 
also  be  inoculated  in  other  animals,  like  rabbits.  The  virus  is  ordinarily  conveyed  in 
the  saliva  of  the  rabid  animal.  This  may  be  wiped  oft"  as  the  teeth  of  the  animal  pass 
through  the  clothing  of  the  injured  individual ;  consequently,  infection  does  not  certainly 
follow  such  bites.  But  those  upon  exposed  portions  of  the  body,  where  animals  generally 
bite,  are  almost  invariably  followed  by  infection.  Hydrophol)ia  is  frequently  spoken 
of  as  rabies,  sometimes  as  lijssa.  While  rare  in  this  country,  it  is  by  no  means  uncommon 
in  Central  Europe,  especially  perhaps  in  Russia,  where  bites  from  infuriated  wolves  are 
common.  In  the  United  States  infection  comes  almost  invariably  from  the  rabid  dog, 
in  which  this  disease  presents  two  types. 

The  so-called  furious  form  is  that  which  is  marked  by  frenzy  and  canine  madness, 
the  objective  symptoms  being  more  pronounced  and  alarming,  though  not  less  dangerous 


HYDRdl'lloiilA  ny> 

than  the  otlior  variety.  Alter  ilie  period  of  iiicultatioii,  which  varies  consideraljly, 
these  animals  show  depression  and  inieasiness,  and  even  thus  early  their  saliva  is  infec- 
tious. Their  sense  of  hunfijer  becomes  jierverted;  they  exhibit  unusual  tastes,  secrete 
saliva  abundantly,  which  becomes  very  tenacious  and  even  frothy,  exhibit  a  drv  and 
edematous  condition  of  the  faucial  mucous  membranes;  the  character  of  the  bark  is 
altered,  while  tlu>y  are  usually  infuriated  at  the  sij^ht  of  other  dojjs.  In  this  stajje  there 
is  usually  insensibility  to  pain.  Finally,  come  more  or  Ic.ss  ])aralysis  of  dejrlutition, 
quickened  respiration,  dilated  pupils,  and  frenzy  and  madness  of  manner,  by  wliich  they 
attack  indiscriminately  men  and  other  animals.  To  this  stage  of  furious  excitation 
succeeds  one  of  paralysis,  and  death  follows  from  exhaustion.  These  manifestations 
usually  last  about  a  week. 

Dumb  liifdrop/iohia  is  the  more  common  form.  Here  paralysis  appears  much  earlier 
and  involves  especially  the  lower  jaw;  the  tongue  falls  out  of  the  mouth;  and  the  |)os- 
terior  extremities  are  quickly  paralyzed.  This  form  is  much  more  (|uickly  fatal  than 
the  other. 

Animals  thought  to  have  hydrophobia  should  be  kept  by  them.selves  in  a  secure 
enclosure  and  carefully  watched,  especially  those  known  to  have  bitten  men  or  other 
animals.  If  a  suspected  dog  have  been  killed  before  the  suspicion  has  been  confirmed, 
the  head  and  Ujipcr  part  of  the  neck  should  be  removed  for  examination.  Veterinarians 
claim  that  what  they  call  the  plexiforni  ganglion  })ermits  an  almo.st  certain  diagnosis 
to  l)e  made.  The  presence  of  foreign  bodies  in  the  stomach  of  the  animal  is  a  corrol)ora- 
tive  feature.  Diagnosis  by  subdural  inoculation  requires  two  or  three  weeks,  and  in 
at  least  one  case  a  human  patient  died  while  waiting  for  diagnosis  to  be  thus  established. 

Hydrophobia  in  man  is  rare  in  this  country,  yet  is  occasionally  observed.  Its  etiology 
is  as  yet  obscure.  That  a  contagion  vivnm  is  present  is  positive,  but  its  nature  is  uncertain. 
Negri,  of  Pavia,  has  recently  described  certain  bodies  observed  in  the  nervous  system 
of  animals  dead  of  hydrophobia  which  may  offer  the  solution  of  the  problem  that  has 
so  long  been  sought.  They  are  found  in  the  protoplasm  of  nerve  cells,  but  not  in  their 
nuclei.  They  are  round  or  oval  in  shape,  vary  in  size  from  25  microns  down  to  those 
which  can  be  barely  seen  with  the  highest  powers.     They  take  ordinary  .stains. 

Negri  maintains  that  the.se  bodies  are  parasites  and  he  has  invariably  failed  to  find 
them  in  animals  which  did  not  have  rabies.  His  work  has  been  confirmed  by  a  number 
of  his  colleagues,  and  bids  fair  to  furnish  a  reliable  and  rapid  means  of  diagnosis.  The 
fact  that  the  virus  of  hydrophobia  will  pass  through  a  porcelain  filter  nowise  contradicts 
the  view  that  these  bodies  may  be  parasitic,  for  it  is  quite  possible  that  they  undergo 
different  stages  of  development,  in  some  of  which  they  are  small  enough  to  pass  even 
barriers  of  porcelain. 

In  fact  it  seems  to  have  been  positively  demonstrated  that  these  bodies  described  by 
Negri,  in  1903,  are  diagnostic  for  rabies.  They  are  most  likely  to  be  found  in  the  horns 
of  Amnion  or  the  cerebellum.  When  found  here,  careful  examination  must  be  made 
of  the  Gasserian  ganglion,  where  may  be  found  the  lesions  first  described  by  Van 
Gehuchten  and  Nelis,  which  consist  of  a  proliferation  of  the  endothelial  cells  to  such 
an  extent  that  the  ganglion  cells  are  first  invaded  and  then  destroyed,  their  places  being 
taken  by  the  new  cells. 

The  Negri  bodies  have  been  generally  regarded  as  protozoa  and  the  specific  cause 
of  the  disease.  At  all  events,  it  seems  possible  always  to  successfully  reproduce  the 
disease  in  rabbits  or  guinea-pigs  by  inoculation  with  these  bodies. 

If  examination  shows  neither  the  Negri  bodies  nor  the  lesions  in  the  ganglion  the 
presence  of  the  disease  can  scarcely  be  suspected,  and  could  only  be  proved  by  animal 
inoculations,  which,  however,  would  be  advisable  in  doubtful  ca.ses  where  human  beings 
have  been  bitten. 

Symptoms. — The  period  of  incuhaiion  in  man  is  variable,  ten  weeks  being  perhaps 
the  average.  It  is  shorter  in  children,  as  also  when  the  bites  are  numerous.  It  is  even 
stated  that  it  may  be  as  long  as  a  year  or  more,  during  which  time  the  poison  seems  to 
lie  latent.  When  the  active  s^Tnptoms  supervene  there  are,  locally,  discomfort  about 
the  wound,  itching,  heat,  and  peculiar  unpleasant  sensations.  It  is  said  also  that 
vesicles  may  make  their  appearance  in  the  neighborhood  of  the  original  lesion.  As 
in  animals,  so  171  man,  the  disease  may  assume  either  the  furious  or  the  parahjtic  type. 
These  cases  are  nearly  all  marked  by  mental  depression  and  apathy,  with  complete 
loss  of  courage.     The  earlier  symptoms  are  connected  perhaps  with  the  respiration, 


104  SURGICAL  DISEASES 

which  is  infrequent,  while  in.sj)inition  is  halting  and  speech  is  interfered  witli.  The 
facial  appearance  is  often  chan<red  to  one  of  anxiety,  even  desy)air.  The  muscles  of 
deglutition  are  next  involved  in  a  conil)ination  of  sj)asni  and  paralysis,  and  the  act  of 
swallowing  is  interfered  with,  sometimes  made  almost  im[)ossil)le.  Although  patients 
can  swallow  their  own  saliva,  they  find  it  difficult  to  swallow  any  foreign  substances, 
such  as  water,  etc.  This  is  not  due  to  the  fear  of  water,  as  the  term  "hydrophobia"  would 
imply — this  being  an  absolute  misnomer — but  is  due  to  reflex  spasm  excited  by  the 
attempt.  It  is  accompanied  by  more  or  less  sense  of  suffocation  and  palj)itation  of  the 
heart.  Indeed,  a  paroxysm  of  this  kind  may  be  precipitated  by  the  attempt  to  swallow, 
so  that  the  patient  instinctively  refuses  water  or  any  other  fluid.  Reflex  exritability 
is  also  very  great,  and  a  breath  of  air  or  a  trifling  disturbance  may  jn"ecij)itate  a  paroxysm, 
almost  as  in  extreme  cases  of  tetanus.  As  the  case  ]:)rogresses  the  saliva  becomes  more 
tenacious  and  viscid,  faucial  irritation  more  marked,  and  the  attempts  to  expel  the  secre- 
tion, along  with  the  disturbed  respiratory  efforts,  have  given  rise  to  the  foolish  lay  notion 
that  these  patients  bark  like  dogs.  The  paroxysms,  as  the  case  progresses,  become 
more  marked,  the  patient  more  restless,  until,  later,  furious  mania  or  muttering  delirium 
is  present,  to  be  followed  by  prostration  and  paralytic  phenomena,  muscle  tremor,  etc., 
and  death. 

The  'paralytic  form  in  man,  as  in  dogs,  is  marked  by  the  much  earlier  paretic  phe- 
nomena, anesthesia,  and,  finally,  respiratory  paralysis  which  terminates  the  case.  Curtis 
and  others  have  insisted  that  the  hydrophobic  paroxysms  are  not  convulsions  in  the 
ordinary  sense  of  the  term,  but  are  due  to  temporary  inhibitions  of  the  most  important 
respiratory  and  cardiac  centres  as  the  result  of  peripheral  imj^ressions.  He  likens  them 
to  the  shock  of  a  shower  bath. 

Postmortem  Changes. — Postmortem  changes  are  indistinct  and  only  suggestive. 
They  consist  for  the  greater  part  of  a  sort  of  vacuolous  degeneration  of  the  ganglion  cells 
of  the  nerve  centres — most  prominently  in  the  medulla,  next  in  the  hemispheres,  and 
then  in  the  spinal  cord.  There  is  hyperemia,  with  minute  ecchymoses,  with  infiltration 
of  the  adventitia  of  the  vessels  and  perivascular  extravasation.  The  changes  met  with 
in  the  other  viscera  bear  no  constant  relation  to  symptoms.  Nevertheless,  Gowers 
holds  that  because  of  the  location  of  the  lesions  and  their  intensity  in  the  neighborhood 
of  certain  nerve  nuclei  we  have  here  a  distinguishing  anatomical  character  of  the  disease. 

The  toxin  (as  we  niay  call  it  for  the  lack  of  a  better  term)  seems  to  be  transmitted 
much  as  is  that  of  tetanus  (q.  v.),  along  the  afferent  nerves  to  the  cells  of  the  anterior 
horns  of  the  cord. 

Diagnosis. — As  between  hydrophobia  and  tetanus  diagnosis  is  not  difficult,  as 
already  described.  In  certain  hysterical  individuals  nervous  paroxysms,  largely  due  to 
fright,  may  be  precipitated  by  dog-bites  and  other  incidents  or  accidents.  In  these 
cases  there  is  rarely  such  a  period  of  incubation,  and  in  a  true  hysterical  case  there  will 
be  no  such  mimicry  of  this  awful  disease.  A  condition  known  as  lyssophohia  (fear  of 
hydrophobia)  has  been  described.  It  is  seen  in  hysterical  subjects.  It  is  said  to  have 
even  been  fatal,  but  this  must  have  been  from  other  complications. 

Treatment. — There  is  no  authenticated  case  on  record  of  recovery  after  medication 
by  drugs.  It  is  probable  that  recovery  has  never  followed  anything  but  the  modern 
inoculation  treatment. 

The  only  successful  treatment  for  this  disease  has  been  elaborated  as  the  result  of 
the  labors  of  that  indefatigable  French  savant,  Pasteur,  and  is  among  the  glorious 
triumphs  of  laboratory  research,  against  which  it  is  so  often  charged  that  it  is  not  practical 
in  its  results.  It  is  in  some  respects  a  curious  commentary  on  the  study  of  infectious  dis- 
ease that  we  can  secure  and  work  with  the  peculiar  virus  of  hydrophobia,  and  at  the  same 
time  be  utterly  unacquainted  with  its  true  character.  To  this  fact  is  due  the  modern 
cure.  It  is  based  upon  the  fact  that  the  virus  is  not  only  in  the  saliva,  but  also  in  the 
nervous  system  of  animals  suffering  from  this  disease,  and  that  its  eft'ects  are  intensified 
and  hastened  by  inoculation  directly  into  the  cerebral  substance.  Accortlingly,  when 
a  diagnosis  of  hydrophobia  can  be  reasonably  well  established,  no  time  should  be  lost  in 
sending  the  patient  to  one  of  the  "Pasteur  Institutes,"  to  be  found  now  in  most  of  the 
great  centres,  there  to  undergo  a  regular  course  of  treatment.  It  was  reported  that  in 
the  Institute  in  Paris,  between  the  years  1886  to  1894,  there  were  treated  a  total  of 
13,817  cases,  and  that  the  mortality  was  0.05  per  cent.  Of  course  but  a  small  pro- 
portion of  these  really  had  or  would  have  developed  the  disease. 


GLANDERS  AXD  FARCY  105 

\  inis  ()l)taiiH'(l  Iroiu  (lie  hraiii  or  cord  and  iiiocnlalcd  into  the  dura  of  ainjtluT  uiiiiiial 
quickly  precipitates  the  disease.  It  is,  uioreover,  mochfietl  in  virulence  as  it  j)asses 
throufjh  successive  animals  ot"  certain  s|)ecies — for  example,  monkevs.  It  is  increased 
l)y  passajje  throu<:jh  rahhits,  and  the  period  of  iiiciihalioii  therchy  shortened.  'J'he 
weakivst  virus  can  hy  proper  handlinfj  and  manipulation  in  this  way  he  so  ititensified  as 
to  j)roduce  disease  within  .seven  days  after  inoculation.  Desiccation  reduces  the  viru- 
lence, and  preparations  from  the  cord  of  an  infected  animal  may  he  attenuated  to  almost 
any  desired  extent  hy  dryinij.  By  inoculating:;  a  do*;  or  a  rahhit  with  virus  prepared  from 
this  weakened  .source,  and  daily  making;  injections  from  stroiifrer  and  stront^er  prei)ara- 
tions,  it  is  in  the  cour.se  of  a  couple  of  weeks  rendered  j)ractically  innnune  to  the  di.sea.sc. 
Animals  tinis  made  inuiiune  are  trephined  and  the  virus  injected  beneath  the  dura,  hy 
which  more  certain  results  are  obtained.  The  treatment  consi.sts  in  usinjj  a  section  of  a 
rabbit's  spinal  cord,  0.5  Cm.  in  lenijth,  rubbed  up  in  (i  Cc.  of  .sterile  .salt  .solution.  Half 
of  this  amoimt  is  injected  each  day  into  the  flank  of  the  jiatient.  The  cord  first  used 
is  one  that  is  thirteen  or  fourteen  days  old,  which  has  been  kej)t  suspen<le(l  in  a  sterile 
flask,  over  caustic  potash,  in  order  to  assist  in  its  desiccation.  The  next  dav  a  cord  one 
day  younger  is  used,  and  so  on  until  by  the  twelfth  day  of  treatment  the  cord  is  one 
only  two  days  old,  and  at  the  end  of  two  weeks  a  fresh  cord  can  be  u.sed  which  would 
convey  th(>  disease  had  it  been  used  first,  If  this  course  of  treatment  can  be  carried 
throuf^jh  before  the  first  symptoms  of  the  disea.se  appear,  the  antidote  has  gained  complete 
mastery  over  the  infecting  agent  and  the  patient  is  saved. 


GLANDERS  AND  FARCY. 

Glanders  as  it  is  known  in  man  is  a  specific  infectious  disease,  transmitfied  usually 
from  the  liorsr,  characterized  by  rapid  formation  of  specific  gramdomas,  ])articulai-ly  in  the 
skin  and  mucous  membranes,  ivhich  quickly  break  down  into  ulcers,  and  l)y  tlie  general 
toxemia  characteristic  of  any  acute  infection.  In  German  it  is  known  as  Rotz,  in  French 
as  morve,  while  its  old  Latin  name  was  "malleus"  (hence  we  speak  of  the  bacillus  mallei). 
It  was  also  known  in  former  days  as  equinia.  In  horses  the  disease  has  also  been  known 
as  farcy,  because  of  the  peculiar  subcutaneous  nodules  which  farriers  and  hostlers,  almost 
from  time  immemorial,  have  called  "farcy  buds."  The  disease,  while  capable  of  trans- 
mission from  man  to  man,  is  generally  produced  by  contagion  from  some  of  the  domestic 
animals,  most  commonly  the  horse,  although  sheep  and  goats  are  known  to  occasionally 
have  it,  and  dogs  are  susceptible,  though  seldom  showing  manifestations  of  it. 

Like  some  of  the  other  infectious  diseases  glanders  appears  to  be  varial)le  in  its  mani- 
festations. While  infection  occurs  probably  through  some  superficial  abrasion,  it  is 
almost  certain  that  it  may  also  occur  through  the  unbroken  mucous  membrane  of  the 
respiratory  organs.  It  is  saiti  to  be  also  capable  of  transmission  from  mother  to  fetus 
in  utero.  So  far  as  known  in  man,  infection  occurs  practically  invariably  through  some 
slight  abrasion,  either  of  the  skin  or  the  mucous  membrane  of  the  no.se,  the  eye,  or  the 
mouth.  The  discharges  from  the  nostrils  of  affected  animals  are  extremely  virulent, 
and  infection  comes  usually  from  this  source.  It  is  said  to  have  been  communicated 
from  one  patient  to  another  by  eating  from  the  same  dish  or  by  drinking  from  a  pail 
used  by  a  diseased  hor.se. 

Glanders  is  due  to  the  specific  bacillus  known  as  the  bacillus  mallei.  It  is  shorter 
and  plumper  than  the  tubercle  bacillus,  in  length  about  one-third  the  diameter  of  a  red 
corpuscle.  It  is  a  non-motile  organism,  occasionally  spore-bearing,  not  very  resistant, 
belonging  to  the  facultative  anaerobic  forms,  growing  best  at  blood  temperature,  taking 
stains  easily,  and  losing  them  in  the  same  way. 

Sjnnptoms. — Glanders  is  seen  usually  in  workers  and  hangers-on  in  stables.  The 
acute — the  common — form  has  a  period  of  incubation  of  from  three  to  seven  or  eight  days, 
after  whicli  both  local  and  general  symptoms  supervene.  About  the  infected  region  a 
form  of  cellulitis  appears,  assuming  often  a  more  or  less  phlegmonous  type,  with  impli- 
cation of  the  adjacent  l}Tnphatic  nodes  and  evidences  of  periphlebitis  and  perilymph- 
angitis. Over  tiie  affected  area  vesicles  appear,  which  become  hemorrhagic  and  later 
suppurate.  A  wound  which  has  healed  may  reopen.  Almost  always  there  are  accom- 
panying constitutional  disturbances  of  septic  type,  occasionally  chills,  pyrexia,  etc. 
It  is  rather  characteristic  of  glanders  to  have  severe  pain  in  the  muscles  and  extremities, 


lOG  SURGICAL  DISEASES 

with  cpistaxis  and  fcjriiiatioii  of  metastatic  tiuiiors  and  fdcmatous  .s\velliii(,'s  in  various 
parts  of  the  body.  Frecjnently,  hiter  in  the  disease,  apj)ears  a  soniewliat  distinctive 
eruption,  papuhir  in  character,  merging  into  pustular.  Hemorrhagic  bulUt  are  also 
often  seen.  Pustulation  and  edema  of  the  face  change  its  ai)pearance.  There  are  also 
edema  of  the  eyelids  and  muropurident  dm-fiarge  from  the  conjunctiva;  and  the  nose. 
This  latter  discharge  is  often  ozenous  in  character.  Upon  inspection  of  the  nasopharynx 
and  oropharynx  a  similar  condition  will  he  noted.  In  connection  with  these  local  signs 
more  or  less  general  furuncuhjsis  also  will  he  observed.  Obviously,  as  these  local 
conditions  intensify  and  nuilti])ly,  septic  disturbance  will  be  increased,  and  the  patient 
dying  of  acute  glanders  dies  generally  of  septicemia  or  intoxication  and  exhaustion 
combined. 

A  chronic  form  is  known,  distinguished  mainly  by  slowness  or  tardiness  of  lesions, 
though  the  local  changes  arc  not  ])articularly  different  in  character.  There  is  perhaps 
more  tendency  to  suppuration  and  less  to  lymphatic  comj^lications.  The  nodule  which 
breaks  down  will  leave  a  foul  ulcer,  the  discharge  from  these  lesions  being  extremely 
infectious. 

Diagnosis. — This  is  not  always  easy,  but  may  be  based  in  suspicious  cases  to  some 
extent  upon  the  occupation  of  the  patient.  The  j)resence  of  multiple  lymphatic  lesions 
and  subcutaneous  nodes,  especially  when  breaking  down  as  above  described,  and 
accompanied  by  ozenous  discharge  from  the  nose,  should  at  least  be  suggestive,  and 
will  serve  to  distinguish  between  this  disease  and,  for  instance,  typhoid  fever.  The 
chronic  type  of  glanders  might  be  mistaken  for  syphilis,  and  here  is  where  the  real  diffi- 
culty of  diagnosis  will  probal:)ly  occur.  In  doubtful  cases  the  crucial  tests  are  the  micro- 
scopic examination  of  discharges,  after  staining  for  bacilli,  and  the  cultivation  test. 

Prognosis. — A  generalized  attack  of  glanders  is  a  matter  of  gravest  import,  especially 
when  acute.  Scarcely  more  than  10  or  15  per  cent,  of  such  cases  recover.  In  the  more 
chronic  manifestations  the  prognosis  is  more  favorable,  half  of  the  patients  making  a 
final  recovery. 

Treatment. — All  infected  animals  should  be  isolated  and  destroyed,  their  carcasses 
being  burned.  If  possible,  the  infected  wound  or  abrasion  should  be  induced  to  bleed 
freely,  and  then  cauterized  with  an  active  caustic.  By  prompt  interference  with  the  first 
manifestations  it  may  be  possil)le  to  cut  short  the  disease.  This  would  necessarily 
be  done  by  excision,  cauterization,  packing,  etc.  Bayard  Holmes  has  reported  a  case 
in  which,  during  two  and  a  half  years  of  chronic  manifestations  of  this  disease,  he  anes- 
thetized the  patient  twenty  times  for  the  purpose  of  opening  new  foci  or  scraping  out  old 
ones,  finally  obtaining  a  permanent  cure.  There  is  no  s])ecific  treatment,  but  the  septic 
symptoms  should  l)e  combated  as  indicated  in  the  chapter  on  Septicemia. 

By  making  a  glycerin  extract  from  the  filtered  and  eva|)orated  culture  of  the  glanders 
bacillus  it  is  possible  to  prepare  a  toxalbumin  analogous  to  tuberculin,  which  reacts  in 
a  similar  way.  By  it  animals  may  be  fortified  against  inoculation,  and  by  its  use  a  pecu- 
liar reaction  is  produced  in  those  affected  by  the  disease.  It  is  known  as  mallcin,  and 
by  it  are  tested  all  horses  used  for  the  pre])aration  of  the  (lii)htheria  antitoxin,  in  order 
tliat  all  possibility  of  glanders  may  be  eliminated.  It  is  probable  that  it  might  be  made 
of  therapeutic  value  in  treating  the  disease  when  actively  present  in  man. 


ANTHRAX. 

Anthrax  is  more  commonly  known  as  splenic  fever,  malignant  pustule,  or  wool. sorters' 
disease;  in  Germany  as  Mihhrand,  and  in  France  as  charhon.  It  is  an  infectious  disease 
of  cattle,  which  has  devastated  many  jxirts  of  Central  Europe,  and  has  been  frequently 
met  with  on  the  Continent  among  men,  though  but  rarely  in  the  United  States.  All 
the  domestic  and  nearly  all  the  experimental  animals  are  si;bject  to  it.  Gronin  has  stated 
that  in  the  district  of  Novgorod,  in  Russia,  during  four  years  more  than  56,000  cattle 
and  528  men  perished  from  anthrax.  Poultry  and  dogs  are  not  strictly  immune,  but 
possess  a  low  susceptibility  to  the  disease.  It  generally  prevails  in  low  districts  and 
in  marshy  grounds. 

The  disease  is  the  result  of  the  invasion  of  the  bacillus  avthraci.'i,  which  is  a  relatively 
large-sized  bacillus,  varying  in  breadth  from  1  to  U  and  in  length  from  5  to  20  microns. 
It  is  easily  cultivated  outside  the  body,  and  multiplies  with  great  rapidity  in  the  bodies 


PLATE   IV 


FIG.   1 


•i».-f_    :-- 


Si 


-^CM^^^K' 


Anthrax  Bacilli.     Spore  Formation.      (Karg  and  Schmorl.) 

From  an  agar  culture  twenty-four  hours  old.     About  the  margin  of  the  photograph  are  a 
number  of  free  spores.      X  600. 


FIG.  2 


i 

Anthrax  Pustule.     Removed  from  Arm  of  Man.     (Karg  and  Schmorl.) 

Marked  edema  of  the  skin,  causing  elevation  and  separation  of  the  papillffi.     In  the  edematous 
exudate  a  large  number  of  anthrax  bacilli  and  leukocytes.      X  50. 


.I.V77/AM.V 


107 


of  ,sii.sc('|)til)lc  animals;  it  is  the  t\  |)r  of  s|)(>n-li(ariii<,'  l)a(illi,  and  is  so  rc-adilv  rcco^iii/cd 
and  worked  wilii  that  it  is  coninionly  nsrd  in  lal»oratorv  invcstifjations.  Tlic  demon- 
stration of  its  .sjH'cificity  we  owe  to  Davaine,  in  iST^i,  althoufjli  he  had  deserihed  it  in  1S')(). 

Anthrax  /^ar//// may  enter  the  body  throuj^h  the  rcspiniiori/ ortjan-s,  through  nu\  ahmdtd 
surface,  and  possil)ly  even  through  the  a/iiiimtari/  canal.  They  niav  also  j)ass  through 
the  phicenta  and  affect  the  fetus  ///  ulcro.  They  are  too  hirge  to  |)ass  tlirough  tlie  walls 
of  the  capillaries  of  ordinary  si/.«-;  conse(|Uently  they  plug  them  and  produce  a  mechanical 
stasis  which  is  ra|)idly  followed  hy  gangrene.  From  the  kidney  structures  and  capil- 
laries, however,  thev  niav  escaj)e,  as  bacilli  are  found  in  the  urine  in  certain  cases  of 
anthrax.      (See  Plate  IV.) 

In  man  the  disease  occurs  usually  as  the  so-called  nia/ir/nanf  jntstutc,  or  voohortcr.s' 
disease,  the  latter  name  being  given  because  of  the  liability  of  tho.se  individuals  who 
come  in  contact  with  the  carca.s.ses  and  hides  of  di.sea.sed  animals  or  their  immediate 
products.  The  period  of  incuhafion  is  brief — on  the  average  two  or  three  davs.  The 
first  lesion  apj)ears  usually  on  the  face,  hands,  or  arms,  and  is  characterized  bv  local 
discomfort  with  formation  of  a  small  ])a|)ule,  which  rajjidly  becomes  a  vesicle  with  an 
areola  of  cellulitis  about  it.  This  is  ra|)idly  followed  by  incluration  and  infiltration,  and 
these  by  local  gangrene,  the  result  being  the  .se])aration  of  a  core-like  mass,  similar 
to  that  of  carbuncle.  The  affected  area  is  usually  discolored,  often  quite  black.  The 
process  is  not  usually  accompanied  by  su])puration,  nor  is  there  the  pain  of  true  carbuncle. 
The  lesions  tend  to  spread  peripherally,  but  there  is  more  or  less  vesication  of  the  sur- 
rounding skin.  On  account  of  the  local  ischemia  there  will  always  be  edema  of  the 
affected  region,  and  sometimes  the  swelling  and  local  disturbance  become  extreme. 
These  peculiar  lesions  have  given  rise  to  the  common  name  vialignant  'pustule,  which 
is  well  deserved.  At  last  a  line  of  demarcation  becomes  manifest,  and  if  the  disea.se 
progresses  favorably  the  included  area  is  sloughed  out,  leaving  a  surface  which  it  is  hoj:)ed 
will  soon  become  covered  with  reasonably  healthy  granulations. 

Absence  of  pain,  and  usually  of  pus,  are  significant  features  of  anthrax.  Should 
mLxed  infection  occur,  however,  we  are  likely  to  see  pus  formation.  When  the 
disease  partakes  less  of  the  characteristics  of  malignant  pustule  and  more  of  a  general 
infection,  the  local  .s}iuptoms  may  not  predominate,  but,  on  the  contrary,  .septic  indica- 
tions may  become  serious  and  even  fatal.  The  evidence  of  more  or  less  toxemia  is 
usually  at  hand,  however,  and  the  toxin  of  anthrax  is  almost  as  destructive  of  muscle 
cell  integrity  as  is  that  of  diphtheria. 

The  local  lesions  may  be  single  or  multiple,  but  will  be  met  with  almost  always  upon 
exposed  areas  of  the  Ixxly. 

Postmortem  Appearances. — These  will  depend  upon  the  clinical  course  of  the 
disea.se.  In  the  sloughing  tissues  the  l)acilli  are  very  numerous,  while  around  the  margin 
more  than  one  bacterial  form  will  probably  be  met — r.  e.,  mixed  infection.  Should 
saprophitic  organisms  complicate  the  ca.se,  they  may  have  replaced  the  anthrax  bacilli 
by  the  time  the  examination  is  made.  The  latter  abound,  however,  in  the  blood,  and 
may  usually  be  found  occluding  the  capillaries  of  the  liver,  spleen,  kidney,  etc.  In 
intestinal  infection,  particularly  in-  animals,  the  mesenteric  nodes  are  involved.  Ina.s- 
much  as  septic  features  accompany  all  fatal  cases,  putrefaction  will  be  found  to  begin 
early,  and  the  changes  in  the  l)lood  and  the  gross  changes  in  the  other  organs  will  resem- 
ble sepsis  rather  than  anthrax. 

Prognosis. — Progno.sis  for  man  is  not  usually  unfavorable,  the  majority  of  ca.ses 
recovering  with  more  or  less  local  destruction  of  tissue.  Should,  however,  infection 
become  generalized,  the  case  will  probably  terminate  fatally.  Cases  assuming  the  type 
of  splenic  fever  are  of  much  more  serious  character,  and  their  prognosis  graver. 

Treatment. — This  should  be  both  local  and  constitutional.  The  former  should  con- 
sist of  the  most  radical  possible  attack  and  include  complete  excision  of  the  infected 
area,  with  the  u.se  of  active  caustic-s  or  the  actual  cautery.  In  fact,  the  latter  instrument 
offers  a  most  valuable  means  for  combating  the  destructive  tendency  of  the  disease. 
Sloughing  and  separation  of  the  cauterized  ma.ss  may  be  hastened  by  warm  antiseptic 
poultices.  Subcutaneous  injections  of  5  per  cent,  carbolic  solution  have  been  given, 
with  apparent  benefit,  in  a  number  of  cases,  but  should  only  be  relied  upon  in  the  treat- 
ment of  the  milder  manifestations. 

Benefit  will  accrue  from  the  use  of  the  ichthyol-mercurial  ointment  whose  formula 
was  given  under  treatment  of  Erysijielas.     It  has  been  suggested  to  treat  these  cases  by 


108  SURGICAL  DISEASES 

the  cinplovniont  of  the  bacillus  pyocyaneus,  since  it  is  known  that  this  organism  when 
injected  with  the  anthrax  haeillus  materially  attenuates  its  efl'ect. 

Prophylaxis. — Prophylaxis  is  most  impcjrtant.  The  bodies  of  all  infected  animals 
should  he  burned,  not  buried,  since  the  resistant  bacilli  are  often  brought  to  the  surfaee 
of  the  soil  by  earth-worms.  Every  discoverable  source  or  medium  of  infection  should 
be  destroyed  or  sterilized. 


MALIGNANT  EDEMA. 

This  diseas(>  has  been  recognized  for  some  time,  mainly  by  French  and  Continental 
clinicians,  and  under  such  names  as  (jangrenr  foudroijanfr,  (/(unjirnc  (jazeusc,  (jarHjrenous 
septicemia,  and  (jangrenous  emphysema.  The  name  malignant  edema  was  given  by 
Koch,  who  identifie(l  the  infecting  organism.  It  is  one  of  the  most  dangerous  forms 
of  gangrenous  inflammation,  and  occurs  sometimes  after  serious  injuries,  and,  again, 
after  most  trifling  lesions,  such  as  those  inflicted  by  the  dirty  pointed  implements  of  the 
gardener,  etc.,  or  even  the  stings  of  insects.  Two  cases  are  on  record  where  the  disease 
followed  a  puncture  of  the  hypodermic  needle  for  the  administration  of  morphine.  In 
one  of  these  the  organism  was  found  in  the  solution;  in  the  other  it  probably  had  been 
deposited  upon  the  skin. 

Malignant  edema  is  essentially  a  specific  form  of  gangrene  (see  Chapter  V),  and  is 
mentioned  here  rather  because  of  its  specific  character.  It  is  characterized  by  rapidity 
of  spread  and  the  specific  nature  of  the  exudate,  as  well  as  by  the  speedy  destruction  of 
the  tissue  involved,  and  by  more  or  less  gas  formation.  It  is  not  the  same  as  the  gaseous 
phlegmons  described  by  some  German  surgeons,  yet  partakes  of  their  general  character. 
Gas  phlegmons  have  been  rarely  notefl,  their  jieculiarity  being  formation  not  only  of 
pus,  but  of  more  or  less  offensive  gases,  which  escape  when  the  phlegmon  is  incised. 
The  gases  are  mainly  due  to  the  presence  of  bacilbis  aerogenes  eapsulatus,  and  gas 
phlegmons,  as  such,  are  to  be  regarded  as  instances  of  mixed  or  rarely  pure  infection. 

Malignant  edema  is  known  by  the  brownish  discoloration  of  the  overlying  skin,  which 
is  streaked  with  blue  where  the  overfilled  veins  show  through  it,  while  the  underlying 
tissues  are  sodden  with  fiuid  and  more  or  less  inflated  by  the  gaseous  products  of  decom- 
position, so  that  the  finger  detects  a  firm  crepitus,  as  is  common  in  subcutaneous  emphy- 
sema. From  the  wound,  if  there  is  one,  flows  a  thin,  foul-smelling  secretion,  which  may 
also  be  expressed  from  the  deeper  layers.  That  the  neighboring  l\anph  spaces  and 
nodes  are  actively  involved  is  evident  from  the  enormous  swelling  of  the  latter,  as  well 
as  from  the  general  condition  of  the  patient.  The  rapid  elevation  of  temperature  wath 
but  trifling  remissions  remains  constant  until  shortly  before  death.  The  tongue  early 
becomes  dry  and  cleaves  to  the  palate,  its  surface  being  covered  with  a  thick,  foul  fur. 
Patients  early  become  apathetic,  complaining  only  of  pain  and  ]:)urning  thirst.  Delirium 
and  coma  usually  precede  death,  which  may  occur  in  fifteen  to  thirty  hours.  After  death 
the  cadaver  bloats  fjuickly  and  j)utrefaction  goes  on  with  amazing  rapidity. 

Postmortem  Appearances. — At  the  seat  of  the  lesion  even  muscles  and  tendons 
will  be  found  macerated,  bone  denuded  and  surrounded  by  a  putrid  fluid,  the  entire 
region  presenting  a  notable  swelling  and  infiltration  of  soft  parts  with  reddish  fluids  and 
stinking  gases.  The  overlying  skin  will  be  stretched,  and  superficial  blisters  may 
deepen  the  intensity  of  the  process.  The  veins  are  clogged  with  decomposed  blood 
and  broken-down  thrombi,  and  in  the  heart  and  large  vessels  will  be  found  putrid  liquid 
as  well  as  gas,  to  whose  pn\sence  early  and  sudden  death  is  probably  due. 

Prognosis. — This  is  unsatisfactory,  especially  when  the  bacillus  of  malignant  edema 
is  alone  at  fault.  Patients  may  escape  with  their  lives,  but  always  at  the  expense  of 
more  or  less  tissue  destruction. 

Treatment. — This  should  consist  of  extensive  incision  to  permit  escape  of  fluids 
and  gases  and  relieve  tension;  of  such  antiseptic  applications  as  can  be  made  available; 
of  immersion  of  the  affected  part  in  a  hot  antiseptic  l>ath ;  and  of  such  vigorous  stimula- 
tion by  the  most  powerful  measures — strychnine,  alcohol,  etc. — in  order  to  support  the 
patient  through  the  period  of  })rofound  depression  characteristic  of  the  disease. 


PLATE   V 


Actinomycosis.     Ray  Fungus  in  Man.     (Gaylord.) 


/lC"y7.V0.1/)7Y>,s7,S  100 


ACTINOMYCOSIS. 


'I'liis  also  is  a  .suhdciitc  luit  always  dcs-lniclirc  in/'cclion  l>i/  a  sixci/ir  iiiicrdiirt/fnii.sni, 
though  not  a  hadcnum.  Known  always  us  artiiioiiti/ro.'ii.s  in  man,  (lie  (Jiscasc,  wliicli 
is  most  common  in  cattlr,  is  called  /iiiiipi/  jaw  or  .swelled  head,  and  years  u^o  was 
usually  refjarded  as  cancer  or  as  a  malifjiiant  afVcclion. 

Many  museum  specimens  labelled  as  cancer  of  the  ton<];ue,  jiiw,  etc.,  have  been  shown 
to  be  instances  of  actinomycosis  of  these  parts.  It  is  occasionally  met  with  in  man,  so 
that  there  are  at  least  four  hundred  cases  on  record  in  this  country  and  in  Europe.  The 
t)ri:;anism  was  recoii'iiized  a  half-century  a<i;o  by  Laii<i;enbecU  and  Lebert,  but  was  ru)t 
scientifically  described  until  many  years  later.  'I'he  names  of  Hollinijjer,  Israel,  and 
Ponfick  will  always  be  coniuH-ted  with  these  researches. 

The  organism  belongs  among  the  rai/  fuiif/i,  is  known  as  the  actinomyci.s,  and  occu- 
pies an  uncertain  place  in  classification.  It  is  large  enough,  when  entire,  to  be  perceived 
by  the  naked  eye,  has  ordinarily  a  yellowish  tint,  a  tallowy  consistence,  and  may  be  seen 
under  the  microscope  to  consist  of  a  cluster  of  branching  prolongations,  club-sha})ed  at 
the  end,  radiating  from  a  conuuon  centre.  They  give  it  a  sunflower  appearance.  It 
is  stained  with  difficulty,  the  best  stain  being  a  combination  of  j)icrocarminc  and  an 
aniline  dye.  In  tissue  sections  the  Gram  stain  is  the  best.  It  is  cultivated  with  diffi- 
culty, but  can  be  grown  upon  solid  media  and  may  be  inoculated.     (See  Plate  V.) 

As  met  with  in  tissue  or  in  pus  these  fungi  constitute  small  graiuilations,  giving  usually 
a  gritty  sensation  to  the  finger,  which  is  due  to  the  presence  of  calcium  salts.  ''Phe  recog- 
nition of  this  calcareous  material  is  of  importance,  since  it  may  enable  a  diagnosis  to 
be  made  oftliand,  in  a  ease  which  otherwise  might  puzzle  one. 

The  disease  is  very  common  among  cattle  in  certain  regions,  and  causes  the  condemiui- 
tion  of  many  animals  in  every  large  stockyard  establishment  where  inspection  is  careful 
and  scientific.  It  occurs  oftener  in  young  than  in  old  animals,  and  most  frequently  in 
those  which  come  from  valley  regions  and  marshes.  In  animals  infection  occurs  almost 
invariably  through  the  mouth,  which  is  easily  explained  by  the  fact  that,  in  grazing,  the 
lijis,  tongue,  ancl  gums  are  likely  to  be  irritated  and  infected  at  any  time  from  soil  con- 
taining these  fungi  along  with  growing  grain.  The  path  of  infection  is  usually  by  the 
mouth,  while  accident  seems  to  determine  whether  the  infection  shall  manifest  itself 
mainly  in  the  intestinal  canal  or  the  respiratory  tract.  In  animals  there  is  less  tendency 
to  suppuration  than  in  man,  the  infection  in  man  being  usually  a  mixed  one.  The  name 
luvipy  jaw,  so  generally  given  to  the  affection,  is  indicative  of  the  most  conspicuous 
lesion  in  cattle,  for  the  organism,  having  once  invaded  the  gum,  for  instance,  ])asses 
quickly  to  the  bone,  or,  having  involved  the  tongue,  is  not  slow  to  infect  the  lymphatics 
of  that  region.  In  consequence  we  have  tumors,  often  of  inordinate  size,  which  nuiy 
involve  the  bones  or  the  soft  parts  and  cause  great  disfigurement,  along  with  necrosis, 
leading  eventually  to  the  death  of  the  animal.  These  tumors  are  essentially  granula- 
tion tumors  due  to  the  presence  of  a  specific  irritant — the  actinomyns — which  acts  here 
as  do  the  tubercle  bacillus,  the  lepra  bacillus,  etc.,  in  other  infectious  granulomata. 

In  man  the  disease  is  generally  accompanied  by  abscess  formation,  the  pus  containing 
the  distinctive  yellow  gritty  particles  which  are  found  in  no  other  disease.  The  strong 
resemblance  between  the  lymphoid  cells  of  this  form  of  granuloma  and  the  embryonal 
ceils  of  sarcoma  has  permitted  the  perpetuation  of  confusion  between  these  two  neoplasms. 

Large  abscesses  form  as  the  result  of  the  coalescence  of  small  ones,  and  by  the  time 
the  disease  is  recognized  extensive  destruction  and  loss  of  substance  may  have  taken 
place.  In  man  it  is  not  alone  about  the  mouth  that  the  disease  is  noted,  although  pri- 
mary lesion  here  is  by  no  means  infrequent.  It  leads  to  afYections  similar  to  that  already 
spoken  of  in  cattle,  with  a  progressive  infiltration  and  breaking  down,  including  actual 
necrosis  of  bone,  etc.  The  pus  will  escape  at  various  points,  and  may  give  to  the  sur- 
face an  appearance  as  of  many  craters  with  a  central  cause.  When  the  disease  has  m- 
volved  the  lung,  either  directly  or  indirectly,  the  fungi  and  the  calcareous  particles  may 
be  found  in  the  sputum.  Should  there  be  suspicion  of  this  involvement,  the  sputum 
should  always  be  examined.  Even  in  the  heart  substaaice  tumors  of  this  same  character 
have  been  found.  The  first  case  noted  in  man  had  undergone  extensive  vertebral  caries. 
Intestinal  infection  is  possible,  in  which  case  multiple  lesions  will  form  in  the  intestinal 
walls,  which  may  contract  adhesions  to  the  abdominal  parietes  and  discharge  externally 


no 


SURGICAL  DISEASES 


Fig.   19 


throu>;h    thorn.     The   appendix   has  been  found    involved  in  such   lesions.     Infection 
of  the  skin  has  also  been  described,  though  this  occurs  more  rarely. 

Diagnosis. — Actinomycotic  lesions  have  been  uiiMakni  for  cnnccr,  sarcoma,  tuhcrcu- 
lo.si.s-,  sijphHi.s,  etc.  In  man  it  will  always  be  characterized  by  more  or  less  suppuration, 
and  in  the  ])urulent  discharo^e  from  the  infected  focus  the  yellow  calcareous  particles 
should  enable  recotfiiitiori  of  this  disease  at  once. 

Prognosis. — As  long  as  the  focus  is  accessible  it  is  a  purely  local  matter,  and  prog- 
nosis is  as  favorable  as  in  local  tuberculosis;  but,  inasmuch  as  in  many  cases  infection 
has  proceeded  to  a  point  where  the  surgeon  cannot  safely  follow  it,  prognosis  must  be 
guarded.  Actinomycosis  is  free  from  acute  manifestations,  for  the  main  part  free  from 
pain,  pursues  a  chronic  course,  and  is  characterized,  as  are  the  other  slow  infections, 
by  progressive  emaciation,  prostration,  etc.  As  it  is  essentially  a  chronic  condition, 
time  is  afforded  for  careful  stufly  in  doubtful  cases,  for  microscopic  examination,  etc. 

Treatment. — This  must  consist  of  extirpation  of  all  infected  tissues  and  areas. 
If  this  can  be  done  thoroughly  there  is  a  prospect  of  positive  cure.     Free  incision,  wide 

dissection,  the  use  of  the  actual  cautery,  etc., 
are  always  called  for  in  these  cases.  If  it  in- 
volves the  tongue  alone,  there  is  an  excellent 
prospect;  if  but  a  portion  of  the  jaw  is  in- 
volved, a  complete  excision  of  one-half  or 
more  may  be  followed  by  excellent  results. 
If,  however,  the  lung,  liver,  vertebrae,  or  other 
vital  and  inaccessible  parts  are  involved,  sur- 
gical measures  may  afford  amelioration,  but 
can  hardly  be  expected  to  cure. 

Iodine,  alone  or  in  combination,  has  been 
foimd  efficacious  in  the  therapy  of  actino- 
mycosis. In  diluted  solutions  used  locally, 
or  as  potassium  iodide  given  internally  or 
injected  into  tumors,  it  doubtless  has  a  bene- 
ficial effect  during  the  period  of  its  adminis- 
tration. Recent  reports  and  ex])eriences 
show  that  great  value  attaches  to  the  use,  as 
suggested  by  Be  van,  of  copper  sulphate  in 
the  treatment  of  actinomycosis,  its  use  hav- 
ing been  suggested  by  the  fact  that  copper 
is  used  to  destroy  rusts  (fungi)  on  grain. 
One-half  grain  (.3  Cg.)  may  be  given  inter- 
nally three  times  a  day,  while  the  sinuses  are 
irrigated  with  a  1  per  cent,  solution.  I  have  seen  apparently  complete  cure  of  an 
aggravated  case  follow  its  use.  Incidentally  it  may  be  stated  that  Bevan  advises  its 
use  also  in  cases  of  blastomycosis. 


^' 


f 


Actinomycosis  in  man.      (Lexer.) 


MADURA  FOOT. 

While  madura  foot  is  not  a  disease  from  which  domestic  animals  suffer,  its  general 
characteristics  make  it  a  proper  subject  for  brief  consideration.  It  is  essentially  a 
disease  of  the  tropics  and  subtropics,  and  is  often  seen  in  some  of  our  new  possessions. 

It  commences  as  a  painless  swelling  upon  either  aspect  of  the  foot,  in  which  hard 
nodules  form,  which  later  soften,  ulcerate,  and  discharge  puruloid  material  containing 
granules  in  which  the  microscope  reveals  mycelia  of  the  peculiar  fungus  that  produces 
the  disease.  In  .some  ca.ses  these  particles  are  black,  in  others  colorless.  The  disea.se 
is  of  slow  progress,  and  the  lower  limbs  become  weak,  atrophied,  and  finally  useless 
Death  results  from  exhaustion  or  some  terminal  infection. 

The  principal  lesion  is  the  slowly  growing  gumma  or  granuloma,  whose  presence  is 
unmistakable.  This  is  due  to  the  presence  of  a  fungus,  called  by  Vincent  the  .ftrepfo- 
thrix  madurcB.  Thus  in  its  jmthology  the  disease  much  reseml)les  actinomycosis.  The 
habitually  bare  feet  of  most  of  the  inhabitants  of  the  tro])ics  and  the  habitat  of  the 
fungus  explain  the  site  of  the  primary  lesion. 

Treatment, — The  only  trealmmt  is   extirpation  of  the  growth — i.  c,  amputation. 


PLATE  VI 


Tuberculosis  of  Testicle. 

Miliary  Tubercle  with  Caseation  and  Giant  Cells.     (Gaylord  and  Aschoff.) 
a,  seminal  tubules;  b,  giant  cells;  c,  caseated  tubercles. 


CHAPTER  IX. 

SURGICAL  DISEASES  COMMON  TO  MAN  AND  THE  DOMESTIC 

ANIMALS  (Continued). 

TUBERCULOSIS. 

The  most  important  and  frequent  of  the  infectious  diseases  common  to  animals  and 
man  is  fiihcrrulo.'ii.s'.  This  appears  usually  as  a  subacute  or  chronic  affection,  althoufih 
in  a  small  projjortion  of  cases  it  assumes  an  acuteness  (jf  type  which  may  make  it  fatal 
■within  as  short  a  time  as  fourteen  or  fifteen  days,  or  even  less,  from  the  first  recognizable 
symptom.  Tul)erculosis  is  more  prevalent  than  any  other  form  of  disease,  and  is  the 
cause  of  death  of  a  proportion  variously  estimated  at  from  20  to  30  per  cent,  of  man- 
kind. It  is  a  disease  which  perhaps  concerns  the  surgeon  more  than  the  physician, 
inasmuch  as  it  is  also  the  most  common  of  the  so-called  surgical  disea.ses.  Its  fre- 
quency varies  in  different  parts  of  the  country.  In  the  average  surgical  clinic  of  the 
United  States  probably  20  to  25  per  cent,  of  cases  are  manifestations  of  this  affection. 

Surgical  tuberculosis  covers  the  entire  range  of  diseases  fonnerly  described  as  .scrofula. 
The  term  scrofula  is  now  expurgated  from  medical  terminology.  All  of  the  ac-tive  mani- 
festations formerly  regarded  as  scrofulous  are  known  to  be  due  to  tuberculosis. 

To  the  presence  of  tubercle  bacilli  in  the  tissues  is  due  that  distinctive  aggregation  of 
cells  which  constitutes  the  so-called  miliar;/  tubercle.  Its  presence  and  arrangement  iire 
apparently  the  direct  outcome  of  the  irritation  produced  by  these  minute  foreign  bodies, 
and  its  method  of  grouping  is  so  characteristic  that  it  may  be  ever^-where  and  usually 
easily  recognized.  Its  centre  is  composed  of  one,  possibly  several,  giant  celb,  who.se 
nuclei  are  generally  arranged  around  its  margin,  with  perhaps  degenerative  changes 
going  on  in  the  interior  of  the  cell  itself.  In  this  giant  cell,  as  well  as  outside  of  it,  may 
be  seen  one  or  several  tubercle  bacilli.  Around  this  centre  are  clustered  a  number  of 
large  cells  known  as  epithelioid,  which  may  also  contain  bacilli.  These  cells  are  probably 
derived  from  epithelium  when  at  hand,  or  from  the  endothelium  of  the  vessel  walls,  or 
from  the  fixed  tissue  cells.  Outside  of  these  are  other,  usually  spindle-shaped,  cells, 
contained  in  a  connective-tissue  network  and  regarded  mostly  as  lymphoid  cells.  "When 
tubercle  is  experimentally  produced  the  bacilli  .seem  more  numerous  than  they  do  in 
instances  of  spontaneous  disease.  This  little  aggregation  of  cells  constitutes  a  ma.ss 
which  may  be  recognized  by  the  naked  eye — a  minute,  usually  white  point  or  nodule, 
which  is  known  as  a  miliary  tubercle.  It  is  suliject  to  any  one  of  several  changes  to  be 
presently  considered,  and  it  is  usually  found  in  large  numbers.  The  punctate  appear- 
ance of  miliary  tuberculosis  is  perhaps  best  seen  upon  the  cerebral  membranes  or  the 
peritoneum  in  cases  of  acute  miliary  tuberculosis.  By  coalescence  of  a  number  of  these 
nodules  larger  tubercles  are  formed,  and  by  combination  of  coalescence  and  caseous 
degeneration  are  produced  the  large  cheesy  masses  which  were  formerly  called  yellow 
tubercle.     (See  Plate  VI.) 

The  epithelioid  cells  are  by  some  regarded  as  modified  leukoc^-tes;  by  others  as  the 
product  of  division  of  the  fixed  cells.  The  giant  cell  is  probably  the  result  of  irritation 
in  one  of  these  cells,  the  stimulus  being  sufficient  to  provoke  division  of  the  nucleus, 
but  not  of  the  entire  cell.  As  the  principal  cellular  activity  occurs  in  the  interior  of 
this  nodule  the  result  is  a  condensation  about  the  periphery  which  furnishes  eventually 
a  sort  of  capsule,  the  tissues  being  hardened  and  condensed  as  if  for  this  special  purpose. 
The  effect  of  this  is  to  interfere  with  vascular  supply  and  finally  to  shut  it  off  completely. 
As  long  as  no  pyogenic  infection  occurs,  the  original  tubercle  may  gradually  shrivel 
down  and  disappear  or  caseous  degeneration  may  occur,  and  it  may  persist  as  a  chee.sy 
nodule  for  an  indefinhe  time.  As  such  a  tubercle  grows  old  the  cells  lo.se  their  identity, 
refu.se  to  take  stains,  and  a  slow  or  quiet  coagulation  necrosis  results.     In  this  nest  some- 

(111) 


112  SURGICAL   DISEASES 

times  calcium  salts  arc  ])recipitatc'(l,  the  result  being  a  calcareous  nodule.  On  the  other 
hand,  during  the  active  stage  of  this  tubercle  formation  cell  resistance  may  be  lowered, 
either  from  general  or  constitutional  causes;  the  original  focus  disintegrates;  tubercle 
bacilli  are  liberated,  and  are  now  carried  hither  and  thither,  metastatic  tubercles  being  the 
result  of  their  dissemination. 

Spontaneous  healing  (jf  tubercle  is  possible,  and  may  be  due  to  three  different  causes: 

(a)  Necrosis  and  exfoliation  of  diseased  tissue  {e.  rj.,  in  lupus); 

(b)  Cicatricial  formation; 

(c)  Retrograde  metamorphosis. 

Looked  at  from  another  point  of  view,  the  possible  fates  awaiting  the  miliary  tubercle 
are  the  following: 

(a)  Absorption; 

(b)  Encapsulation; 

(c)  Cheesy  degeneration; 

(d)  Calcareous  decjeneration; 
(r)  Suppuration. 

Absorption. — Absorption  of  tubercle  undoubtedly  is  possible  under  favorable  cir- 
cumstances, but  just  what  constitute  these  favoring  circumstances  no  one  knows,  since 
they  occur  in  cases  which  do  not  terminate  fatally.  To  Vje  able  to  describe  them  would 
be  to  detail  minutely  the  changes  which  permit  of  recovery  after  non-traumatic  tuber- 
culous infection,  which  clinical  fact  is  amply  demonstrated  by  the  experience  of  the  pro- 
fession.    Absorption  is  probably  largely  a  matter  of  phagocytosis. 

Encapsulation. — Encapsulation  has  already  been  spoken  of,  the  capsule  being  formed 
by  the  ((jndensation  of  the  original  cells  of  the  tuberculous  agglomeration,  the  infectious 
organisms  being  thereby  imprisoned  as  long  that  they  are  practically  starved  and  finally 
die.  The  tubercle  bacilli,  hcjwever,  may  long  lie  latent  in  such  a  cellular  prison,  and 
should  anything  occur  to  break  the  j)rison  wall  they  may  escape  and  still  prove  actively 
infectious.  In  this  way  are  to  be  accounted  for  the  fresh  eruptions  from  old  miliary  or 
other  deposits. 

Caseation. — Caseation  comprises  a  series  of  changes  in  the  chemical  constitution  of 
the  cells  by  which  an  albuminoid  mass  much  resembling  casein  in  composition  and 
appearance  is  produced.  The  English  equivalent  cheesy  well  describes  many  of  these 
masses,  which  both  cut  and  appear  very  much  like  domestic  cheese.  They  have  a 
yellowish  color,  and  are  met  with  in  masses  in  size  from  a  pin's  head  up  to  a  robin's 
egg.  These  are  the  yellow  tubercles  of  the  older  writers,  and  such  a  cheesy  tumor  has 
been  called  tyroma. 

Calcification. — Calcification  refers  to  a  peculiar  deposition  of  calcium  salts  within 
the  interior  of  these  nodules,  the  first  precipitation  occurring  usually  in  the  centre  of 
the  giant  cell,  which  is  itself  the  topographical  centre  of  the  miliary  tubercle.  It  may 
spread  from  this  until  a  mass  easily  recognizable  by  the  naked  eye  and  detectable  by 
the  finger  is  produced.  Such  calcareous  particles  are  frequently  found  in  sputa,  and 
are  always  an  index  of  the  tuberculous  character  of  the  case.  They  differ  markedly 
from  the  yellow  calcareous  nodules  found  in  the  pus  of  actinomycosis,  the  circum- 
stances under  Avhich  they  are  likely  to  be  confused  being  met  in  pulmonary  disease. 

COLD  ABSCESSES. 

Suppuration,  as  indicated,  is  the  result  of  a  mixed  or  secondary  infection  with  pyo- 
genic (jrganisms.  In  the  previous  chapter  tubercle  bacilli  were  groujied  as  among  the 
facultative  pyogenic  bacteria,  yet  pus  is  not  forined  in  this  disease  except  in  consequence 
of  coincident  activity  of  other  bacterial  organisms.  Suppuration  of  tuberculous  foci  is 
of  importance  to  the  surgeon,  because  thereby  is  produced  a  distinct  class  of  so-called 
abscesses — namely,  the  cold  or  congestion  ab.s-ces.ses.  These  are  of  the  chronic  type,  and 
are  generally  free  from  the  ordinary  signs  of  abscess  formation.  They  are  invariably  the 
result  of  local  infection,  sometimes  perhaps  by  the  tubercle  bacilli  alone,  but  frequently 
by  the  combined  action  of  these  with  pyogenic  forms.  For  their  formation  a  previous 
tuberculous  lesion  is  essential.  Wherever  old  tuberculous  lesions  are  encountered  cold 
abscesses  also  may  form.  No  tissue  or  organ  is  exemj)t:  they  are  found  in  the  brain, 
in  the  bones,  viscera,  joints,  skin — in  fact,  in  all  parts  of  the  body. 


coLh  .\jis('i-:ssi-:s  ]  \-^ 

Cold  ahsccsscs  liavr  not  oiilv  a  .si<:;iuficaiuc  ol"  tlicir  own,  l)ut  for  the  inosl  oait 
an  identity.  Tlu-ir  (li.stinj2;ui.shiiif^  iVaturoisa  limiting  vinnhran<\\\\\\v\\  forms  when- 
ever .sufficient  time  iias  elapsed.  Afucfi  fias  f)een  written  af)out  it,  aiuf  mucli  error 
has  f)een  perpetuated  witii  ri<j;ard  to  it.  Tfiis  is  tlie  mend)rane  formeriy  eonsi(iere(f  and 
eafled  pi/ot/ciiic,  un<fer  tlie  niisa|)|)reliensi()n  tiiat  l)y  it  tiie  pus  or  contents  of  the  af)s<'e.ss 
weri>  ])ro(luced.  I  desire  to  enipliasize  in  every  j)o.ssif)le  way  ttiat  tiiis  is  a  mistaf<e. 
Tiiis  nu'nil)raiie  does  not  act  to  produce  j)Us,  fjut  is  ratlier  tiie  resiiit  of  condensation  of 
celts  around  tlie  niar<fin  of  the  tuberculous  lesion,  formintf,  as  it  were,  a  .sanitary  cordon, 
for  the  absolute  and  definite  purpo.se  of  protection  airainst  further  ravages.  I  wouhl 
suggest  that  the  term  pyogenic  UKMnbrane  be  abolished,  there  being  no  such  nienil)rane 
under  any  circumstances,  and  that  this  be  known  as  that  which  in  efl'ect  it  is — namely,  a 
■pyoplit/lacfir  nirmbronc.  It  /.v  a  protection  against  pus-,  and  were  it  not  for  its  preseiice 
there  would  be  no  limit  to  the  spread  of  tuberculous  invasion.  A  lesion  thus  surrounded 
is  shut  oft'  from  most  possibilities  of  harm,  rarely  encroaches,  excej)t  by  the  most  gradual 
proce.s.ses,  and,  on  the  contrary,  often  contracts  and  reduces  its  dimensions,  the  waterv 
portion  of  its  contents  being  gradually  absorbed  and  the  more  solid  and  cellular  portions 
becoming  condensed  into  matter  which  undergoes  ca.seous  degeneration,  so  that  eventu- 
ally recovery  may  ensue  as  the  conse(]uence  of  a  metamorphosis  of  an  original  cold 
abscess  into  a  ca.seous  nodule  surrounded  by  the  old  pyophylactic  membrane,  which 
is  now^  .serving  as  a  capsule. 

The  contents  of  the  cold  abscess  are,  in  some  instances  at  lea.st,  of  acute  origin,  and 
con.seciuently  may  have  been  originally  pus  or  its  near  ally.  On  the  other  hand,  in  ca.ses 
which  have  occurred  very  slowly  this  material  is  not  real  pus,  but  is  a  .semifluid  debris 
having  certain  jjroperties  which  remind  one  of  pus.  It  has  been  my  effort  hitherto  to 
devise  for  this  nuiterial  a  name  which  should  distinguish  it  from  pus  and  indicate  what 
it  really  is.  Inasmuch  as  most  of  it  has  been  of  a  puruloid  character,  at  least  at  one  time, 
I  have  suggested  that  it  be  called  archepyon  (i.  e.,  originally  pus  or  j)uruloid).  As  this 
flows  from  such  a  cold  abscess,  it  is  more  or  less  watery  and  contains  caseous,  sometimes 
calcareous,  nodules  in  masses  of  considerable  size,  and  not  infrequently  sloughs  of  tissue 
and  old  shreds  of  white  fibrous  tissue  which  resist  decomposition  for  a  long  time.  This 
material  has  been  thus  imprisoned,  sometimes  for  months  or  even  years,  and  consequently 
has  lost  most  of  its  resemblance  to  what  it  w^as  originally.  The  organi.sms  which 
first  produced  it  have  long  since  died,  and  it  is  practically  sterile.  If  any  organisms 
survive,  they  are  the  tubercle  bacilli,  which  are  more  resistant  and  tenacious  of  life  than 
the  ordinary  pyogenic  organisms.  This  is  why  most  culture  experiments  fail,  and  why 
even  inoculation  with  the  contents  of  an  old  cold  abscess  is  often  without  effect  even  on 
most  susceptible  animals.  Nevertheless  the  bacilli  which  the  semifluid  contents  do  not 
contain  may  yet  linger  in  the  meshes  of  the  pyophylactic  membrane;  and  here  lurks  the 
greatest  danger  in  dealing  with  these  lesions. 

In  old  cases  the  pyophylactic  membrane  is  very  tough  and  very  adherent  by  its  outer 
surface.  It  can  sometimes  be  peeled  off  in  .strips  of  considerable  extent,  at  other  times 
cannot  even  be  separated,  or  sometimes  is  so  placed  as  to  render  it  impossible  to  follow 
it  to  its  termination.  There  must  be  complete  extirpation  of  this  membrane,  or  at  least 
destruction;  and  when  its  removal  is  impracticable,  failure  to  remove  it  should  be  atoned 
for  by  some  powerful  caustic,  such  as  zinc  chloride,  nitric  acid,  caustic  pyrozone  or 
the  actual  cautery,  which  should  be  made  to  follow  it  to  its  ultimate  ramification.  The 
membrane  and  the  ti.ssues  underlying,  when  thus  cauterized,  will  separate  as  .sloughs, 
and  these  will  be  replaced  by  presumably  healthy  granulations,  which  should  be  encour- 
aged imtil  the  original  cavity  is  filled  or  the  surface  healed. 

Acute  abscesses,  as  indicated  in  the  previous  chapter,  have  no  real  limiting  membrane, 
although  there  is  more  or  le.ss  condensation  of  ti.ssues  about  the  focus  of  infection.  A 
typical  mem})rane  is  distinctive  of  tuberculous  abscesses,  and  is  to  be  regarded  always 
as  their  natural  protection  and  a  barrier  against  their  further  encroachment — a  mem- 
•  brane  whose  inner  surface  may  harbor  active  organisms  which  cannot  escape  through 
its  outer  texture.  Con.sequently,  to  simply  incise  it  or  inefficiently  scrape  it  is  to  do  a 
worse  than  u.seless  thing;  and  one  should  never  attack  it  unless  he  is  prepared  to 
extirpate  it  or  destroy  its  integrity,  and  in  this  way  flispose  of  it. 

Cold  abscesses  when  near  the  surface  cause  a  bluish  or  dusky  discoloration  of  the 
overlying  skin,  while  the  superficial  and  subcutaneous  veins  of  this  region  are  usually 
enlarged.     Fluctuation  is  also  a  prominent  phenomena  in  connection  with  them  when 


114  SURGICAL  DISEASES 

they  can  bo  j)iilpate(l.  Deep  collections  of  this  kind  may  he  mistaken  for  cysts  or  tumors, 
in  which  case  the  asj)irator  needle  may  he  used  to  facilitate  diajfiiosis.  They  vary  in 
size  from  the  smallest  possible  collection  of  fluid  to  abscesses  which  may  contain  a  frallon 
or  more  of  puruloid  material  or  arche|)yon.  They  are  known  often  as  gravitation 
ahscesses,  because  by  the  weight  of  the  contained  fluid  they  tend  to  elonifate  or  spread 
themselves  in  the  direction  in  which  (gravity  would  naturally  carry  a  collection  of  fluid. 
Thus  cold  abscesses  oritj;inatiiifi;  from  tuberculous  disease  of  the  lower  spine  fre(iuently 
work  their  way  along  the  psoas  muscle  and  j)resent  below  Poujmrt's  ligament  as  yaoas 
abscesses,  or  elsewhere  about  the  thigh,  while  those  which  come  from  similar  disease  of 
the  u])permost  cervical  vertebra?  may  present  behind  the  pharynx,  as  the  so-called 
retropliarijii(/ral  abscesses,  and  those  from  the  dorsal  spine  present  not  infrequently  as 
lumbar  abscesses.  These  are  but  two  or  three  familiar  examples  of  what  may  occur  in 
any  part  of  the  body. 

Treatment. — Aside  from  the  treatment  of  cold  abscesses,  already  indicated  by  radical 
measures,  other  means  have  been  suggested,  and  j)articularly  for  the  treatment  of  those 
in  which  such  extreme  measures  are  impracticable  or  impossible.  It  is  sometimes 
efficacious  to  simply  tap  or  remove  by  aspiration  the  contents  of  such  a  cavity.  It  may 
never  refill,  or  but  slowly,  and  after  repeated  tap|)ing  alone  a  very  small  percentage 
of  such  cases  will  subside  into  inactivity  and  the  lesion  be  subdued,  if  not  absolutely 
cured.  Treatment  by  injection  of  emulsions  of  iodoform  has  found  favor  with  many 
surgeons.  I  have  never  been  able  to  secure  the  good  results  reported  })y  others,  and 
conseciuently  have  abandoned  it;  yet  it  deserves  mention  here  because  of  the  repute  it 
has  enjoyed. 

This  is  based  upon  the  alleged  specific  properties  of  iodoform  as  being  peculiarly  fatal 
to  tubercle  bacilli,  j)resumably  by  liberation  of  free  iodine.  A  cavity  to  be  thus  treated 
should  be  first  emptied  as  completely  as  possible,  after  which  may  be  thrown  into  it  a 
glycerin  emulsion  or  an  ethereal  solution,  or  a  suspension  in  sterilized  oil  of  5  to  10  per 
cent,  of  iodoform.  From  25  to  200  Cc.  of  some  such  preparation  is  introduced,  while  the 
walls  of  the  abscess  are  more  or  less  mani])ulated  in  the  endeavor  to  completely  dissemi- 
nate the  mixture.  The  cannula  through  which  it  has  been  introduced  is  then  withdrawn ; 
and  this  can  usually  be  done  with  but  little  un])lcasant  iodoform  effect.  This  is  due  to 
the  pyophylactic  membrane,  which  limits  the  activity  of  the  drug  as  it  has  done 
that  of  the  previous  contents  of  the  abscess.  Such  cavities  have  also  been  treated  by 
washing  out  through  a  trocar  with  an  injection  of  various  antiseptic  or  stimulating 
solutions,  among  wliich  may  be  mentioned  hydrogen  {)er()xide,  weak  iodine  solutions, 
etc.  My  own  advice  is  to  treat  all  tuberculous  lesions  radically  when  such  measures 
are  not  contra-indicated  by  their  multiplicity  or  by  too  great  depression  of  the  j)atient, 
and  so  long  as  lesions  are  accessible  to  ordinary  operative  proce(hires.  This  same 
advice  pertains  also  to  those  which  have  already  spontaneously  evacuated  themselves, 
or  where  the  overlying  skin  is  threatening  to  break  and  permit  escape  of  contents. 
Almost  any  case  where  this  is  imminent  is  one  in  which  the  surgeon,  as  such,  ought  to 
interfere.  On  the  other  hand,  in  deep  collections  and  in  debilitated  intlividuals  the 
treatment  by  injection  may  be  tried. 

The  best  way  to  treat  accessible  tuberculous  lesions  is  by  extirpation,  as  this  hastens 
convalescence  and  leads  to  more  permanent  results. 


THE    GUMMAS    OF    TUBERCULOSIS. 

The  other  and  essential  characteristic  of  tuberculous  disease  is  the  infectious  granu- 
loma to  which  it  gives  rise.  This  is  a  term  first  a))jilicd  by  Virchow  to  new  formations 
of  granulation  tissue  which  are  the  result  of  the  presence  of  invading  and  specific 
irritants.  This  tissue  varies  little  in  type  froiu  that  already  described  under  Ulcers, 
and  is  common  to  the  neoplasms  which  are  found  in  tul)erculosis,  syphilis,  leprosy, 
glanders,  and  other  local  infections.  So  little  does  the  tissue  type  vary  in  these  dift'er- 
ent  instances  that  it  is  difficult  to  distinguish  by  microscopic  sections  of  the  unstained 
tissues,  or  at  least  those  unstained  for  bacteria,  to  which  class  of  lesions  they  belong. 

This  tissue  may  be  met  with  in  any  of  the  tissues  of  the  body,  but  is  less  seen  upon 
the  serous  membranes  of  the  cranial  and  peritoneal  cavities,  whereas  in  the  jomt  cavities 
it  is  common.     It  is  provoked,  as  just  stated,  by  the  presence  of  tubercle,  and  has  the 


PLATE  VII 


4^^|^' 


:.W..,.  V  >,    ,k, 


Lupus  of  Skin.       Gaylord.j 

a,  fresh  tubercles  containing  numerous  plasma  cells ;  b,  mature  tubercle  with  giant  cells.     Below 

are  accumulations  of  plasma  cells  about  the  vessels.     Low  power. 

Unna's  polychrome  methylene  blue. 


Tin:  <;iMM.\s  or  Tcni-.ucri.osis  ]j5 

power  (>r  |M"iu-tratioii  into  and  suhstitutioii  for  almost  all  tlic  other  tissues  of  the  Ixxlv. 
Thus  in  a  |)riniarv  tuhereulous  foeus  within  the  bone  a  f^ramiloina  will  form  ami  exteiid 
its  limits,  while  the  siirroimdinfi;  hony  tissue  melts  away  hefore  it;  and  it  is  hy  the  f,'rowth 
of  this  tissue  in  a  |)arti(iilar  direction  that  tuherenlons  products  from  within  the  l>one 
cavity  are  iinally  carried  t(»  the  sin-face.  When  this  material  has  escaped  from  hone, 
or  from  tissues  without  the  hone,  toward  the  surface  its  presence  is  marked  hv  induration, 
by  livid  discoloration  of  a  limited  area  of  skin,  with  elevation  of  the  surface,  which  finallv 
breaks  down  and  shows  discolored,  l)leedin<;,  and  poutinj;  <jranulations,  which  in  the 
absence  of  restraiiU  now  proliferate  more  raj)idly,  and  often  to  the  point  where  they 
loose  their  former  blood  supply,  and  consequently  necrose  upon  the  surface.  This 
is  the  fungous  granulation  iis.sur,  especially  of  the  German  writers,  and  may  be 
met  with  uj)()n  the  surface,  or  is  frecpiently  seen  in  oj)enin<;  into  joint  cavities  and  other 
ti.ssues  infected  by  tubercle.  The  a|)j)earances  of  this  fuuf^ous  tissue  are  modificil 
somewhat  by  enviromnent  and  ])ressure:  in  joints  Hat  and  radiating;  masses  of  it  will 
be  found,  extending  aloni;  the  synovial  surfaces  and  into  the  articular  crevices.  This 
fuufious  tissue  nuiy  <jrow  in  any  direction,  but  apparently  advances  in  the  direction  of 
least  resistance.  It  leads  to  complete  j)erforations  of  the  flat  bones,  like  those  of  the 
skull,  while  tuberculous  masses  from  the  dura  may  cause  multij)le  perforations,  the  granu- 
lation ti.ssue  finally  escaping  through  the  overlying  skin.  In  tuberculosis  of  synovial 
sheaths  and  bursas  it  extends  along  and  may  completely  fill  and  even  di.stend  them. 
It  will  separate  tissues  which  were  united  together,  and  it  may  lead  to  disintegration  and 
di.sorganization  of  the  firmest  textures  in  the  body.  So  long  as  it  is  not  exposed  to  the 
air  nor  to  pyogenic  infection,  it  will  preserve  its  characteristics  for  a  considerable  Icno-th 
of  time.  Immediately  upon  exposure  it  is  likely  to  break  down,  and  infection  will  travel 
speedily  along  it  into  the  deeper  cavity  whence  it  has  sprung.  A  mass  of  this  tissue  con- 
tained within  the  normal  tissues,  condensed  more  or  less  by  pressure,  uninfected,  and 
not  freely  supplied  with  blood,  is  entitled  to  the  name  of  tuberculous  gumma,  who.se 
tendency,  however,  is  too  often  to  break  down  and  suppurate.  Such  gummas  may 
be  found  in  any  part  of  the  body,  and  differ  only  in  unessential  respects  from  the 
diffuse  and  more  or  less  infiltrated  masses  of  granulation  tissue  which  occupy  .serous 
cavities  or  which  extend  in  various  cUrections. 

The  lesions  of  surgical  tuberculosis,  except  those  already  spoken  of  as  constituting 
cold  abscess,  are  so  essentially  connected  with  the  presence  of  granulation  tissue,  ju.st 
describetl,  or  of  this  form  of  the  infectious  granulomas,  that  no  student  can  appreciate 
the  subject  until  he  is  familiar  with  this  tissue  in  its  various  phases  and  in  various  loca- 
tions. Of  such  great  importance  is  it  that  this  be  realized  that  some  of  the  local  mani- 
festations of  this  new  tissue  must  here  be  considered,  although  they  may  be  rehearsed 
in  other  form  in  succeeding  chapters. 

In  the  skin  and  subcutaneous  tissues  and  iri  and  under  mucous  membranes  this 
granulation  tissue  may  be  studied  at  places  where  it  is  free  from  most  mechanical 
restraints  to  growth,  and  where,  in  other  respects,  its  apjiearances  are  typical.  The 
most  characteristic  manifestations  in  the  skin  occur  as  lupus,  a  disease  considered  can- 
cerous or  of  uncertain  etiology.  Lupus  is  always  a  cutaneous  manifestation  of  this 
protean  disease.     (See  Plate  VII.) 

In  its  incipient  stages  lupus  consists  of  multiple  minute  nodules  of  granulation  tissue 
just  beneath  the  surface,  containing  all  the  elements  of  true  miliary  tubercle,  with  infil- 
tration of  the  surrounding  skin,  even  into  the  subcutaneous  fat.  The  most  common 
location  of  these  lesions  is  on  exposed  surfaces.  Bacilli  are  not  numerous  in  them, 
yet  may  be  demonstrated.  The  tendency  is  more  or  less  rapidly  to  break  down, 
the  result  being  a  tuberculous  ulcer,  which,  as  it  extends,  manifests  usually  a  disposition 
to  cicatrize  in  the  centre  while  enlarging  around  its  periphery.  The  dermatologists 
describe  several  different  forms  of  lupus  under  the  names  hijpertrophicus,  vulgaris, 
maculosus,  etc.,  all  of  which  are  essentially  the  same  in  character,  the  differences  being 
largely  constituted  by  the  rapidity  or  slowness  with  which  the  granuloma  of  the  skin 
breaks  down.  From  the  surface  these  growths  may  extend  and  involve  parts  at 
considerable  depth,  even  the  periosteum.  This  name  should  also  include  the  lesions 
described  as  scrofuloderma  or  scrofulous  ulcers  of  the  skin,  they  being  all  of  the  same 
character. 

A  variety  known  as  anatomical  tubercle  has  been  descril)ed  by  some  writers,  found 
especially  upon  the   hands  of  those  who  frequent  dissecting-rooms  or  handle  dead 


116 


SURGICA  L  1)1  SEA  Sl'JS 


Fig.   20 


bodies,  and  is  supposed  to  be  the  result  of  local  inoculation.  It  appears  usually  as  a 
warty  growth,  which  ulcerates  and  becomes  covered  with  a  scab — is  usually  indolent 
in  character,  l)ut  is  followed  by  lymphatic  involvement,  and  in  rare  instatices  by  death 
from  tuberculous  disease. 

In  flic  li/iitpliatic  structures  and  lijniph  nodes  tuberculosis  is  a  most  fre(juent  affection. 
In  these  localities  it  may  occasionally  be  primary,  but  is  almost  always  a  secondary 
lesion.  It  is  in  separating  from  the  lymph  stream  the  tubercle  bacilli,  which  would 
otherwise  be  passed  into  the  general  circulation,  that  the  lymj)li  nodes,  acting  as  filters, 
render  us  the  greatest  possible  service.  These  filters  themselves,  however,  almost  always 
become  infected,  and,  enlarging,  they  assume  the  appearances  known  to  the  laity 
as  scrofula,  which  have  been  generally  referred  to  as  scrofulous  glands.  These  lesions 
abound  rather  about  the  axilla  and  the  cervical  and  bronchial  nodes  than  about  the 
lower  extremities.  Nevertheless,  the  retroperitoneal,  mesenteric,  and  inguinal  nodes 
are  occasionally  infected.  In  these  nodes  will  be  found  giant  cells  surrounded  with 
epithelioid  cells,  containing  bacilli  and  undergoing  cheesy  (legeneration  or  suppuration. 
Infection  often  proceeds  from  centre  to  periphery,  and  then  to  the  surrounding  tissues, 
the  filter,  as  such,  having  become  so  choked  that  nothing  seems  to  pass  h.  By  virtue 
of  this  surrounding  infiltration  (which  used  to  be  known  as  'peri-adenUis,  when  lymph 
nodes  were  spoken  of  as  lymph  glands)  generalized  infection  is  in  some  measure  pre- 
vented, while  the  natural  barriers  are  altered  and 
natural  distinctions  between  tissues  are  lost.  This 
makes  complete  extirpation  of  these  tuberculous  foci 
often  very  difficult,  while  the  adhesions  which  they 
contract,  for  instance  in  the  neck,  are  often  to  the 
large  vessels  and  nerve  sheaths,  by  all  of  which  their 
operative  treatment  is  naturally  complicated.  When 
infection  from  the  superficial  nodes  extends  toward 
the  surface  it  is  easily  recognized  by  the  dusky  hue 
of  the  overlying  skin,  the  hardness,  infiltration,  and, 
later,  the  fixation,  of  these  masses,  accompanied 
usually  by  evidences  of  suppuration. 

In  and  on  the  serous  membranes  we  find  tuberculous 
lesions,  either  primary  or  metastatic,  usually  miliary 
in  type.  In  the  pleural  cavity  they  produce  effusion 
(hydrothorax),  which  may  necessitate  repeated  para- 
centesis, or  by  a  mixed  or  secondary  infection  may 
cause  empyema,  for  which  much  more  radical  and  even 
extensive  operations  are  demanded.  (See  Thoraco- 
plasty.) 

In  the  case  of  the  peritoneum  we  find  (a)  miliary 
tuberculosis,  (6)  a  slower  non-exudative  form  with  firm,  sometimes  pigmented  nodules, 
and  (c)  a  form  characterized  by  small  gummas  which  become  caseous,  coalesce,  and 
ulcerate,  binding  together  intestinal  coils  and  producing  extensive  and  irregular  adhe- 
sions, with  seropurulent  exudation,  often  enclosed  in  walled-off  sacs.  In  all  of  these 
cases  surgical  intervention  should  be  considered,  while  in  the  more  acute  miliary  forms 
abdominal  section,  with  flushing,  has  in  many  instances  afforded  relief. 

Tuberculous  meningitis,  cerebral  or  spinal,  is  in  surgical  cases  practically  always  of 
miliary  type,  accompanied  by  the  inevitable  increase  of  fluid,  and,  in  the  cerebrospinal 
canal,  of  consequent  tension.  Inasmuch  as  the  latter  constitutes  the  most  formidable 
feature  of  these  cases,  its  possible  relief  by  puncture  may  be  considered.  And  so  lumbar 
puncture  (q.  v.)  may  be  practised,  and  even  tapping  the  cerebral  ventricles  after  making 
the  small  trephine  opening  has  been  done  a  few  times,  though  not  with  encouraging 
success.  (See  Hydrocephalus.)  Too  often  tul)erculous  meningitis  is  the  terminal 
infection  which  ends  many  a  case  of  local  tuberculous  disease  in  other  parts  of  the 
body. 

In  general  the  more  acute  and  miliary  the  lesions  presented  in  tuberculous  disease  of 
serous  membranes  the  greater  the  tendency  to  profuse  watery  (serous)  exudate,  whose 
volume  may  demand  operative  measures  for  relief. 

In  the  bones  we  often  find  indications  of  tuberculous  disease.  It  is  not  much  more 
than  sixty  years  since  N^laton  called  attention  to  the  frequency  of  these  intra-osseous 


Tuberculosis  of  cervical  lymph  nodes. 


THE  GUMMAS  OF  TUIiKliCULOSlS 


117 


lesions,  and  doinnnstratcd  the  ossontially  luhcn  ulous  character  of  imich  llial  had 
hitherto  been  overlooked  or  considered  under  tiiat  vafj;ne  term  serotnla.  All  those 
forms  of  hone  disease  comj)rehen(led  under  the  names  I'olC.s  (ILsto-st,  .spina  vctiiona, 
tumor  alhii.s,  etc.,  are  now  known  to  he  distinctly  luherculous  lesions.  In  many 
instances  these  follow  the  sliffht  circulatory  disturhaiices  l)rou<jht  about  hy  contusions 
sprains,  etc.  This  is  esiH'cially  the  case  in  those  who  are  |)redis|)ose(l  to  this  disease. 
TulxM-culosis  of  bone  always  assumes  the  phase  of  miliary  lesions,  followed  bv  the 
formation  of  a  ojranuloma,  which  may  gradually  encroach  upon  surrounding  tissues 
or  may  assume  a  more  fulminating  tyj)e  and  spread  rapidly.  Apparently  because  of 
tlu>  <irculatory  conditions  these  lesions  generally  occur  near  the  ej)i|)hyseal  lines  of 
the  long  boiK's,  a])parently  seeking  the  ends  of  th(>  bones,  as  j)ulmonary  lesions  seek  the 
terminations  of  the  lungs.  These  lesions  may  be  solitary  or  nniltiplc.  Beginning 
always  mitnitely,  they  si)read  so  as  to  produce  foci  p(>rhaps  two  inches  in  diameter. 
As  the  ri'sult  of  the  formation  of  grainilation  tissue,  the  surrounding  bone  melts  away 
and  disapj)cars,  the  result  being  a  great  weakening  of  its  structure  and  exj)ansion  of  its 
dimensions  in  order  to   make  room  for 

the  growing  mass  within.     The  tendency  ^'o.  21 

of  this  granulation  tissue  thus  imprisoned 
is  always  to  escape  in  the  direction  of 
least  resistance.  This  carries  it  some- 
times into  the  joint,  sometimes  out 
through  (>pi])hyseal  junctions,  and  some- 
times through  channels  in  the  bone 
made  by  its  own  ])ressure,  with  external 
escaj)e  and  appearance  of  the  dusky 
distinctive  tissue,  felt  beneath  and  then 
upon  the  skin.  Where  bone  is  so  weak- 
ened in  one  direction  it  is  usually 
strengthened  by  compensatory  deposi- 
tion of  calcium  salts  at  other  points,  and 
the  result  frequently  is  a  striking  comhi- 
naiion  of  osteoporosis  in  the  immediate 
presence  of  the  disease,  with  osteosclerosis, 
sometimes  to  a  remarkable  degree,  even 
to  eburnation,  of  an  adjoining  portion. 
When  this  mass  undergoes  caseous  de- 
generation the  progress  of  the  disease  is 
much  slower  and  the  pain  less.  When 
it  undergoes  sujjpuration  there  are  more 
evidences  of  inflammation,  with  more 
pain  and  systemic  disturbance,  as  well 
as  local  swelling,  tenderness,  etc.  The 
surrounding  musculature  is  rarely  in- 
volved, although  the  periosteum  is  nearly 
always  so.     In  fact,  it  is  stated  that  in  an 

inflamed  and  suppurating  bone  lesion,  if  the  muscles  are  extensively  invaded,  it  may 
be  regarded  as  of  svjihilitic  rather  than  of  tuberculous  origin.  The  pi/oplii/lacttc 
membrane  alreadv  alluded  to  is  seen  in  almost  every  instance  of  tuberculous 
disease.  The  spina  ventosa  of  some  writers  refers  to  the  expansion  of  the  shaft  and 
medullarv  cavitv  of  a  long  bone  whose  interior  is  occupied  by  a  mass  of  tuberculous 
gumma,  which  'is  perforated  at  one  point,  and  through  which  opening  it  escapes  as 
does  lava  from  a  crater,  to  involve  the  structures  on  the  outer  side.  The  ajipearance 
of  this  granulation  tissue  in  joints  as  fungous  tissue  has  already  been  mentuMied.  In 
a  general  way  it  preserves  its  fungoid  characteristics  until  attacked  by  pyogenic  or  sap- 
rogenic organisms,  when  it  quickly  breaks  down,  forming  an  ulcer  if  upon  the  surface, 
or  a  cold  abscess  if  not  externally  open.  Tuberculous  disease  of  the  bone  is  most 
common  in  the  voung,  and  in  them  the  majority  of  tuberculous  joints  are  those  whose 
bonv  structures  have  been  first  involved.  In  other  words,  the  majority  of  cases  of  tuber- 
cuhius  pvarthrosis  are  due  to  primary  bone  disease.  As  the  result  of  the  tuberculous 
infection'  the  bones  become  distorted,'  which  is  best  illustrated  in  Pott's  disease  of  the 


Tuberculous  sjiondylitis  (caries):  a,  ostei.geue.^is  and 
osteosclerosis;  c,  cavity  formed  by  degeneration  of  tuber- 
culous focus.      (Krause.) 


118  SURGICAL  dis/:as/:s 

spine;  while,  as  the  result  of  the  constant  irritation,  joint  ends  become  displaced  by 
chronic  muscle  spasm,  and  joint  contours  entirely  altered  by  expansion  of  the  afi'ected 
bone  and  thickening  and  infiltration  of  the  overlying  soft  parts. 

I  have  often,  for  the  sake  of  illustration  to  medical  students,  drawn  a  certain  analogy 
(following  Savory)  of  the  gross  resemblances  between  lungs  and  bones  in  their  Ijchavior 
when  involved  in  tuberculous  disease.  In  either  case  the  structure  is  in  a  measure  sjKjngy 
and  contains  cavities  and  networks  of  tissue;  in  each  case  the  structures  are  invested  by 
a  resisting  meml)rane — in  the  one  instance  pleura,  in  the  other  periosteum.  Again, 
each  is  closely  related  to  a  serous  cavity — the  lungs  to  the  pleural  cavity,  the  bones  to 
the  serous  cavities  of  the  joints.  Tuberculous  disease  manifests  a  predilection  for  the 
extremities  of  both  organs.  Perforation  into  the  adjoining  serous  cavity  is  frequent, 
and  previous  to  perforation  collections  of  serous  fluid  are  frequently  noted — in  one 
instance  pleurisy,  in  the  other  hydrarthrosis.  Moreover,  the.se  fluids  may  frequently 
become  c(jntai.iinated,  and  then  become  purulent,  constituting  emjnema  or  jjyarthrosis 
as  the  condition  may  be.  One  sees,  too,  in  each  place  the  same  striking  combinations 
of  weakening  of  tissue  and  strengthening  in  order  tcj  atcjiic  for  the  undermining  of  the 
disease.  These  are  not  all  of  the  similarities  that  miglit  be  adduced,  but  are  perhaps 
sufficient  for  the  purpose  of  showing  that  tuberculous  disease  is  essentially  one  and  the 
same  thing,  no  matter  what  tissue  is  invaded. 

In  the  tendon  sheaths  and  bursae  we  frequently  find  manifestations  of  tuberculosis. 
When  seen  early  the.se  are  always  in  the  direction  either  of  miliary  affection,  or,  most 
commonly,  of  tuberculous  gumma,  while  when  seen  late  the  disease  has  usually  advanced 
to  the  point  of  suppuration,  and  we  now  have  cold  abscess  of  the  affected  })art. 

In  many  joints  and  tendon  sheaths,  particularly  the  latter,  we  find  certain  detached, 
usuallv  colorless,  firmly  resistant  masses,  of  smooth  and  polished  surface,  lying  in  a  col- 
lection of  fluid,  in  size  from  a  minute  particle  up  to  that  of  a  melon-seed.  These  have 
l)een  known  at  various  times  as  rice  (jrains,  melon-seed  bodies,  corpora  oryzoidea,  etc., 
and  for  a  long  time  their  explanation  was  a  mystery.  It  is  now  well  established  that  in 
the  majority  of  instances  these  are  the  result  of  fungous  granulations  which  have  become 
detached  in  small  pieces,  which  then,  in  the  aljsence  of  infection,  have  shrunken  and 
become  rounded  and  polished  Ijy  attrition.  The  bursal  enlargement  and  distention  with 
fluifl  in  which  they  are  usually  found  is  commonly  spoken  of  as  hygroma  of  that  par- 
ticular bursa.  Tuberculosis  of  these  burspe,  however,  does  not  always  result  so  harm- 
lessly as  the  formation  of  these  bodies,  but,  on  the  contrary,  tuberculous  infiltration  may 
extend  beyond  the  serous  limits  to  the  surrounding  soft  parts,  with  a  tendency  finally  to 
external  escape,  just  as  in  the  case  of  bone  lesions.  These  constitute  affections  of  the 
soft  parts  which  are  more  or  less  destructive,  and  are  difficult,  often  impossible,  to 
deal  with,  because  of  the  mutilation  which  a  tlujrough  extirpation  of  the  disease  would 
necessitate. 

In  the  testicles  and  ovaries,  particularly  in  the  former,  tufjcrculous  disease  is  frequently 
met  with.  In  the  testicles  it  l)egins  usually  in  the  epididymis,  forming  a  somewhat  den.se 
nodule  and  a  distinct  tumor,  easily  observed  from  the  outside,  although  its  minute  char- 
acter may  be  still  concealed.  The  tendency  here  is  almost  invariably  to  progressive 
infiltration  and  breaking  down,  either  into  a  caseous  mass  or,  more  commonly,  into 
piu'uloid  material,  while  sometimes  acute  infection  su])ervenes. 

It  is  not  always  easy  to  distinguish  between  syphilis  and  tuberculosis  of  the  testicle, 
though  the  latter  is  usually  characterized  by  the  same  tendency  to  effusion  into  the 
acljoining  serous  cavity,  i.  e.,  that  of  the  tunica  vaginalis,  as  is  manifested  in  disease  of 
the  lungs  or  bones.  When  the  disease  is  extensive  the  overlying  skin  is  involved,  and 
frequently  the  surgeon  is  called  to  deal  with  cases  of  perforation  and  escape  of  fungoid 
tissue  on  the  outside. 

In  the  kidneys,  in  the  ureters,  as  also  in  the  bladder,  tuberculous  lesions  are  noted,  the 
miliarv  form  being  particularly  frequent  in  the  former.  Tuberculous  di.sease  of  the 
kiclnev  leads  scjoner  or  later  to  caseation  and  a  condition  of  jnoncjjhrcjsis  or  its  ef|uivalent, 
which  calls  practically  always  for  extirpation  of  the  affcctecl  organ.  Tubercle-  bacilli 
are  sometimes  recognized  in  the  urine,  but  only  when  the  lesion  has  an  opportunity  of 
discharging  into  one  of  the  urinary  ])assag(\s. 

In  the  peritoneum  tubercle  appears  usually  in  the  miliary  form,  leading  sometimes 
to  such  extensive  involvement  of  and  interference  with  visc-eral  functions  as  to  produce 
anasarca  or  more  general  disturbance  prior  to  death.     Acute  miliary  disease  here  is  as 


77/ a;  r/r'.U.U.IN  OF   TlliHUCULOSIS  ]  [(j 

rapid  and  as  rssfiitially  fatal  as  tlu-  same  allVctioii  oi  tlu'  dura  or  pia,  while  (he  more 
cliroiiic  forms  are  follovyed  by  dcgciu'rations  that  may  involve  tiic  iiilcstiiics  cillicr  in 
aijijlutiiuited  masses  or  in  ulcerations  and  possible  perforations.  The  indication  in  all 
tuberculous  lesions  of  serous  mend)raiies  is  for  exposure  by  o[)eration,  disiiifeclion  of 
the  surface,  and  evacuation  of  retained  fluids.  Recovery  from  tuberculous  |)crilonilis, 
even  of  acute  ty|)e,  after  abdominal  section,  is  now  definiiely  eslablislicd  as  a  possibility.' 
The  same  would  probably  be  tru(<  of  tuberculous  menin<jitis  were  we  |)crmitted  to  expose 
the  membranes  and  attack  them  or  drain  them  in  the  same  way. 

.\lthoii<;h  a  few  distinct  orj^ans  or  tissues  have  here  been  specifically  considered  in 
their  relations  to  tuberculous  disease,  there  is  no  orf^an  or  tissue  in  the  body  which 
is  exempt  from  its  ravages  and  in  which  evidences  of  tuberculous  disease  may  not  be 
found.  Kven  the  niaiiiinari/  g/and  occasionally  presents  tumors  composed  of  tuberculous 
(franulonia  which  more  or  less  simulate  mali<,niant  disease,  while  calliiif^  for  th(!  same 
radical  tri'atmcnt  (l''ia'.  '22). 

Fir..   22 


Gross  appearance  in  tuberculosis  of  the  mamma.     (Dubar.) 

Paths  of  Infection. — The  tuberculous  virus  may  enter  the  body  through  various 
channels.  Probably  in  the  majority  of  instances  it  gains  entrance  through  the  respira- 
tory tract,  less  often  by  the  alimentary  canal,  and  occasionally  by  air  contact  of  open 
wounds  or  direct  infection  by  local  agencies.  It  is  now  well  established  that  tuberculous 
disease  is  easily  inherited,  although  a  predisposition  to  its  ravages  is  transmitted  from 
parent  to  children. 

In  what  this  predisposition  consists  is  not  always  easy  to  say.  As  the  tubercle  bacillus 
grows  in  the  tissues,  it  is  by  preference  an  anaerobe,  and  it  seems  to  be  lowered  in  activity 
or  banished  by  access  of  oxygen.  It  has  been  shown  that  in  those  individuals  in  whose 
pallid  skin,  long  bones,  flabby  muscles,  and  pale  conjunctivfe  we  recognize  a  predis- 
position to  this  disease,  the  heart  is  disproportionately  small  as  compared  with  the 
weight  and  size  of  the  lungs.  This  means  a  relatively  feeble  pumping  power,  and  is 
perhaps  the  best  explanation  for  what  is  accepted  as  a  fact.  The  mucous  7ncmbranes 
of  the  nose  and  throat  are  usually  the  first  lodging  places  for  germs  carried  by  the  air, 
they  finding  here  the  w^armth  and  moisture  necessary  for  their  detention,  development, 
and  growth.  As  long  as  these  membranes  are  unbroken  and  healthy,  infection  is  rarely 
possible;  but  let  tubercle  bacilli  become  caught  in  the  crypts  of  the  tonsils  or  in  adenoid 
tissue  in  the  nasopharynx,  and  the  other  disturbance,  set  up  by  irritant  organisms  of 
various  species,  will  usually  bring  about  conditions  favoring  their  growth  and  incorpora- 
tion into  the  living  tissues.  This  lymphadenoid  tissue  is  often  the  port  of  entry  for 
these  organisms.  The  explanation  for  local  and  surgical  tuberculosis  in  bones  and 
other  accessible  tissues  probably  is  connected  with  causes  determining  at  these  points  an 
area  of  least  resistance,  in  which  the  germs  find  tissues  more  suscei)tible  than  elsewhere, 
and  in  wdiich  they  may  live  and  thrive. 

Not  the  least  interesting  and  important  of  the  considerations  regarding  tuberculous 
disease  is  the  possibility  of  an  acute  outbreak  of  tuherculosin  after  long  latent  or  chronic 
manifestations  of  the  disease.  This  means,  in  effect,  the  onset  of  general  miliary  tuber- 
culosis which  soon  terminates  fatally,  and  death  is  not  the  infrequent  result  of  such 
extremely  rapid  outbreaks  from  tuberculous  disease  of  joints,  bones,  ovaries,  etc. 
For  the  disease  when  it  has  assumed  this  extremely  rapid  type  there  is,  so  far  as  known, 
no  relief. 


120  SURGICAL  DISEASES 

Diagnosis. — So  far  as  the  general  recognition  of  tuberculous  disease  is  concerned, 
it  is  not  often  difficult.  It  is  accompanied  usually  bv  more  or  less  marked  cachexia 
(at  least  this  is  the  case  when  infection  is  serious  and  widespread),  one  of  whose  principal 
characteristics  is  the  so-called  hectic  (habitual)  fever  of  old  writers.  This  was  a  fever 
of  a  remittent  tyj>e,  accompanied  also  by  more  or  less  colliquative  night  sweats,  with 
dryness  of  the  skin  during  the  daytime,  and  flushing  of  the  face.  Hectic  fever,  as  a  matter 
of  fact,  often  accompanies  tuberculous  disease,  but  is  seldom  encountered  until  pyogenic 
infection  has  occurred  and  sujjj)uration  is  taking  or  has  taken  place.  There  is  now 
much  reason  to  consider  hectic  fever  as  an  auto-intoxication  from  absorption  of  morbid 
products.  In  advanced  cases  we  may  find  evidence  of  amyloid  changes,  although  these 
are  seldom  recognized  prior  to  autopsy.  It  is  seldom  difficult  to  recognize  tuberculous 
disease  except  when  at  a  considerable  depth.  Here,  as  long  as  there  is  no  suppuration, 
there  is  little  tendency  to  leukocytosis,  by  which  diagnosis  as  between  .sarcoma  and  tuber- 
culous infection  may  f>erhaps  be  made.  Sometimes  when  in  doubt  the  exploring  trocar 
or  an  exploratory  incision  may  l>e  resorted  to,  it  being  always  best  to  be  prepared  at 
the  same  time  to  proceed  with  whatever  further  operative  procedure  the  findings  may 
indicate. 

Treatment.— It  is  well  to  emphasize,  first  of  all,  that  tuberculous  disease  when  circum- 
scribed and  accessible  is  a  distinctly  curable  affection.  If  this  is  accepted,  it  puts  a  much 
more  hopeful  aspect  upon  the  condition  than  it  formerly  bore.  It  moreover  justifies 
operations  of  a  more  radical  nature  than  were  formerly  practised.  Treatment  should 
be  divided  into  the  hygienic  and  constitutional  and  the  local  and  operative. 

Of  all  the  natural  remedies,  oxygen  undoubtedly  ranks  first.  This  means  the  best 
of  ventilation,  an  outdoor  life  if  possible,  and  preferably  in  localities  and  at  altitudes 
free  from  dust  and  well  supplied  with  ozone.  When  this  is  impossible  inhalations  of 
dilute  oxygen  are  capable  of  doing  much  good.  The  two  canons  of  successful  treatment 
of  pulmonary  ttiberculosis  are  equally  of  value  in  surgical  tuberculosis,  viz.,  abundayice 
of  o.ryrjen  and  hypernutrition.  The  diet  should  be  rich  and  nutritious,  at  the  same  time 
capable  of  complete  digestion.  The  emimctories  should  be  stimulated  and  elimination 
favored  in  every  possible  way.  Undoubtedly  the  old  standard  remedies — cod-liver 
oil,  compound  syrup  of  hypophosphites,  etc. — are  beneficial,  and  much  good  may  be 
accomplished  by  their  proper  use. 

Certain  remedies  have  been  at  various  times  supposed  to  be  endowed  with  specific 
properties,  and  for  many  years  clinicians  have  endeavored  to  find  that  substance  with 
which  the  system  could  be  safely  saturated  and  prove  inimical  to  the  parasite  causing 
this  disease.  Such  agent  has  not  yet  been  discovered;  nevertheless,  much  has  been 
done  in  this  direction.  Of  the  remedies  highly  spoken  of  for  this  purpose,  creosote  and 
guaiacol  are  considerefl  the  best.  These  are  somewhat  difficult  of  administration,  but  if 
the  latter  is  given  in  the  form  of  the  carbonate,  generally  known  as  benzosol,  it  comes 
the  nearest  to  the  ideal  for  which  we  are  striving.  Benzosol  should  be  given  to  the  adult 
in  doses  of  at  least  a  gram  a  day,  perhaps  more.  It  Ls  better  tolerated  and  less  offensive 
than  the  guaiacol  from  which  it  is  made.  I  have  never  seen  anything  but  benefit  result 
from  its  use,  and  yet  would  not  extol  it  as  a  positive  cure.  Nevertheless  in  conjunction 
with  other  local  and  constitutional  measures  its  administration  may  be  followed  by 
complete  recovery. 

Of  the  various  local  measures,  physiological  rest  should  be  placed  first,  and  can  be 
achieved  in  some  places  better  than  in  others.  The  various  forms  of  apparatus  resorted 
to  by  orthop)edists  are  simply  mechanical  measures  in  furtherance  of  this  purpose. 
Some  surgeons  have  faith  in  iodoform,  used  locally  in  soliuion  or  susfx-nsion  in  some 
menstruimi  like  glycerin,  oil,  etc.  The  l^enefit  which  has  been  claimed  in  some  cases 
is  not  duplicated  in  the  experience  of  all  surgeons;  nevertheless,  it  has  undoubtedly 
been  of  service.  A  recent  and  most  promising  method  of  treating  tuberculous  disea.se 
of  the  extremities  has  been  suggested  by  Bier,  and  consists  in  the  establishment  of  a 
permanent  hyperemia  by  the  application  of  a  rubber  tourniquet  on  the  proximal  side  of 
the  lesion.     (See  chapter  on  the  Joints.) 

It  would  appear  that  the  access  of  more  blood  which  is  thus  permitted  is  inimical, 
presumably  by  the  presence  of  the  oxygen  which  it  brings,  to  the  flevelopment  of  the 
disease  genn.  The  method  depends  for  its  rationale  upon  the  fact  that  the  congested 
lung  does  not  become  tuberculous.  Lannelongue  has  suggested  what  he  calls  the 
sclerogenic  treatment  of  tuberculous  lesions,  by  injection  of  a  very  dilute  solution  of  zinc 


THE  GUMMAS  OF  TUBERCULOSIS  121 

chloride,  wliich  sorvcs  as  an  irritant  and  produces  a  tissue  sclerosis  that  serves  the 
purposi-  of  a  pro|)li\  lactic  nicnil)raii(',  wliilc  at  the  same  time  the  solution  is  fatal  to 
those  <;ernis  with  which  it  comes  in  contact.  This  treatment  is  j)ainful  and  has  not 
proved  acceptahle. 

Tlu>  astute  surifcon,  who  gains  the  confidence  of  his  patients  and  retains  it,  will  not 
hesitate  to  remove  hy  a  suitable  oju-ration  the  tuhcrcidous  focus  which  he  feels  con- 
fident that  he  can  reach  and  extirpate.  The  rcsultin*;  tissue  defects  may  he  in  many 
instances  atoned  for  hy  |)lastic  ojjcrations.  At  other  times  this  j)rocedure  means  excision 
of  some  joint,  which  leaves  usually  a  much  better  functionating  member  than  would  the 
disea.se  if  permitted  to  go  on  to  spontaneous  recovery — i.  c,  ankylosis — and  at  the 
same  time  removes  a  focus  of  di.sease  which  is  a  menace  if  left  to  tlu'  future  welfare  of 
the  patient.  It  may  mean  at  other  times  ampuiaiion,  but  the  artificial  lind)maker  now 
supplies  a  member  vastly  more  useful  than  a  natural  one  cri))plcd  by  this  iid'cctious  dis- 
ease. In  a  general  way,  then,  time  may  be  saved  and  recovery  ensured  by  early  and 
judicious  operation,  while  later  in  the  course  of  this  j)rotean  malady  it  may  be  absolutely 
necessitated  in  the  endeavor  to  save  life. 

After  operations  where  clean  extirpation  and  reunion  of  the  parts  with  prinuiry  healing 
is  impossil)le  a  local  dressing  of  balsam  of  Peru  containing  10  per  cent,  of  guaiaeol  is 
recommended.  Gauze  saturated  with  this  dressing  and  packed  into  the  cavity  best 
accomplishes  the  purposes  of  a  surgical  dressing  for  such  cases. 

The  superficial  and  ulcerative  (skin)  lesions  due  to  tuberculosis  often  yield  very  readily 
to  exposure  to  the  Rontgen  rays  and  the  ultraviolet  rays.  Recrudescenc-es  apj)ear  not 
infrequently,  and  the  treatment  should  be  administered  at  intervals  long  after  the 
apparent  subsidence  of  the  lesion. 

Deep  pain  of  tul)erculous  lesions,  especially  in  bone,  is  often  relieved  by  igmjninrtnre, 
meaning  thereby  a  j^erforation  into  the  depth  even  of  the  bone-marrow  by  the  actual 
cautery  (Paquelin's),  which  may  be  thrust  directly  through  the  skin  or  which  may  be 
used  after  exposing  the  bone  by  incision.  The  use  of  the  actual  cautery  is  indicated 
in  eradicating  and  destroying  tuberculous  tissue  when  a  neat  dissection  or  extirpation  is 
impossible. 

Tuberctilin. — Finally  the  treatment  of  tuberculosis  cannot  be  dismissed  without  a 
reference  to  the  glycerin  extract  made  from  a  filtered  culture  of  the  tubercle  bacillus, 
containing  the  peculiar  toxalbumin  first  prepared  by  Koch,  forever  associated  with 
his  name,  and  first  given  to  the  world  in  1800,  when  its  announcement  created  a 
furore  and  aroused  hopes  that  have  never  been  completely  realized,  let  in  spite  of 
disappointments  which  have  often  followed  its  use,  it  is  a  remedy  of  great  value  when 
judiciously  used  in  selected  cases.  The  diagnostic  value  of  the  material  should  also  not 
be  forgotten,  as  by  its  use  one  may  possibly  decide  in  doubtful  cases  as  between  tuber- 
culous or  some  other  disease.  The  best  preparation  for  use  today  is  that  made  by 
Koch's  new  process,  by  which  the  possibility  of  the  presence  of  microorganisms  is 
eliminated.  It  contains  those  constituents  of  the  bacilli  which  are  insoluble  in  glycerin, 
and  which  have  distinct  immunizing  power.  On  the  market  it  is  known  as  inhercuhn 
resi,  indicated  simply  as  T.  R.  The  initial  dose  is  -i^  Mg.,  to  be  increased  with  each 
injection.     Its  effect,  e.  g.,  on  lupus,  is  very  marked. 


CHAPTER   X. 

SYPHILIS. 

The  younger  generation,  when  studying  the  subject  of  syphilis,  sliould  l)e  referred 
hack  one  hundred  years  or  more  to  the  time  when  the  opinions  held  hyJohn  Hunter 
generally  ])revailed — when  venereal  diseases  were  groujx'd  under  one  heading,  and  con- 
sidered to  he  but  three  manifestations  of  the  same  morbid  condition.  It  took  years 
for  the  profession  to  break  away  from  this  mistaken  teaching,  and  a  generation  had  passed 
before  gonorrhea  was  separated  from  the  others.  This  left  chancroid  and  syphilis 
still  more  or  less  confused  in  the  minds  of  many,  and  until  the  middle;  of  the  previous 
century  they  were  considered  as  difl'erent  types  of  the  same  disease  by  some  of  the  most 
experienced  observers.  Thus  it  happened  that  those  who  made  a  special  study  of  this 
subject  were  grouped  into  two  classes,  the  unicists  and  the  ihmlists,  according  as  they 
held  to  the  unity  or  duality  of  syphilis  and  chancroid.  It  was  a  question  of  importance, 
and  ditferences  of  opinions  led  to  bitter  antagonisms.  Its  im|)ortance  inhered  in  this: 
either  all  venereal  sores  were  to  be  subjected  to  constitutional  treatment,  or  else  differ- 
ences in  treatment  were  to  be  made  according  to  the  local  or  constitutional  nature  of 
the  malady.  Men  sacrificed  their  own  health,  even  their  own  lives,  in  their  willingness 
to  make  experiments  upon  themselves,  and  auto-inoculability  was  proved  by  one  ob- 
server through  some  1700  inoculations  produced  upon  his  own  body.  Such  devotion 
to  medical  science  has  been  rarely  eclipsed.  In  the  latter  half  of  the  eighteenth 
century  came  clearer  distinctions,  and  toward  its  close  there  were  none  who  ranked  as 
authorities  who  held  to  the  old  view  of  the  unity  of  these  diseases. 

Syphilis  is  a  disease  of  ancient  if  not  of  respectable  origin.  We  read  much  of  the 
possibility  of  so-called  pre-Columbian  syj)hilis,  implying  by  that  term  that  the  Spaniards 
who  came  over  to  this  country  found  it  here  and  carried  it  with  them  back  to  Europe. 
This  is  proliably  the  case,  and  yet  the  disease  antedates  the  Christian  era,  as  may 
be  established  by  familiarity  with  ancient  literature,  whether  Arabian,  Egyptian,  or 
Hebraic.  No  one  can  read  the  Psalms  of  David,  for  instance,  without  finding  therein 
intrinsic  evidence  that  the  writer  thereof,  whoever  he  may  have  been,  suffered  from  this 
disease.  Of  its  antiquity,  however,  as  well  as  of  its  universal  distribution,  we  need  not 
speak.  History  has  shown  that  whenever  it  has  appeared  in  a  community  previously 
unaffected  by  it,  it  has  assumed  malignant  and  epidemic  features,  and  has  spread  rajiidly 
while  claiming  many  victims;  on  the  other  hand,  in  those  communities  where  it  has  long 
been  domesticated,  it  assumes  usually  a  milder  type,  as  though  a  racial  immunity  were 
being  gradually  established. 

Si/phiHs  is  an  infectious  chronic  disease,  acquired  either  hi/  inlieritance  or  by  coiitarjion, 
mediate  or  immediate,  with  a  certain  period  of  incubation,  characterized  by  an  initial 
lesion  at  the  site  of  infection,  which  is  followed  in  time  by  a  series  of  systemic  disturbances, 
usually  quite  characteristic,  in  a  commonly  determinate  order.  A  large  proportion  of 
these  consist  of  neoplastic  lesions  of  the  general  type  of  the  infectious  granulomas.  In 
the  majority  of  instances  it  is  of  distinctly  venereal  origin,  although  not  always.  It  is 
known  among  the  common  people  as  '}wx,  while  a  frequent  synonym  for  it  in  foreign 
literature  is  lues  venerea,  or  often  lues  alone,  the  adjective  being  Inetic. 

Syphilis  is  always  transmitted  as  such  and  is  not  interchangeable  with  leprosy,  tuber- 
culosis, or  anything  else,  although  it  is  not  unfrequently  complicated  with  them  as  well 
as  with  cancer.  It  has  certain  resemblances  to  the  exanthemas  in  its  periods  of  incuba- 
tion, and  in  the  fact  that  one  attack  is  supposed  to  confer  immunity,  as  well  as  that  many 
of  the  typical  symptoms  of  syphilis  pertain  to  the  skin  and  mucous  membrane;  further 
resemblances  may  also  be  found  in  each  case. 

Within  certain  limits  the  specific  infection  of  syphilis,  or,  as  it  is  frequently  spoken 

of,  the  specific  disease,  passes  through  a  somewhat  regular  program  in  which  periods  of 

activity  and  latency  seem  to  alternate.     The  first  visible  lesion  is  at  the  point  of  entrance 

of  the  virus,  in  acquired  cases,  after  a  certain  period  of  incubation,  and  is  known  always 

(122) 


SYPHILIS 


123 


as  the  chancre.  Of  course,  in  inherited  ,s\|»liilis  no  chaiiere  or  prijiiarv  sore  is  round. 
Then  occurs  a  second  j)erio(l  of  iiKuhation,  (huiii<^  wiiicli  llicre  is  a  still  more  widespread 
gen«M-ai  infection  of  the  body,  in  which  at  first  the  lymphatic  system  seems  to  suffer  most. 
This  is  characterized  hy  a  certain  dcirree  of  fever,  j)ro<i;ressive  anemia,  malaise,  tender- 
ness and  pain  in  Koiics  and  joints,  all  of  which  indicate  a  pnx/rc.s.s-irc  io.rcmla. 

Manner  of  Contagion. — The  manner  of  contajfion  in  ac(|uired  cases  is  naturalK  most 
often  that  of  the  sexual  act,  aithou<;h  contaifion  may  come  from  many  sources,  inclndinc 
unclean  utensils,  pi|)es,  etc.,  as  well  as  the  instruments  of  the  dentist  or  the  surj,'eon. 
Some  abrasion  of  the  infected  surface  is  almost  invariably  presup|)osed,  since  it  is  not 
established  that  the  virus  of  syphilis  will  ent(M-  an  imbroken  surface,  thoui;h  it  mav  link 
thereon;  but  the  abrasion  may  be  triflinj;  and  occur  in  such  situation,  especially  on  the 
female  jxcnitalia,  as  to  be  undiscoverabie  or  unnoticed.  It  is  then  j)ossil)le  that  patients 
may  speak  truthfully  when  (lenyin<r  the  existence  in  the  past  of  any  venereal  sores.  'J'he 
transmission  of  infection  from  ])arent  to  ott'sprino;  in  the  uterus  will  be  discussed  later. 

Nature  of  the  Virus. — That  syphilis  is  a  disease  of  parasitic  character,  i.e.,  ronfof/ioii.s-, 
there  can,  of  course,  be  no  question.  The  nature  of  the  ccmtagiiim  vivnm  which  pro- 
duces these  changes,  long  unknown,  is  now  believed  to  be  revealed  in  th(>  .ipirnchafn 

Fig.  23 


Spirochaita  pallida  (syphilis)  in  adrenal  of  child  with  congenital  sypliilis.     (Gaylord.) 


pallida  recently  described  by  Schaudinn  and  others;  an  organism  4  to  10  /J.  in  length, 
A  fi  in  width,  possessing  several  curves  like  those  of  a  corkscrew,  with  sharpened  poles, 
mobile,  its  motions  consisting  of  rotations  and  bendings.  It  has  been  demonstrated 
that  primary  lesions  contain  the  organism,  either  constantly  or  in  the  majority  of  cases, 
while  in  skin  and  nearly  nil  other  lesions  it  can  be  also  shown  (Fig.  23). 

Evolution  of  the  Disease. — Ever  since  the  days  of  Ricord's  writings  on  the  subject 
it  has  been  customary  to  group  the  manifestations  of  .syphilis  into  three  groups  or  stages: 
the  primary,  the  secondary,  ami  the  tertiary.  Less  stress  is  laid  upon  these  stages  tlian 
previously,  yet  it  is  convenient  to  retain  them  for  descriptive  purposes.  It  should  be 
emphasized,'  however,  that  between  them  there  are  no  arbitrary  limits  of  time  or  tissue. 
Primary  syphilis  under  this  classification  includes  the  first  periotl  of  incubation  and 
the  symptoms  and  appearances  of  the  initial  lesions.  Secondary  syj^hilis  may  be  made 
to  include  the  earlier  constitutional  s,\niiptoms  which  involve  or  at  least  liecome  apparent 
upon  the  more  superficial  portions  of  the  body,  i.  e.,  skin,  mucous  membrane,  lymphatics, 
etc.  Later  comes  the  so-called  tertiary  period,  in  which  the  body  surfaces  are  not  neces- 
sarily spared,  but  in  which  also  deep  lesions  of  the  viscera,  the  bones,  the  brain,  etc.,  are 
noted.     Between  the  first  and  the  second  stages  comes  the  so-called  second  period  of 


124  SURGICAL  DISEASES 

incubation.  The  second  and  third  stages  arc  characterized  hy  frequent  neoplastic 
formations,  which  assume  the  type  of  the  infectious  granulomas  and  are  commonly 
spoken  of  as  gummas;  these  lesions  are  destructive  in  tiicir  tendency,  and  will  so  prove 
unless  dissipated  or  aborted  by  suitable  treatment. 

In  the  first  and  second  stages  of  the  disease  it  can  he  conveyed  hy  inheritance  and  inocu- 
lation; in  the  later  stage  such  an  occurrence  is  exceptional. 

That  syphilis  is,  'perse,-Aw  infection  is  proved  by  the  constitutional  symptoms  which 
accompany  its  earlier  manifestations;  the  fever,  usually  mild,  though  sometimes  well 
marked,  which  comes  early  in  the  course  of  the  disease,  the  general  lymphatic  involve- 
ment, the  malaise  and  depression,  all  indicate  the  systemic  disturbances  of  a  true  toxemia. 

The  periods  of  quiescence  between  successive  outbreaks  of  the  disease  are,  moreover, 
characteristic,  although  they  sometimes  lull  the  patient  and  his  ))hysician  into  an  inactive 
state,  during  which  medication  is  too  often  suspended,  so  that  when  fresh  disturbance 
arises  vigorous  treatment  must  be  renewed. 

The  infection  of  syphilis  occurs  on  the  instant  of  inoculation,  as  in  the  case  of  tetanus. 
This  is  important,  as  upon  it  depends  the  question  of  early  local  treatment.  While 
excision  of  the  primary  sore,  or  even  of  an  area  which  might  have  become  infected  during 
exposure,  and  before  the  actual  formation  of  the  chancre,  has  been  often  practised  and 
urged  by  some,  experience  has  shown  that  it  has  little  to  commend  it,  since  the  general 
experience  is  that  it  does  not  prevent  the  development  of  the  disease. 

In  its  tendency  syphilis  is  constantly  progressive  and  destructive,  although  it  often 
behaves  in  a  capricious  manner,  sometimes  when  under  efficient  treatment  and  generally 
when  treatment  is  inefficient.  It  is  usually  more  virulent  in  the  dissipated  and  those 
who  are  weakened  by  inheritance  or  poor  constitutions,  or  by  other  disease.  One  reads 
in  literature  on  the  subject  about  the  malignancy  of  some  cases  and  the  benignancy  of 
others.  Some  cases  seem  to  have  a  malignant  aspect,  while  others  run  an  unusually  mild 
course,  so  much  so  as  to  raise  the  question  whether  the  j^atient  hatl  sy]:)hilis.  As  far  as 
the  nature  of  the  parasitic  cause  is  understood,  this  would  depend  on  differences  in  the 
make-up  of  the  individual  rather  than  in  the  actual  virulence  of  the  germ.  In  the 
extremes  of  life  individuals  are  more  susceptible.  When  implanted  upon  a  tuber- 
culous constitution  it  sometimes  renders  the  tuberculous  lesions  more  active;  whether 
it  acts  as  a  mixed  infection  is  not  definitely  known.  Tuberculous  lymph  nodes  fre- 
quently break  down  during  the  course  of  secondary  syphilis,  and  consumptive  patients 
grow  rapidly  worse.  Syphilis,  like  alcohol,  tends  to  play  havoc  with  the  bloodvessel 
walls,  and  their  combined  effects  in  this  direction  are  greatly  to  de  deprecated  and 
should  be  prevented. 

The  Lesions  and  Secretions  which  Convey  Infection.— As  far  as  acquired 
syphilis  is  concerned  ahsolute  contact  is  necessary  between  the  infecting  material  and  the 
infected  area,  while  upon  the  latter  must  exist  some  abrasion  of  the  surface.  Chancres 
and  the  early  eruptions  or  mixed  lesions  have  been  proved  to  be  absolutely  virulent. 
The  genitalia  of  both  sexes  are  frequently  the  site  of  wart-like  lesions  referred  to  as 
condylomas,  which  are  usually  kept  more  or  less  moistened  by  the  secretion  of  the 
parts,  and  are  fruitful  sources  of  contagion.  The  discharginei  lesion  of  those  suffering 
from  syphilitic  disease  should  he  regarded  as  capahle  of  transmitting  it,  while  during  the 
primary  and  secondary  stages  the  blood  and  lymph  should  be  regarded  as  probable 
sources  of  danger. 

Inoculation  with  the  blood  of  patients  during  these  stages  has  been  known  to  be 
successful.  How  long  the  blood  retains  its  power  of  infection  is  uncertain;  it  is  usually 
regarded  as  free  from  it  when  the  disease  is  latent. 

The  natural  and  physiological  secretions  of  various  organs,  e.  g.,  saliva,  milk,  perspira- 
tion, tears,  and  urine,  are  not  generally  believed  to  he  capahle  of  transmitting  the  disease. 
The  semen  of  syphilitic  men  may  reproduce  the  disease  by  heredity  but  not  by  direct 
inoculation.  It  is  possible  under  these  circumstances  for  the  father  to  transmit  the 
disease  to  the  ovum  without  previously  infecting  the  mother;  such  infection  of  the  ovum 
by  diseased  spermatozoa  is  quite  different  from  the  infection  of  the  ovum  by  the  mother 
who  has  acquired  the  disease,  the  father  having  escaped  it. 

In  a  general  way  it  may  be  held  that  secretions  of  organs,  or  even  of  lesions,  which  are 
non-specific,  are  not  contagious  except  as  they  happen  to  be  mixed  with  blood  or  with 
disintegrated  portions  of  actual  syphilitic  lesions;  thus,  for  instance,  vaccinal  lymph  might 
be  safely  taken  from  a  syphilitic  subject  if  there  were  absolutely  no  admixture  of  blood. 


SYl'iiii.ls  ]25 

Bui  tlir  ilifficii/li/  (>l  .scnirnnf  pun  /i/iiipli  i,s  such  ax  to  luaLr  j/.s-  u.s-r  iuadrisahlr  hmni.ie 
of  /7.V  daiujcr. 

Su})j)urafi()n  fm/urni/i/  coinyliralrs  .s-i/plillifir  K-sions.  This  is  to  he  nj^iirdcd  ms  in 
tlu-  iiatiiiv  of  a  srcoiidarv  and  jnop-nic  int't'ctioii.  It  has  not  been  cstahlishcd  (hal  the 
fvrux  of  syphilis  is  by  itscll"  a  |)y()<;(Miic  orfjaiiisni. 

llonorrlica  or  cJuuicroid  y.s-  ojtni  .siniulhinrou.s/ij  roulmrfcd  irifli  NijpJiiH.s,  with  rcsuh- 
in<;  (linical  r()ni|)ncati()ns  that  arc  pcrplcxinj;  as  well  as  diflic  iiU  to  treat.  The  con- 
tafjion  t)f  chancroid  acts  j)ronij)tly,  as  will  he  stated  in  the  cha|)tcr  on  Chancroid; 
and  so  it  may  happen  that  the  sore  which  hcf^ins  as  a  chancroid  is  ^radnally  converted 
into  a  true  chancre,  the  change  taking  j)lace  so  gradually  that  it  is  difficult  to  state  when 
it  begins  or  is  completed.  In  this  way  result  the  so-called  mixed  sores,  which  may  give 
rise  to  so  iiuich  doubt  that  the  surgeon  feels  it  wise  to  wait  for  some  secondary  manifes- 
tations before  deciding  that  syphilis  has  l)een  acf|uired.  Confusion  is  oftc-n  created  by 
j)reliminary  treatment  which  the  local  lesion  has  received  previous  to  its  examination 
by  the  surgeon.  Patients,  esj)ecialiy  in  the  lower  walks  of  life,  freciueiitly  go  to  a  druggist 
or  to  someone  who  will  cauterize  the  sore  and  thus  mask  its  charac-teristics  to  a  degree 
which  makes  prompt  diagnosis  imj)ossil)le.  Again,  jjaticnts  are  often  unc-ertain  regard- 
ing the  matter  of  time,  which  is  of  great  importance;  thus  the  sore  which  appears  within 
a  few  days  after  exjiosure  may  be  chancroidal,  while  one  which  comes  on  twenty  or  thirty 
days  afterward  may  be  syphilitic.  These  periods,  how-ever,  afford  little  help  when  there 
have  been  repeated  exposures,  by  which  confusion  may  be  caused ;  but  an  accurate  and 
complete  personal  history  will  be  hel])ful  toward  a  correct  diagnosis. 

Location  of  Primary  Lesions. — Owing  to  the  greater  delicacy  of  the  mucous  mem- 
branes they  are  more  frec|iiently  the  site  of  primary  lesions  than  the  skin:  S.')  to  90  per 
cent,  of  all  jirimarv  sores  occur  about  the  genitalia;  in  men,  especially  on  the  inner  side 
of  the  prepuc-e,  the  glands,  and  the  sulcus  behind  it;  externally,  chancre  may  occur 
upon  any  part  of  the  surrounding  skin;  in  women,  the  tissues  about  the  vulva  are  most 
frecjuently  its  scat.  Occasionally  it  is  found  within  the  vagina,  but  rarely  upon  the  os. 
The  so-called  extragenital  chancres  are  met  with  anywhere,  especially  on  the  most 
exposed  parts,  as  the  lips,  tongue,  tonsils,  eyelids,  and  nipples.  Syphilis  is  occasionally 
conveyed  to  a  wet-nurse  by  the  infected  mouth  of  an  infant  suffering  from  hereditary 
disease;  even  multiple  chancres  sometimes  occurring.  Conversely,  children  have  been 
infected  by  wet-nurses  with  syphilitic  lesions  about  the  nipple.  The  disease  has  been 
conveyed  by  bites,  as  upon  the  face  and  fingers.  Surgeons  and  obstetricians  are 
peculiarly  exposed,  as  are  also  nurses,  to  this  disease,  especially  occurring  upon  the 
fingers  and  hands.  Infants  have  been  known  to  be  inoculated  during  j)arturition.  These 
are  all  examples  of  direct  or  immediate  contagion.  On  the  other  hand,  the  disc^ase 
may  be  positively  conveyed  by  utensils  in  common  use  between  different  individuals, 
as  table-ware  or  tobacco-pipes;  by  tools  of  trade  which  are  passed  from  one  person  to 
another,  as,  for  instance,  the  blowpipe  in  glass  factories;  and  by  cigars  as  they  are  made 
in  some  places,  the  wrapper  being  moistened  from  the  mouth  of  the  cigarmaker.  These 
are  examples  of  its  indirect  transmission.  Physicians  are  familiar  as  well  with  instancs 
where  the  disease  has  been  conveyed  by  instruments,  either  surgical  or  those  of  the 
dentist.  So  possible  is  this  last  form  of  contagion  that  dentists  are  trained  to  sterilize 
their  instruments  as  carefully  as  does  the  surgeon. 

Possibility  of  conveying  syphilis  by  vaccinal  lymph  has  been  alluded  to  as  occurring 
only  in  those  instances  where  the  blood  of  the  syphilitic  patient  is  mingled  with  the 
lATnph.  The  production  of  vaccinal  virus  is  now,  however,  so  well  regulated  that  it 
is  rare  that  the  surgeon  employs  humanized  lymph.  Some  cases  considered  vaccinal 
have  been  due  to  the  use  of  infected  instrutnents;  hence  the  necessity  for  extreme  caution 
in  this  regard.  When  the  disea.se  is  acquired  in  a  non-venereal  manner  it  is  called 
syphilis  insontium,  or  syphilis  of  the  innocent;  this,  however,  is  an  unfortunate 
expression,  as  it  tends  to  cast  reflections  upon  other  cases  which  may  be,  in  effect,  just  as 
innocent. 

Symptoms  of  the  Ulcer.— In  all  probability  the  initial  sore  and  the  ensuing  lymphatic 
involvement  are  due  to  the  parasite  and  to  its  toxic  products.  These  latter  are  quickly 
taken  into  the  general  circulation  and  are  held  to  confer  the  immunity  which  syphilitics 
enjoy  before  the  outbreak  of  the  general  eruption.  Anemia,  malaise,  and  other  like 
.s}TTiptoms  are  evidences  of  a  progressive  intoxication  or  toxemia,  while  the  earlier  erup- 
tions, which  tend  to  evince  the  contagious  element  in  a  rather  virulent  form,  may  be  due 


126  SURGICAL  DISEASES 

to  the  germs  alone,  or  eoiiil)iiie(l  witli  their  toxins.  On  this  hyjiothesis  can  be  exphiined 
the  partial  or  eoin))lcte  immunity  evinced  by  mothers  who  bear  syphilitic  children, 
the  infection  comin^j  from  the  father. 

From  the  first  evidence  of  infection  the  whole  syphilitic  j)rocess  gives  evidence  of  its 
infectious  character.  The  bloodvessel  walls  undergo  a  thickening  of  their  coats  and 
more  or  less  obliteration  of  their  lumen,  and  this,  of  course,  causes  a  disturl)ance  in  the 
nutrition  of  the  parts  su|)i)licd  by  them.  This  vascular  change  can  be  recognized  even 
in  the  minute  vessels  of  the  initial  lesion,  and  thereafter  j)ertains  to  most  if  not  all 
specific  manifestations  of  the  disease. 

Our  knowledge  of  the  nature  of  this  disease  would  be  more  complete  were  it  possible 
to  convey  it  to  animals,  but  these  are  practically  exempt  from  it,  for  the  few  and  rare 
instances  where,  it  is  said,  the  disease  has  been  inoculated  upon  the  higher  quadru- 
mana  furnish  insufhcient  data.  In  this  respect  the  disease  is  like  the  exanthemas,  of 
whose  parasitic  origin    there    can   be    no    question. 

The  First  Period  of  Incuhafion  and  tlir  Chancre. — The  time  which  elapses  between 
the  exposure  and  the  first  a])j)earance  of  the  initial  lesion  is  known  as  the  first  period 
of  incubation.  This  varies,  within  wide  limits,  from  ten  dajjs  to  fort//  or  fiftij;  some 
writers  have  made  it  even  seventy  days.  The  average  jieri(jd  varies  from  three  to  ff)ur 
weeks.  There  is  often  uncertainty  as  to  when  the  induration  l)egan,  and  patients, 
women  especially,  may  easily  make  a  mistake  of  several  days  in  fixing  this  date. 

Every  case  of  acquired  syphilis  begins  with  an  initial  sore,  though  this  may  be  so  located 
or  so  complicated  with  some  other  lesion  as  to  be  overlooked.  The  character  of  the 
induration  varies  somewhat  with  the  location,  i.  e.,  whether  upon  the  skin  or  mucous 
membrane.  The  amount  of  moisture  or  maceration  to  which  it  is  exposed  will  also 
influence  its  appearance.  It  may  be  minute,  so  as  to  almost  elude  observation  even 
on  visible  parts,  or  it  may  spread  and  involve  an  area  1  Cm.  in  diameter.  The  lesion 
is  usually  solitary,  but  when  several  abraded  spots  are  infected  at  the  same  time  there 
may  be  multiple  sores.  When  a  surgeon  sees  a  lesion  of  this  character  it  has  usually 
changed  its  original  appearance — perhaps  by  some  previous  treatment,  ])erhai)s  by 
maceration.  There  is  one  invariable  feature  upon  varying  expressions  of  which  diagnosis 
is  based,  and  that  is  induration.  The  instances  in  which  this  fails  are  very  rare;  on  the 
other  hand,  it  is  possible  that  it  may  be  the  result  of  treatment  already  undergone,  and 
for  this  reason  the  recent  history  of  the  case  should  be  obtained;  in  other  words,  the 
typical  chancroid  is  always  indurated,  but  an  indurated  sore  does  not  of  itself  necessarily 
indicate  syphilis  if  it  can  be  satisfactorily  accounted  for  in  other  ways.  The  presence  of 
an  active  primary  lesion  seems  to  confer  immunity  to  sul)seciuent  infection  for  a  period 
co-equal  with  the  active  manifestations  of  the  disease,  although  even  in  this  respect 
exce])ti(jns  are  occasionally  to  be  noted. 

The  induration  of  syphilis  devclojjs  beyond  and  beneath  the  limits  of  the  superficial 
lesion,  and  gives  the  sensation,  when  grasped  between  the  fingers,  of  a  piece  of  firm 
material  embedded  in  the  skin  or  membrane.  It  is  firm,  slightly  elastic,  with  usually  well- 
defined  boundaries,  which  accounts  for  the  expression,  parchment  induration .  Ordinarily 
no  pain  or  other  sensations  accompany  its  formation  or  attract  attention;  hence  the  fre- 
quency with  which  it  escapes  observation  for  some  time  and  the  uncertainty  which  the 
patient  feels  regarding  the  dates.  The  surface  of  the  induration  usually  l)ecomes  moist 
or  abraded  and  frequently  ulcerated;  but  these  surface  lesions  tend  eventually  to  heal, 
even  if  let  alone,  except  in  those  parts,  e.  g.,  the  lips,  where  they  are  constantly  bathed 
by  discharge. 

The  characteristic  induration  disappears  slowly  in  a  few  weeks  or  months,  leaving 
ortlinarily  no  trace  of  its  existence,  although  sometimes  a  small  scar,  occasionally 
pigmented,  is  left  to  mark  its  site. 

There  are  two  or  three  classical  varieties  of  chancre  which  deserve  more  minute 
description.  As  ordinarily  seen  upon  the  genitalia,  a  chancre  may  assume  the  following 
types: 

A.  Dry,  scaly  papule. 

B.  Superficial  erosion. 

C.  Hunterian,  or  ulcerating  chancre. 

A.  Dry  Papule. — The  dry  papule  commences  as  a  small  rounded  area  of  redness, 
becoming  infiltrated  and  rising  above  the  surface,  gradually  developing  into  a  nodule 
the  size  of  a  pea  or  larger,  over  which  the  superficial  skin  seems  to  be  thickened.     Should 


S)  I'll  1 1.  IS 


127 


the  stiiiiiiiil  of  this  nodule  hccoiiic  abraded  there  will  cscaiM' a  serous  fluid,  whicli  diifs 
and  forms  a  thin  seal).  This  |)a|)ule  may  disaj)|)ear  more  slowly  ihaii  it  came,  or  mav 
becomi'  more  iiifillrated,  while  its  surface  hreaks  down  into  an  ulcer,  whose  area  will 
be  dro|);)ed  a  little  helow  that  of  the  surrounding^  tissue.  In  this  ease  the  induration  is 
|)roduced  almost  entirely  by  new  round-cell  iidiltration,  as  in  the  other  varieties;  when 
it  ulcerates  these  cells  are  the  ones  mainly  to  sulVer,  so  that  there  is  not  much  destruction 
of  the  ori«^inal  elements,  and  but  little  sear  remains. 

H.  Superficial  Erosion.  The  su|)er(ieial  erosion  is  the  most  eonunon  of  the  |)riniitive 
sores,  but  is  not  often  si'eii  so  early  as  to  have  its  first  apjx-aranee  noted.  It  l)ef,Mns  as 
a  well-defined,  dark-red  area,  which  loses  its  e|)ithelium  and  exposes  a  raw  surface, 
with  a  triflino;  dej)ression  whose  edges  are  usually  on  a  level  with  the  surrounding  skin, 
while  in  the  previous  case  the  edges  are  generally  characterized  by  an  elevated  margin. 
The  base  of  this  sore  is  also  indurated,  and  partakes  usually  of  the  parchment-like 
character  already  descril)(>d. 

('.  Hunterian  Chancre.  The  Ilunterian  chancre,  so  named  after  John  Hunter's 
descrij)tion  of  it,  is  the  most  distinct  and  typical  of  these  primary  lesions.  It  begins  as 
a  pajiule,  with  some  erosion,  increasing  slowly  in  size,  sharply  outlined,  with  a  some- 
what flat  top.  As  it  grows  larger  it  increases  in  firmness  until  its  base  is  extremely  dense. 
In  color  it  is  greenish  or  bluish  red,  and  this  color  ajjpearance  is  more  distinctive 
than  in  the  other  forms.  In  from  one  to  three  weeks  its  surface  epithelium  is  usually 
loosened  by  maceration,  and  serous  discharge  is  the  consecjuence,  or  else  it  becomes 
covered  with  a  grayish  exudate,  w^hich,  by  its  location,  is  rarely  allow^ed  to  form  a  scab. 
The  centre  of  the  ulcer  Ixn-omes  deeper,  its  edges  more  elevated,  and  in  typical  cases  a 
minute  crater  is  formed  l)y  a  c-haracteristic  destructive  process.  While  the  Hunterian 
chancre  tends  in  ordinary  cases  to  slowly  disa])pear  of  itself,  tliis  involution  can  l)e  nuite- 
rially  hastened  l)y  local  and  constitutional  treatment,  and  usually  heals,  when  properly 
treatecl,  with  but  slight  local  evidence  of  its  previous  existence. 

The  Mixed  Chancre. — Chancroid  will  now  be  described,  and  its  consideration 
will  include  the  statement  that  it  may  be  followed  by  true  syphilitic  chancre.  Such  a 
lesion  is  known  as  mixed  chancre  or  mixed  sore,  and  indicates  a  simultaneous  infection 
by  two  distinct  infecting  agencies;  it  may  easily  cause  confusion,  for  if  seen  early  it  will 
lack  the  characteristic  induration  of  syphilis.  This  latter  will  only  a])pear  about  the 
time  that  the  chancroidal  ulcers  should  be  healed,  if  promptly  and  properly  treated. 
Supposing  this  treatment  to  consist  at  least  in  part  of  caustics,  the  surgeon  may  be 
in  doubt  as  to  whether  the  induration  is  due  to  this  agency  or  to  develojMug  syphilis. 
It  seems  justifiable  to  imagine  causes  of  this  kind  while  awaiting  the  further  develop- 
ments of  the  case,  and  to  })ostpone  vigorous  antisyphilitic  remedies  until  the  diagnosis 
is  established.  It  is  a  serious  thing  to  condemn  to  a  long  course  of  mercurials  a  patient 
who  perhaps  does  not  need  such  drastic  drugs.  Instances  arise  where  the  situation  is 
to  be  carefully  considered  in  view  of  these  possibilities.  Should  the  healing  and  api)ar- 
ently  healthy  ulcer,  however,  take  on  an  indurated  base  and  develop  the  typical  scleroses 
of  chancre,  it  may  be  supposed  that  all  doubt  has  been  removed.  The  possil)ility  of 
syphilitic  infection  being  implanted  U])on  a  chancroidal  base  by  subseciuent  exposure 
shoulfl  also  be  taken  into  consideration.  This  will  require  an  accurate  history  and  a 
faithful  narration  of  the  same  l)V    the  patient. 

There  are,  also,  the  extragenital  chancres,  wiiich  may  be  met  wath  uj)on  the  hands, 
upon  the  breasts,  in  the  oropharynx,  as  well  as  about  the  eyelids.  Chancres  on  those 
surfaces  of  the  body  where  tissues  are  loose  may  attain  considerable  size  and  ulcerate 
early,  the  discharge  drying  into  scabs  or  crusts,  which  mask  the  underlying  ulcer. 
Around  the  margins  of  the  nails  these  lesions  show  but  slight  induration.  Sometimes 
suppuration  and  granulation  are  profuse.  When  appearing  upon  the  tonsils  there  is 
nearly  always  ulceration,  with  considerable  swelling  and  often  a  false  membrane.  A 
patient  with  this  lesion  will  complain  of  sore  throat,  and  involvement  of  the  surrounding 
lymphatics  is  usually  extensive. 

When  chancre  appears  upon  the  lips  there  is  usually  extensive  induration ;  the  lesion 
attains  considerable  size,  with  protrusion,  unless  recognized  and  treated,  and  ulceration 
takes  place  early  and  deeply.  It  may  be  confused  here  with  epithelioma.  The  latter 
occurs  during  the  later  period  of  life,  is  slower  in  its  evolution,  and  its  involvement  of 
the  neighboring  lymph  nodes.  The  local  changes  which  often  precede  cancer,  e.  g., 
hyperkeratosis  and  papilloma,  will  be  lacking  in  chancre  of  the  lip. 


128 


SURGIC.  \  L   DISi:.  1 SES 


Sometimes  at  the  site  of  the  original  cliaiuiv,  whicii  may  have  iiealed,  there  will  be 
found  one  of  the  later  lesions  of  the  disease,  whieh  may  he  mistaken  for  another  j)rimary 
sore  ()eeui)ying  the  site  of  the  first  one.  It  may  be  distinguished  by  its  central  ulceration, 
its  tendency  to  extend,  and  by  the  absence  of  the  lymphatic  involvement  which  is  met  with 
in  the  carlv  stages  (A'  the  disease. 

Pathology  of  the  Chancre.  The  chancre  sliould  be  regarded  as  the  first  neoplastic 
evidence  of  a  disease  which  is  throughout  characterized  by  its  tendency  towanl  new- 
cell  formation.  In  the  develojjed  chancre  there  is  a  well-defined  cell  pnjliferation  in 
the  skin  or  mucous  membrane,  whose  bloodvessels  show  the  same  character  of  change 
already  mentioned,  since  in  the  walls,  both  of  the  minute  arteries  and  veins,  are  found 
many  "new  cells,  some  of  whieh  were  originally  le\ikoc}tes,  but  most  of  which  are  prod- 
ucts of  cell  division,  as  shown  by  their  numerous  mitoses.  All  the  coats  of  the  vessels 
are  involved  and  even  the  jKTivascular  spaces  are  involved  and  obliterated.  Essen- 
tially, then,  the  chancre  consists  of  a  local  infiltration  of  the  superficial  tissues  by  cells, 
most  of  which  are  of  the  round  type;  the  whole  constitutes  what  may  be  spoken  of  as 
the  initial  sclerosis,  which  remains  or  disa])j)ears  as  such  unless  infected  secondarily. 
This  sclerosis  should  be  carefully  sought  in  every  suspected  region  when  the  patient  is 
first  examined.  It  may  range  in  bulk  from  a  millet-seed  to  that  of  a  good-sized  grape;  it 
is  usually  movable  upon  the  tissues  beneath ;  it  may  ulcerate  deeply,  and,  should  it  persist 
for  a  long  time,  it  may  seem  unusually  active  just  before  the  outbreak  of  the  so-called 
secondary  symptoms. 

But  little  can  be  predicted  with  regard  to  the  future  course  of  the  disease  from  the 
size,  number,  or  appearance  of  the  primary  sores.  The  nature  of  the  tissues  upon  which 
the  virus  has  been  im])lanted  is  a  more  important  feature  in  the  evolution  of  the  disease 
than  anything  pertaining  to  its  primary  lesions,  so  far  as  appearances  go.  In  patients 
of  de])rayed  habits  or  vitiated  constitutions  the  chancre  may  often  become  gangrenous 
or  ])hag(nl('nic. 

Lymphatic  Involvement. — Soon  after  the  appearance  of  the  primary  sore,  or  coinci- 
dent with  it,  the  enlargement  of  the  adjoining  lymphvessels  and  nodes  begins.  This 
is  noted  first  in  those  which  are  in  closest  communication  with  the  site  of  the  chancre, 
usually  in  the  groin.  Occasionally  thickened  lymphvessels  may  be  felt  as  cords  extending 
along  the  dorsum  of  the  penis.  There  may  be  enough  involvement  of  the  perivascular 
spaces  to  produce  this  appearance  and  sensation  even  around  the  bloodvessels.  This 
lymphatic  involvement  is  exceedingly  significant,  and  yet  may  be  found  to  some  degree 
after  chancroid  and  even  after  herpes  of  the  genitals.  It  is,  of  course,  an  expression 
of  a  travelling  infection — in  the  first  case  produced  by  the  sy|)hilitic  virus;  in  the  second, 
by  the  chancroidal  virus;  and  in  the  third,  by  ordinary  pyogenic  organisms  which  enter 
through  the  pathway  afforded  by  the  herpes. 

The  involved  lymph  nodes  of  syphilis  suppurate  much  less  often  than  do  those  of 
chancroid,  and  suppurating  bubo  is,  therefore,  not  common  in  syphilis.  The  term 
bnho  generally  means  an  involvement  of  the  lymphatics  in  the  groin,  although,  strictly 
speaking,  it  implies  a  similar  conflition  in  any  part  of  the  body.  Si/pliilifir  bubo,  there- 
fore, is  to  be  distinguished  from  chancroidal  as  well  as  from  non-sf)ecific  bubo.  These 
l\Tnphatic  lesions  are  sometimes  spoken  of  as  constituting  the  characteristic  adetiopaihy 
of  the  disease,  but  this  is  an  unfortunate  expression,  as  it  implies  giondiilor  involvement, 
and  the  term  lymph  gland  should  never  be  used,  since  the  structures  are  not  glandular 
in  any  respect.  The  enlargement  and  persistence  of  these  lyni])h  nodes  constitute 
peculiar  features  of  the  disease,  and  may  be  noted  long  after  the  subsidence  of  active 
manifestations. 

Treatment. — With  the  earliest  possible  recognition  of  a  syphilitic  chancre  or  sore 
there  is  need  for  active  and  prolonged  constitutional  treatment,  in  addition  to  whatever 
may  be  required  locally.  If  the  diagnosis  can  be  made,  consiitutionaJ  treatment  should 
commence  at  once;  only  in  cases  of  doubt  is  it  advisable  to  wait.  The  local  treatment 
is  a  matter  of  ordinarily  small  importance;  the  sores  tend  to  heal  spontaneously  and 
quickly  when  the  system  is  brought  under  the  influence  of  mercurials.  There  are  few 
authorities  who  recommend  excision  of  the  primary  lesion  or  believe  it  is  possible  to 
abort  syphilis  by  anything  that  can  be  done  to  the  chancre.  It  is  advisable  to  make 
mild  antiseptic  api)lications  only.  A  chancre,  however,  in  a  location  which  makes  it 
difficult  to  keep  the  parts  clean,  should  be  exposed  to  treatment  by  a  minor  operation,  as 
an  incision  of  the  prepuce,  circumcision,  or  a  flilatation  or  incision  of  the  h}Tnen.     Aside 


coxsiri  (TioxAL  sv  rill  US 


121) 


from  sucli  oprratioii  tlu-  iiidicalion  is  for  siirj^ical  (•Icaiiliiics.s;  soaj)  ami  water  followed 
by  hv(lr()t;eii  peroxide,  wliieli  may  he  coiitiiuied  as  an  a|)|)li(alioii,  or  dusliiiir  willi 
ealomel,  will  usually  prove  suHieieiit.  \'arioiis  antiseptic  solutions  mav  he  used.  Drv 
a|)plieati()ns,  however,  are  the  most  convenient  and  usually  the  most  serviceable;  iodo- 
form should  lu-  avoided  on  account  of  its  ])cnctralinij  odor;  and  pure,  drv  calomel  will 
sometinu's  prove  a  mild  caustic,  and  is  hest  reduced  with  one  to  three  parts  hv  wei<r|it 
of  hismuth  suhnilrate.  The  stron<jer  ap|)lications,  especially  caustic,  are  onlv  em|)lo\((| 
when  there  is  unheallhy  ulceration.  If  the  sore  is  ifani^renous  it  should  he  cocainized, 
then  the  surface  tliorou«;hly  treated  with  some  |)owerful  caustic  like  nitric  acid,  and  there- 
after ke|)t  moist  with  a(pieous  antiseptic  .solutions.  When  the  surface  is  |)racticallv 
healthy,  dry  preparations  or  unijucnts  may  he  employed,  preferably  the  mercurial  oint- 
ments. Tliere  is  greater  difficulty  in  preserving  cleanliness  about  the  female  genitalia, 
and  here  the  use  of  anti.septic  cotton  or  gauze  will  probably  be  necessary  in  addition  to 
the  other  precautions.  Surfaces  should  be  kept  apart  by  their  aid,  and  it  is  well  t«)  use 
fre(pient  antiseptic  douches  or  occasionally  to  insert  a  suj)jK»sitorv  contaim'iig  an  anti- 
septic drug.  Of  the  various  preparations  used  those  containing  mercury  in  some  form 
are  doubly  serviceable.  The  inguinal  lym])hatics  should  be  ki'pt  anointed  with  a  mer- 
curial ointUKMit,  which  should  l)e  thoroughly  rubbed  in,  and  the  parts  afterward  jjrolcctcd 
with  oiled  silk. 

While  these  local  measures  are  being  employed  vigorous  general  treatment  should  be 
promptly  instituted.  This  will  be  discussed  when  dealing  with  treatment  of  the  con- 
stitutional features  of  the  disea.se. 

There  are  locations  in  which  chancre  gives  rise  to  considerable  distress,  as,  for  instance, 
upon  the  lip  and  tonsils.  (Jreat  im|)rovement  and  relief  of  |)ain  in  these  lesions  is 
afforded  by  proper  use  of  auxiliary  drugs. 

In  regard  to  local  precautions,  the  patient  should  be  im])resse(l  w  ith  the  virulent  and 
infectious  character  of  the  discharge  from  every  primary  lesion,  and  given  mimite  and 
cautious  directions  so  that  its  transmission  to  others  can  be  j)revented.  This  will  mean 
the  use  of  sejiarate  utensils,  as  well  as  soap,  towels,  etc.,  possibly  the  temporary  isolation 
of  the  patient. 

CONSTITUTIONAL  SYPHILIS. 

Between  the  time  of  appearance  of  the  primary  sore  and  the  develoj^ment  of  wide- 
spread constitutional  symptoms  there  intervenes  a  period  of  latency,  the  second  -period 
of  incubation.  This  is  more  variable  in  duration  thau  the  first.  The  shortest  time  on 
record  is  about  two  weeks,  and  the  longest  about  two  hundred  days,  the  average  time 
being  six  or  seven  weeks.  The  secondarij  .si/mptoms  indicate  complete  generalization  of 
the  syphilitic  poison,  and  follow  the  early  manifestations  in  almost  every  case;  never- 
theless, there  are  instances  in  which  they  are  either  wanting  or  are  so  trifling  as  to  escape 
observation.  A  careful  examination  during  the  second  period  will  usually  show,  how- 
ever, that  the  lymph  nodes  throughout  the  body  are  gradually  becoming  enlarged, 
especially  those  in  the  neck,  along  the  border  of  the  stcrnomastoid,  the  occipital  nodes, 
those  in  the  axilla  and  groin,  and  particularly  one  or  two  small  ones  al)ove  the  iimer 
condyle  of  the  humerus,  known  as  the  supmcondijloid  or  epifroch/ear  notles.  When  these 
latter  become  involved  without  evident  and  local  cause,  syphilis  is  always  to  be  suspected 
or  even  diagno.sticated.  This  node  is  to  be  found  by  bending  the  patient's  elbow  and 
feeling  for  it  on  the  inner  side,  above  the  condyle,  in  the  interval  between  the  biceps  and 
the  triceps.  The  other  lymph  nodes  of  the  body  might  also  be  found  involved  if  they 
could  be  as  easily  palpated.  This  lymphatic  involvement  is  quite  independent  of  skin  or 
other  lesions,  and  does  not  yield  as  readily  to  mercurial  treatment,  l^lie  enlargemciUs 
are  usually  movable,  distinct  in  outline,  and  never  suppurate  unless  locally  and  second- 
arily infected.  In  tulx-rculous  patients,  however,  they  may  break  down.  This  general- 
ized involvement  of  the  l}7uphatics  is  also  of  importance  in  diagnosticating  old  syphilitic 
infections. 

During  the  second  period  of  incubation  there  is  generally  a  certain  degree  of  malaise 
and  progressive  anemia.  Examination  of  the  blood  will  show  diminution  of  hemo- 
globin, and  a  relative  if  not  actual  leukocv-tosis,  due  to  reduction  in  the  number  of 
the  red  corpuscles.  Occasionally  the  anemic  features  become  pronounced;  the  patient 
may  complain  of  weakness,  lassitude,  sleeplessness,  failure  of  appetite,  and  of  pain  and 
9 


130  SURGICAL  DISKAShS 

discoinlort  in  the  bones  and  joints,  more  pronouiieed  at  nij^lit,  and  often  re<farded  by 
patients  as  "rheumatic."  The  painful  joints  may  also  show  a  slight  swelling  due  to 
increase  of  the  joint  serum. 

Sometimes  intermittent  fever  accompanies  these  cases,  especially  during  the  early 
eruptive  |)eriod.  The  rise  of  temperature  is  noted  mainly  in  the  evening,  when  it  may 
reach  104°  or  even  105°  F.  It  does  not  last  long,  and  often  j)recedes  the  appearance 
of  a  well-marked  and  characteristic  eruption.  It  is  a  peculiar  feature  of  the  syphilitic 
poison  that  it  seems  to  attack  ])oints  of  least  resistance  in  (>ach  patient,  as  is  the  case 
with  that  of  inHuenza.  In  one  patient  fibrous  tissues  will  suffer  most;  in  another,  joints; 
in  others  there  will  be  headache  or  expressions  of  j)erverted  nerve  activity,  as  vertigo, 
convulsions,  disturljances  of  sensation,  temporary  paralysis;  again  there  occur  disturb- 
ances like  mild  pleurisy,  splenic  enlargement,  or  jaundice.  Occasionally  there  will  be 
a  typhoidal  condition,  during  which  the  kidneys  are  seriously  com|)romised.  Morbid 
conditions  are  intensified  by  an  attack  of  syphilis.  During  rheumatism  and  the  various 
forms  of  neuritis,  and  during  almost  all  affections  of  the  central  nervous  system, 
symptoms  are,  under  these  circumstances,  frequently  aggravated.  In  malarial  countries 
it  is  said  that  latent  syphilis  sometimes  becomes  active  when  malaria  is  present.  Lesions 
of  the  bones  and  joints  are  occasionally  influenced,  while  some  claim  that  fractures  occur 
more  readily  in  syphilitic  subjects,  and  it  is  generally  conceded  that  delayed  union  of 
fractures  is  often  due  to  this  cause.  I  have  seen  fracture,  apparently  spontaneous,  of 
both  tibise,  one  after  the  other,  in  a  patient  with  .sy})hilitic  disease  of  the  cord  and  bones. 
I  have  also  seen  exuberant  callus  form  around  a  fracture  in  a  syphilitic  subject,  as  it 
never  does  under  ordinary  circumstances.  Injury  seems  sometimes  to  localize  the 
manifestations  of  the  disease;  thus  chronic  irritation  at  the  site  of  old  syphilitic  lesions 
frequently  becomes  a  point  of  develo])ment  for  epithelioma,  or  some  other  expression 
of  malignant  growth.  This  is  seen  particularly  in  cancer  of  the  tongue,  which  sometimes 
follows  the  change  in  the  epithelimn  known  as  leukoplakia. 

The  uifiiicnce  of  an  attack  of  eri/sipclas  upon  certain  specific  lesions  is  remarkable. 
In  many  instances  eruptions  and  ulcerations  have  been  known  to  subside,  and  gummas 
and  exostoses  to  disappear,  after  an  attack  of  erysipelas  involving  their  site,  but  these 
lesions  are  likely  to  reappear  after  the  disappearance  of  the  acute  infectious  process. 
The  temporary  effect  of  the  toxins  of  erysipelas  upon  syphilitic  lesions  is  similar  to 
their  influence  upon  some  malignant  growths. 

Syphilis  of  the  Skin. — Passing  now  to  the  lesions  of  early  constitutional  syphilis 
as  manifested  in  ])articular  regions  or  organs  of  the  body,  we  take,  first,  the  skin.  When 
syphilis  seems  to  have  ended  its  existence  during  the  primary  stage  (Fordyce)  no  further 
disturbances  are  expected,  and  only  by  waiting  can  the  termination  of  the  disease  be 
determined. 

The  malignancy  of  the  disease  may  be  estimated  by  noting  the  rapidity  a\  ith  which 
the  destructive  lesions  apjjear;  thus  gummas  which  appear  early  in  the  skin  or  mucous 
membranes,  or  elsewhere,  indicate  a  serious  type  of  the  tlisease.  So  also  does  profound 
cachexia,  including  in  this  term  more  than  mere  anemia.  The  devastations  of  the  dis- 
ease in  Europe  during  the  fifteenth  century  show  that  it  presented  at  that  time  a  severe 
tyj)e. 

The  eruptions  of  syphilis  have  been  grouped  under  tlistinctive  terms,  and  are  usually 
referred  to  as  sijphilides  or  sijphilodermas.  It  has  })een  already  stated  that  among  the 
new  formations  of  syphilis  are  those  known  as  syphilodermas;  any  of  the  former  which 
are  distinctly  due  to  syphilis  may  be  syphilomas.  Thus,  we  may  have  syphiloma 
in  the  skin,  in  the  bones,  in  the  viscera,  etc.  It  has  been  customary  to  speak  of  the 
sy|)hilides  as  simulating  the  non-specific  eruptions  and  identify  them  by  placing  before 
them  the  adjective  syphilitic.  Thus  writers  formerly  described  syphilitic  psoriasis,  syphil- 
itic erythema,  etc. ;  but  these  terms  have  been  abandoned,  because  it  is  recognized  that 
the  skin  lesions  of  syphilis  while  imitating  most  of  the  features  of  the  non-specific 
diseases  are  yet  distinctly  different  from  them.  We  speak,  therefore,  now  of  a  macular, 
vesicular,  papular,  squamous  syphilide,  etc.,  implying  thereby  that  it  is  vesicular,  scaly, 
or  otherwise,  as  the  case  may  be,  and  at  the  same  time  that  it  is  a  cutaneous  expression 
of  syphilis. 

The  siiphilodcrmas  have  certain  peculiarities  which  are  striking  and  distinctive;  they 
are  symmetrically  distributed;  their  color  is  characteristic,  and  is  due  to  the  disease 
of  the  bloodvessel  walls,  which  has  been  referred  to,  by  which  stasis  is  favored  and 


PLATE  Vlll 


Grouped  Miliary  Papular  Syphilide. 


PLATE    IX 


Mixed  Papular  and  Papulopustular  Syphilide. 


PLATE  X 


Tuberculous  Ulcerating  Syphilide,  showing  Lesions  in  Different  Stages. 


CO.\\STlTUTl()\AL   SV  I'll  I  LIS  131 

cxiidatioii  t'liciniraficd.  The  pitiiiicntulioii  is  oftrn  striking,  and,  whatever  it  may  Ik* 
at  (irst,  il  assiiiiies  a  tint  di-scrilu'd  hy  I  lie  terms  "raw  ham"  or  "cfjppery."  Dark 
|)i<jmeiitati()ii  may  take-  the  |)Uice  of  tlie  H«;liter  colored,  as  the  sole  evidence  of  the  exist- 
ence of  thi'  |)revious  lesion.  Occasionally,  how<'ver,  the  normal  pijfinent  of  the  skin 
disappears  and  a  hleached-out  area  marks  the  site  of  the  previons  lesion.  This  is  often 
irre<;nlar  in  shape  and  considerahle  in  size.  Such  a  spot  is  sj)oken  of  as  Iciikodcnna. 
Attain,  the  .syphilodernuis  are  fjenerally  po/i/inorplioii.s,  and  .seem  to  be  ca|)able  of  imitating 
almost  every  known  non-specific  skin  ati'ection;  so  close  is  the  resemblance  that  it  often 
re(iuires  careful  study  of  the  case  to  permit  of  diagnosis.  The  absence  of  itching  is  also 
a  feature  of  most  of  these  ca.ses. 

The  early  .syj)hilides  are  superficial,  distributed  generally  and  .symmetrically,  and  dis- 
aj)|)ear  spontaneously. 

\Vhcn  skin  lesions  are  clustered,  as  in  the  macular  and  j)apular  forms,  they  usually 
grouj)  them.s(>lves  .symmetrically  and  in  more  or  less  circular  outline.  When,  however, 
tiiey  are  too  regularly  arranged,  it  may  be  taken  as  evidence  of  their  older  and  more 
ri>la])sing  character. 

The  later  skin  lesions  of  .syphilis  diit'er  in  .several  respects  from  the  earlier.  They  are 
less  regularly  grouped;  they  involve  a  greater  depth  of  tissue;  they  tend  to  ulcerate  and 
to  leave  })crmanent  scars;  and  they  have  around  them  a  more  infiltrated  area,  jirobably 
becau.se  they  arc  deeper.  They  are,  however,  not  so  infectious  as  the  earlier  lesions, 
and  it  is  rare  that  they  are  of  serious  menace  to  others.     (See  Plates  VIII,  IX,  X.) 

Fordyce  and  others  have  pointed  out  that  the  prompt  and  specific  influence  of  mercury 
and  even  of  iodine  uj)on  these  eruptions  is  an  instance  of  the  selective  action  of  certain 
drugs,  and  nothing  could  l)e  more  conspicuous  in  demonstrating  it. 

Certain  types  of  syphilide  are  common  in  the  earlier  stages  and  others  in  the  later; 
there  may  be  a  well-defined  limit  between  the  two,  since  in  not  a  few  instances  all  types 
seem  to  be  combined. 

The  first  eruption  of  so-called  secondary  syphilis  assumes  the  erythematous  or  macular 
type,  and  has  been  referred  to  as  roseola  sijphilifira.  It  appears  as  a  generalized  eruption, 
in  spots  varying  from  0.5  to  1  Cm.  in  size,  which  are  of  a  vivid  color  and  scarcely  elevated 
above  the  surface.  It  commences  usually  upon  the  abdomen,  proceeds  to  the  chest, 
and  then  to  the  extremities.  It  does  not  often  appear  upon  the  face.  Two  or  three 
weeks  may  be  consumed  in  its  generalization  over  the  entire  body.  If  let  alone  it  has  a 
duration  of  a  few  days  to  several  weeks,  and  may  then  fade  away,  leaving  nothing  to 
indicate  its  presence  save  a  .slight  pigmentation. 

Of  more  pronounced  character  is  the  papular  eruption,  which  commences  as  a  small 
papule,  and  is  described  as  Icnticulopapular  and  viiliari/  papular.  At  first  these  are 
generalized,  then  become  circumscribed,  and  exhil)it  transition  forms  from  the  early 
to  the  later  type  of  lesions.  The  papules  vary  in  size  from  that  of  a  millet-.seed  to  that 
of  a  split  pea;  even  this  type  may  disa])pear  without  ulceration  or  suppuration. 

Lichen  planus  may  be  mistaken  for  papular  .syphilide,  but  may  be  distinguished  from 
it  by  intense  itching  and  by  lack  of  the  pigment  changes  which  characterize  the  .syphilide. 

The  squamous  syphilide  is  sometimes  a  continuance  of  the  papular,  and  sometimes  it 
begins  as  such.  It  is  characterized  by  a  variety  of  scaly  macules  and  papules,  which 
strikingly  resemble  the  lesions  of  psoriasis.  The  latter  are  seldom  seen  on  the  palms  and 
soles,  while  the  squamous  syphilide  is  very  frequently  seen  in  these  locations.  More- 
over, along  with  the  squamous  lesions  are  frequently  associated  other  skin  lesions,  which 
give  the  case  a  complex  type,  resembling  at  one  point  one  of  the  non-specific  affections, 
and  others  at  other  points.  Such  changes  are  mainly  expressions  of  various  stages  in 
the  involution  or  degeneration  of  the  papule,  but  they  may  give  the  case  a  variegated 
appearance,  in  which  pigmentation  may  be  prominent. 

Some  years  ago  Biett  described  a  form  of  syphilide  which  he  claimed  was  unmistak- 
able and  indicative.  Since  he  described  the  lesion  it  has  been  known  as  Bieit's  collarette. 
It  appears  in  from  ten  to  twenty  weeks  after  the  secondary  symptoms  are  fully  declared, 
is  superficial,  usually  situated  upon  the  trunk  and  extremities,  but  never  upon  the  palms 
or  soles.  It  consists  of  a  flat  papule  almost  level  with  the  skin,  1  to  2  Cm.  in  diameter, 
rounded  in  contour,  while  around  it  there  is  seen  a  zone  of  white  epidermal  scales  pretty 
sharply  defined  and  giving  it  the  name  of  collarette.  The  area  within  is  dry  and  painless, 
and  the  ring  itself  narrow.  There  is  little  or  no  itching.  It  may  be  followed  by  some 
other  skin  lesion.     The  lesion  is  often  so  mild  as  to  pass  unnoticed. 


132  SllUlK'AL   DISEASES 

At  other  times  pu.stulocrusidccous  KiipltUhics  will  apjjear  above  the  level  of  the  skin, 
surrounded  hy  a  series  of  narrow  concentric  rinj^s,  not  sealy,  hut  eomposed  of  a  ruunher 
of  small  pustules,  the  first  rin<;  heinff  perhaps  an  inch  from  the  centre  of  tlie  inner  lesion. 
This  is  seen  more  often  in  males  than  in  females,  and  it  seems  as  thouo;h  the  snuiUer 
pustules  were  the  result  of  an  auto-infeetion  of  ordinarv  pyoi;enic  character.  In  the 
j)resence  of  either  of  these  lesions  a  positive  diagnosis  of  sy])hilis  can  he  made. 

The  piisfii/ar  s'l/philiflr  may  <:;ive  rise  to  larjje  or  small  pustules,  which  soon  lu-eome 
superficial  ulcers,  often  irrejfular  in  shape,  with  an  unhealthy  floor  which  may  he  livid 
or  fjanwrcnous,  or  may  resemble  a  diphtheritic  lesion,  while  from  its  surface  e.xudes  a 
mixture  of  blood,  debris,  and  j)us,  which  dries  into  dark-colored  crusts  and  constitutes 
the  lesion  known  as  ecthyina.  These  lesions  are  often  deceptive,  since  while  scabbing 
seems  to  be  occurring  over  the  surface  the  ulceration  may  be  extending  beneath.  This 
is  an  intermediate  or  earlier  tertiary  rather  than  a  .secondary  lesion. 

Another  type  of  pustular  syphilide  is  that  known  as  rupia,  where  the  ulcers  are 
larger  and  are  covered  with  concentric  layers  of  crust  resembling  an  oyster-shell. 
These  lesions  begin  as  papules  and  undergo  c-hanges  which  make  them  bulla-  or  pu.s- 
tules  and  then  open  ulcers.  The  peculiar  scabs  are  somewhat  conical  in  shaj)e  when 
not  disturl)ed,  and  are  greenish  or  brownish  in  color.  Jf  they  are  dislodged,  irregular, 
indolent,  and  often  .sensitive  ulcerated  areas  will  be  found  beneath  them.  Even  when 
these  ulcers  heal  they  are  irregular  in  outline  and  show  a  white  scar  often  surrounded 
by  an  areola  of  pigment.  This  rupia  is  the  most  visible  lesion  of  syphilis,  as  no  other 
skin  disease  assumes  any  such  type. 

In  the  last-described  and  ulcerative  forms  of  syphilide  there  is  a  possibility  of  septic 
infection,  or  at  least  of  septic  intoxication  In'  absorption;  hence  the  need  for  care  in  this 
direction.  In  fact,  into  the  treatment  of  every  pustular  indication  of  syphilis  the  elements 
of  local  protection  and  local  antisepsis  should  enter. 

The  Mucous  Membranes. — Here  the  manifestations  of  syphilis  are  of  great  impor- 
tance t)ecause  (jf  their  extreme  infectiousness.  The  earlier  manifestations  are  seen  mainly 
about  the  mouth.  When  an  eruption  ajijiears  upon  the  skin  a  condition  corresponding 
to  it  may  often  be  recognized  in  the  j)harynx  and  upon  the  uvula  and  soft  palate.  This 
will  be  accompanied  by  discomfort,  and  the  patient  complains  of  "soreness  of  the 
throat."  These  throat  lesions  are  chronic,  liable  to  recur,  and  disappear  slowly,  unless 
the  patient  is  vigorously  treated;  they  sometimes  cause  dryness  of  the  fauces,  followed 
by  a  free  flow  of  mucus.     The  dusky  discoloration  of  the  rash  is  quite  distinctive. 

The  congested  areas  have  a  dusky  hue  on  the  skin  and  are  spoken  of  as  "coppery"  or 
"raw-ham"  in  tint.  They  are  usually  well  outlined;  should  the  disease  progress  they 
become  eroded.  "Syphilitic  sore  throat,"  as  this  condition  is  often  called,  may  be 
aggravated  by  the  use  of  tol)acco  and  by  unclean  mouths.  The  involvement  of  the 
cervical  lymphatics  will  be  proportionate  to  the  vividness  of  the  lesion. 


TERTIARY  OR  CONSTITUTIONAL  SYPHILIS. 

There  is  no  distinctive  time  limit  between  the  so-called  .secondary  and  the  tertiary 
symptoms  of  .syphilis.  (Generally  the  lesions  disappear  with  but  little  treatment;  in 
uuiiiy  instances  they  will  fade  away  without  any.  In  most  cases,  however,  the 
patient,  even  under  poor  uumagement,  takes  enough  medicine  to  dis])erse  the  lesions 
more  quickly  than  they  would  spontaneously  subside.  If  he  discontinues  medicine 
for  .several  weeks,  .sometimes  many  months  will  elapse  l)efore  there  are  any  active 
manifestations  of  the  disease.  During  this  period,  however,  the  lymphatic  enlargements 
will  not  decrea.se  perceptibly,  and  there  may  be  evidence  of  advance  in  this  direction. 
The  so-called  tertiary  .symptoms  appear  usually  without  fever  or  other  .symptoms,  and 
not  often  in  less  than  five  or  six  months  after  the  commencement  of  the  disease.  On 
the  other  hand,  their  advent  may  be  delayi-d  for  years,  even  when  the  early  treatment 
of  the  ca.se  has  been  but  partially  effective. 

No  organ  or  tissue  in  the  body  is  exemj)t  from  the  ravages  of  tertiary  syphilis.  Even 
the  finger-nails  and  the  hair  may  suffer,  while  the  teeth  are  affected  in  the  hereditary 
manifestations.  Affections  of  the  skin  occur,  according  to  Haslund,  in  about  12  per 
cent,  of  the  cases. 

The  mucous  membranes  are  liable  to  exhibit  those  lesions  above  described,  known 


TERTIAHY   OR   (OS STITrTlOS M.   SYI'IIILIS 


133 


as  mitrous  pairhrs,  iistially  n'fjjardi-d  as  late  si'coiidiirv  sym|)t<)iiis.  TIr"  doscription 
a|)|)li('s  (>(|iially  well  to  the  tertiary  lesions.  They  oecjir  al)()Ut  the  ()r(»|)harynx,  ujjon 
tile  toiitjiie,  the  lips,  the  nostrils,  and  the  eyelids.  Tlu-y  are  fre(|iieiitly  t'oiiiid  also  ahout 
the  reetiini,  anus,  and  t;enilalia  of  either  sex.  In  {general  they  present  about  the  same 
a|)pearanee.  They  eoniineiice  usually  with  a  slifjht  elevation  ol'  the  surface  and  at  several 
points,  sometimes  sinniltaneonsly  and  successively.  These  sin't'aces  ulcerate  superficiallv, 
and  thus  are  |)ro(luced  irre<;ular  hut  rounded  ])atches,  witii  uneven  ed^es,  of  j^ravish- 
yellow  surfac-e,  which  ordinarily  are  not  sensitive,  hut  occasionally  extremely  so.  They 
may  disap|)ear  under  local  treatment,  hut  in  that  ea.se  tend  to  recur  at  frequent  intervals. 
If  unnoticed  or  not  pro|K"Iy  cared  for  the  ulcers  may  become  dee|>er  and  assume  an 
unhealthy  ap|)earance.  In  the  nincus-lined  cavities  afVected  the  condition  of  the.se 
ulcers  will  depend  upon  the  ])crs()iial  habits  of  the  patient.  In  mouths  where  tartar 
has  accumulatecl  ujjon  the  teeth,  or  where  the  toothl)rush  is  seldom  used,  the  patches 
may  b(>conie  lartje  and  foul. 

Tlii'.s'f  Ir.s-ioiis  arc  c.rfrcnir/i/  ni/'cchoii.s  and  the  disease  may  be  conveyed  by  kissinj;, 
by  the  conunon  use  of  small  domestic  utensils,  by  the  pi|)e,  by  dentists'  instruments, 
etc.  Patches  occurring  at  the  junction  of  the  skin  and  nnicous  meud)rane  may  extend 
over  onto  the  latter  and  become  deep,  specific  ulcers.  Lesions  of  this  character  need 
judicious  local  as  well  as  constitutional  treatment.  They  will  often  disappear  under  the 
latter  alone,  but  it  should  be  combined  with  local  measures.  The.se  consi.st  in  cleanli- 
ness and  the  use  of  various  antiseptic  solutions  or  applications.  An  antiseptic  mouth 
wash,  as  diluied  hydro<;cn  dioxide,  or  of  water  <2;iven  a  maho<rany  color  by  tincture  of 
iodine,  should  be  frequently  u.sed.  There  should  be  an  a|)pIication  of  a  5  })er  cent, 
solution  of  silver  nitrate,  or  some  other  astringent,  .stimulating,  or  mild  caustic. 

Fig.  24 


Grouped  papuiopustular  syphiliJe  ami  numerous  pigmented  spots  from  former  Icsi.jiib.      (Fordyce.) 

The  Skin. — The  late  syphilides  of  syphilis  belong  to  the  gummatous  or  tuherculotis 
types  (/.  c,  tuberculous  in  the  anatomical  sen.se,  or  nodular).  The  latter  may  occupy  the 
entire  thickness  of  the  skin  or  lie  even  deeper.  Such  lesions  may  begin  as  papules  and 
develop  into  distinct  and  circumscribed  nodules,  while  these  may  coalesce  into  considerable 
masses.  These  tend  to  break  down  and  leave  scars  after  they  have  disappeared.  There 
is  little  difference,  microscoj)ically,  between  the  nodule  and  the  gmiima.  Clinically, 
the  tuberculous  lesions  spread  usually  in  a  .serpiginous  manner,  producing  a  more  or 
less  curvilinear  outline.  (See  Figs.  24  to  27.)  These  ulcerations  undermine  the  tissues 
to  a  greater  or  less  extent,  and  pus  and  debris  will  be  formed  in  consequence.  In  this 
way  they  imitate  considerably  the  lesions  of  lupus,  and  it  may  require  a  careful  study 
of  the  ca.se  and  of  its  history  to  make  a  diagnosis.  Some  of  these  lesions  are  extremely 
slow  in  their  course  and  long  in  duration.  When  scars  form  they  are  usually  white  and 
smooth,  with  irregular  borflers,  but  sometimes  are  surrounded  by  pigment  that  makes 
them  characteristic.  The  extent  of  the  scar  is  no  criterion  as  to  the  size  of  the  originating 
lesion,  the  former  being  always  smaller  than  the  latter. 

The  Gumma  of  Syphilis. — This  is  as  characteristic  of  late  .syphilis  as  is  the  co7i- 
dyloma  of  the  earlier  stage.  By  this  term  is  meant  a  new  formation  which  may  vary  in  size 
from  a  millet-seed  to  a  large  mass.  Sometimes  it  is  diffuse,  or  it  may  be  circumscribed.  It 
seems  to  originate  from  connective  tissue,  and  may  be  met  in  all  parts  of  the  body.  Micro- 
scopically it  consists  of  a  delicate  .stroma  filled  with  small,  round  cells,  the  mass  being 
furnished  usually  with  bloodve.s.sels,  also  of  new  formation.     Such  a  gumma  may  pass 


134 


SURGICAL  DISEASES 


Fig.  25 


through  various  stages  of  integration  and  (Hsintegration.  The  eells  sometimes  undergo 
fatty  changes  l)y  which  the  entire  mass  is  softened,  and  its  interior  contains  a  puruloid 
material  resembHng  j)us.  The  gumma,  as  it  increases,  will  replace  other  tissues  and 
cause  them  to  disappear,  and  thus  it  hapj)ens  that  when  it  disajjpears  the  region  pre- 
viously occupied  by  it  seems  to  have  diminished  in  size.  Sometimes,  however,  cicatricial 
tissue  takes  its  place  and  not  only  distorts  an  organ  or  [)art  but  impairs  its  function. 
Thus  softening  and  melting  may  occur  at  one  time  and  a  dense  scar  or  mass  at  another. 
The  degree  of  infectiousness  of  gummatous  and  other  late  syphilitic  ulcerations  is 
uncertain.  The  later  they  occur,  the  less  infectious.  It  would  be  safe,  however,  to 
assume  that  they  are  all  dangerous. 

The  Gummatous  Syphilide. — This  begins,  as  a  rule,  as  a  subcutaneous  gumma 
which  quickly  proceeds  to  and  involves  the  skin.     At  first  it  appears  as  an  induration, 

developing  into  a  distinct  tumor, 
becoming  more  indurated  and 
firmly  implanted  as  it  grows,  the 
overlying  skin  becoming  reddened 
and  swollen.  After  a  time  there 
occurs  softening  in  the  interior  of 
the  mass,  and  upon  incision  there 
will  escape  not  pus  but  viscid, 
puruloid  fluid,  yellowish  gray  in 
color,  which  may  contain  corpus- 
cles resembling  those  of  pus.  It 
is  the  content  of  such  a  tumor  as 
this  which  has  given  it  its  peculiar 
name,  gumma.  Should  proper 
treatment  be  rapidly  pushed,  it 
is  possible  for  a  softened  gumma 
to  disappear  by  absorption,  but 
if  ulceration  or  evacuation  has 
taken  place,  there  remains  usually 
a  permanent  disfigurement  at  the 
site  of  the  mass;  like  tuberculous 
gummas  these  growths  may  un- 
dergo caseous  or  even  calcareous 
degeneration. 

A  gumma  of  the  skin  will  open  at 
one  or  several  points,  and,  becom- 
ing thus  secondarily  infected,  may 
give  exit  to  sloughing  tissue  and 
foul  discharge.  If  the  skin  directly 
overlies  the  bone,  then  the  tumor 
may  involve  the  latter  as  well; 
and  when  it  ulcerates,  the  bone 
will  be  exposed.  In  the  healing 
process,  however  brought  about, 
deformity  from  cicatricial  contrac- 
tion may  cause  much  disfigure- 
_  ment.      When   a   gumma   appears 

beneath  the  true  skin  and  then  disappears  it  may  leave  areas  of  depression,  with  more  or 
less  adherent,  bleached-out  scars,  perhaps  with'a  pigmented  margin.  The  appearance 
of  such  scars  is  suggestive  of  the  disease  even  without  a  definite  history. 

The  gummas  form  the  most  important  features  of  svphilis,  at  least  from  a  surgical 
standpoint,  since  they  frequently  appear  in  the  depths  "as  well  as  on  the  surface  of  the 
body,  without  any  other  symptoms,  and  they  often  cause  no  little  perplexity  in  diagnosis. 
Syphilomas,  tuberculous  gummas,  phlegmons,  innocent  and  benign  tumors,  as  occurring 
especially  in  and  upon  the  bone,  in  the  muscles,  tongue,  the  breast,  the  testicle,  and 
elsewhere,  may  be  diflicult  of  diagnosis.  Of  course,  a  history  of  syphilis  is  a  great  help. 
Doubt  frequently  arises  when  such  a  history  cannot  be  obtained'.  Scarcelv  anv  other 
disease  will  produce  multiple  lesions  such  as  are  seen  in  syphilis,  and  wlien  multiple 


.iV' 


Ulcers  resulting  from  deep  ecthymatous  syphilide.      (Fordyce.) 


TFJiriMiV   <)l{  CON^TITVriOSM.   SY/'IfJLIS 


135 


tliev  arc  usually  distribntcd,  willi  sonic  appearance  oi'  synnnelrv.  I'lcers  formed  l»v 
tlioir  hivtikiiij;;  down  are  often  extremely  sensitive,  hut  do  not  Meed  easily,  nor  show  a 
tcndeney  to  exuberant  granulation.  In  eases  of  douht  the  most  successful  test  is  |)crliaps 
the  tlienipcutic,  and  consists  in  t^ivinf]r  mercurial  or  mixed  treatment  to  the  point  of 
toleration  and  noting;  its  ett'ect. 

In  many  patients,  cs|)ccially  of  the  hospital  class,  scars,  which  are  stronj^ly  sugf^estive, 
will  he  visible  u\nn\  the  Icfjs.  It  docs  not  follow,  however,  that  an  old  scar  upon  iIk' 
lejfs,  even  if  surrounded  by  a  i)i<rm(>nte(l  area,  is  necessarily  of  syphilitic  orifrin.  Old 
ulcers  of  the  lind)s  arc  frcciucntly  seen  in  coiuiection  with  varicose  veins,  and  mav 
show  exceedingly  chronic  tendencies;  moreover,  it  is  jmssible  for  chronic'  and  non- 
s|H'ciHc  ulcers  to  occur  in  old  syphilitic  subjects  when  the  course  of  the  local  lesions 
may  be  influenced  by  the  old  affection,  although  they  are  not  sf)ecific  ulcers.  Benefit, 
however,  will  in  such  cases  accrue  by  the  reasonable  administration  of  antispecific 
treatment,  but  it  should  be  com- 


F-ia.  20 


bincd  with  suitable  local  measures. 

The  Vascular  System.-  -The 

lesions  whicii  arc  encountered  in 
the  bloodvessel  walls  in  chancre 
and  early  sy|)hilis  have  been  de- 
scribed. The  heart  and  vessels 
are  liable  to  suffer,  as  they  contain 
connective  tissue.  Gummas  have 
been  noted  in  the  heart,  while  the 
poison  also  may  produce  thicken- 
ing of  the  valves,  and  disease  of  the 
coronary  arteries,  the  endocardium 
and  the  myocardial  structure. 

The  arteries  often  suffer  from 
arterioscleroshi,  which  is  either  dif- 
fu.se  or  nodular.  Endarteritis  is 
a  common  manifestation  of  .syph- 
ilis and  leads  frequently  to  the 
formation  of  aneurysm.  Some- 
times this  appears  as  a  single  and 
large  lesion;  at  other  times  hun- 
dreds of  small  aneurysms  will 
form  in  the  arterial  system  of  the 
brain,  so  that  the  arteries  are 
studded  with  them.  The  expla- 
nation of  aneurysm  under  these 
circumstances  is  that  the  arterial 
walls,  being  weakened,  dilate 
under  the  influence  of  blood  pres- 
sure. Thus  the  arteries,  from 
the  largest  to  the  smallest,  also 
may  suffer.  The  veins  likewise  are 
subject  to  syphilitic  phlebitis, 
which  is  frequent  in  the  superficial 
veins  of  the  extremities. 

Bones  and  Joints.— Syphilitic  manifestations  in  bones  are  frequent,  but  are  not  so 
common  in  the  joints.  While  earlv  syphilitic  periostitis  is  not  mfrequent  the  actual 
lesions  of  the  bone  are  mostlv  expressions  of  late  syphilis.  Nearly  all  of  them  are  pain- 
ful. The  pain  is  worse  at  flight,  and  is  called  the  osteocopic  pam  of  .syphilis.  At 
first  the.se  bone  lesions  are  hvperplastic,  because  of  the  connective  tissue  m  the  bone. 
Periostitis  is  a  common  manifestation,  and  here,  again,  the  neoplastic  tendency  ot  the 
disease  is  manifested,  in  that  the  periosteum  is  thickened  as  well  as  the  bone  beneath,  aiK 
swellings  called  t^odes  are  thus  formed.  Nodes  are  met  with  more  often  on  the  tibia  and 
the  sternum  than  elsewhere,  but  are  frequent  upon  the  skull  and  clavicles.  No  bone 
is  exempt  from  these  lesions.  They  often  form  at  points  where  there  ha.s  been 
previous  injurv.     These  swellings  are  ill-defined,  and  usually  quite  tender,  wiulc  tlie  skin 


Tuberculous  serpiginous  sypliilide  resembling  lupus  vulgaris. 
(Fordyce.) 


136 


SURGICAL  DISEASES 


Fig.  27 


over  them  i.s  easily  niovaljle  unless  seeoiuiurv  iiifeetioii  lias  oeeurred  and  suppuration 
is  present.  The  nocturnal  pains  in  these  lesions,  of  which  patients  often  complain,  are 
sometimes  excruciating.  Should  suppuration  occur,  with  subsequent  formation  of 
ulcer,  there  may  be  necrosis  of  the  exposed  bone.  Another  bone  lesion  of  syphilis 
assumes  the  type  of  osiitiJi.  Physiologically  this  consists  essentially  of  gummatous 
involvement  of  the  connective  tissue,  which  may  be  either  localized  or  diffuse.  ^Yhen 
this  underc-oes  retrocession  there  occurs  a  rarefaction  of  the  bone,  by  which  it  is  weakened 
and  easilv  broken,  so  easily  in  fact  that  we  have  to  deal  sometimes  with  what  is  referred 
to  as  spontaneous  fracture.  There  is  frecjuently  a  thickening  and  condensation  of  the 
entire  bone,  with  some  distortion,  so  that  the  actual  weight  of  the  bone  may  be 
nearly  doubled.  Dactylitis  is  the  name  given  to  syphilitic  ostitis  of  the  phalanges,  which 
increase  in  size  and  become  tender  and  useless,  while  the  skin  becomes  glazed.  Occa- 
sionallv  the  disturbance  appears  to  involve  the  extra-osseous  tissues  rather  than  the 
bones  "themselves.  Bones  which  are  spongy  are  liable  to  this  disease.  Some  of  the 
bones  in  the  face  are  peculiarly  susceptible;  hence  the  loss  of  the  bridge  of  the  nose,  or 
of  a  portion  of  the  hard  palate,  by  the  ulcerative  processes  so  common  in  this  disease. 

The  joints  are  subject  to  changes  somewhat  similar  to  those  occurring  in  tuberculous 
disease.     There  may  be  either  a  gummatous  synovitis  or  an  arthritis,  or  else  destruction 

of  articular  surfaces.  These  joint  lesions 
of  syphilis  are  all  slow  in  their  course,  and 
sometimes  difficult  of  distinction  from 
tuberculous  and  other  lesions.  They  have 
so  much  in  common  with  the  joint  ex- 
pressions of  tabes  that  some  writers  believe 
that  tabes  is  necessarily  an  expression  of 
syphilis  of  the  cord. 

As  long  as  no  active  destruction  has  oc- 
curred  within  a  bone  or  jomt  these  cases 
are  usually  amenable  to  treatment,  but 
for  the  actual  destructions  caused  here 
or  elsewhere  by  syphilis  there  is  no  repair 
possible,  and  the  harm  once  done  cannot  be 
undone.  Plastic  operations  and  injections 
of  paraffin  may  have  to  be  practised  for  cos- 
metic purposes  and  relief  of  disfigurement. 

Muscles  and  Tendons. — It  is  the  con- 
nective tissue  of  muscles  which  suffers  most 
in  the  luetic  aff'ection  of  these  structures. 
It  may  be  met  with  as  a  diffuse  process  or 
as  a  gumma.  In  the  former  cases  the 
nniscle  becomes  irregular  in  shape  and  size, 
and  in  the  latter  distinct  tumors  are  formed. 
As  such  growths  advance  and  contract  ad- 
hesions to  surrounding  structures,  there  is 
interference  with  muscle  play. 
Syphilitic  myositis  causes  little  pain,  and  patients  with  gummas  in  muscles  are  often 
not  seen   until  ulceration  has  begun. 

The  dense  fibrous  structure  of  tendons  and  aponeuroses  is  frecpiently  involved  in  late 
syphilis,  causing  pain  and  disability.  Little  is  discovered  on  physical  examination, 
but  considerable  loss  of  function  may  result.  Points  of  tenderness  sometimes  are 
noted  along  junctions  with  the  adjoining  periosteum.  Such  a  tendoperiostitis  may 
be  painful,  and  even  crippling. 

Bursse. — Bursje  are  prone  to  be  involved  in  syphilis,  especially  those  in  front  of 
the  patella.  A  gumma  frequently  develops  at  this  point,  where  it  constitutes  a  painless, 
somewhat  tender  enlargement,  which  may  be  dense  or  elastic.  After  it  has  become 
adherent  to  the  skin  it  is  usually  infected,  and  a  chronic  ulcer  results  at  this  point,  which 
mav  often  manifest  gangrenous  tendencies.  This  constitutes  one  form  of  so-called 
houseiiianrs-  knee. 

The  Eye. — Of  the  manifestations  of  .syphilis  in  ])articular  organs  the  eye  some- 
times suffers  severelv.     /;'///.v  is  the  most  commo'i  and  serious  manifestations  of  consti- 


An  ulcerating  gumma  of  the  leg.     (F^ordyce.) 


Ti'.RTiMn   Oh'  ('ossTrnriosM.  svi'i/ius  i;^7 

tutidiKil  svpliilis.  It  lias  hccii  cstiinaUMl  tliat  iicarix  (iO  |)ci-  cciil.  ot"  all  cases  of  iritis  arc 
due  l()  this  cause.  It  may  occur  in  two  iiionllis  al'lcr  I  lie  [uiniaiy  sore;  it  is  usually  acute, 
and  rarely  l)eji;iiis  in  hotli  eyes  at  tlie  same  time,  hut  may  involve  one  alter  the  other. 
The  <iliarv  hody  is  rre(|uently  associated  in  (he  lesion,  and  iridori/r/ili.s  occurs.  It  com- 
mences with  congestion  of  the  conjunctiva,  |)hoto|)hol)ia,  and  lacrymation.  The  pain 
is  not  always  severe.  Insju'ction  of  the  iris  will  show  heads  of  lymph,  a  small  pupil,  with 
loss  of  contractility,  or  the  dull  iris  may  a|)pear  itifiltrated  and  indexihle.  The  pain 
in  some  ca.ses  is  extreme.  Where  treatment  has  been  only  partialh  ell'eclive  relapses 
are  common,  "^riic  <j;reatest  dant^er  to  he  feared  is  formation  of  adhesions  helwccn 
the  anterior  surfaci"  of  the  lens  and  the  margin  of  the  pupil,  /.  r.,  anterior  synechia-. 
These  are  detrimental,  and  serve  as  the  cau.se  of  many  irritations. 

Tlie  treatment  of  these  affections  is  constitutional;  locally  solutions  of  atropine  of 
sulficient  strength  to  ensure  dilatation  of  the  pupil  should  he  used,  not  oidy  to  relieve  the 
pain,  hut  to  carry  the  martjjin  of  the  |)U])il  from  the  central  portion  of  the  lens  and  |)revent 
adhesions.  The  |)atii'nts  should  he  kept  in  the  dark  hecause  of  their  photophohia. 
Atroj)ine  may  he  suhstituted  by  duhoisine  if  the  former  tends  to  j)roduce  conj^festion. 
Leeclu>s  a])i)lied  to  the  temples  will  also  ijive  relief  from  j)ain. 

The  cornea  is  often  ailected  hy  a  deposit  on  its  posterior  surface  of  particles  of 
debris,  whieh  give  it  a  ])unctate  a])pearance  known  as  keratitis  punctata.  It  also 
becomes  the  seat  of  opacities  which  materially  interfere  with  vision,  and  prove  only 
partially  amenable  to  treatment.  Lesions  of  the  cornea  are  fre(|uent  in  hereditary 
sy|)hilis. 

Rcfnntis  and  cJtoroidiiis,  of  either  acute  or  chronic  ty])e,  are  the  most  common  syphilitic 
lesions  of  tlu>  fundus.  They  are  usually  associated  and  involve  l)oth  eyes.  Tliev  come 
on  .so  insidiously  that  they  are  often  far  advanced  when  first  discovered.  The  lesions 
consist  of  patches  of  exudation  and  areas  of  atrophy,  accom])anicd  by  some  haziness  in 
the  vitreous.     Vision  is  affected  in  pro])ortion  to  the  area  involved. 

The  movements  of  tlie  eyes  are  interfered  with  by  lesions  which  jx'i'tain,  however, 
rather  to  the  brain  and  the  ocular  nerves  than  to  the  eye  itself.  The  sixth  nerve,  lying 
on  the  floor  of  the  skull,  is  affected  by  .syphilitic  disease  at  the  base  of  the  bone.  As  a 
result  of  these  nerve  lesions  paralysis  is  often  seen,  or  at  least  disturbances  of  motility 
from  which  diplopia  results.  Ptosis  occin-s  from  affection  of  the  third  nerve.  In  lesions 
situated  below  the  aqueduct  of  Sylvius,  the  paralytic  condition  which  Hutchinson  has 
spoken  of  as  oplitJialmopJegia  is  likely  to  appear.  Optic  neuritis  is  also  a  late  mani- 
festation of  .syphilis,  and  may  be  either  chronic  and  mild,  with  a  small  disturbance  of 
vision,  or  acute,  with  rapid  loss  of  eyesight. 

The  Ear. — The  ear  may  suffer  in  various  w^ays.  The  external  ear  may  par- 
ticipate in  affections  of  the  adjoining  skin.  The  middle  ear  may  be  affected  as  a 
result  of  extension  of  trouble  from  the  nasopharynx,  while  in  the  late  stages  of  the 
disease  patients  may  suffer  from  labyrinthine  disease,  with  partial  or  almost  total 
deafness. 

The  Nose. — The  lesions  of  .syphilis  in  the  nose  are  numerous  and  offensive.  Ulcera- 
tion is  frequent  and  followed  by  jX'rforation  through  the  .septum  or  into  the  mouth. 
When  the  vomer  is  involved  the  bridge  of  the  no.se  falls  in.  In  neglected  cases  the  whole 
substance  of  the  nose  may  be  involved  and  subsecpiently  lost.  The  bone  is  often 
exfoliated.  These  ulcerations  of  the  mucous  membrane  and  periosteum  give  rise  to 
a  characteristic  condition  known  as  ozena,  with  its  characteristic  discharge. 

The  Oropharynx. — The  tongue  may  be  the  site  of  intermediate  and  late  syphilitic 
lesions.  JNIen  suffer  more  than  women,  a):)parently  because  of  their  use  of  tobacco. 
Mucous  patches,  deep  ulcers,  and  even  gummas,  single  or  multiple,  are  .seen  here.  (Gum- 
mas in  the  tongue  are  inclined  to  undergo  superficial  ulcerative  infection  and  become 
abscesses.  In  these  lesions  there  will  be  notable  involvement  of  the  adjoim'ng  lymphatics. 
The  appearance  of  smooth,  bluish-gray  patches  upon  the  mucous  membrane  of  the 
tongue  and  cheeks  is  known  as  letikopiakia  or  leukokeratosi.s.  Tlu\se  lesions  do  not 
respond  readily  to  treatment;  they  give  rise  to  little  or  no  complaint,  and  are  often 
followed  by  malignant  disease. 

It  is  difficult  to  distinguish  between  gumma  of  the  tongue  and  ej)itheHoma.  Usually 
the  latter  is  a  single  lesion;  the  former  often  multiple.  In  epithelioma  the  ulcer  is  super- 
ficially painful,  with  more  elevated  and  indurated  edges,  while  the  ))ain  is  sometimes 
intense  and  radiates  toward  the  ears. 


138  SURGICAL  DISEASES 

Inierstiiial  rjlo.s-.sitis-  is  a  late  manifestation  of  a  sclerosis  beginning  in  the  connective 
tissue  and  involving  the  muscle  fibers,  leading  to  enlargement  of  the  tongue  and  later  to 
atnmhy  and  inflexibility. 

Tne  Larynx. — Syphilis  of  the  larynx  appears  cither  as  one  or  more  ulcers,  as 
gumma,  or  as  chondritis  or  prrirliotidrlfi.s,  often  with  necrosis  of  cartilage.  When 
ulcers  form  they  are  deep  and  destructive,  involving  even  the  intrinsic  muscles  of  the 
larynx,  and  causing  harshness  or  loss  of  voice,  with  dyspnea.  Sub.sequently  they 
lead  to  cicatrization,  often  leaving  a  stricture  which  may  call  U)r  tracheotomy.  The 
epiglottis  is  also  liable  to  ulceration  and  gummatous  lesions. 

In  these  cases,  aside  from  the  general  treatment,  there  is  need  also  for  local  applica- 
tions of  combined  anti.septic  and  anodyne  character.  Cocaine  or  one  of  its  less  toxic 
substitutes  may  be  used  in  spray  or  by  insufflation,  in  connection  with  an  antiseptic 
powder,  morphine  or  heroine.  Edenui  of  the  glottis  may  be  subdued  by  the  local  u.se 
of  adrenalin. 

The  Alimentary  Tract. — Between  the  mouth  and  the  rectum  the  intestinal  canal 
is  rarely  involved  in  syj)liilitic  disease.  In  the  rectum,  however,  ulcers,  as  well  as  gum- 
matous infiltrations,  are  frecjuently  encountered.  If  the  ulcers  are  low,  within  two  inches 
of  the  anus,  they  will  cause  great  pain.  Higher  up  the  rectum  is  not  so  well  supplied 
with  sensory  nerves.     Ulceration  may  involve  the  entire  circiunfcrence  of  the  anus. 

In  the  rectum  chronic  ulcers  are  liable  to  be  followed  by  stricture,  which  will  call  for 
surgical  relief.     (See  chapter  on  the  Rectum.) 

In  the  colon  chronic  ulcers  have  been  so  serious  as  to  lead  to  dysentery,  followed  by 
stricture  formation.  It  has  been  suggested  to  make  an  artificial  anus  at  the  cecum 
and  allow  the  large  intestine  to  rest,  treating  it  at  the  same  time  with  irrigation  through 
the  opening. 

The  Viscera. — Of  the  solid  viscera  the  liver  is  more  commonly  affected  than  the 
s{)leen  or  kidneys.  Chronic  interstitial  liepatiti.f  may  lead  to  cirrhosis,  the  new  tissue 
being  less  distinctly  distributed  than  when  due  to  alcohol,  the  liver  consecjuently  becom- 
ing irregular,  with  a  deep  separation  between  its  lobes.  The  pain  is  sometimes 
intense. 

On  the  other  hand  isolated  gummaft,  or  confluent  masses  of  smaller  gummas,  may 
be  found  beneath  the  capsule  or  in  the  substance  of  the  liver.  From  one  or  both  of  these 
cases  combined  this  viscus  may  attain  an  enormous  size,  with  acute  pain.  Under 
these  conditions  there  may  occur  albuminuria  and  evidences  of  amyloid  disease. 

Likewise  in  the  spleen  there  may  be  diffuse  or  localized  trouble.  Here  the  lesions 
cause  but  slight  distress. 

The  mercurials  are  of  greater  importance  than  the  iodides  in  treatment  of  these  lesions. 
The  kidneys  sutt'er  less  often  than  the  spleen.  Syphilitic  patients  do  not  lo.se  their 
liability  to  renal  disorders,  but  there  seems  to  be  but  .small,  direct  connection  between 
sypliilis  and  the  common  changes  in  these  organs. 

The  Genitalia. — In  both  sexes  the  genitalia  are  subject  to  gummatous  involvement 
during  the  later  stages;  in  the  male  more  frequently  in  tho  corpora  caverriosa  and  testicle. 
In  the  latter  a  chronic  induration,  with  some  enlargement  of  the  epididymis,  is  one  of  the 
manifestations  of  constitutional  di.sease  Most  of  the  enlargements  of  the  testicle  are 
slow  and  jminless,  and  occasionally  some  fluid  will  collect.  The  prostate  and  the  seminal 
vesicles  are  rarely  involved  in  syphilis,  but  frequently  in  a  tuberculous  process.  This 
is  an  important  diagnostic  point. 

In  the  ovaries  there  may  occur  a  diffuse  cirrhotic  process. 

The  Nervous  System. — Here  the  manifestations  of  .syphilis  are  often  serious  and 
widespread.  They  are  produced  by  the  same  new  tissue  to  which  we  have  so  often 
alluded,  with  its  tendency  at  first  to  degeneration  and  later  to  sclerosis.  They  are  always 
insidious.  Gummatous  thickening  may  occur  at  any  point,  springing  often  from  the  pia 
of  the  brain  and  cord.  The  arterial  walls  are  frequently  so  affected,  and  at  many  j)oints, 
that  multiple  minute  aneurysms  are  produced,  any  one  of  which  may  give  way  and 
produce  the  fatal  results  of  a  cerebral  hemorrhage.  In  diffuse  gunnna  of  the  membranes 
or  cortex  the  process  is  slow,  and  likely  to  involve  areas  which  may  be  recognized  by  cere- 
bral localization.  Many  cases  presenting  the  features  of  brain  tumor  will  yield  to 
antisyphilitic  treatment,  and  thus  show  themselves  to  be  .syphilomas. 

In  the  spinal  canal  implication  of  the  membranes  is  more  likely  to  occur  than  in  the 
vessels.     In  the  cord  these  sclerotic  changes  are  also  quite  connnon  and  produce  .symp- 


SYPHILIS  IX  rillLDREX  130 

toins  stroniijly  suijiicstivc  of  lahcs;  in  fad,  tlicrc  arc  those  w  lio  liold  that  tabos  is  of  specific 
orifjin. 

In  the  motor  and  sensory  nerves  niucli  connective  tissue  is  present,  and  conse{jucntlv 
these  nerves  are  not  exenij)t  from  sclerotic  dianges  with  pressure  symptoms,  which  will 
give  the  cHnical  picture  of  a  neuritis. 


SYPHILIS  IN  CHILDREN. 

Syphilis  appears  in  young  children  inider  the  following  circumstances: 

A.  The  disease  may  have  been  transmitted  from  the  father  to  the  ovum,  at  the  time 
of  concej)tion,  by  infected  spermatozoa. 

B.  From  the  mother,  who  may  have  acquired  it  before  impregnation  or  during  the 
early  part  of  her  pregnancy.  In  the  latter  case  the  infecting  influence  is  transmitted 
through  the  placental  circulation. 

C.  From  the  mother  at  the  time  of  its  l)irth,  from  a  recently  infected  puerperal  tract. 

D.  From  some  possible  extrinsic  source,  a  short  time  after  its  birth,  as,  p.  g.,  through 
the  umbilicus. 

The  later  the  mother  acquires  the  disease  after  conception,  the  less  likelihood  that 
the  child  will  be  infected.  If  infection  take  place  from  the  ])lacenta,  then  it  also  will 
be  found  to  be  dist>ased. 

Profeta's  "Law."— Profeta  first  made  the  statement  that  the  child  of  an  infected 
mother  who  ac(juired  the  disease  late  in  her  pregnancy  may  not  only  be  born  healthy, 
but  may  be  immune  to  subsequent  infection,  as  are  other  healthy  children  of  syphilitic 
parents.  But,  on  the  other  hand,  such  a  child  may  be  anemic,  puny,  with  small  resisting 
power,  or  it  may  develop  a  late  hereditary  syphilis.  When  the  ovum  is  infected  by  the 
father  the  healthy  mother  may  escape,  or  she  may  acquire  the  disease  through  the 
j)lacenta  in  her  own  uterus,  or  she  may  suffer  from  a  mitigated  form  of  syphilis  whose 
|)rincinal  features  will  appear  as  late  manifestations  of  the  disease. 

Colles'  "Law." — Colics,  in  1S37,  made  the  statement  that  such  a  mother  may  remain 
healthy  with  an  acquired  immunity  to  subsequent  infection.  The  statements  above 
made  have  often  been  alluded  to  as  Profeta's  and  Colles'  "laws."  These  should,  how- 
ever, be  regarded  sim})ly  as  statements  of  what  usually  occurs,  and  too  much  dependence 
should  not  be  placed  upon  them.  In  fact,  the  immunity  which  the  mother  or  the  child 
may  enjoy  under  conditions  mentioned  above  is  not  likely  to  be  permanent,  though  it 
may  last  for  a  varying  periofl  of  time.  There  is  no  limit  to  the  time  when  a  parent 
may  transmit  .syphilis  to  the  child.  The  five-year  limit  given  for  the  father  is  often 
overstepped,  and  the  longer  the  man  waits  before  marrying  after  acquiring  the  disease, 
and  the  more  thoroughly  he  submits  to  judicious  treatment,  the  less  likely  he  is  to 
convey  it  to  offspring.  This  is  the  strongest  kind  of  argument  that  can  be  used  to  delay 
marriage  of  syphilitics. 

The  indication  of  syphilis  on  ihe  pari  of  fhe  mother  is,  in  addition  to  those  already 
given  above,  a  tendency  to  miscarriage  or  abortion.  The  earlier  she  acquires  the  disease 
the  earlier  will  the  mishap  occur.  Should  she  escape  the  child  may  go  on  to  full  term, 
or  it  may  die  and  be  expelled  as  a  dead  fetus  two  or  three  months  before  the  exjiiration 
of  term.  Should  a  child  be  born  alive  with  hereditary  syphilis,  the  evidences  may  ap- 
pear at  birth  or  within  three  months.  Should  a  child  apparently  escape  for  six  months 
;  it  may  grow  up  to  be  puny  or  develop  some  form  of  late  hereditary  disease,  or  it  may 
possibly  remain  well.  These  children  usually  show  developmental  defect  in  some  direc- 
tion, and  manifest  a  much  weakened  resisting  power  to  other  diseases;  moreover,  the 
spleen  will  usually  be  found  enlarged. 

Among  the  changes  which  may  occur  are  the  following:  The  skin  becomes  loose  and 
resembles  that  of  an  old  person.  This  is  partly  because  it  grows  even  faster  than  the 
tissues  beneath  it,  so  pronounced  is  the  emaciation.  Snuffles,  or  nasal  catarrh,  \s  one 
of  the  earliest  features.  This  is  due  to  specific  swelling  of  portions  of  the  Schnciderian 
membrane.  Snuffles  may  occur  in  children  without  syphilis,  but  syphilis  will  nearly 
always  produce  snuffles,  which  may  last  for  some  time,  and  cause  a  widening  at  the 
root  of  the  nose  which  will  persist  through  life.  Following  the  snuffles  there  usually 
appears  a  rash  over  the  trunk  and  thighs  and  about  the  anus,  accompanied  by  mucous 
patches.     This  will  have  the  same  bright,  coppery  tint  as  ro.seola  syphilitica,  already 


140  SUR'HCAL  DISEASES 

mentioned,  which  it  much  resembles.  Sometimes  it  assumes  the  mixed  t_vj)e  of  eruption, 
Avhile  upon  the  ])ahns  and  soles  a])pears  the  so-called  ])enipliiifus  sy])hiliticus.  Should 
the  child  live  nodular  or  (gummatous  syphilides  may  develop. 

In  the  bone  and  cartilage  c-haracteristic  changes  are  met  at  tlu'  lower  end  of  the 
femur  and  at  the  eostochondral  junctions.  This  consists  of  an  o.ifrorlinudnths-  .fi/plnl- 
itica.  At  the  affected  j)oints  enlargements  take  place,  which  may  disaj)j)ear  under 
treatment  or  may  go  on  to  ulceration  and  necrosis.  In  the  fingers  and  toes  there  are 
manifestations  already  described  as  syphilitic  dartyliti.s. 

The  bones  of  the  skull  are  likely  to  be  involved  in  thickenings,  especially  about  the 
anterior  fontanelle,  where  they  form  the  so-calletl  Parrot's  nodes.  These  may  disappear, 
with  or  without  treatment,  and  the  affected  bone  may  undergo  atro{)hy  or  may  entirely 
disappear. 

Among  the  viscera  the  spleen  generally  becomes  affected  first  and  then  the  liver. 
Syphilitic  iritis  may  occur  early,  but  is  rather  rare;  ocular  changes  occur  more  often  in 
the  choroid.  In  the  brain  distinctive  lesions  may  occur  to  such  an  extent  as  to  lead  to 
considerable  thickening  of  the  dura,  with  or  without  hydroci'phalus.  and  subsecjuent 
imbecility  or  idiocy. 

Deafness  is  not  infrequent  in  hereditary  syphilis.  It  may  begin  suddenly  and  at  any 
age,  even  during  infancy.  It  is  j)roduced  by  deep  lesions  which  do  not  yield  readily  to 
treatment,  and  sometimes  leads  to  deaf-mutism,  especially  when  it  occurs  before  the 
child  has  learned  to  talk. 

Among  the  later  manifestations  of  hereditary  sy])hilis  are  opacities  of  the  cornea 
from  interstitial  keratitis.  This  may  occur  in  children  who  are  ap])arently  in  good  health 
and  free  from  other  signs  of  hereditary  di.sease.  The  condition  is  rather  obstinate,  l)ut 
it  can  be  made  to  disappear  under  suitable  treatment.  Retinitis  occurs  fretjuently  in 
young  women,  and  is  likely  to  lead  to  atrophy  or  detachment. 

The  Teeth. — The  permanent  teeth  often  show  peculiar  changes  that  are  distinctive, 
especiallv  in  those  who  have  shown  signs  of  corneal  involvement,  which,  having  been 
first  described  by  Hutchinson,  are  frequently  alluded  to  as  Hutchinson's  teeth.  When 
they  first  apjx^ar  they  are  smaller  than  natural  and  irregular.  Later  they  become 
notched.  The  crescentic  notches  show  best  upon  the  incisor  teeth.  Sometimes  the 
canines  are  also  affected,  being  narrow,  rounded,  and  i)eg-like,  with  jagged  edges.  These 
teeth  are  usually  so  formed  that  they  do  not  meet  projx-rly,  and  so  small  that  they  scarcely 
touch  each  other.  The  most  characteristic  changes  are  met  with  in  the.  upper  incisors, 
which  may  be  affected  when  all  the  others  are  fairly  normal.  In  such  cases  they  will 
be  found  narrow  and  short,  with  a  single  broad  notch  at  the  edge,  with  ])erhaps  a  furrow 
passing  from  it  upward  and  on  both  anterior  and  posterior  aspects.  Notching  is  usually 
symmetrical.  No  conclusions  can  be  drawn  from  the  teeth  if  they  are  normal,  as  they 
may  be,  l)Ut  when  they  present  the  above-described  features  they  ]irove  a  very  im])ortant 
indication. 

The  relations  between  syphilis  and  rickets  have  attracted  much  attention,  and  there 
is  little  doubt  but  that  rachitic  changes  are  prone  to  occur  in  subjects  with  inherited 
syphilis.  The  two  conditions  are  sometimes  blended  in  various  degrees  and  ways,  and  yet 
it  is  not  safe  to  say  that  rickets  is  always  an  expression  of  inherited  syphilis. 


TREATMENT  OF  SYPHILIS. 

There  is  no  question  but  that  some  of  the  above-described  lesions  constitute  as  dis- 
gusting and  repelling  diseased  conditions  as  the  physician  or  surgeon  is  ever  called  upon 
to  treat.  In  spite  of  these  circumstances,  however,  it  is  generally  believed  that  .sy])hilis 
is  a  most  satisfactory  disease  to  treat.  This  is  because  of  the  almost  mathematical 
certainty  with  which  results  can  be  predicted  and  estimated.  There  is  nothing  more 
satisfactory  in  therapeutics  than  the  rapidity  with  which  many  pronounced  and  .serious 
manifestations  of  syphilis  will  disappear  under  the  influence  of  j)roper  treatment.  These 
statements,  however,  should  be  modified  to  make  room  for  exceptional  cases,  where 
the  disease  assumes  a  malignant  type,  owing  probably  to  some  defect  in  the  patient's 
constitution,  or  where  patients  show  peculiar  idiosyncrasies  and  susceptibilities  to 
the  influence  of  mercury  and  iodine.  Such  cases  happen  occasionally  and  prove  difficult 
of  solution,  while  they  sorely  try  the  silrgeon's  ingenuity  and  resources. 


Th'j:AT.\n:.\T  of  svi'iiil/s  141 

///  l/ir  )ii(ij(>rilif  (>l  inslancrs  .si/pliilis  /.v  o  curahlc  di.sra.s-r.  A  patifiil  slioiild  l)c  first 
impressed  with  tlie  necessity  of  failliriilly  followiiij];  the  directions  of  his  })hysician,  and 
contiiiiiiiij;  under  treatment  lor  a  |»eriod  of  at  least  three  years  after  the  disappearance 
of  thi-  last  manifestation  of  tlie  (hsease.  The  disease  is  cnral)le,  hut  only  hy  the  judicious 
comhinalion  of  two  principal  remedies,  /.  c,  wrrriinj  and  Kxinir.  Those  rare  instances 
in  which  cure  seems  to  have  followed  lines  of  treatment  which  do  not  include  the  use 
of  these  two  dru<i;s  are  so  exceptional  and  mislcadinj;  that  they  should  not  he  con- 
sidered criteria.  Mercury  and  iodine  are  powerful  remedies,  necdinj;  to  he  administered 
with  caution  and  jud<;ment.  I'nfortunately  there  is  no  arbitrary  limit  of  time  for  any 
<;iven  case.  The  time  stated  above  is  that  usually  considered  refpiisite.  While  .sy|)hilis 
may  be  curable  in  .some  eases  in  le.ss  than  the  .stated  time,  it  is  better  to  give  it  longer 
treatment  than  is  absolutely  re(|uirc<l  rather  than  the  reverse.  The  treatment  entails 
no  unpleasant  conse(iuences.  Warnings  as  to  the  approach  of  toxic  .symptoms  from 
the  drugs  can  be  easily  recognized. 

Of  the  two  drugs  the  i)rcparations  of  mercury  are  the  more  ini|)()rtant.  The  surgeon 
may  ad()|)t  as  his  motto,  ntrrruri/,  more  mrrriir;/,  (uid  again  tiirmiri/,  and  if  he  begins  with 
this  measure  early  in  the  disea.se  he  may  be  able  to  conduct  it  to  a  successful  termiiuition 
with  but  little  re.sort  to  iodine.  Iodine  is  effective  rather  in  tho.se  ca.ses  where  treat- 
ment has  been  begun  relatively  lat(>,  and  where  it  seems  necessary  to  make  a  double 
im|)re.ssion  upon  the  disease. 

When  the  nature  of  the  primary  lesion  is  positive  treatment  should  l)egin  with  the 
first  visit  of  the  patient  to  the  surgeon.  When  there  is  uncertainty  regarding  the  char- 
acter of  the  venereal  sore,  treatment  mai/  be  postponed  until  the  appearance  of  the  first 
eru|)tion.  As  soon  as  this  has  appeared  the  treatment  should  be  hastened.  It  is 
necessary  to  begin  with  mercury.  The  patient's  mouth  should  be  examined  by  a  dentist 
and  all  tartar  removed  from  the  teeth,  especially  from  the  gingival  borders,  at  which 
lines  the  gums  are  likely  to  become  sore  when  mercury  is  too  freely  used.  All  diseased 
teeth  should  be  extracted  or  filled,  and  the  mouth  and  its  contents  .should  be  put  in 
normal  condition.  The  dentist  should  be  informed  as  to  the  rea.son  for  the  vi.sit.  Smok- 
ing should  be  discontinued,  especially  when  there  are  mucous  patches,  since  it  is  apt  to 
irritate  and  make  subsecpient  lesions  of  the  mucous  membrane  more  likely  to  occur. 
The  habits  of  the  patient  should  be  regulated  as  to  alcohol  and  other  indulgences,  and 
lie  should  be  warned  as  to  the  infectious  nature  of  the  disea.se,  in  order  that  others  may 
he  proirrfed.  In  many  instances  tonic,  even  roborant  treatment  may  be  advantageously 
combined  with  the  antispecific.  It  will  be  found  that  the  anemia  so  characteristic  of 
well-marked  secondary  .syphilis  will  improve  materially  under  the  influence  of  mercury 
alone. 

Should  the  disease  occur  in  a  married  person,  or  develop  after  marriage,  caution 
.should  be  given  as  to  the  danger  to  offspring,  and  to  the  other  associate  in  the  marriage 
relation,  which  might  follow  the  occurrence  of  pregnancy. 

iNIercury  may  be  given  by  the  mouth,  by  inunction,  by  hypodermic  injection,  or  by 
jumiyatinn.  The  intent  should  be  to  get  the  patient  under  its  influence  as  rapidly 
as  is  consistent  with  safety.  The  most  effective  of  these  methods  to  which  patients 
will  ordinarily  submit  is  that  by  inunction.  This  consi.sts  e.s.sentially  in  the  use  of 
mercurial  ointment  (blue  ointment),  of  which  15  Gm.  may  be  u.sed  daily  or  nightly, 
which  should  be  thoroughly  rubbed  into  some  area  of  the  body;  the  areas  selected 
being  changed  at  perhaps  three-day  intervals,  in  order  that  irritation, which  its  prolonged 
use  produces,  may  be  avoided.  It  takes  consideral)le  effort  to  so  completely  rub  this 
in  as  to  make  most  of  it  disappear,  and  it  can  be  done  more  easily  upon  tho.se  parts  of 
the  body  which  are  free  from  hair.  It  can  be  best  done  by  employing  someone  for  the 
purpose,  but  [)atients  can  be  easily  taught  to  u.se  it  themselves.  There  are  upon  the 
market,  ointments  containing  mercury  made  with  other  excipients  than  lard,  which  are 
le.ss  uncomfortable  to  the  skin  and  .seem  to  be  absorbed  better;  among  the.se  is  a  prep- 
aration made  with  a  petroleum  compound  called  vasogen,  which  may  be  procured  in 
different  strengths;  that  containing  33  per  cent,  or  50  per  cent,  is  the  best. 

Inunction  should  be  practised  at  least  once  every  twenty-four  hours,  until  either  the 
gums  become  tender  or  swollen,  with  an  offensive  odor  of  the  breath,  or  until  the  skin 
is  irritated.  The  mouth  shoukl  be  protected  by  u.se  of  an  a.stringent  antiseptic  mouth- 
wash, such  as  the  following:  Carbolic  acid  10  parts,  oil  of  wintergreen  1  part,  tincture 
of  myrrh  50  parts.     A  little  of  this  solution  in  a  tablespoonful  or  more  of  water  makes 


142  SCRf;lCAL   DISEASES 

a  serviceable  wash,  wliich  should  be  used  several  times  a  day.  There  are  sanitaria 
and  springs,  or  health  resorts,  in  this  country  where  a  specialty  is  made  of  this  manner 
of  treatment.  At  these  resorts  inunction  is  practised  freely  anfl  thi^roughly,  but  the 
l^nefit  which  is  obtained  comes  rather  from  the  attention  which  patients  give  to  the 
treatment,  and  their  abstention  from  business  or  dissipation,  than  from  any  inherent 
medicinal  features  either  in  the  mineral  water  or  climate. 

Under  the  influence  of  mercurial  ointment  alone,  if  a  patient  is  willing  tf)  i)ersist  in 
its  use,  many  cases  of  s\-philis  may  Ije  conducted  to  a  successful  termination;  but  its 
use  is  disagreeable  to  some  people,  and  it  may  be  im|K)ssible  to  resort  to  it  for  any 
great  length  of  time.  It  has  its  inconveniences  and  dLsadvantages,  but  it  should  be 
applied  in  at  least  the  first  stages  of  the  disease. 

When  mercurial  ointment  is  .seen  to  have  made  a  distinctive  impression  upon  the 
constitution  of  the  patient  it  may  be  discarded  and  the  treatment  changed  to  the  internal 
administration  of  the  drug. 

Mercurials  may  be  given  internally  in  any  one  of  several  different  preparations. 
Hutchinson  has  recommended  gray  jxjirder,  in  doses  of  |  to  ^  Gm.  three  or  four  times  a 
day.  Corro-nve  sublimate  is  a  reliable  form  in  which  to  administer  mercur}-  in  doses 
which  can  be  tolerated,  from  1  to  2  Mg.,  three  or  four  times  a  day.  The  red  iodide 
may  be  given  in  similar  doses,  or  the  green  iodide  may  be  administered  in  doses  of 
0.15  to  2  Cg.  These  preparations  sometimes  irritate  the  intestinal  tract  and  produce  a 
certain  amount  of  colic  or  looseness  of  the  bowel.  For  the  latter  some  astringent 
may  be  combined  with  the  mercury,  while  intestinal  pain  may  be  checked  by  the  use 
of  extract  of  coniima. 

The  hypodermic  use  of  mercury  can  be  made  effective,  Ijut  tliere  are  but  few  prepara- 
tions which  can  be  used  that  do  not  caase  pain  and  subsequent  irritation.  Perhaps 
that  which  gives  least  pain  is  the  sozoiodolate  of  mercury.  This  is  sparingly  soluble  in 
water,  dissolving  in  about  .5(X)  parts  by  weight.  As  the  do.se  is  9  or  10  Cg.,  the  amount 
of  water  necessary  for  this  solution  is  so  bulky  that  the  do.se  should  be  injected  into  the 
gluteal  region.  Corro.sive  sublimate  is  also  used  in  1  per  cent,  .solution,  made  up  in 
common  salt  solution  of  the  usual  .strength  of  9  to  1000.  Of  this  10  minims  represent 
a  suitable  do.se  to  commence  with,  which  may  be  increased  to  30  or  40  minims  when 
necessar}-.  This  should  be  given  in  the  same  region,  the  needle  being  driven  in  its  full 
length  perpendicularly  to  the  surface.  When  this  is  done  an  injection  is  made  into  the 
mascle,  where  it  .seems  to  be  more  effective  than  in  the  subcutaneous  fat.  When  the 
dose  is  increased  to  more  than  20  minims  a  2  per  cent,  solution  may  be  used  and  the 
amount  of  fluid  corresp<^;ndingiy  reduced. 

Fumigation  is  a  method  now  not  often  adopterl,  caloinel  Ijeing  used  for  the  purpose,  an 
ordinary  cabinet  hot-air  bath  confining  the  vapor  about  the  patient.  One  treatment 
a  day  by  either  of  these  methods  is  usually  sufficient. 

About  the  initial  sore  drt-  calomel,  pure  or  reduced  with  bismuth  subnitrate,  may  be 
used.  The  condylomas  met  with  about  the  perineum  will  often  shrink  and  disappear 
under  the  influence  of  this  application.  Mucous  patches  should  be  treated  with  absf)lute 
cleanliness;  in  the  mouth  a  wash  of  diluted  hydrogen  dioxide  may  be  u.sed,  and  the 
patches  touched  with  a  strong  nitrate  of  silver  solution,  pure  carbolic  acid,  or  campho- 
phenol.  This  will  not  prevent  contagion  from  such  a  source,  but  will  reduce  it  to  a 
minimum   beneficial   in   every  respect. 

The  various  eruptions  of  syphilis  will  disappear  gradually  under  the  influence  of  a 
local  application  of  one  of  the  mercurial  preparations,  either  the  ordinary  mercurial 
ointment  or  ammoniated  mercur}\ 

In  cases  of  inherited  syphilis,  especially  in  young  children,  a  reduced  mercurial  oint- 
ment, or  the  use  of  gray  powder  (mercury  with  chalk)  will  give  the  best  results.  The 
dose  .should  be  regulated  by  the  age  of  the  patient ;  for  instance,  of  the  latter  1  to  2  Cg. 
for  an  infant.     The  iodides  have  also  proved  succ-essful. 

Iodine  and  its  preparations  have  by  many  authorities  been  held  to  be  useful  in  the 
later  and  especially  in  the  gummatous  lesions  of  syphilis.  There  are  patients  who  cannot 
take  iodine  to  any  extent  without  suffering  from  such  disturbance  of  mucous  mem- 
branes, especially  in  the  nose  and  intestines,  as  to  make  it  an  exceedingly  unpleasant 
remedy. 

The  iodides  have  not  proved  as  successful  as  the  mercurials;  nevertheless,  the  com- 
bination is  a  popular  one  and  sometimes  of  peculiar  value.     The  potassiima  salt  is  the 


TRi:.\TMi:sT  OF  syrniijs  143 

one  generally  used,  as  it  is  clK'apcr  than  the  sodium  (•()nij)()un(l.  The  latter,  however, 
is  less  irritatiuff  and  often  more  available.  The  lithium  eomj)ound  is  ideal  in  some 
respects,  but  very  expensive'.  The  iodides  may  he  jjjiven  in  large  do.ses,  to  the  extent  of 
30  (Jm.  or  more  (an  ounce  or  more)  in  twenty-four  hours.  Large  doses  are  sometimes 
necessary  in  the  treatmciu  of  late  syphilis  of  the  nervous  system.  When  it  is  necessary 
to  put  the  j)atii'nt  rapidly  under  tlu'  influence  of  antispecific  medication  the  cond)ined 
u.se  of  these  two  drugs,  as  for  examj)le  by  mercurial  inunction  and  the  use  of  one  of  the 
iodides  internally,  will  most  s|)eedily  bring  about  the  desired  result.  This  result  may 
be  overreached,  and  sore  mouth  or  other  toxic  manifestations  may  appear  suddenly  and 
unexjiectedly. 

The  mercuric  salts  are  .soluble  in  .solutions  of  tlu-  iodides,  atid  what  is  known  as 
mixed  trrafnirnt  is  often  emi)loyed.  The  salts  may  be  combined  in  any  desired  prepa- 
raticHi.  Donovan's  solution  is  exceedingly  valuable,  the  ansenie  which  it  contains 
seeming  to  reinforce  both  tlu>  mercury  and  the  iodine. 

The  iodides  produce  eruptions  or  rashes  which  strongly  simulate  both  .syphilitic  and 
non-.syj)hilitic  skin  diseases,  and  confusion  may  arise  from  their  u.se.  In  those  who  are 
sensitive  to  the  iodides,  and  in  whom  catarrh  of  the  mucous  membranes  is  easily  produced, 
it  is  best  to  begin  with  small  doses,  increasing  them  as  circumstances  may  warrant. 
Some  patients  cannot  take  iodine  in  any  form.  ^Vhen  iodides  irritate  the  stomach  they 
should  be  given  in  es.sence  of  pepsin. 

Of  the  various  vegetable  remedies  some  are  unreliable  and  of  little  value.  Certain 
combinations  can,  however,  be  effected  in  some  cases  by  which  the  value  of  the  effective 
agents  may  l)e  enhanced.  Ziitmanns  decoction  or  McDade's  jnrmnia  will  occasionally 
prove  of  service.  In  aggravated  cases  the  former  is  believed  to  be  the  most  effective 
of  all  methods  of  administering  mercury.  Tonics  or  any  other  medicines  which  may 
be  called  for  in  particular  cases  should  be  given  judiciously.  There  is  nothing  in  anti- 
syphilitic  treatment  which  precludes  other  treatment  when  needed. 


CHAPTER    XL 

CHANCROID  OR  VENEREAL  ULCER. 

Since  the  time  of  John  Hunter  and  his  pupils,  who  confused  the  three  totally  different 
and  so-called  venereal  diseases,  patholofjists  have  drawn  a  distinct  line  between  chancre, 
which  is  simply  the  initial  sore  of  syphilis,  and  chancroid  or  venereal  ulcer,  which  is  a 
distinctly  local  lesion,  often  destructive,  but  never  followed  by  constitutional  disease, 
except  of  septicemic  or  pyemic  type.  It  is  usually  found  uj)on  the  genitals,  about  the 
foreskin,  glans,  and  vulva,  but  maybe  met  anywhere  upon  the  body  where  infection  has 
occurred.     It  is  distinctly  auio-inoculablc,  in  which  respect  it  differs  from  chancre. 

Varying  views  have  been  held  as  to  the  minute  agency  concerned  in  the  production 
of  this  lesion.  The  bacillus  discovered  and  studied  by  Ducrey,  in  1889,  is  now  accepted 
as  the  exciting  cause.  This  is  L5/'  long  and  1  /'-  thick,  with  rounded  deep-staining  ends 
and  fainter-staining  central  portion,  occurring  with  great  constancy  in  chancroidal  pus, 
less  often  in  buboes  than  in  ulcers,  in  and  outside  of  the  cells,  and  in  chains.  It  is 
cultivated  with  difficulty,  grows  best  on  human  blood,  takes  basic  aniline  stains,  but  is 
easily  decolorized  by  alcohol  or  by  ( iram's  method.  Characteristic  ulcers  can  be  produced 
by  inoculating  it,  even  in  monkeys. 

Chancroid  begins,  in  twenty-four  hours,  as  a  red  point  or  papule,  which  is  quickly 
converted  into  a  pustule  and  then  into  an  nicer.  The  borders  of  this  ulcer  enlarge,  its 
depth  increases,  imtil  after  a  few'  days  it  forms  a  more  or  less  deep,  often  undermined 
excavation,  irregular  in  contour,  discharging  grayish  ])urulent  material.  In  this  respect 
it  differs  also  from  chancre,  whose  natural  discharge  is  more  like  serum.  In  other 
words,  chancroid  iff  es.sentialli/  destrucfive,  chancre  conMruciive,  since  the  latter  forms 
a  new-growth  which  ordinarily  has  little  or  no  discharge.  When  the  necrosis  of  chan- 
croid becomes  extensive  and  tends  to  spread  ra])idly  the  idcer  is  sj)oken  of  as  phage- 
denic This  tendency  to  rapid  local  gangrene  is  the  combined  result,  probably,  of  viru- 
lence of  virus  and  lowered  local  or  constitutional  tissue  resistance.  It  is  consequently 
most  often  seen  in  alcoholics  and  prostitutes.  In  rare  instances  a  surface  larger 
than  the  hand  may  be  rapidly  destroyed,  every  particle  of  material  sloughed  being 
infectious. 

In  chancroids  of  the  mild  variety  the  discharge  may  dry  upon  their  surfaces  and  scabs 
or  crusts  result,  beneath  which,  when  detached,  the  characteristic  ulcer  is  present. 

Under  ]>roper  treatment  this  foul  ulcer  is  soon  converted  into  an  ordinary  granulating 
surface,  which  heals  by  cicatrization. 


CHANCROIDAL  BUBO. 

Infection,  by  propagation  along  the  lymphatics,  of  the  inguinal  nodes  is  frequent,  and, 
since  the  infection  is  almost  always  a  mixed  one,  suppuration  is  frequent. 

The  pus  of  a  suppurating  chancroidal  bubo  is  as  infectious  as  the  discharge  from 
the  original  sore;  hence  the  need  of  great  caution.  The  edges  of  the  local  incision  should 
be  promptly  cauterized  so  that  they  may  not  become  lin(>ar  chancroids.  Phagedena 
shows  itself  here  as  well  as  about  the  genitals  proper,  and  differs  only  in  that  it  makes 
the  case  more  serious.  A  chancroidal  bul)o  may,  however,  subside  without  abscess 
formation.  The  signs  of  suppuration  are  those  incident  to  pus  formation  anywhere 
near  the  surface.     When  pus  is  present  its  early  evacuation  is  demanded. 

Diagnosis. — Chancroid  is  likely  to  be  confounded  with  chancre  and  herpes  pre- 
putialis.  It  has  no  period  of  incubation.  Destruction  commences  after  infection,  so 
that  within  twenty-four  hours  macroscopic  evidence  may  be  observed,  and  within  two 
or  three  days  the  sore  has  attained  distinct  size  and  shape. 

(144) 


CHANCROIDAL   JUBO 


145 


Chancroid. 
Local  ulcer. 

A  (lisliiicth-  \cii(>rcal  infcclioii. 


No  inculial  ion  ;  lesion  noticed 
wit  iiin  a  lew  days. 

Conunences  and  remains  as  an 
ulcer. 

Isually  multiple.  , 

Secri'tion   |)urulent    and  abun- 
dant. 
May  occur  aiiain  and  asjiain. 


Auto-inoculahle. 

Phageilena  I'requent. 

Buboes  in  about  (i/i  per  cent. 

ol'  cases. 
Buboes  usually  suppurate. 


Chimcrc. 
I<'irst  local  si^n  of  a  consti- 
tutional disease. 
I'sualh'  a  venereal  infection. 


Incubation  from  ten  to  se\en- 

tv  days  before  first  lyni|)li- 

atic  induration. 
Conunences  as  a  papule,  or 

occasionally     an     ero.sion. 

This    /»«//    ulcerate    later. 
Usually  single. 

Secretion    slif!;lit  and    serous 

or  bloody. 
As  a  rule,  it  only  occurs  once 

in  the  same  patient. 

Not  auto-inoculal)le. 
Phagedenic  action  \evy  rare. 
Bubonic  enlargement  nearly 

always. 
Bul)oes,    as   a    rule     do    not 

su])])urate. 


Herpe.i. 
Local  neurosis. 

May  be   non- venereal,   from 
friction,    irritation,    un- 
cleanliness,  etc. 

.No  incubation. 


Commences  as  a  crop  of 
^■esicles. 

Multiple    and    occurring    in 

crops  or  .series. 
I>ittle  or  no  secretion. 

Patients  who  once  have  it 
are  frequently  subject  to 
it. 

Not  inoculable 

Never. 

Lymphatics  rarel\'  iuAolved. 


Prognosis. — E.xcept  in  the  most  debilitated  and  dissipated,  in  whom  phagedena  may 
jirove  fatal,  recovery  always  occurs,  but  often  with  the  loss  of  tissue  and  disfiguring 
scars. 

Treatment. — In  mild  cases — i.  e.,  those  showing  but  little  destructive  tendency — 
cleanliness  and  the  use  of  hydrogen  peroxide,  followed  by  local  use  of  any  of  the  ordinary 
anti.septic  powders,  or  even  of  calomel,  will  usually  prove  sufficient.  Sodium  sozoiodo- 
late  nuikes  an  excellent  application.  It  is  odorless  and  non-toxic.  At  first  its  use  may 
be  preceded  by  morphine  or  cocaine,  but  after  a  few  days  it  will  prove  a  painless  appli- 
cation. If  the  ulcer  manifest  any  tendency  to  spread,  it  should  be  cleansed,  cocainized, 
and  then  cauterized  with  nitric  acid  or  the  actual  cautery,  after  which  it  should  be 
so  treated  as  to  encourage  granulation.  This  plan  should  be  followed  in  phagedenic 
ca.ses,  which  may  call  for  general  anesthesia,  with  the  use  of  scissors  and  a  sharp  spoon, 
followed  by  cauterization  of  every  particle  of  raw  or  diseased  surface. 

Widesjiread  phagedena  is  more  rare  now  than  formerly.  Cases  which  are  extensive 
do  best  when  submitted  to  continuous  immersion  of  the  hips  in  a  sitz-bath  as  hot  as  can 
be  tolerated.  All  aggravated  cases  call  for  invigorating  and  tonic  measures,  laxatives, 
imj)r()yed  nutrition,  and  stimulants. 

Suppurating  buboes  should  be  incised,  usually  curetted,  and  thoroughly  swabbed 
with  pure  carbolic  acid,  followed  by  pure  alcohol  to  neutralize  the  acid,  then  packed 
lightly  with  antiseptic  gauze,  and  allowed  to  close  by  granulation.  Virulent  cases  w^ll 
be  accomj^anied  by  sloughing  of  so  much  tissue  that  it  is  best  to  remove  all  sloughs  with 
scissors.  Here  even  stronger  caustics  will  be  called  for.  Pliiniosis  often  complicates 
chancroifl,  and  will  necessitate  circumcision  or  incision  along  the  dorsum  of  the  prepuce, 
with  such  attention  to  the  parts  thus  exposed  as  their  condition  may  require. 

Mixed  Chancre. — Mixed  chancre,  or  the  combination  of  the  two  lesions,  has  been 
already  discussed. 

Extragenital  Chancroid. — Extragenital  chancroid  may  occur  uyK)n  any  portion 
of  the  body,  but  is  more  rare  than  extragenital  chancre.  It  is  characterized  by  the 
same  peculiarities  as  pertain  to  the  venereal  sores  already  described,  and  is  amenable 
to  similar  treatment. 


10 


CHAPTER    XII. 
GONORRHEA. 

Gonorrhea  is  an  acute  infectious  process,  iiivolvinc;  especially  the  mucous  mem- 
branes of  the  (jeiiito-urinarv  organs,  hut  met  with  elsewhere  about  the  body,  in  both  super- 
ficial and  deep  tissues.  The  name  itself  is  a  misnomer,  since  it  imj)lies  a  flow  of  semen, 
whereas  the  discharge  which  issues  from  the  male  urethra  is  simply  mucoj)us,  and  is 
the  product  of  a  severe  inflammation  of  the  mucous  membrane.  A  less  inaccurate 
name  for  it  is  blennorrhea,  although  this  is  usually  limited  rather  to  a  discharge  from  the 
vagina,  and  indicates  a  whitish  and  copious  fluid  exudate,  mingled  with  pus  corpuscles 
and  bacteria.  It  is  stated  that  probably  (SO  ])er  cent,  of  men  have  at  some  time  contracted 
this  disease.     Neisser  claims  that  it  is  a  more  conunon  affection  than  measles. 

True  gonorrhea  is  the  result  of  an  infection  by  a  sjx'cific  organism  universally  recognized 
as  the  cjonococcnf!  oi  Neisser,  though  the  discharge,  when  studied  in  the  clinical  lal)oratorv, 
may  give  evidence  of  being  the  pnHluct  of  a  mixed  infection  and  contain  the  ordinary 
pyogenic  or  other  organisms.     The  conmion  name  for  the  disea.se  is  claj). 

The  gonococcus  is  a  diplococcus  which  seems  to  be  injurious  only  to  the  tissues  of 
the  human  being,  as  inoculations  in  animals  have  produced  no  definite  or  reliable  result. 
Like  syphilis,  it  is  spread  by  direct  or  indirect  contagion,  and  usually  in  the  same 
way.  It  is  generally  found  in  the  genito-urinary  mucosa  of  both  sexes,  but  it  has  been 
accidentally  and  even  innocently  conveyed  by  innnediate  and  mediate  transfer  to  the 
mucous  membranes  of  the  eye,  the  reef)tm,  and  even  to  the  vioiith,  although  here,  as  in  the 
nose,  the  mucous  membrane  is  but  little  susceptible  to  its  activity.  It  is  generallv  stated 
that  20  per  cent,  of  the  blindness  occurring  in  the  young  is  due  to  gonorrheal  conjunctivitis. 
Those  membranes  covered  with  cylindrical  epithelium  are  more  liable  to  succumb  to 
infection  by  this  parasite  than  are  those  covered  with  scpnimous  ejMthelium.  The  more 
the  epithelial  cells  conform  to  the  former  type,  the  more  difficult  it  is  to  get  rid  of  the 
infection;  hence  the  disease  lingers  in  the  cervical  canal  longer  than  in  the  vagina. 

The  disease  always  commences  as  a  contagious  catarrhal  discharge  from  the  mucous 
membrane.  It  may  spread  much  farther  than  this,  invading  deeper  tissues  by  continuity, 
or  tissues  at  a  distance  by  the  lym])h  stream,  or  jiroducing  even  metastatic  expressions 
of  infection  in  distant  tissues  and  organs.  Under  these  circmnstances  the  serous  mem- 
branes are  likely  to  suft'er,  and  the  ]X'ritoneum,  the  endocardium,  the  jiericardium, 
the  ])leurie,  the  meninges,  and  particularly  the  .serous  linings  of  some  of  the  joints,  as 
the  elbow  and  knee,  show  umnistakablc  evidences  of  infection;  while  through  the  medium 
of  the  venous  and  then  the  arterial  systems  typical  representations  of  pyemia  following 
gonorrhea  may  occur. 

The  disease  as  it  usually  appears  is  seriously  and  often  obstinately  complicated  by  the 
structure  of  the  membranes  which  it  involves.  The  mucous  membranes  throughout  the 
body  are  more  than  mere  nuicous  surfaces;  they  are  dotted  with  openings  for  the  escape 
of  glandular  secretions,  and  nowhere  is  this  more  c()ns])icuous  than  in  the  urethra, 
where  many  minute  follicles,  so  called,  empty  tiny  dro])s  of  secretion  into  the  nnicous 
canal.  Infection  may  easily  travel  along  these  routes  and  lurk  within  such  minute  recesses 
long  after  it  has  apparently  disa])])eared  from  the  surface;  and  so  it  often  hap])ens  that 
in  the  male  not  only  the  urethral  follicles  but  the  ducts  leading  to  Cowper's  glands  and 
prostate  become  involved,  while  in  the  female  the  follicles  around  the  meatus,  the 
urethra,  and  the  vulva  rarely  escape.  The  clinical  importance  of  this  statement  is  of 
interest,  as  by  it  may  be  explained  many  of  those  cases  where  an  old  infection  seems 
to  have  been  lighted  up,  or  where  the  contagion  has  been  conveyed  to  another  after 
an  attack  which  was  supposed  to  have  been  entirely  cured.  Nothing  seems  to  favor 
outbreaks  of  this  kind  as  do  alcoholic  and  .sexual  exces.ses. 

The  gonococcus  maybe  scarcely  regarded  as  an  obligate  pyogenic  organism  by  itself, 
but  the  parts  most  often  involved  in  this  disease  may  be  regarded  as  never  free  from  the 
(146) 


COSOlih'llEA  147 

presence  of  other  <;erin.s  of  <;n>;it(T  or  less  activity,  ami  l)V  association,  if  not  hy  aclnal 
svinhiosis,  such  an  intense  reaction  is  provoked  that  the  resultinjf  products  do  not  dirt'er 
from  true  j)us,  save  by  the  added  |)resence  of  the  sjx'ciHc  orjfanisni  most  at  fault. 
Under  these  circumstances  abscesses  may  form  in  any  tissue  infected.  Another  exj)ression 
of  this  fact  would  he  the  establishment  of  a  pyarthrosis  after  involvement  of  one  or  more 
joints.  (lonococci  may  be  found  in  almost  every  abscess  of  truly  {jonorrheal  orijjin;  on 
the  other  hand,  in  some  of  the  serous  cavities  it  is  possibles  at  least  for  a  time,  that 
{jonococci  maybe  present  in  the  serous  fluid  without  producing  in  it  more  than  a  <hsturb- 
intretVect,  the  fluid  now  appearinj;  turbid  rather  than  puruloid. 

The  amount  of  toxemia  which  may  be  ])n)duced  by  jronococci  without  reference  to 
formation  of  pus  has  not  yet  been  established.  It  is,  moreover,  a  difficult  tiling'  to 
estimate  in  cases  of  mixed  infection.  Occasionally  there  are  cases  of  metastasis  and 
(gonorrheal  invasion  which  are  free  from  evidences  of  suppuration,  and  yet  there  may 
be  anemia  and  cachexia  of  profound  type;  these  can  only  be  explained  on  the  theory  of 
an  intoxication. 

Bcsld(\s  the  .serous  tissues  of  the  body  the  fhwu-f  structures  may  suti'er  seriously, 
not  only  in  an  acute  manner,  but  also  in  a  chronic  and  obstinate  form. 

It  has  been  the  custom  to  speak  of  inrfliriii.'i  as  a  synonym  for  {gonorrhea,  and  to 
divide  it  into  the  specific  and  non-specific  forms,  includinjj  under  the  former  expression 
ca.ses  where  the  gonococcus  can  be  demonstrated,  and  under  the  latter  term  tho.se  which 
do  not  seem  to  show  it.  There  is  no  doubt  but  that  urethritis  may  be  set  up  by  the 
introduction  of  a  foreign  body,  such  as  a  sound  or  catheter,  as  well  as  by  some  irritating 
discharge  from  the  vagina,  and  also  as  the  result  of  excess  of  uric  acid  in  the  .system, 
perhaps  even  of  alcohol.  These,  if  occurring  in  a  previously  uninfected  urethra,  may 
be  regarded  as  distinctly  non-specific  lesions.  It  is  also  supposed  that  under  certain 
circumstances  inflammation  may  be  set  up  by  other  organisms  than  the  gonococ*cus; 
nevertheless  almost  all  cases  of  so-called  clap  are  positively  gonococcus  infections, 
simple  or  mixed,  and  have  but  one  origin. 

Diagnosis. — Diagnosis  can  he  made  positive  only  with  the  viirroscope.  A  recog- 
nition of  the  gonococci  by  staining  them  and  then  watching  the  effect  of  iodine  in  their 
decolorization  will  be  of  great  importance  and  reliable.  The  affinity  of  these  germs  for 
basic  aniline  dyes,  and  the  fact  that  they  do  not  take  the  iodine  stain  of  Gram,  will  serve 
to  differentiate  them  from  the  numerous  other  organisms  with  which  they  may  be 
found  mixed.  By  staining  a  cover-glass  preparation  first  with  methyl  lilue  or  other  basic 
color,  then  placing  it  in  Gram's  solution,  and  finally  in  a  solution  of  Bismarck  brown, 
the  true  gonococci  which  have  been  made  visible  by  the  methyl  blue  will  have  disappeared 
under  the  influence  of  the  iodine,  while  other  bacteria  will  be  stained  by  it.  It  has  been 
mentioned  that  the  germ  is  a  diplococcus  of  rather  ovoid  form,  met  in  clusters  but  not 
in  chains,  and  in  groups  of  four  or  multiples  of  four;  it  may  be  attached  to  epithelium 
and  pus  corpuscles,  or  found  within  them,  and  is  rarely  found  free  in  fluid  except  when 
present  in  large  numbers.  These  organisms  are  capable  of  culitvation,  growing  best 
upon  a  mixture  of  human  serum  and  neutral  agar,  at  a  temperature  of  36°  C. 

The  urethra  may  be  infected  from  icitliout  and  from  within,  and  this  infection  may  be 
either  of  a  truly  specific  type  (gonococcus)  or  of  the  pyogenic  type;  as  between  these 
forms  information  may  be  gained  by  the  history  and  the  clinical  course,  but  the  minute 
diagnosis  is  only  to  be  made  with  the  microscope.  This  is  of  more  than  theoretical 
value,  inasmuch  as  it  substitutes  a  certainty  for  a  working  hypothesis.  It  is,  moreover, 
sometimes  of  great  value,  as  when  the  question  of  infection  of  one  of  the  opposite  sex 
comes  up,  or  it  may  have  at  times  even  an  important  medicolegal  value,  as  in  cases  of  rape. 

Infection  from  without,  so  far  as  the  male  urethra  is  concerned,  is  a  question  of  the 
venereal  origin  of  the  disease.  Infection  from  within,  in  the  specific  form,  is  a  matter 
of  recrudescence  of  a  formerly  active  lesion  supposed  to  have  disappeared.  Infection 
of  non-specific  type  from  without  affects  the  introduction  of  germs  either  by  venereal 
contact  or  by  the  medium  of  an  unclean  catheter,  sound,  or  some  other  instrument, 
or  from  within  by  the  extension  forward  of  an  inflammation  higher  up  in  the  genito- 
urinary tract,  such  as  may  be  due  to  stone  in  the  bladder,  cystitis,  enlarged  prostate, 
or  uric  acid  or  oxalic  acid  crystals.  Urethritis,  usually  of  mild  ty])e,  is  not  infrequent 
in  old  men  from  either  of  these  causes.  It  may  also  be  produced  by  the  infection  of 
a  too  strong  or  irritant  injection,  whether  used  either  for  prophylaxis  or  for  ordinary 
treatment. 


148  SURGICAL  DISEASES 

Classifying  them  we  may  then  have  urethritis  of  the  followiiifr  four  types: 

A.  Gonorrheal  of  extrinsic  origin. 

B.  (ronorrheal   of  intrinsic  origin   (originally  extrinsic). 

C.  Non-specific  urethritis  of  extrinsic  origin. 

D.  Non-specific  urethritis  of  intrinsic  origin. 

A.  The  period  of  incubation  is  short,  usually  two  to  six  days,  and  the  resulting  inflam- 
mation is  severe;  the  conse(|uences  are  often  remote  and  s(jnictimes  disastrous,  (iono- 
cocci  will  he  found  in  the  jnis  and  epithelial  debris. 

B.  This  has  been  described  as  "  ha-stard  clap."  It  is  really  an  auto-infection,  with 
an  incubation  period  of  a  few  hours,  and  is  practically  the  reawakening  of  a  quiescent 
stage  of  A.  It  is  characterized  by  abundant  purulent  discharge;  this  latter  is  thin  and 
mucilaginous,  more  like  that  of  so-called  gleet,  with  an  abundance  of  {)us  threads,  or 
"clap  threads,"  in  the  urine.     In  this  form  gonococci  are  also  found,  but  less  frequently. 

C.  Much  like  A  in  its  clinical  course,  but  less  violent,  and  with  less  widespread 
reaction.  Its  period  of  incubation  is  rarely  over  thirty-six  hours.  This  type  is  most 
common  after  alcoholic  and  sexual  excesses;  the  latter  especially  with  one  already 
suffering  from  vaginal  discharge,  ])articularly  so  when  near  the  time  of  menstruation. 
Here  the  microscope  will  show  few  if  any  true  gonococci,  but  a  profusion  of  pyogenic 
organisms. 

D.  This  form  of  disease  is  of  non-venereal  origin,  and  is  susceptible  of  easy  explana- 
tion and  of  satisfactory  treatment  if  the  cause  be  properly  treated.  No  case  of  urethral 
discharge  which  does  not  seem  to  fall  easily  into  one  of  the  above  categories  should  be 
treated  without  a  search  of  the  anterior  urethra,  especially  the  fossa  navicularis,  for 
possible  chancre  or  chancroid,  as  well  as  for  stricture. 

Among  the  laity  the  idea  is  prevalent  that  gonorrhea  is  a  disease  of  more  or  less  trifling 
import,  while  many  of  the  profession  regard  it  as  rarely  worthy  of  serious  consideration. 
This  is  an  unfortunate  notion  regarding  this  disease,  and  those  who  have  had  largest 
experience  unite  in  expressing  the  opinion  that  gonorrhea  reckons  more  vic-tims  in  the 
death  list  than  does  syphilis — not  because  it  is  more  common,  but  because  of  its  com- 
plications and  the  ravages,  especially  in  the  kidneys,  resulting  therefrom.  It  has  been 
shown  that  the  specific  organism  producing  it  may  linger  for  years  in  the  follicles  of  the 
urethra,  whence  it  may  issue  forth,  unexpectedly,  to  produce  vaginitis,  perhaps  in  the 
most  innocent  of  women,  and  thus  bring  on  a  train  of  pelvic  disorders  which  may 
involve  the  ovaries,  the  tubes,  and  the  peritoneum.  Doubtless  gonorrhea  has  made  in 
this  indirect  way  many  more  viciims  than  syphilis. 

Regarding  gonorrhea  thus  seriously,  it  is  well  to  treat  it  cautiously  and  to  inculcate 
vigilance  in  the  daily  life  and  habits  of  the  patient.  There  are  no  arbitrary  limits 
during  which  danger  exists  and  then  passes;  peril  lurks  about  such  a  case  for  an  almost 
indefinite  time.  There  is  danger  not  alone  to  the  individual,  but  to  all  with  whom  he 
may  have  sexual  or  even  other  relations.  This  advice  pertains  not  alone  to  the  ure- 
thral discharge  and  the  care  of  the  urethra,  but  especially  to  the  avoidance  of  all  possible 
contamination  of  the  conjunctiva.  One  of  the  saddest  spectacles  in  the  domain  of 
medicine  is  to  see  one  or  both  eyes  of  an  innocent  victim  injured  or  ruined  by  gonorrheal 
infection. 

There  is  no  denying  the  clinical  fact  that  individuals  vary  considerably  in  their  sus- 
ceptibility to  this  disease;  moreover,  individual  susceptibility  varies  at  different  times. 
Alcoholic  and  sexual  indulgence  seem  to  materially  lower  this  susceptil)ility.  Thus 
from  the  same  individual,  and  within  twenty-four  hours,  one  may  acquire  the  disease 
while  others  escape.  In  some  instances  immunity  seems  to  be  afforded  by  repeated 
attacks;  in  other  individuals  repeated  attacks  .seem  only  to  enhance  the  liability  to  the 
disease.  The  gonococcus  grows  best  in  alkaline  media.  Prolonged  sexual  excitement 
diminishes  the  acidity  of  the  urethral  fluids,  and  this  favors  the  growth  and  development 
of  the  germ.  No  credence  should  be  given  to  popular  notions  concerning  the  possible 
avoidance  of  infection  after  exposure.  Even  a  careful  foilet  is  usually  inefficient  for 
this  purpose,  while  the  use  of  prophylactic  injections  is  to  be  reprehended.  They  do 
more  harm  than  good.  If  strong  enough  to  l)e  bactericidal,  they  should  be  extremely 
irritant;  if  weak  enough  to  be  tolerated,  they  will  prove  useless.  The  patient  should 
also  be  warned  concerning  possible  transfer  of  the  disease  without  sexual  contact,  and 
all  toilet  utensils,  towels,  etc.,  should  be  kept  by  themselves,  and  all  syringes  and  instru- 
ments used  in  the  treatment  of  the  case  should  be  carefully  sterilized. 


(lOXOHRIlKA  149 

Course.  The  period  of  iiicul);itioii  <;eiierally  varies  within  wide  Hmits,  as  meiilioiied 
above  under  c  lassifieatioii  of  the  various  tyix's;  it  may  Ih'  as  short  as  a  few  iunirs  or  may 
extend  to  ten  days,  or  possibly  even  h)n<jer.  I'sually  it  is  from  two  to  five  (hiys.  The 
earlv  symptoms  consist  of  (hseond'ort  aloni;;  the  eoursi'  of  the  urethra,  eliemosis  or  edenui, 
and  swelling;  of  the  meatus.  Within  a  short  time  after  these  symptoms  the  characteristic 
discharge  ai)|)ears.  It  may  at  first  be  viscid,  but  soon  becomes  j)ur\ih'nt,  and  then 
more  or  less  profuse,  while  urination  prives  rise  to  o;reat  discomfort.  By  the  end  of  the 
first  week  the  discharijje  is  usually  jjrayish  in  color,  thick,  continuous,  and  so  profuse 
as  to  equal  in  volume  20  to  50  Cc.  in  twenty-four  hours.  The  lesion  is  not  confined 
to  the  urethra,  and  soon  s])reads  to  the  j)eri-urethral  tissues  and  thence  to  the  lymphatics. 
A  peri-un>thritis  with  venous  enijortjiement  is  added  to  the  urethritis,  and  there  is  such 
an  obstruction  of  tlu>  return  circulation  as  to  produce  swelling  and  edema  of  the  |)repuce; 
this  not  only  makes  access  to  the  urethra  difficult,  but  conceals  any  e.\<'oriation  and 
ulceration  which  may  be  goiug  on  beneath  it.  Sometimes  this  tumefaction  proceeds 
to  a  degree  where  gangrene  results. 

All  these  local  disturbances  \\\\\  be  accompanied  by  more  or  le.ss  lym{)hatic  involve- 
ment in  the  groins  and  in  the  perineum,  with  great  .soreness  and  tenderness  throughout 
the  entire  genital  tract.  Chordee  (painful  erection)  is  a  common  and  painful  compli- 
cation of  this  stage  of  the  di.sea.se.  Finally  a  well-marked  degree  of  aiifo-inlo.ricafian, 
with  its  ordinary  febrile  and  .septic  manifestations,  may  ensue.  As  the  disea.se 
spreads  farther  back  into  the  deep  urethra  there  is  irritability  of  the  bladder,  while  in 
.severe  ca.ses  the  frequent  attempts  at  urination  thus  exc-ite(l,  with  the  accomj)anying 
pain  during  the  act  of  expelling  a  few  drojxs  of  urine,  are  distressing  features  of  the  dis- 
ease. The  pains  are  not  limited  to  the  organs  involved,  but  are  often  referred  to  the 
back,  to  the  perineum,  and  down  the  thighs.  The  symptoms  above  referred  to  belong 
to  a  w'cll-marked  case  of  acute  specific  type.  There  may  be  milder  manifestations  of 
each  kind,  and  occasionally  a  case  will  run  its  course  with  but  a  minimum  of  the  diffi- 
culties aiul  discomforts  above  mentioned.  Sometimes  by  the  end  of  the  third  week, 
usually  before,  the  disease  will  show  a  tendency  to  subside,  even  if  inadequately  treated. 
The  inflammatory  symptoms  become  less  marked,  the  discharge  thinner  and  less  volu- 
minous, imtil  jjerhaps  by  the  end  of  the  seventh  week  there  is  noticed  only  a  small  amount 
when  the  patient  rises  in  the  morning.  With  all  this  apparent  and  spontaneous  improve- 
ment there  may  be  present,  nevertheless,  a  serious  and  distressing  amount  of  peri-urethral 
infiltration,  which  will  soon  be  followed  by  cicatricial  contraction  and  the  formation  of 
a  stricture,  the  most  frequent  sequel  of  gonorrhea. 

Complications. — Complications  may  occur  along  any  portion  of  the  genito-urinary 
tract.     These  will  be  considered  in  their  anatomical  order. 

Balanitis. — Balanitis  signifies  an  inflammation  of  the  mucosa  covering  the  glans. 
^Yhen  the  mucous  surface  of  the  prepuce  is  also  involved,  as  it  usually  is  when  the 
orifice  is  contracted,  then  the  condition  is  known  as  haJanopoMhitis.  In  the  absence  of 
ordinary  cleanliness  of  the  parts  this  may  go  on  to  erosion  or  extensive  ulceration.  It 
is  sometimes  complicated  with  chancroid  or  chancre.  When  such  a  condition  exists, 
and  the  glans  cannot  be  sufficiently  exposed  for  purposes  of  cleanliness,  the  dorsum 
of  the  prepuce  should  be  slit  up  sufficiently  to  permit  of  complete  exposure,  while  in 
some  cases  the  edema  and  the  infiltration  will  be  such  as  to  justify  circumcision.  When 
needed  these  operations  should  be  practised  even  if  raw  surfaces  are  thereby  left  exposed 
to  infection.  Such  possibility  may  be  usually  obviated  by  cauterizing  a  fresh  surface, 
as  soon  as  exposed,  with  pure  carbolic  acid  or  one  of  the  stronger  caustics,  or  operation 
may  be  made  with  the  thermocautery. 

Folliculitis. — Folliculitis  implies  the  extension  of  the  infection  to  the  follicles  and 
lacunse  which  abound  within  the  urethral  canal.  As  long  as  their  orifices  do  not 
become  occluded  they  easily  discharge  their  contents  into  the  urethra,  but  when  so  swollen 
as  to  become  occluded  they  lead  to  the  formation  of  abscesses,  which,  beginning  in  a 
minute  way,  may  sometimes  give  relatively  extensive  disturbance.  These  discharge 
internally;  sometimes  they  so  present  that  they  may  be  opened  externally,  as  they  should 
be  under  these  circumstances.  They  form  a  communication  between  the  urethra  and 
the  exterior,  and  in  this  manner  the  majority  of  the  ordinary  urinary  fistuhe  are  produced. 
These  often  occur  in  the  perineum,  but  sometimes  even  in  the  pendulous  portion. 

Peri-urethritis. — Inflammation  frequently  extends  beyond  the  anatomical  confines 
of  the  urethra,  and  produces  a  degree  of  infiltration  which  is  often  well  marked  and 


150  SURGICAL  DISEASES 

disastrous.  The  site  of  such  a  lesion  is  marked  by  a  nofhile,  more  or  less  tender,  which 
may  subsequently  break  down  into  an  abscess.  The  {)us  from  these  abscesses  will 
usually  escape  into  the  urethra.  Sometimes  it  burrows  into  the  tissues  of  the  corpus 
spr)ngiosum,  or  travels  even  farther,  and  {)roduces  locally  extensive  destruction  of 
tissue,  with  its  possibility  of  urinary  infiltration  as  a  sequel,  and  all  the  septic  disturbances 
which  can  be  imaffined  as  resulting  therefrom.  Thus  fistulas  often  folhnv  abscess  forma- 
tion, and  these  may  be  succeeded  l)y  phlebitis  of  the  jjeri-urethral  and  |)n>static  plexuses, 
extensive  destruction  or  nuilti[)le  abscesses,  or  even  (gangrene  and  jncniia.  Peri- 
urethritis is  the  essential  factor  in  the  production  of  strictures  of  tiic  urethra,  which 
constitute  an  exceedingly  common  condition. 

While  urethral  stricture  is  a  common  result  of  gonorrhea  it  constitutes  by  itself  a  special 
lesion.  (See  chapter  on  the  Genito-urinary  Tract.)  These  peri-urethral  infiltrations 
may  occur  in  irregular  patches,  so  variously  placed  as  to  encroach  upon  the  urethra  at 
different  points  without  completely  surrounding  it,  or  they  may  form  tubular  lesions 
by  which  very  serious  annidar  constriction  is  produced.  The  degree  of  infiltration  is, 
to  some  extent,  a  measure  of  the  violence  of  the  inflammatifjn  and  of  the  virulence  of  the 
infection.  This  is  true,  however,  only  up  to  a  certain  point.  One  object  of  properly 
directed  treatment  should  be  to  guard  against  the  deep  extension  of  a  gonorrheal 
iid'ection,  in  order  to  limit  the  tenclency  to  the  formation  of  stricture. 

Between  the  folds  of  the  triangular  ligament  are  situated  two  racemose  follicles  known 
as  Cowper's  glands.  These  occasionally  become  infected  in  the  same  way  as  the  anterior 
follicles  of  the  urethra  and  give  rise  to  a  painful  swelling  in  the  perineum,  which  gives 
most  discomfort  to  the  patient  in  the  sitting  posture.  This  condition  is  known  as 
Cowperifis.  It  may  proceed  to  abscess  formation,  in  which  case  incision  in  the  perineum 
should  be  made  for  its  relief. 

Prostatitis. — The  prostate  consists  of  a  collection  of  follicles  embedded  in  a  mass 
of  involuntary  muscle  fiber.  The  largest  of  these  follicles  is  known  as  the  ufriele,  or, 
under  the  old  anatomical  name,  utenis  mascu/inufi.  These  are  liable  to  invasion  when 
the  infection  has  reached  the  deep  urethra.  The  reaction  which  follows  in  this  tissue 
after  such  invasion  gives  rise  to  prostatitis  and  causes  much  pain  and  general  reaction. 
The  prostate,  being  embedded  within  a  fibrous  capsule,  cannot  expand  easily  when 
it  becomes  infiamed,  and  the  pressure  thus  made  not  only  causes  intense  pain,  but 
will  also  obstruct  the  urethra  and  occasion  great  difficulty  in  urination,  sometimes 
retention  of  urine.  In  proportion  to  the  other  disturbance  will  be  the  general  reaction, 
and  fever  may  run  high,  with  early  expressions  of  septic  intoxication  or  of  septicemia. 
The  prostate  becomes  tender,  and  pain  is  felt  not  only  in  the  pelvic  region,  but 
in  the  back  and  in  the  thighs,  as  well  as  along  the  urethra.  Prostatic  abscess 
is  a  frequent  sequel  to  this  condition ;  it  sometimes  evacuates  spontanef)Usly  into  the 
urethra,  or  bursts  thrf)ngh  the  capsule  and  burrows  along  the  structures  in  the  |)erineum 
and  lower  pelvis;  occasionally  it  empties  into  the  rectum.  Intensity  of  symptoms  should 
give  rise  to  a  suspicion  of  prostatic  abscess,  and  a  perineal  incision  should  be  made  early 
and  the  abscess  evacuated.  Occasionally  these  abscesses  present  toward  the  rectum, 
when  they  should  be  tapped  or  incised  through  the  bowel. 

From  the  prostatic  urethra  inflammation  may  extend  on  one  side  or  both  along 
the  vas  deferens  to  the  seminal  vesicles.  The  production  in  this  way  of  a  vesiculitis 
is  made  known  by  the  reference  of  pain  to  the  rectum  and  by  the  a|)pea ranee  of 
blood,  sometimes  with  pus,  in  the  seminal  discharge.  By  a  digital  examination 
of  the  rectum  the  enlarged  and  tender  vesicles  can  be  recognized  above  the  pros- 
tate. 

When  the  deep  urethra  has  become  seriously  involved  the  condition  of  the  patient  is 
impromising.  Belfield  calls  attention  to  the  trij)le  function  of  the  deep  urethra,  in  that 
the  impulse  to  urinate  originates  therein,  that  it  is  a  sphincter  for  the  bladder,  and 
that  it  is  intimately  concerned  with  the  sexual  act.  When  it  is  disturbed  by  gonorrheal 
infection  all  of  these  functions  are  disturbed,  the  most  .serious  symptoms  being  in- 
creased desire  to  urinate,  amounting  to  almost  constant  vesical  tenesmus;  marked 
difficulty  in  exjnilsion  of  urine,  which  may  increase  to  comj)lete  retention,  and  frequent 
bloody  emissions,  with  chordee.  The  pain,  the  heat,  and  the  sense  of  tension  in  the 
perineum  and  in  the  parts  around  it  are  distressing,  as  well  as  pain  during  and  after 
urination,  which  is  usually  referred  to  the  end  of  the  urethra.  The  last  few  drops  of 
urine  will  often  be  bloodv. 


aosoiauiEA  151 

Cystitis. — Cystitis  is  the  not  iiit"rc(iiiciit  rcsuli  of  iIk-  fm-ilici-  iiii<rration  of  tlic  infectious 
process  from  the  deej)  urethra  to  tlie  l)la<l(ler.  'I'lie  process  is  usually  acute  and  serves 
to  further  couiplieate  llu'  case  and  to  liarass  ihi'  patient.  Iv\ce|)t  in  the  nature  of  the 
excilinij;  causes  cystitis  (htlers  but  little  from  the  other  varieties  to  he  considered  in  their 
a|)propriate  place  (</.  v.).  Cystitis  of  ironorrheal  orij^in  is  likely  to  travel  alon<^  the  ureters 
and  lead  to  involvement  of  the  kidneys.  Ascendinif  infection  is  most  conunonlv  of  fjonor- 
rheal  orii^iu.  In  proportion  to  the  extent  and  rapidity  with  which  the  (hsease  travels 
uj)wartl  the  ease  is  marked  by  expressions  of  septic  intoxication  and  infection,  such  as 
chills,  fever,  pain  in  the  loins,  alonj;  the  ureters,  and  in  the  testicles.  The  kidneys  may 
lu'come  enlarif(>tl.  .\  more  minute  appreciation  of  the  condition  of  affairs  can  be  obtained 
by  microscopic  examination  of  the  urine.  In  proportion  as  the  kidney  is  involved, 
there  is  a  |)repondcrance  of  albumin,  ^  r.,  more  than  ])us  alone  would  j)roduce. 
One  of  the  numerous  ways  in  which  fjonorrhea  kills  its  victims  is  by  the  production  of  a 
pilfloiicphntis  of  the  tyjjc  known  as  '' smv/icd/  Icidnci/.^' 

Lymphangitis. — No  such  invasion  of  mucous  membrane  by  sej)tic  ortfanisms  can 
take  |)lace  without  active  participation  of  the  lym])hatics  in  the  region  involved.  In 
eases  of  (gonorrheal  or  even  non-gonorrheal  urethritis,  not  merely  enlarp;ement  of  the 
lymj)h  nodes  in  the  groin  may  occur,  but  an  active  lymphangitis,  manifested  as  a  tender, 
sensitive  cord  beneath  the  skin,  especially  along  the  dorsum  of  the  penis.  The  lymph 
nodes  thus  become  involved  and  sometimes  suppurate,  and  these  abscesses  are  referred 
to  as  suppurafi)uj  f/oiiorrJteal  buboes.  The  sui)purative  feature  is  j)robably  caused  by 
contamination  with  the  ordinary  pyogenic  organisms. 

The  Testicles. — Gonorrheal  infection  seems  often  to  extend  along  the  vas  and  thus 
invades  the  e})ididymis,  where  evidences  of  activity  are  more  frequent  than  in  the  vas  itself. 
Epididipniti.s  complicates  cases  of  clap  usually  after  the  second  week.  It  is  character- 
ized by  pain,  tenderness,  and  swelling  of  the  epididymis,  ^vhich  occupies  the  same  j)osi- 
tion  relative  to  the  testis  proper  that  the  heel  does  to  the  rest  of  the  foot  when  a  person 
stands  in  the  ordinary  military  position,  i.  e.,  to  the  rear  and  inner  side.  The  swelling 
becomes  pronounced,  and  it  is  not  unusual  for  a  certain  degree  of  swelling  to  be 
manifested  in  the  testis  proper,  with  the  accumulation  of  a  small  amount  of  fluid  in  the 
sac  of  the  timica  vaginalis,  thus  constituting  a  mild  degree  of  acute  hydrocele.  While 
the  inflammation  is  confined  to  the  epididymis  the  jmin  is  not  intense,  but  of  a  dull, 
heavy  character;  but  when  the  testis  proper  is  involved  there  is  a  true  orchitis,  the  inflam- 
mation being  confined  within  the  inelastic  sclerotic  tunic,  and  the  pain  then  may  be 
severe.  Considerable  fever  accompanies  many  of  these  cases,  with  occasionally  some 
edema  of  the  scrotum  and  congestion  of  the  testicular  coverings.  The  weight  of  such 
a  "swelled  testicle,"  as  this  condition  is  called  by  the  laity,  is  irksome,  and  occasionally 
causes  extreme  discomfort.  Under  these  circvmistances  physiological  rest,  i.  e.,  in 
bed,  and  the  use  of  a  suitable  suspensory  apparatus  are  essential. 

While  resolution  of  this  swelling  ordinarily  begins  early  and  proceeds  satisfactorily, 
the  latter  portion  of  the  process  is  often  slow  and  tedious,  and  the  epididymis  thus  once 
involved  will  for  months  contain  nodules  and  irregularities  of  contour.  Usually  the 
affection  is  limited  to  one  side;  but  both  testicles  may  be  involved.  If  the  infection  be 
violent  and  the  treatment  inefficient  abscesses  may  result. 

This  condition  calls  for  early  and  effective  treatment.  If  seen  at  the  very  outset, 
progress  of  the  lesion  may  be  checked  by  embedding  the  affected  part  in  cold,  wet  com- 
presses, and  keeping  them  cold  w^th  ice.  Relief  later  is  more  likely  to  be  afforded  by  hot 
applications,  and  a  hot  poultice  containing  a  small  amount  of  fine-cut  tobacco  has  been 
popular  as  a  local  application — the  tobacco  apparently  being  anodyne  in  its  effect, 
although  perhaps  no  more  so  than  belladonna  leaves.  This  may  be  regarded  as 
a  good  emergency  dressing  when  it  affords  the  only  means  of  treatment.  The  greatest 
relief  will  be  obtained  by  the  application  of  guaiacol,  diluted  with  three  volumes  of  olive 
oil  or  castor  oil,  well  ap])lied  over  the  scrotum,  and  covered  with  oiled  silk  or  rubber 
tissue.  This  application  should  be  made  twice  a  day.  Later,  in  the  more  chronic  and 
less  painful  stages,  a  reduced  mercurial  ointment  containing  a  little  guaiacol  or  ichthyol 
may  be  used  to  advantage,  resolution  being  thereby  assisted.  In  quite  tedious  cases 
the  flying  application  of  the  actual  cautery  is  serviceable.  Internally  tincture  of 
Pulsatilla  has  proved  beneficial.  It  should  be  given  in  1  Cc.  doses  every  two  hours. 
While  the  benefits  accruing  from  its  use  are  questionable,  it  has  helped  to  allay  fever  and 
subdue  pain. 


152  SURGICAL   DISEASES 

Much  has  been  said  about  the  sterility  which  resuhs  from  epidid\-njitis,  especially 
when  both  sides  have  been  involved.  It  is  easy  to  understand  how  the  vas  may  become 
occluded  in  many  cases,  either  temporarily  or  permanently,  and  yet  within  my  own 
observation  men  have  suffered  from  the  double  lesion  and  vet  l)efrotien  children. 

Gonococcus  Septicemia  and  Pyemia.  Postgonorrheal  Arthritis  (Gonorrheal  Rheuma- 
tism).— Cun.-.idering  the  extent  of  tiie  mucuu.-^  tract  involved,  tlic  (jpcn  \H>n  (jf  entry 
for  germs,  and  the  virulence  of  these  organisms  in  many  cases,  it  is  remarkable  that 
there  are  not  more  conspicuous  illustrations  of  septic  absorption  in  cases  of  gonorrheal 
urethritis.  That  these  do  occur  and  have  a  widespread,  sometimes  disastrous,  effect  ha.s 
long  l>een  recognized.  The  severe  forms  are  usually  the  more  acute,  and  if  they  a.ssume 
the  septicemic  type,  go  on  to  abscess  formation,  and  in  parts  which  are  not  always  acces 
sible.  In  rare  instances  septic  disturbance  assumes  the  pyemic  tyjx'.  Tlie  writer  believes 
that  he  was  the  first  to  report  a  case  of  typical  pyemia  following  gonorrhea,  and  to  recog- 
nize it  as  such. 

Aside  from  these  acute  manifestations,  more  chronic  and  mild  affections,  especially 
of  the  serous  membranes,  are  well  known.  The  mo.st  common  of  these  e.vhibitions 
occur  in  the  joints,  mostly  in  the  knee.  A  gonococcus  peritonitis,  pericarditis,  or  endo- 
carditis are,  however,  well  known.  B?cau.se  of  the  similarity  of  the  discomfort  and  the 
disability  resulting  from  the  joint  complications  of  clap  to  the  ordinary-  joint  manifesta- 
tions of  rheumatism,  these  lesions  have  long  been  popularly  called  rjonorrlieal  rJwuma- 
tism.  The  name,  however,  should  be  discarded  as  l>eing  incorrect,  and  for  it  the  best 
substitute  would  be  postgonorrheal  arthritis. 

These  lesions  may  be  sudden  in  their  onset  or  may  come  slowly.  They  may  occur 
at  any  time  during  the  acute  stage  or  after  its  apparent  subsidence.  The  first  manifes- 
tations involve  the  seroas  membranes  proper;  the  filjrous  tissues  participate  sooner  or 
later,  and  the  infiltration  resulting  from  the  inflammation  thus  set  up  will  often  perma- 
nently compromise  their  integrity  and  cau.se  an  impairment  of  their  function  for  the  rest 
of  the  patient's  life.  They  are  usually  confined  to  one  of  the  larger  joints,  but  may 
involve  several,  either  simultaneously  or  consecutively.  In  acute  cases  the  swelling  is 
somewhat  pronounced  and  the  pain  and  soreness  intense.  The  local  sMiiptoms  simu- 
late those  of  acute  articular  rheumatism.  In  the  fluid  drawn  from  the.se  joints  the 
gonococcus  can  be  occasionally  demonstrated.  The  course  of  the  disease  is  usually 
slow,  and  convalescence  may  be  protracted.  Xor  is  the  disability  acute  only  and  tem- 
porary, but  it  is  often  made  pennanent  by  the  formation  of  adhesions  resulting  from  the 
condensaiim  of  exudates.  Panial  or  complete  ankylosis  may  result,  with  considerable 
deformity.  The  muscle  spasm  provoked  Vjy  the  acute  joint  inflammation  will  occasion 
the  same  distonions  and  subluxations  as  are  produced  by  tuberculous  and  other  forms 
of  arthritis,  and  of)erations  varying  in  severity  from  forced  motion  to  joint  exsection 
may  later  be  necessar}-.     (See  pp.  392  and  393.) 

The  writer  has  seen  cases  of  postgonorrheal  toxemia  of  extremely  chronic  and  even 
fatal  tyjx",  where  the  joints  were  conspicuously  involved  and  where  they  did  not  con- 
stitute the  most  serious  features  of  the  disease.  These  cases  proved  most  intractable  to 
treatment  and  illustrate  the  possible  complications  of  gonorrhea. 

In  addition  to  the  joints  various  hursop  and  tendon  sheaths  may  suffer  in  the  same  way 
as  do  the  joint  membranes.  Such  lesions  are  .seen  about  the  hands  and  feet,  especially 
about  the  tendo  Achillis,  and  are  also  seen  in  the  muscles  of  the  neck  and  of  the  orbit. 

The  treatment  of  these  gonorrheal  complications  should  be  effected  largely  by  improv- 
ing elimination  and  getting  rid  of  the  general  toxemia;  thus  hot-air  baths,  diuretics,  and 
cathartics  are  ad\-isable.  The.se  eliminants,  with  free  ma.ssage,  are  u.seful  in  dislodging 
the  toxic  products. 

Treatment. — The  treatment  of  gonorrhea  is  directed  not  alone  toward  the  mere 
alleviation  of  symptoms,  but  to  the  destruction  of  the  invading  germs  The  patient 
should  abstain  from  much  exerci.se,  and  in  ca.ses  of  severity  should  be  kept  in  bed,  avoid 
alcohol  and  tobacco,  and  eat  sparingly  of  meats  and  of  richly  seasoned  foods.  He  should 
wear  a  "gonorrnea  bag,"  or  large  condom,  and  there  .should  be  no  obstruction  to  the  out- 
flow of  pus.  His  hands  should  be  washed  immediately  after  contact  with  the  parts 
involved,  and  all  dressings  and  linen  which  may  have  been  contaminated  should  be 
promptly  burned. 

The  actual  treatment  of  gonorrhea  should  be  both  internal  and  local.  Internal 
treatment  should  consist  (1)  of  the  administration  of  la.xative.s;  (2)  of  such  amount  of 


aosouiaii.A  ir)3 

iilkali  as  may  he  iicccssarv  to  ovfrcniiic  Ii\  pd'acidily  of  tlu'  urine  and  iiiiii^^atc  llic  dis- 
tress caused  duriuij  its  |)assajj;e;  (o)  of  remedies  which,  l)eiuif  elimiuiiti'd  l)y  the  kichieys, 
serve  to  medicate  the  urine  and  tjive  it  the  etVect  of  a  retrojcction ;  (I)  of  such  anodynes 
and  sedatives  as  may  he  necessary  to  i,nve  comfort,  alhiy  distress,  and  produce  sleep  or 
relievi'  and  prevent  chordi-e. 

Of  tlie  (Irufjs  which  are  supposed  to  be  eliminated  hy  the  kidneys,  the  balsuins  have 
sustained  a  hii;h  rej)utation.  Among  tiiese  is  eiihehs,  of  which  2  or  W  (Jm.  nuiy  he  taken 
every  two  or  three  hours,  as  this  remedy  favorably  influences  the  amount  of  disclwirifc, 
thou<;h  sometimes  disturbinjj  the  stomach.  Of  the  oleoresin  of  co|)aiba  a  \  dm.  capsule, 
taken  .several  times  a  day,  is  more  pleasantly  borne  by  the  stomach,  and  with  nearly 
as  go«)d  effect  as  cubebs.  Copaiba  is  known  to  produce  a  vivid  scarlatiniform  rash. 
The  oil  of  sandal-wood,  or  santal  oil,  is  the  most  efficient  of  the.se  remedies,  and  may  be 
given  in  the  same  dose  as  copaiba.  That  tlu'.se  drugs  are  eliminated  by  the  kidneys 
is  shown  by  the  odor  which  tliey  impart  to  the  urine.  It  must  be  .said,  however,  that 
these  remedies  are  of  but  trifling  benefit  tmtil  the  t)ladder  is  involved;  wlien  this  occurs, 
they  may  j)rove  of  great  value. 

The  urine  should  be  diluted  that  it  may  be  less  irritating,  and  also  to  overcome  its 
aeidity.  Fluids  shoukl  be  administered  in  profusion  and  alkaline  diuretics  in  con- 
siderable doses.  Hyjieracidity  is  readily  (H)ntrolled  by  the  administration  (jf  lif|Uor 
pota.ssie,  or  the  common  sodiimi  l)icarbonate. 

Sedatives  may  be  necessary  even  from  the  first.  The  stronger  anodynes  are  rarely 
needed  diu'ing  the  first  day  or  two,  but  by  the  end  of  the  first  week  vesical  tenesmus  and 
ehordee  may  be  .so  markd  that  remedies  such  as  cannabis  indica,  lactucarium,  chloral, 
and  the  bromides  may  prove  insufficient,  and  an  opiate  should  then  be  administered. 
When  required,  morphine  or  heroine  subcutaneously  and  in  doses  sufficient  to  promptly 
bring  about  the  eftect  desired  are  preferable. 

The  local  treatment  of  urethritis  is  directed  to  the  alleviation  of  discomfort  and  dis- 
tress and  the  cure  of  the  local  disea.se.  Much  has  been  said  about  abortive  treatment. 
There  is  no  such  thing  as  aborting  the  disease,  ^luch  may,  however,  be  done  in  the  way 
of  mitigating  and  shortening  its  course,  and  mild  cases,  especially  of  the  non-sj)ec-ific 
fonn,  may  be  considerably  relieved  within  a  few  days. 

The  local  treatment  is  carried  out  by  injections  into  the  lU'ethra,  which  must  be  made 
with  a  syringe,  preferably  of  hard  rubber,  with  a  blunt  tip  and  without  a  nozzle,  or  by 
a  douche  bag  connected  with  a  soft  catheter,  all  of  which  should  be  kept  constantly  steril- 
ized. During  the  first  days  of  an  attack,  when  only  the  anterior  part  of  the  urethra  is 
affected,  treatment  can  be  made  more  readily  and  effectively  with  a  small  "P"  syringe, 
and  at  this  time  only  15  to  20  Cc.  of  fluid  will  be  recpiired,  which  should  be  held  in  the 
urethra  for  some  time.  When  irrigation  is  decided  upon  a  douche  should  be  emjiloyed. 
Accurate  directions  should  be  given  the  patient  as  to  how  to  make  the  injections,  and 
he  should  be  cautioned  to  first  em])ty  the  bladder  before  using  the  .syringe.  The  patient's 
comfort  may  be  increased  by  injections  of  water  up  to  a  temperature  of  115°  F.  Antisep- 
tics, /.  e.,  pota.ssium  permanganate,  boric  acid,  or  one  of  the  new  preparations  of  the  silver 
salts,  may  be  added  to  the  water.  The  parts  may  be  advantageously  immersed  in  hot 
water  at  intervals  during  the  day,  and  for  fifteen  or  twenty  minutes  at  a  time.  There 
are  many  ways  of  conducting  local  treatment  in  the.se  ca.ses.  Those  mentioned  below 
have  given  the  best  results  in  the  practice  of  the  writer. 

A  very  satisfactory  method  would  be  to  commence  the  local  treatment  with  the  use 
of  hot  water,  as  above,  every  two  to  six  hours,  and  to  follow  it  with  a  small  injection  of 
an  emulsion  of  bismuth  sul)nitrate,  with  sufficient  cocaine  and  a  little  morphine  to  bhmt 
sensibility  and  diminish  tenderness  and  pain.  The  following  formula,  which  may  be 
varied,  will  accomplish  this  purpo.se:  ^lorphine  sulphate  0.3,  cocaine  muriate  2,  bismuth 
subnitrate  20,  cherry-laurel  water  150,  mucilage  of  acacia  50. 

The  injection  should  be  retained  for  a  few  moments  and  no  effort  made  to  expel  it. 
The  bismuth  salt  is  not  only  antiseptic,  but  is  soothing,  .slightly  astringent,  and  non- 
irritating. 

Belfield  has  recommended  the  use  of  the  yellow  hydrastia  muriate  in  connection  with 
protargol.  His  formula  is  as  follows:  Yellow  hydrastia  miu-iate  2.50,  protargol  1.50, 
glycerin  15,  water  500.  After  using  this  for  a  few  days  the  proportion  of  protargol 
may  be  doubled.  Of  this  preparation  15  to  20  Cc.  should  be  injected  .several  times 
a  dav.     The  silver  salts  are  the  least  irritating  of  all  the  stronger  and  more  reliable 


154  SURGICAL  DISEASES 

antiseptics,  and  drug  manufacturers  are  putting  up<jn  the  market  at  frequent  intervals 
new  pre])arations  for  which  much  is  claimed.  Among  the  latest  of  these  is  argyrol,  a 
combination  of  silver  with  albumen  (vitellin),  in  such  form  as  to  make  it  antiseptic  and 
non-irritating.  In  solution  it  is  of  a  dark  mahogany  color  and  stains  whatever  it  comes 
in  contact  with;  these  stains,  however,  are  readily  washed  out.  Argyrol  in  solutions  of  2 
to  5  per  cent,  strength  has  proved  reliable,  and  if  such  a  solution  be  retained  in  the  urethra 
for  five  minutes  at  a  time  a  pronounced  effect  may  be  made  upon  the  disease.  It  is 
mv  custom  to  alternate  the  use  of  the  bismuth  formula  with  a  solution  of  argyrol  as  above, 
and  in  this  way  give  the  greatest  relief  in  the  shortest  time.  It  has  been  demonstrated 
that  under  the  influence  of  this  preparation  all  gonococci  which  are  reached  by  it  are 
destroyed;  therefore  the  earlier  it  is  employed  the  better.  Before  using  either  of  these 
formulas  the  anterior  urethra  should  be  washed  with  hot  water  or  with  hot  normal  salt 
solution.  Xo  harm  need  be  feared  should  either  of  the  above  injections  reach  the 
deep  urethra,  and  the  effort  should  be  to  make  them  reach  at  least  as  deeply  as  the 
disease  has  gone. 

When  the  discharge  has  reached  what  Finger  ha>  called  "tlic  mucous  terminal  stage," 
then  the  argyrol  may  be  used  two  or  three  limes  a  day  only,  and  one  of  the  following 
solutions  substituted  for  it  part  of  the  time:  Zinc  sulphate  0.75,  bismuth  suVjnitrate  S, 
colorless  liquor  hydrastis  15,  cherry-laurel  water  (lO.  Df  this  solution  10  Cc.  may  be 
used  three  or  four  times  a  day. 

Belfield  strongly  recommends  the  use  at  this  time  of  a  solution  of  muriate  of  hterberine, 
in  strength  of  ^  to  1  per  cent.,  or  the  yellow  hydrastia  muriate  in  about  the  same  strength. 
He  also  recommends  zinc  chloride  0.25,  zinc  iodide  0.50,  water  500.  Either  of  the 
above  salts  may  be  added  to  this. 

When  nothing  remains  of  the  discharge  but  the  so-called  "morning"  or  "militarv'  drop," 
and  the  urine  is  almost  clear,  argyrol  solution  at  night  and  one  of  the  afjove  formulas 
once  or  twice  through  the  day  will  be  sufficient.  This,  in  brief,  is  a  description  of  how- 
a  case  of  urethritis  may  be  satisfactorily  treated. 

The  systematic  use  of  potassium  ])ermanganate  solutions  was  introduced  by  Janet, 
and  has  been  enthusiastically  described  and  prescribed  by  Valentine.  The  treatment 
LS  more  complicated  anfl  less  satisfactory  than  that  advised  above. 

With  deep  extension  of  the  disease  and  its  added  s^nuptoms  of  tenesmus,  pain  local 
and  referred,  etc.,  the  limit  of  the  injection  should  be  extended  and  the  entire  urethra 
should  now  be  treated.  The  bladder  being  empty,  the  patient  should  make  a  strong 
effort  to  empty  it  again  at  the  moment  when  fluid  is  being  injected  into  the  urethra;  the 
compressor  muscle  being  thus  relaxed,  the  fluid  passes  into  the  deep  urethra.  It  will 
take  a  little  practice  to  enable  him  to  flo  this,  but  when  once  learned  the  procedure  is 
simj)le,  and  those  who  cannot  accomplish  it  in  the  standing  position  will  succeed  if  they 
lie  down  before  making  the  attempt.     In  this  way  the  entire  urethra  may  be  traversed. 

In  the  treatment  of  deep  urethritis  it  is  not  necessary  to  change  the  formulas  or  drugs 
above  advised. 

Under  this  line  of  treatment  it  may  be  po.-;.-ible  to  cure  ilie  majority  of  cases  of 
gonorrhea  in  from  two  to  five  or  six  weeks.  This  by  no  means  indicates  that  the 
lesion  is  actually  cured,  for  trifling  evidences,  such  as  adhesion  of  the  lips  of  the 
meatus,  with  the  retention  of  a  drop  or  so  of  mucopus,  and  the  presence  in  the  urine 
of  the  so-called  "clap  threads,"  i.  e.,  threads  of  fiocculent  material  that  consist  of  mucus 
and  epithelial  debris  loaded  with  bacteria,  will  for  a  long  time  be  noted.  These  appear- 
ances indicate  that  there  are  still  areas  along  the  urinary  tract  which  are  infected,  and 
are  sources  of  possible  danger. 

The  vesiculitis  which  often  follows  deep  urethritis,  as  shown  by  the  enlargement  of 
the  vesicles,  detected  by  rectal  examination,  requires  physiological  rest,  hot  sitz  baths, 
hot  enemas,  and  opiates,  the  latter  usually  by  suppository.  After  a  short  time  the 
vesicles  should  be  "milked"  with  a  finger  in  the  rectum,  gentle  pressure  being  made 
toward  the  prostate  in  the  direction  of  their  outlet.  This  will  frequently  cause  an  out- 
flow into  the  urethra  of  pus  and  debris  and  give  great  relief.  Should  the  infection  per- 
sist and  the  above  manipulation  prove  insufficient,  the  vesicles  may  be  opened  through 
the  rectum,  washed  out,  and  packed  with  gauze. 


(iiiioMc  (iOXORRiiEA,  on  (;LI:I:T 


155 


CHRONIC  GONORRHEA,  OR  GLEET. 

(ili't>t  is  the  nanio  <,mvcii  to  oroiionhca  wliicli  persists,  hciiii;  oiilv  j)artly  iiifliiciurd 
by  treatment,  and  which  has  extended  over  an  arbitrary  j)eriod  phieed  nsiially  at  six 
weeks  to  two  months.  Strictly  spcakiiijj  the  term  (//ni  shonld  he  restri<ted  to  ca.ses 
where  there  is  a  mnco|)nrnlcnt  (hscliarjie  from  the  meatus,  often  complicated  hy  for- 
mation of  strictures  in  the  (inferior  urethra;  on  tiie  other  hand,  a  rhrotiir  f/ojiorrhra 
may  for  a  l<in»r  time  persist  in  the  drrj)  urethra  and  the  <jlands  and  duets  adjoining;, 
whence  will  issue  a  diseharije  which  appears  aiUciimly,  hut,  nevertheless,  comes  from 
the  dc])ths  of  the  <;enito-urinary  tract. 

It  is  po.ssil)l(>  to  have  a  chronic  gonorrhea  with  little  or  no  true  f:;lcet,  the  infection 
beinij  latent,  l)Ut  nevertheless  persisting.  In  n;j(.(.t  the  dischar<;e  varies  from  a  thin 
watery  flow  to  one  which  is  profuse  and  j)urulent,  most  noticeable  in  the  morninjr  on 
risini;,  when  the  meatus  may  be  occluded  by  adhesion  of  the  surfaces  and  there  ap|)ears 
the  so-called  "morning  droj)."  Careful  investigation  of  the  lU'ethra  will  generally  dis- 
clo.se  at  least  some  constriction,  with  tender  areas  along  the  anterior  urethra.  To 
sueeessfully  treat  the  di.seaso  these  areas  and  constrictions  should  be  determined  and 
suitably  medicated.  For  this  purpose  two  instruments  especially  are  necessary — the 
hull)()us  houf/ir,  for  which  a  sound  of  the  same  size  is  an  unsatisfactory  substitute,  and 
the  cndo.scopr,  through  which  the  lesions  may  be  not  only  viewed  but  suitably  treated. 

The  peculiar  discharge  comes  from  a  lesion  of  one  of  the  following  varieties — either 
from  i.solated  areas  of  inflamed  mucous  membrane  with  underlying  exudate,  from  fol- 
licles and  vesicles  which  fail  to  completely  em])ty  them.selves,  or  from  preexisting  stric- 
tures. The  endoscope  will  easily  reveal  the  first  and  second  of  these;  the  l)ulbous 
bougie  the  first  and  third,  while  further  examinati(jn  by  the  rectum  may  be  necessary  to 
decide  in  regard  to  the  seminal  vesicles. 

Fig.  28 


^s 


Bulbous  sound. 


The  bulbous  bougie  is  an  instrument  of  great  importance  in  uretliral  work.  It  should 
be  carefully  sterilized  before  introduction,  and  the  urethra  should  be  cleansed  before 
its  use.  The  instrument  should  be  gently  passed  into  the  urethra;  its  course  will  be 
obstructed  by  any  constriction  which  will  give  rise  to  stricture  of  smaller  caliber  than 
the  bougie  itself,  while  the  discomfort  or  ])ain  which  it  will  excite  as  it  passes  over 
a  tender  or  ulcerated  area  will  be  significant.  The  urethra  is  most  distensible  at  its 
bulbous  portion,  while  its  caliber  varies  in  different  individuals,  ranging  ordinarily  from 
30  to  35  of  the  French  scale,  while  the  urethral  diameter  is  al)out  four-tenths  of  the 
circumference  of  the  penis.  We  owe  more  to  the  studies  of  Otis  in  this  matter  than  to 
any  other  investigator.  He  also  showed  that  the  size  of  the  meatal  opening  is  not  a 
criterion  as  to  the  size  of  the  urethra;  that  the  contracted  meatus  often  produced  a  cer- 
tain degree  of  reflex  and  spasmodic  .stricture  behind  it,  and  that  when  the  meatus  is 
too  small  to  permit  the  introduction  of  such  an  instrument  as  the  urethra  should  take 
it  should  be  enlarged,  the  operation  for  its  enlargement  being  known  as  mrafofomij, 
which  may  be  easily  effected  with  a  blunt    bistoury    under   the  local  u.se  of  cocaine. 

Fig.  29 


G  .Tvtwfcun-co: 


Uretlirometer. 


The  meatus  having  been  enlarged  to  suitable  size,  any  consistent  and  organic  constric- 
tion which  then  prevents  the  passage  of  the  bougie  should  be  considered  a  stricture 
and  treated  accordingly.  Such  a  constriction  may  be  of  recent  origin,  when  it  will  be 
found  easily  dilatable,  or  it  may  be  old,  resillient,  and  tough.  Otis  also  devised  an 
instrument  known  as  the  iirethromrtrr,  which  is  of  value  in  the  accurate  estimation 
but  not  necessary  in  the  treatment  of  many  cases. 


156  SUnaiCAL  DISEASKS 

These  instruments  may  be  passed  down  to  the  liiilhous  portion  of  the  urethra;  beyond 
this  further  investigation  should  be  made  with  the  ordinary  sounds.  By  their  use 
mueh  may  be  determined  in  regard  to  prostatie  tenderness,  and  the  combined  use 
of  the  sound  in  the  deep  urethra  with  the  finger  in  the  rectum  will  give  more  accu- 
rate information  regarding  the  size  of  the  prostate  than  can  easily  be  obtained  in 
any  other  way.  Much  reaction,  however,  may  occur  from  the  use  of  the  sounds  in  this 
way,  and  it  is  a  good  rule  never  to  introduce  an  instrument  into  the  deep  urethra 
without  having  ample  reason  therefor,  and  then  doing  it  under  antisej)tic  precautions; 
while,  as  a  formal  measure  after  it,  the  patient  should  be  placed  at  absolute  rest. 
This  serious  reaction,  which  occasionally  follows  instrumentation  of  the  deep  urethral 
passage,  is  commonly  known  as  urethral  fever.  It  is  characterized  by  chills,  elevation 
of  temperature,  and  often  by  local  indic-ations,  the  constitutional  features  being 
sometimes  pronounced,  and  in  rare  cases  terminating  fatally.  Such  .serious  .SMuptoms 
are  difficult  to  explain.  Doubtless  the  use  of  the  instrument  opens  up  paths  of 
fresh  infection,  and  absorption  rapidly  follows,  which  may  be  limited  to  the  surround- 
ing tissues  or  cause  widespread  trouble.  This  may  ensue  after  every  precaution  has 
been  adopted,  although  doubtless  many  of  the.se  ca.ses  have  been  the  result  of  careless- 
ness and  failure  in  antisepsis.  Much  may  be  done  in  the  way  of  prevention  when  this 
condition  is  feared,  for  these  cases  are  rarely  so  urgent  but  that  the  urine  can  be  medi- 
cated and  its  quality  improved,  while  a  ]nirt  of  the  procedure  may  consist  in  having  the 
patient  empty  the  bladder  and  then  carefully  washing  it,  or  filling  it  with  an  antiseptic 
solution,  which  may  be  e.xpelled  before  any  instrument  is  used  except  the  catheter, 
through  which  it  may  be  necessary  to  introduce  the  bladder  wash.  The  administration 
of  2  or  3  Gm.  do.ses  of  urotropin,  with  or  without  quinine,  previous  to  the  exploration, 
may  also  be  of  great  ser\-ice.  The  surgeon  perhaps  does  not  always  take  these  precau- 
tions, but  he  should  when  the  history  of  the  ca.se  shows  that  patients  have  already 
suffered  in  this  way.  In  the  presence  cjf  such  a  history  the  urethra  should  be  explored 
with  great  caution. 

When  the  rectal  examination  is  made  the  intent  should  be  to  discover  any  enlargement, 
irregularity,  or  undue  .sensitiveness  of  the  pro.state,  and  then  to  pass  the  finger  still 
farther  and  asc-ertain  if  there  is  involvement  of  the  .seminal  vesicles.  At  the  .same  time 
a  species  of  manipulation  described  as  "milking"  may  be  conducted,  by  which  the 
contents  of  the  vesicles  as  well  as  of  the  prostatic  utricle  may  be  incited  by  gentle 
pressure,  directed  from  above  downward,  to  empty  into  the  deep  urethra,  whence  they 
may  be  promptly  expelled  or  may  be  carried  out  by  the  urinary  stream,  or  removed 
through  the  endoscope.  The  discharge  of  pus  or  catarrhal  debris  in  any  visible  amount 
is  suggestive,  and  indicates  that  these  ])assages  have  participated  in  the  infectious 
process.  This  act  may  be  repeated  at  three  or  four  clay  intervals;  it  should  be  scj 
gently  done  as  not  to  cause  much  pain,  and  will  be  found  of  great  value  in  cases  calling 
for  it. 

Treatment. — The  treatment  of  gleet  is  essentially  treatment  oi  the  causes  which 
produce  it,  and  the.se  should  be  carefully  determined.  In  the  urethra,  as  in  all  other 
tubular  channels  of  the  body,  an  abnormal  constriction  is  accompanied  by  an  area 
of  excitement  behind  it,  from  which  will  i.ssue  more  than  the  normal  mucous  dis- 
charge. We  see  this  in  stricture  of  the  esophagus,  intestine,  or  any  of  the  ducts.  This 
discharge  is  not  to  be  subdued  by  mere  applications  nor  by  astringent  and  antiseptic  injec- 
tions, but  the  stricture  it.self,  being  the  most  important  factor,  must  be  suitably  managed. 
In  recent  cases  its  gradual  distention  by  the  u.se  of  c-onical  sounds  will  usually  suffice. 

In  long-existing  strictures  more  radical  measures  should  be  adopted,  and  they  should 
be  divided  with  one  of  the  numerous  urethrotomes  in  general  u.se.  Mere  division, 
however,  is  not  sufficient,  but  the  patient  should  be  impressed  with  the  fact  that  cicatricial 
ti.ssue  tends  invariably  to  contract,  and  that  persi.stent  dilatation  is  to  be  practised  lest 
the  stricture  recur.  The  old  saying  u.sed  to  be,  "Once  a  stricture,  always  a  stricture." 
If  this  is  to  be  disproved,  it  can  only  be  by  the  frequent  and  long-continued  use 
of  .sounds.  Ignorance  or  indifference  impel  many  a  patient  to  return  for  further 
treatment,  sometimes  in  a  condition  worse  than  at  first,  while  occasionally  the  penalty 
paid  for  carelessness  is  life  it.self. 

Xo  routine  in  the  treatment  of  gleet  will  give  .satisfactory  rc^sults  beyond  this  fact,  that 
patients  should  be  instructed  to  regulate  their  lives  by  absolute  rules  as  regards  indulgenc-e 
of  every    desc-ription,  and    avoidance  of   intestinal    inactivity   and    c-onstipation.     The 


Cllh'O.MC  (.nXORRIlKA,   OR  (il.KllT  157 

iiriiir  will  hi-  toiiiid  coiu-i'iitratt'd  and  irritating  in  nianv  ot"  these  cases,  and  this  sht)iihl 
l)e  overcome  l)V  the  free  use  of  water  and  (Uhient  drinks.  IIy|)eracidity  slioiild  be  cor- 
rected by  suitable  alkaline  medication,  and  remedies  administered,  already  mentioned, 
which  arc  sin)j)osed  to  medicate  the  urine.  Caj)siiles  may  be  ])rocured  containinfi; 
salol,  oli'orcsin  of  cubebs,  balsam  of  coj)ail)a,  and  |)ej)sin,  and  except  in  cases  where 
there  is  already  jjreat  irritation  of  the  urinary  tract,  these  serve  their  ])urj)osc  admirably. 

WhiMi  the  anterior  urethra  alone  seems  to  be  involved,  one  of  the  milder  injections 
already  mentioned  in  dcscribini;  the  treatment  of  acute  ca.S(>s  may  be  emj)l()yed.  When 
till'  di'c|)  iM'i'.thra  appears  to  be  tlu'  sit(>  of  continu(>d  irritation,  it  should  then  be  treated 
extensively  with  deep  irrigations  and  injections  of  suitable  medicaments.  The  deep 
irrifjations  can  be  practised  with  or  without  the  use  of  a  catheter.  The  deep  urethra 
may  be  Hushed  through  a  smaller  catiieter  than  the  urethra  will  comfortably  take, 
allowing  the  fluid  to  return  through  the  urethral  channel  outside  of  the  catheter  it.sclf. 
\\  hen  this  prac-tice  is  adopted,  hot  water  which  has  been  made  antiseptic  should  be  u.sed, 
j)refcrably  with  one  of  the  silver  salts.  I'he  nitrate  may  be  used  in  jjrojiortion  of  1  to 
")()(),  and  the  citrate  or  lactate  in  strength  of  1  to  300  or  1  to  400.  Protargol  is  effective 
in  1  per  cent,  solution,  or  argyrol  in  1  to  3  per  cent,  strength. 

In  the  (Miiployment  of  irrigation  in  these  cases  a  shield  should  be  used,  by  which  the 
end  of  the  penis  may  be  coveretl  and  all  danger  of  spattering  avoided.  The  simplest 
expedient  for  this  purpose  is  one-half  of  an  old  atomizer  bulb,  which  may  be  punctured 
and  slipped  over  the  catheter  or  irrigator  tube. 

Apart  from  mere  irrigation  it  is  well  to  deposit  within  the  depths  of  the  urethra,  in 
the  membranous  portion,  by  means  of  a  deep  urethral  syringe,  a  drop  or  two  of  a  fresh 
solution  of  silver  nitrate  in  distilled  water,  in  strength  of  ^  to  1  per  cent.  This  should 
be  deposited  behintl  the  "cut-off"  muscle,  where  it  will  cause  a  burning  sensation  for  a 
short  time.  The  strength  of  the  solution  is  to  be  regulated  by  this  complaint,  as  no 
benefit  is  derived  from  using  it  too  strong. 

Of  all  the  medication  that  has  been  suggested,  nothing  gives  better  results  for  this 
purpose  than  this  silver  nitrate. 

For  ordinary  urethral  injections,  besides  those  already  mentioned,  formalin  may  be 
used,  but  in  weak  solution  (1  to  2000,  or  stronger  if  the  patient  can  tolerate  it);  while 
picric  acid  has  been  recommended  by  Belfield  and  others  in  strength  of  1  to  1000  or 
1  to  2000. 

Some  surgeons  believe  that  patients  can  learn  to  flush  the  deep  urethra,  or  even  the 
bladder  itself,  without  the  use  of  the  catheter  or  internal  tubing  of  any  kind.  The  pro- 
cedure may  have  to  be  learned  in  the  sitz  bath,  the  pelvis  being  immersed  in  warm  water; 
the  nozzle  of  the  irrigator  tube  is  inserted  into  the  urethra  and  the  patient  is  told  to  make 
an  effort  as  if  to  void  his  urine.  This  will  so  relax  the  "cut-oflF"  muscle  as  to  permit 
the  passage  of  fluid  into  the  bladder,  and  this,  which  is  most  desirable  in  many  cases  of 
cystitis,  where  the  bladder  washing  is  an  essential  feature  of  the  case,  is  to  be  avoided 
when  the  gonorrheal  infection  has  travelled  backward  beyond  the  prostate;  no  attempt 
should  be  made  to  pass  the  solution  into  the  bladder,  but  simply  to  wash  out 
the  urethra.  The  better  plan  is  to  teach  the  patient  the  proper  use  of  a  small  soft 
catheter,  which  may  also  be  u.sed  in  the  sitz  bath,  inserted  to  the  proper  extent. 

Recent  -strictures  should  be  treated  by  sounds  after  the  urethra  has  been  thoroughly 
cleansed.  For  this  purpose  a  conical  cylindrical  sound  should  be  selected,  whose 
urethral  end  will  comfortably  enter  the  stricture.  Gentle  force  should  then  be  brought 
to  bear  to  pass  it  beyond  the  stricture.  If  gradual  dilatation  be  aimed  at,  it  is  well  not 
to  go  beyond  the  point  of  drawing  a  drop  or  two  of  blood;  even  this  may  be  avoided. 
On  the  other  hand,  should  it  be  decided  to  use  sufficient  force,  the  dilatation  should  be 
done  thoroughly  and  at  one  sitting,  in  order  to  avoid  repetition  of  the  irritation.  The 
instrument  generally  in  use  in  this  country  for  this  purpose  is  the  Oti.s  dilating  vrcthro- 
tome,  by  which  the  degree  of  dilatation  and  the  size  of  the  cicatricial  ring  can  be  estimated 
and  the  extent  of  the  division  and  the  effect  gained  also  regulated.  (See  Operative 
Surgery  of  the  Urethral  Canal.) 

The  divnJ.sion  of  strictures,  formerly  in  vogue,  is  now  abandoned  for  the  more  accurate 
division  performed  by  this  instrument.  The  strictures  having  been  thus  divided,  sounds 
should  be  passed  at  intervals  of  from  three  to  five  days,  by  which  the  urethra  is  distended 
to  its  full  caliber  and  the  divided  surfaces  not  allowed  to  contract.  This  is  an  important 
part  of  the  treatment,  and  gives  opportunity  for  widest  discretion  in  their  emplo\Tnent. 


158  SURGICAL  DISEASES 

Ordinarily  they  should  not  l)e  carried  farther  l)a(k  than  the  lesion  calls  for,  as  the 
deep  urethra  is  best  let  alone.  On  the  other  hand,  there  are  many  cases  where  the 
stimulus  of  the  cold  metal  passing  the  entire  length  of  the  urethra  and  the  effect 
which  it  seems  to  have  in  expressing  from  the  various  follicles  any  retained  contents 
seem  beneficial.  It  has  been  stated  that  instrumentation  sometimes  leads  to  epididy- 
mitis or  "swelled  testicle;"  should  this  take  place  in  a  case  undergoing  treatment  for 
gleet  it  may  necessitate  a  temporary  cessation  of  the  mechanical  treatment.  It  is  not 
good  surgery  to  introduce  any  instrument  into  the  urethra  when  one  or  both  testicles 
present  this  complication. 

In  the  local  treatment  of  these  lesions,  cocaine  or  one  of  its  substitutes  should  be 
employed.  It  is  questionable  whether  the  full  benefit  of  applications  is  obtained  when 
the  surfaces  are  so  anesthetized;  on  the  other  hand,  the  treatment  can  be  made  more 
endurable  by  its  use. 

This  is  true,  also,  of  the  use  of  the  endoscope,  and  applications  which  may  be  made 
through  it  to  inflamed  or  hypersensitive  patches.  When  these  are  recognized  or  exposed, 
they  are  best  treated  by  a  pr()l)ang  moistened  with  silver  nitrate  solution,  in  5  to  10  per 
cent,  strength,  or  by  the  solid  stick  or  crystal  of  copper  sulj)liate,  pure  or  mitigated,  as 
used  by  the  oculists. 

One  of  the  most  important  features  in  the  consideration  of  gonorrhea  is  to  determine, 
if  possible,  when  a  given  case  has  ceased  to  be  dangerous  to  others.  In  theory  the 
danger  passes  with  the  disappearance  of  the  gonococci,  but  it  is  so  difficult  to  determine 
when  this  has  occurred  that  it  is  almost  impossible  to  fix  a  time  limit  in  any  given  case. 
An  excellent  method  of  determining  the  matter  in  a  reasonably  accurate  way  is  by 
having  the  patient  void  urine  in  two  different  glasses;  a  small  quantity  in  the  first,  which 
will  contain,  then,  the  washings  of  the  urethra.  In  this  glass  will  be  found  those  chains 
of  gonococci  clustering  around  masses  of  epithelial  cells  or  debris  which  have  been 
especially  described  as  "clap  threads"  (tripper-faden  of  the  Germans),  upon  which, 
by  careful  examination,  gonococci  can  often  be  recognized.  As  long  as  these  threads 
are  in  evidence  it  may  be  held  that  the  infection  still  persists,  and  might  be  either 
brought  into  activity  again  by  excitement  or  convey  the  disease  in  the  sexual  act. 

Gonococci  have  been  found  in  clap  threads  years  after  the  last  known  infection,  and 
this  will  illustrate  why  they  are  such  a  source  of  danger,  and  how  an  innocent  woman  has 
been  made  to  suffer  when  it  w^as  supposed  that  all  danger  of  infection  had  passed  away. 


GONORRHEA  IN  WOMEN. 

This  naturally  assumes  the  type  of  a  specific  vaginitis,  usually  with  active  partici- 
pation of  the  mucous  membrane  of  the  mtlva  and  of  the  vnlvovaginal  glands,  the  urethra 
and  bladder  being  sometimes  secondarily  involved,  while  the  role  of  the  Innphatics 
is  about  as  described  in  the  male.  In  the  young,  especially  in  young  girls  upon  whom 
rape  has  been  attempted,  the  mucosa  is  extremely  susceptible.  In  adults,  particularly 
in  those  who  have  borne  children,  the  vaginal  walls  offer  more  resistance.  The  nature 
of  the  parts  permits  of  more  violent  chemosis  of  the  mucous  membrane,  while  in  serious 
cases  there  will  be  well-marked  edema  of  the  labia.  The  urethral  orifice  is  usually 
inflamed  and  chemotic,  even  though  the  infection  travel  no  farther  in  this  direction. 

It  has  been  stated  that  SO  per  cent,  of  deaths  from  pelvic  disease  in  women  are 
due  directly  or  indirectly  to  gonorrhea,  as  well  as  one-half  of  the  cases  of  involuntary 
sterility. 

As  in  the  male,  there  may  be  different  types  of  so-called  gonorrheal  infection  of  the 
vagina,  varying  from  the  pure  gonococcus  type  to  that  in  which  the  preponderating 
bacteria  are  of  the  ordinary  pyogenic  varieties.  The  detection  of  gonococci  in  the 
discharges  sometimes  assumes  medicolegal  importance,  and  upon  it  has  depended  the 
guilt  or  innocence  of  more  than  one  individual. 

The  intensity  of  the  vaginitis  will  vary  with  that  of  the  infection.  In  the  worst  ca.ses 
the  discharge  is  profuse  and  acrid.  It  may  amount  to  50  Cc.  or  even  100  Cc.  in  twenty- 
four  hours.  The  burning  pain  will  be  extreme,  while  backache  and  pelvic  soreness 
will  be  bitterly  complained  of.  In  mild  cases  the  disease  assumes  the  clinical  form  of 
a  low-grade  vaginitis  with  abnormal  discharge,  such  as  may  be  characterized  as  a  severe 
case  of  '  'whites." 


r;o.\<)Rh'iii:.\  i\  woMhW  159 

III  tli('S(>  cases  of  cillicr  ly|K'  tlic  (iiicstioii  is,  wIkiIk  r  iiit'cctioii  lias  already  travelled 
upward  heyoiid  the  vajfiua  into  the  uterine  cavity  or  throiiffh  it  into  tlie  tuhes. 

(ionorrlu'a  is  the  most  coniiiiou,  and  some  believe  almost  the  sole,  cause  of"  pi/o.salpitix 
with  its  atteiulant  complications  and  danj^ers.  Even  when  not  severe,  vuf^initis  may 
permit  of  such  extension,  and  so  not  only  induce  sterility,  hut  compromise  the  physical 
welfaiv  of  the  j)atient;  while  in  acute  cases  the  activity  is  so  <rreat  that  it  occasionally 
terminates  in  ju-ritonitis,  prinuirily  of  fjjonorrheal  orifjjin.  When  both  tuhes  have  become 
involved,  the  patient  is  almost  invariably  sterile. 

In  nearly  all  of  these  cases  string's  of  mucopus  will  be  found  liaiitriiio;  out,  or  beads 
of  it  presentinji  at  the  external  os,  and  when  examined  this  exudation  will  aiVord  a  fair  test 
as  to  the  character  and  degree  of  the  infection.  Here,  as  in  the  male,  there  are  so  many 
follicles  diflicult  of  access,  and  so  many  recesses  in  which  germs  nuiy  lurk,  that  a  com- 
plete disinfection  of  tiie  parts  is  ahnost  impossilile.  For  this  reason,  then,  latent  gonor- 
rhea is  a  frequent  outcome  of  the  disease  when  once  it  has  existed,  and  a  yjossible  and 
more  or  less  constant  source  of  danger  to  others. 

Treatment. — A  ca.se  of  acute  gonorrheal  vaginitis  with  its  accompaniments  will 
present  a  diflicult  ])roblem.  The  discharge  is  so  great  that  the  danger  to  others,  and 
esj)ecially  to  the  eyes,  is  jironounced,  while  the  exquisite  tenderness  of  the  parts  nuikes 
ratlical  treatment  difficult.  The  treatiuent  should  consist  of  antiseptic  douches,  which 
in  serious  cases  should  be  made  as  nearly  continuous  as  possible,  l^he  water  used  for  the 
purpose  should  be  as  warm  as  the  patient  can  tolerate,  and  contain  an  antiseptic,  of 
which  corrosive  sublimate,  in  strength  of  1  to  2000,  silver  nitrate  in  the  .same  strength, 
or  formalin  in  double  this  strength,  are  the  most  serviceable.  The  irrigating  tube  should 
be  carrietl  to  the  upper  end  of  the  vagina  and  the  stream  made  to  flow  outward.  In 
milder  cases  a  douche  at  intervals  through  the  day  may  suffice.  The  vaginal  surface 
should  later  be  exposed  through  a  speculum  and  the  entire  mucous  surface  treated  with 
nitrate  of  silver  solution  in  from  G  to  10  per  cent,  .strength.  Should  the  surface  be 
tender,  this  will  be  painful,  and  might  ju.stify  the  use  of  an  anesthetic,  especially  of 
nitrous  oxide. 

If  the  disease  extend  upward  and  there  is  an  endometritis  or  a  salpingitis,  external 
applications  of  ice  may  be  used  to  lull  the  pain ;  but  probably  hot  poultices  or  some 
application  of  external  heat  might  afford  greater  comfort  to  the  patient.  Byford  has 
used  succinic  dioxide  in  the  treatment  of  specific  vaginitis  with  great  satisfaction. 
It  is  sold  in  the  open  market  under  the  trade  name  "Alphozone." 

The  edema  of  the  vulva  will  subside  with  the  general  improvement  of  the  case. 
Abscesses  in  the  vulvovaginal  glands  are  not  uncommon.  These  are  easily  recognized, 
are  often  painful,  and  should  be  incised  early  or  as  soon  as  recognized,  cleaned  out 
thoroughly,  the  interior  of  the  cavity  cauterized  to  prevent  the  result  of  fresh  infec- 
tion, and  then  packed  and  left  to  heal  by  granulation. 

Urethritis  and  cystitis  may  be  treated  as  when  they  occur  in  the  male.  There  is  the 
same  liability  in  women  as  in  men  to  IvTnphatic  involvement,  with  the  consequent  bubo, 
which  may  perhaps  suppurate.  They  are  less  liable  to  the  widespread  manifestations 
of  postgonorrheal  infections  of  the  joints,  etc.,  although  they  are  even  more  liable  to 
infection  of  the  endocardium,  and,  as  will  be  readily  understood,  more  so  to  infection 
of  the  peritoneum.  It  will  then  be  .seen  that  the  treatment  of  the  disease  is  essentially 
the  same  in  either  sex,  certain  differences  in  method  rather  than  in  principle  having  to 
be  made  in  accordance  with  anatomical  requirements. 

As  to  the  rectal  mucous  membrane  participating  in  gonorrheal  infection,  under 
ordinary  circumstances  it  would  escape.  In  the  treatment  of  any  of  these  cases  by  the 
sitz  bath,  the  question  might  arise  whether  there  would  be  danger  of  extending  the  con- 
tagion in  this  direction.  It  does  not  appear  that  much  fear  need  be  felt,  for  two  reasons: 
the  grasp  of  the  sphincter  is  usually  sufficient  to  prevent  entrance  of  fluid,  and,  further- 
more, the  rectal  mucosa  is  itself  extremely  resistant  to  the  gonococcus.  Gonorrheal 
proctitis  is  an  exceedingly  uncommon  infection,  and  one  rarely  seen,  except  in  extreme 
cases  of  sexual  perversion.  It  should  be  treated  in  about  the  same  manner  as  gonor- 
rheal vaginitis,  i.  e.,  by  continuous  irrigation  with  hot  water,  and  .stretching  the  sphincter 
in  order  to  overcome  the  spasm  into  which  it  would  be  thrown  by  reflex  activity. 

Gonorrheal  urethritis  in  women  is  best  treated  with  local  applications  of  argyrol  or 
one  of  the  other  silver  compounds.  These  can  be  made  with  a  syringe  or  with  a 
small  swab.     Cystitis  is  to  be  treated  in  the  same  manner  as  when  it  occurs  in  the  male. 


CHAPTER    XIII. 

SCURVY   AND    RICKETS. 
SCURVY. 

Scurvy  is  placed  among  the  so-called  surgical  diseases,  since  it  manifests  many 
distinctly  surgical  features  and  is  possibly  of  parasitic  character,  although  this  feature 
of  its  existence  has  not  been  incoiitrovertibly  established.  It  is  a  starvation  disease, 
its  principal  characteristic  being  that  of  mala-ssimilation ,  accompanied  by  profoun(l 
aneviia.  Well-marked  cases  are  seen  during  long  sieges,  like  thai  of  Paris,  in  1871, 
or  during  long  imprisonment,  as  in  Andersonville  prison.  It  has  certain  points  of 
resemblance  to  that  condition  of  multiple  neuritis  met  with  in  warm  climates,  and 
known  usually  as  herihrri.  The  former  is  apparently  due  to  the  absence  of  a  vegetable 
regimen,  while  beriberi  is  largely  due  to  the  absence  of  an  animal  regimen,  nature 
having  intended  that  man's  diet  should  be  mixed,  and  having  ordained  that  suffering 
and  disease  always  follow  confinement  to  one  or  the  other. 

Pathology. — The  pathology  of  scurvy  is  obscure.  It  has  been  shown  that  gastric 
digestion  is  seriously  at  fault,  that  there  is  much  intestinal  putrefaction,  that  the  urine 
shows  great  absorption  of  toxins,  that  the  hematopoietic  function  is  incomplete:  that 
scurvy  is  a  toxemic  or  chronic  ptomain  poisoning,  which  may  in  part  or  at  times  be 
due  to  the  use  of  tainted  food.  Morphological  changes  are,  however,  neither  distinct 
nor  pathognomonic.  It  has  been  described  as  a  disease  of  diet  and  occupation  rather 
than  of  race,  age,  sex,  or  season.  The  ease  with  which  hemorrhagic  effusions  occur, 
the  degeneration  of  muscles  and  other  tissues,  the  frequent  detachment  of  cartilages, 
can  be  accounted  for  by  conditions  thus  summarized,  for  which,  however,  we  have  no 
minute  explanation.  Scurvy  may  so  complicate  various  other  diseases,  and  usually 
does  when  occuring  in  large  bodies  of  men — as  in  armies,  prisons,  among  convicts,  etc. — 
that  it  is  hard  to  dissociate  morbid  phenomena  and  assign  to  each  its  proper  place. 

Symptoms. — The  disease  begins  by  a  condition  of  generalized  prostration,  with  an 
icteric  tint  of  the  skin,  malaise,  mental  torpor,  loss  of  appetite,  insomnia,  etc.  The 
first  recognizable  or  distinctive  local  appearances  occur  about  the  margins  of  the  gums. 
Here,  in  tlie  intervals  between  the  teeth,  the  gums  become  livid,  friable,  and  bleed  easily, 
while  the  breath  assumes  a  characteristic  fetid  odor.  The  skin  becomes  dry  and  brittle, 
and  covered  with  minute  prominences,  which  give  it  the  popular  name  "goose-flesh." 
These  appearances  are  followed  by  local  pains,  diversified  and  sometimes  excessive, 
and  extravasations  of  l)lood  in  the  skin  and  under  the  visible  mucous  membranes, 
causing  small  ecchymoses,  which  by  themselves  would  be  considered  as  simple  purpura 
hsemorrhagica.  These  pass  through  the  usual  phases  of  extravasations,  while  it  is  made 
evident  by  pain,  nodular  masses,  etc.,  and  by  postmortem  examination,  that  similar 
hemorrhages  occur  in  the  deeper  tissues,  especially  in  the  muscles,  even  in  the  bones 
and  epiphyses.  So  easily  do  hemorrhages  occur  in  advanced  stages  that  there  is  often 
external  bleeding,  particularly  from  the  gums  and  mucous  membranes,  while  from  points 
thus  involved  pyogenic  infection  may  proceed  internally.  Near  the  close  the  victim  pre- 
sents a  picture  apparently  of  an  animated  corpse,  with  surface  discolored  and  mottled, 
often  appearing  bruised,  with  ulcerations  where  extravasations  have  failed  to  resolve, 
and  where  infection  has  occurred,  ])ossil)ly  with  epiphyses  looscMied,  and  necTosis  of 
the  bones  of  the  extremities.      In  such  cases  death  results  from  marasmus  and  sepsis. 

Treatment. — As  long  as  the  patient  is  not  in  the  desperate  condition  just  described 
the  prognosis  and  outlook  for  treatment  are  promising,  as  all  the  milder  manifestations 
of  scurvy  can  be  dispersed  by  suitable  feeding  and  medication.  Loss  of  teeth  and 
cicatrices  of  ulcers  leave  permanent  traces,  but  function  can  be  restored.  The  jmrpiira- 
is  but  one  expression  of  the  scorbutic  condition.  Nearly  all  cases  of  scurvy  will  pre- 
sent purpuric  manifestations,  but  all  cases  of  purpura  are  not  necessarily  scorbutic. 
The  course  of  treatment  may  be  sunimed  up  in  pr()|)er  diet  and  in  the  administration. 
(160) 


PLATE  XI 

FIG.    1 


Rickets.      Rib.     Very  low  power.      (Gaylord  ana  Asciioff.) 

FIG.  2 


Rickets.     Flat  Bone  of  Skull  (Craniotabes).     (Karg  and  Schmorl.) 


ri<ki:ts  161 

of  ciTtaiii  (Iruj^s.  Proper  dirt  should  Ik-  piv.scrilM-d  at  oiuf,  hut  achuinistcrcd,  espo- 
cially  in  severe  eases,  trith  extreme  caution.  Tlie  food  selected  should  he  given  in  small 
quantities,  hut  fre(|uently.  It  should  consist  in  large  measure  of  fresh  fruits  and 
vegetahles,  while  cranberries  and  lime-juice  figure  largely  among  the  former.  Butter- 
milk is  excellent,  and  cider  may  he  allowed;  also  lemonade,  with  hut  little  sugar. 

For  the  local  condition  in  the  mouth  an  antiseptic  mouth-wash  containing  a  fair 
proportion  of  hydrogen  dioxide  is  advi.sahle.  Alcoholic  stimulants  are  called  for,  at 
least  u|)  to  a  certain  j)oint.  Strychnine  and  cinchona  prc|)arations  will  give  force 
to  the  heart's  action,  and  the  horizontal  |)osition,  for  a  time  at  least,  will  j)revent  sudden 
heart  failure.  Compound  ,syru|)  of  the  hy])ophosj)liites,  with  meat  prejjarations,  will 
suj)j)ly  lac-king  material,  while  the  hemorrhagic  manifestations  are  hest  controlled  hy 
tile  fiuidextract  of  ergot  and  aromatic  sulphuric  acid,  .separately  or  cond)ined.  Particular 
attention  should  l)c  given  to  cleanline.ss  and  fresh  air. 

Infantile  Scorbutus. — Infantile  scorbutus  sometimes  furnishes  the  surgeon  with 
very  young  patients  who  are  brought  to  him  esi)ecially  for  disability  of  the  lind)s,  with 
pain  and  frctfulness,  leading  to  immobility,  followed  by  enlargement  of  the  lower  ends 
of  the  femurs  (due  to  subperiosteal  hemorrhages)  with  fixation  by  muscle  spasm;  this 
may  be  followetl  by  "sjjontaneous"  fractures.  The  gums  will  show  the  same  changes 
as  arc  seen  in  adults,  while  subcutaneous  hemorrhages  and  infiltrated  muscles,  with  foul 
breath,  ashen  pallor,  listlessness  and  apathy,  and  perhaps  several  swollen  joints,  will 
complete  an  unmistakable  picture. 

Fresh  milk  with  orange-juice  in  small  amounts  between  feedings,  combined  with 
more  strictly  surgical  measures  if  needed,  will  secure  good  results  in  these  little  patients. 


RICKETS. 

Rickets,  or  rachitis,  is  another  of  the  diathetic  conditions,  in  this  instance  not  yet 
considered  of  parasitic  origin,  most  commonly  occurring  in  infancy  and  early  childhood, 
although  its  resulting  lesions  may  persist  throughout  life.  It  is  characterized  by  nutri- 
tional disturbances  and  organic  irregularities. 

Pathology. — Rickets  is  generally  referred  to  as  "fetal"  or  "congenital,"  according 
to  whether  the  infant  presents  characteristic  markings  at  birth  or  whether  they  develop 
later.  The  most  marked  constitutional  defect  seems  to  be  in  the  supply  of  calcium 
salts,  which  leads  apparently  to  formation  of  bone  which  has  not  sufficient  compact 
tissue  to  make  it  strong.  Especially  along  the  line  of  junction  between  bone  and  cartilage 
do  we  see  the  most  marked  expressions  of  rachitic  lesions.  Here  the  cartilage  is  evidently 
actively  growing,  Avhile  the  bone  formation  proceeds  with  difficulty,  and  the  proportion 
of  vascular  tissue  is  excessive.  The  result  is  prolongations  of  soft  vascular  into  the 
cartilaginous  tissue,  by  which  the  latter  becomes  more  or  less  absorbed,  and  this  essen- 
tially interferes  with  ossification.  In  severe  cases  it  may  be  lacking.  At  epiphyseal  lines 
one  may  see  a  layer  of  osteoid  tissue  which  is  not  cartilage  and  will  not  become  bone. 
Because  of  its  yielding  nature  it  warps  under  the  mechanical  strain  to  which  the  bones 
of  the  extremities  in  young  children  are  constantly  subjected. 

The  obscure  but  unmistakable  relations  existing  between  rickets  and  the  status  lym- 
phaticiis  will  be  referred  to  in  Chapter  XIV. 

The  osseous  lesions  of  rickets  differ  from  those  seen  in  osteomalacia,  since  in  the  latter 
the  softened  tissue  is  practically  decalcified  bone,  while  in  the  former  case  most  of  the 
affected  tissue  has  never  gone  so  far  as  genuine  bone  formation,  but  is  arrested  in  its 
perverted  state. 

The  result  of  rickety  changes  in  the  skeleton  is  a  thickening  of  the  shafts  of  the  long 
bones,  of  the  outer  table  of  flat  ones,  of  the  epiphyseal  extremities  of  shafts,  and  fre- 
quently a  stunting  of  their  development,  so  that  they  do  not  attain  their  normal  length. 
The  periosteum  is  also  affected  in  rickets,  with  the  result  that  when  the  changes  occur, 
mostly  subperiosteally,  there  are  warpings  and  curvings  of  the  bone  shafts,  while  so  long 
as  the  disturbance  is  epiphyseal  more  or  less  abrupt  curvatures  and  angular  deformities 
will  be  produced  as  the  result  of  muscle  action.  So  marked  are  the  changes  in  some 
instances  that  it  has  been  stated  that  bones  may  even  lose  three-fourths  of  their  calcium 
salts.  When  rachitic  bones  are  so  soft  as  to  be  easily  cut  with  a  knife,  marked  deform- 
ities occur  as  the  result  of  muscular  activity.  (See  Plate  XL) 
11 


J62  SURGICAL   DISEASES 

In  the  extremities  we  see  boir-lerj.t,  knork-knrr.t,  clubbing  of  the  ends  of  the  long  bones, 
bending  of  the  neck  of  the  femur,  flat-foot,  rlub-joot,  etc. ;  while  the  clubbing  of  the  bone 
ends  also  may  be  well  marked  in  the  bones  of  the  upper  extremity,  where,  however, 
marked  deformity  is  less  common,  Ix'cause  the  upjx'r  extremity  does  not  bear  the 
weight  of  the  growing  body.  In  the  skull  the  bones  remain  soft  and  yielding  to  pressure, 
with  a  tendency  to  return  to  their  original  membranous  condition,  and  this  is  the  con- 
dition comprised  under  the  temi  craniotafjes  raehitira.  The  jontanelles  always  remain 
open  for  an  undue  time;  the  sutures  are  broad  and  membranous.  The  bones  of  the 
face  grow  less  rapidly,  giving  to  the  face  a  dispro|)ortionately  small  size;  dentition  is 
delayed  and  the  teeth  decay  easily.     The  upj)er  incisors  often  project  far  over  the  lower. 

In  the  thorax  there  are  enlargements  of  the  sternal  ends  of  the  ribs,  causing  a  row  of 
nodules  referred  to  as  the  rachitic  rosary.  The  ribs  tend  to  sink  in,  the  sternum  to  be  pro- 
truded forward,  and  the  deforaiity  known  as  pigeon-breast  becomes  often  pronounced. 
Curvatures  of  the  spinal  column,  especially  kypho-ns,  are  common,  and  distinct  degrees 
of  lateral  curvature  are  frequently  begun  as  rachitic  deformities,  to  be  magnified  by 
perverted  muscle  action  as  the  child  grows  older.  In  the  pelvis  the  innominate  bones 
approach  each  other,  causing  the  pelvic  cavity  to  become  contracted,  or  the  sacral 
promontory-  projects  too  far,  or  in  various  other  ways  the  normal  pelvic  diameters  are 
so  far  compromised  that  rachitic  deformities  of  the  pelvis  constitute  the  most  common 
and  serious  obstacles  to  normal  labor  in  adult  women,  and  are  frequently  the  cause  of 
major  obstetric  operations. 

While  the  rachitic  changes  in  the  osseous  system  are  the  most  distinctive  and  easily 
recognized,  numerous  other  organs  and  tissues  of  the  body  are  more  or  less  seriously 
compromised.  Ventricular  dilatation,  leading  to  chronic  hydrocephalus,  is  one  of  the 
common  results  of  rachitis  of  the  skull,  which  may  be  followed  by  convulsions  and 
terminate  fatally.  Porencephalon  and  cerebral  sclero-ns  may  also  ensue.  Disturbances 
of  digestion  are  common  in  rickety  children — the  liver  may  decrease  in  size  or  become 
much  enlarged;  the  spleen  often  enlarges,  sometimes  to  enormous  dimensions.  In 
various  other  parts  of  the  lx)dy  there  are  the  same  expressions  of  malnutrition  as  are 
met  with  in  tuberculous  disease.  Rickety  children  perspire  ea-nly,  particularly  at  night, 
when  the  head  \\\\\  often  be  found  bathed  in  perspiration.  They  are  fretful  and  irritable, 
as  a  rule,  and  difficult  to  control.  A  child  with  protul^erant  belly,  due  to  enlargement  of 
liver  and  spleen,  as  well  as  to  crowding  of  pelvic  organs,  with  relaxation  of  abdominal 
walls,  and  a  contracted  and  distorted  thorax,  the  skull  flattened  on  the  top,  clubbed 
bone  ends,  a  history  of  resting  badly  at  night  and  sweating  profusely,  constitute  a 
clinical  picture  of  rachitis  so  marked  that  it  can  l>e  recognized  at  a  glanc-e.  Between 
this  picture  in  its  worst  forms  and  the  slightest  deviation  from  the  ideal  ty])e  there 
may  be  met  all  degrees  in  manifestations  of  rickets  in  the  chiUlren  of  the  rich  or  the  poor, 
while  in  adults  may  often  be  .seen  evidences  of  that  which  prevailed  during  early  child- 
hood. In  order  that  all  these  features  may  be  made  out  the  child  should  be  stripped 
and  examined  from  head  to  foot. 

Laryngismus  stridulus  is  a  frequent  accompaniment.  It  may  be  followed  by  general 
convulsions  and  tetany.  (See  Chapter  XIV.)  While  rickets  may  be  a  verA-  acute  dis- 
ease, it  is  as  a  rule  chronic,  and  children  d^nng  essentially  from  this  flisease  die  rather 
from  c-erebral  or  other  manifestations  which  may  be  regarded  as  in  some  degree  acci- 
dental.    Scurvy  and  other  nutritive  disturbances  may  l)e  associated  with  rickets. 

Treatment. — The  treatment  for  the  condition  consists  mainly  in  proper  nutrition. 
Morlirr-  milk  is  certainly  preferable  to  any  other,  and  should  be  demanded.  If 
feeding  mu.st  be  artificial,  it  should  be  in  accordance  with  the  best  precepts  of  modem 
theraf>eutics.  Cod-liver-oil  emulsions  are  of  advantage;  comjx)und  s\Tup  of  the  hypo- 
phosphites  is  a  remedy  of  great  virtue.  Minute  doses  of  phosphonis  seem  to  be  of  value 
— 1  ^Ig.  pro  die.  It  is  a  mistake  to  let  rickety  children  \^g'm  to  walk  or  even  to  creep 
too  early.     They  should  be  kept  upon  the  back  in  their  cribs  . 

The  modem  opotherapy  of  rickets  includes  the  employment  of  thyroid  and  pituitary 
e.rtracts.  The  dose  should  be  graduated  to  the  age  of  the  patient,  based  upon  30  Cg. 
for  an  adult,  and  given  thric-e  daily.  This  will  not  preclude  the  necessity  for  a  careful 
regulation  of  diet.  etc..  but  will  constitute  a  valuable  adjunct  in  treatment. 

The  defonnities  due  to  rickets  are  so  numerous  as  to  constitute  a  large  part  of  those 
to  which  special  or  orthopedic  surgery-  is  addressed.  The  mechanical  and  operative 
treatment  of  these  cases  will  be  referred  to  in  their  appropriate  plac-e, 


CHAPTER    XTV. 
THE  STATUS  LYIMPIIATICUS. 

rNDi.K  {\\v  ti'iin  .siatK.s  li/iiipliafirus  has  been  described  a  eoiiditioii  which  is  of  interest 
to  the  surt;(M)n,  as  it  inclndes  not  only  minor  coniphcations,  and  even  those  which  are 
serious,  which  follow  snr<i;ical  ])rocedure,  but  it  also  has  reference  to  the  cases  of  sudden 
death  durinfj  or  after  operation,  some  of  which  have  been  attributed  to  the  anesthetic, 
wliilc  others  have  \)vvn  considered  absolutely  unexplainablc.  The  condition  is  so  easily 
described  or  d(>finc(l  that  it  should  be  recognized  durin<^  life,  but  it  has  often  been 
discovered  only  aflt-r  sudden  death. 

'I'he  essential  feature  of  tlu>  condition  is  nil(ir(/ri)inif  of  the  li/iii pluifir  ii.i.iuc  (uid  nppa- 
rdfu.s',  j)erliaps  throughout  the  (>ntire  body,  more  frecpicntly  through  its  internal  j)ortions. 
It  usually  occurs  in  children.  It  is  accompanied  by  nnich  lowering  of  the  power  of 
resistance,  and  results  in  sudden  death  from  cardiac  failure,  as  the  result  of  causes 
which  seem  disproportionately  trivial ;  as,  for  instance,  such  deaths  as  occur  not  merely 
during  anesthesia,  but  during  bathing,  convalescence  from  the  exanthemas,  etc.  It 
stands  in  close  relation  to  dii)htheria,  perhaps  because  of  its  peculiarly  depressing  toxins, 
and  probably  accounts  for  cases  of  sudden  demise  in  that  disease,  even  when  mild. 

The  status  lymphaticus  is  also  designated  by  other  names,  as  l//inp}iuti.wi,  hpnphaiic 
cousfifiifion,  and  .status-  fhi/inirit.'i,  the  latter  because  of  the  active  participation  of  the 
thvnuis.  Enlargement  of  this  body  has  been  noted  at  autopsy,  but  its  relation  to  the 
other  features  of  status  lymphaticus  were  unknown  until  Rokitansky,  in  1842,  first 
recognized  the  condition  in  its  entirety,  but  confused  it  with  the  tuberculosis  of  the 
lymphatics  formerly  called  scrofula. 

The  death  of  a  son  of  a  German  jn'ofessor,  a  few  years  ago,  shortly  after  an  injection 
of  antitoxin  to  protect  him  from  diphtheria,  and  the  subsequent  discovery  that  the 
boy  was  the  victim  of  this  condition,  caused  a  widespread  interest  in  and  a  most 
careful  study  of  the  prolilems  involved.  They  occur  in  the  thymus  more  frequently 
than  in  any  other  organ  of  the  body.  Normally  the  thymus  begins  its  involution  within 
a  few  months  after  birth,  and  this  process  should  be  completed  at  puberty.  In 
the  status  lymphaticus  this  involution  does  not  occur,  but  enlargement  persists  or 
increases  even  into  adult  life,  varying  in  different  cases,  the  weight  of  the  thymus  varying 
from  20  to  135  grams. 

While  the  thymus  may  for  some  purposes  be  grouped  among  the  lymphatic  tissues 
of  the  body,  little  is  known  as  to  its  function.  Its  juice  contains  leukocytes,  which  find 
their  way  into  the  general  circulation,  and  it  is  supposed  to  have  an  internal  secretion 
correlated  with  that  of  other  ductless  glands. 

Injections  into  dogs  of  thymus  extract  produce  a  fall  in  the  blood  pressure,  with 
acceleration  of  the  heart,  and,  in  fatal  doses,  dyspnea  and  collapse.  While  enlarge- 
ment of  the  thymus  may  cause  death  by  pressure  on  important  structures  other  than 
the  trachea,  it  produces  a  type  of  asthma  known  as  thi/nnc  asthma,  in  which  death 
sometimes  occurs  unexpectedly  and  rapidly  by  strangulation. 

An  examination  of  the  thymus  rarely  shows  anything  more  abnormal  than  the  enlarge- 
ment of  its  natural  structure,  with  perhaps  acute  hyperemia,  while  occasionally  the 
cut  surfaces  will  exude  a  milky  fluid;  there  will  be  found,  in  addition  to  these  changes 
in  the  thymus,  a  general  hyperplasia  of  the  lymphatic  system,  with  enlargement  of  the 
superficial  and  deep  nodes,  especially  the  cervical  and  axillary,  the  inguinal  and  those 
in  the  abdomen.  The  spleen  enlarges  and  the  Malpighian  bodies  seem  to  be  packed 
with  lymphoid  cells.  There  may  be  enlargement  of  the  heart  and  increase  in  the  thick- 
ness of  the  arterial  walls.  This  is  so  marked  that  Virchow  suggested  the  name  lymphatic 
chlorotic  cmistitution.  It  has  been  suggested  that  the  narrowing  of  the  aortic  valve 
in  these  cases  is  due  to  this  lymphoid  infiltration. 

The  relations  betiveen  rickets  and  the  stains  hjmphaticus  are  so  frequent  and  so  con- 
spicuous as  to  make  one  suspect  a  more  than  casual  connection  between  them.     Nearly 

(163) 


164  SURGICAL  DISEASES 

all  cases  of  lymphatism  show  the  ordinary  clinical  evidences  of  rickets.  By  some  such 
relation  may  be  explained  the  benefit  which  accrues  in  rickets  from  the  administration 
of  the  extract  of  thymus,  as  well  as  of  the  thyroid  and  the  j)ituitary  body. 

Enlargement  of  the  lymphoid  tissue  in  the  wall  of  the  alimentary  canal  also  occurs, 
and  in  those  rings  of  adenoid  tissue  which  mark  the  site  of  the  embryonic  canals.  This 
tissue  may  be  seen  around  the  origin  of  the  appendix,  while  its  most  conspicuous 
illustrations  are  seen  about  the  pharynx,  where  not  only  the  faucial,  but  the  lingual 
and  the  pharyngeal  tonsils  are  enlarged.  In  many  of  these  cases  there  are  the  so-called 
"adenoids"  of  the  throat  specialists,  while,  of  still  greater  interest  to  the  surgeon,  the 
deaths  that  have  occurred  from  the  status  lymphaticus  have  happened  repeatedly  in 
operations  for  these  growths  within  the  nasopharynx.  Furthermore,  the  yellow  marrow 
of  the  bones  seems  to  be  replaced  by  red  marrow,  but  whether  this  is  due  to  the  anemia 
which  always  accompanies  the  condition  is  not  known. 

Kaposi  some  years  ago  described  under  the  name  h/mphodermin  jjerniciosa  a  rare  con- 
dition characterized  by  a  scaly  and  itching  skin,  exuding  fluid,  with  later  a  diffuse  and 
doughy  condition  of  the  affected  parts,  and  then  by  nodules  which  sometimes  ulcerate, 
lymph  nodes  and  spleen  being  also  enlarged,  and  the  general  health  impaired.  While 
some  have  held  that  this  is  a  variety  of  mycosis  fungoides,  it  is  supposed  that  it  is  only 
another  expression  of  lymphatism. 

Another  variety  of  this  condition  occurs  in  young  people,  in  Avhich  coma  comes  on 
suddenly,  followed  by  death  in  twelve  to  eighteen  hours.  Vomiting  may  occur  during  the 
coma,  but  it  is  convulsions  and  spasm  of  the  glottis  that  cause  the  death  of  the  patient. 

Thymic  asthma  has  been  called  laryngismus  stridulus.  Whether  the  latter  can 
ever  occur  without  the  former  is  not  definitely  known,  but  doubtless  the  asthma  is  very 
frequently  the  cause  of  the  obstruction  and  the  difficulty  in  breathing. 

Medicolegal  questions  arise  in  this  connection  which  are  of  interest.  Death  occurs, 
except  under  anesthesia,  after  a  series  of  convulsions,  yet  it  may  happen  almost  instantly. 
Some  claim  that  death  may  take  place  as  the  result  of  pressure  of  an  enlarged  thymus 
upon  the  vessels,  and  especially  upon  the  nerves,  while  others  claim  it  to  be  due  to  a 
sudden  arrest  of  heart  action  by  reflex  activity. 

Convulsions  of  any  character  in  adolescent  individuals  and  young  children  should 
raise  a  suspicion  of  this  condition,  and,  of  greater  importance  for  the  surgeon,  all  pos- 
sibility of  existence  of  the  condition  should  be  eliminated  before  operation  is  under- 
taken. Deaths  occurring  during  anesthesia  are  often  attributable  to  the  anesthetist; 
nevertheless  there  are  instances  where  he  is  absolutely  blameless,  and  where  death  may 
occur  as  by  a  flash  of  lightning. 

It  does  not  follow  that  chloroform  is  the  agent  at  fault  in  these  cases,  and  opinion  seems 
to  trend  in  the  direction  of  ascribing  the  censure  to  the  status  itself  rather  than  to  the 
anesthetic  used.  Deaths  may  occur  at  any  stage  of  anesthesia,  or  some  minutes  after 
the  anesthetic  has  been  stopped.  It  is  significant  that  the  most  conspicuous  illustra- 
tions of  the  relations  between  the  condition  and  sudden  death  have  occurred  during 
operations  upon  the  throat  and  nose.  This  seems  to  show  the  role  played  by  the  adenoid 
tissue. 

Another  interesting  question  is  why  individuals  with  well-marked  status  Ijinphaticus 
should  live,  apparently  comfortable  for  years,  and  then  suddenly  succumb  from  appar- 
ently trifling  causes. 

The  relations  between  the  thymus  and  the  thyroid  are  unmistakable,  yet  obscure.  In 
perhaps  one-half  of  the  cases  where  the  thymus  is  enlarged  the  thyroid  is  also  increased 
in  size.  When  one  is  removed  the  other  seems  to  undergo  more  or  less  compensatory 
enlargement.  This  would  seem  to  indicate  a  species  of  interchangeable  function. 
Much  less  has  been  ascertained  between  the  relations  of  either  of  these  bodies  and  the 
pituitary,  while  nothing  has  as  yet  appeared  concerning  any  sympathetic  involvement 
of  the  coccygeal  body  or  Luschka's  gland. 

Diagnosis. — Recognition  of  the  status  lymphaticus  during  life  is  somewhat  difficult, 
nevertheless  there  are  certain  suggestive  features  which  should  arouse  suspicion.  Of 
these  the  close  relation  between  the  status  l\Tnphaticus  and  rickets,  already  alluded  to, 
furnishes  a  hint,  and,  when  recognized,  a  positive  warning.  Widespread  enlargement 
of  the  lymph  nodes  may  furnish  another.  Adenoid  growths  in  the  nasopharynx  accom- 
panied bv  enlargement  of  the  spleen  should  be  regarded  as  a  suspicious  combination; 
and  when  an  area  of  dulness  is  discovered  over  the  thymus,  or  when  it  can  be  detected 


TlIK  STATUS  LYMJ'JIATICUS  165 

bv  palpation,  the  (lia<;nn.si.s  may  ho  rcfjanlcd  as  ostahhshcd.  Moreover,  eliihlren  who 
are  siihjeet  to  tliis  eoiKHtioii  usually  have  a  pasty  eoiiiplexioii  and  an  anxious  faeies. 
Besides  sliowiiiijj  evidences  of  rickets  tliey  are  anemic,  with  liability  to  spasm  of  the 
tjjloltis.  The  thyroid  is  often  enlarjijed.  In  youn<j  adults  the  condition  may  simulate 
cretinism,  in  that  they  are  retarded  in  growth  and  infantile  in  aj)j)earance,  while  sexual 
development   is  incomj)lete. 

Treatment. — In  well-marked  instances  of  status  lymphaticus  there  should  he  ordin- 
arily no  operative  intervention;  yet  when  the  nose  and  pharynx  are  obstructed  it  is 
advisable  to  give  free  channels  for  breathincr  purpcxses. 

Assuminji;  that  the  result  of  experimental  injection  of  thymic  juice  shows  it  to  have 
a  depressintj  and  ])ressure-lowerin<i;  effect,  an  effort  should  be  made  to  ward  off  danger 
by  the  use  of  adrenalin,  which  should  be  given  previous  to  the  commencement  of  the 
anesthesia.  These  are  cases  where  it  is  best  to  treat  the  surfaces  to  be  oj)erated  with 
a  spray  of  mild  cocaine  solution,  in  order  to  deaden  liability  to  those  impressions  which 
may  produce  secondary  and  refl(>x  cardiac  disturbance's  if  conveyed  to  the  brain.  When 
o|)eration  is  neces.sary  for  glottic  spasm  or  laryngismus  stridulus  it  may  be  commenced 
with  a  tracheotomy,  with  the  use  of  a  long  trachea  tube.  When  operation  is  required 
for  the  relief  of  thymic  enlargement,  a  preliminary  tracheotomy  should  be  made, 
with  the  u.se  of  a  long  tube.  The  improvement  which  results  after  the  completion  of 
the  surgicid  treatment,  for  instance  after  removing  adenoids  from  the  nasopharynx,  is 
gratifying. 

The  most  reliable  measures  have  proved  to  be  adrenalin  and  artificial  respiration, 
used  as  described  in  the  chapters  on  Blood  Pressure  and  Shock  and  Anesthetics. 


CHAPTER  XV. 

SURGICAL  ASPECTS  AND  SEQUELS  OF  OTHER  INFECTIONS 

AND  DISEASES. 

As  a  result  of  the  conditions  which  two  centuries  ago  and  more  so  distinctly  separated 
the  barber  surgeon  from  the  practitioner  of  medicine,  there  has  been  evolved  an  arti- 
ficial separation  of  surgery  from  so-called  internal  medicine.  The  consequence  has 
been  a  UKjre  or  less  deej)-rooted  feeling  that  medical  cases  were  to  be  treated  exclusively 
by  non-operative  measures,  and  that  surgical  cases  could  scarcely  be  e.\j)ected  to  present 
any  perplexities  that  were  not  to  be  solved  by  an  operating  surgeon.  It  has  been  no 
small  part  of  the  beneht  resulting  from  modern  teachings  that  these  imaginary  boundaries 
and  limitations  have  been  swept  away;  and  one  of  the  lessons  which  this  text-book  is 
intended  to  inculcate  is  that  broad  principles  underlie  disease  conditions,  and  that 
their  bearings  must  be  ap])reciate(l  thoroughly  in  order  to  practise  either  medicine  or 
surgery  successfully.  In  order  better  to  inculcate  this  teaching  a  chajjter  with  the  above 
general  heading  has  been  inserted,  in  order  to  impress  the  statement  that  any  of  the 
so-called  internal  diseases  may  j)resent  at  almost  any  time  indications  for  distinctly 
surgical  intervention. 

Some  of  the  surgical  scfpicls  of  the  exaiithematous  and  continued  fevers  are  well  known 
and  conmionly  recognized:  for  exam))le,  orrhiti.s  jollouniui  tninups,  suppurahvp  uijUnii- 
mafioii  of  the  middle  car  after  .srarlafina,  and  hed -sores  after  ijjplnis  and  t uphold.  These 
are  easily  recognized.  Moreover,  scarlatiniform  eruptions  occasionally  follow  various 
operations  and  give  rise  to  great  perplexity.' 


DYSENTERY. 

Joint  complications  in  this  disease  have  been  n-cognized  from  the  earliest  times. 
One  hundred  and  fifty  years  ago  Strack  ex))resscd  himself  thus:  "If  the  dysenteric 
poison  affect  only  the  chest,  it  causes  asthma;  if  the  limbs,  it  |)roduces  arthritis;  if  both, 
abscess." 

Joint  pains  and  swellings,  with  other  suppurations,  have  been  noted  in  several  of 
the  epidemics  of  this  disease  which  have  ravaged  various  jxirts  of  the  world  at  different 
times.  Postdysenteric  arthritis  may  assume  noticeable  and  even  pyemic  aspects,  and 
is  occasionally  fatal.  The  bones  and  joints  may  become  involved  in  ])ainful  and  even 
suppurative  swellings,  not  alone  during  the  active  stage  of  the  disease,  but  during  the 
period  of  convalescence;  while  mildness  of  the  primary  attack  does  not  necessarily  pro- 
vide immunity  from  later  complications.  Here  thrombosis  of  large  veins  or  throndu)- 
|)hlebitis  are  also  observed.  When  the  joints  are  involved  it  is  usually  in  irregular  order 
and  not  simultaneously.  Joint  lesion  does  not  necessarily  proceed  to  su])puration,  but 
j)erhaps  only  to  the  point  of  edema  and  fluid  exudation  or  hydrops.  In  the  Cuban  and 
South  African  campaigns,  during  which  dysentery  prevailed,  joint  complications  were 
noted. 

CHOLERA. 

Cholera  is  usually  too  rapid  and  too  violent  in  its  course  to  be  followed  by  secondary 
infections.  Nevertheless,  Poulet  reports  from  Val-de-(irace  several  instances  of  articu- 
lar and  (xsseous  lesions,  some  of  these  characterized  by  effusion  of  fluid  which  was  some- 
times very  thick  and  resembled  balsam,  while  at  other  times  pus  was  present. 

'  Medical  News,  February  20,  1897,  p.  234. 
(166) 


TV  I' I  Id  1 1)  FEVER  167 


PNEUMONIA. 

Piicuinoiiiu  having  now  taken  its  place  as  a  distinct  (fcrin  disease,  and  the  micrococcus 
of  Friinkcl  and  the  ca|)siilc  coccus  of  Friedliinder  hein<^  well  estahlished  as  the  active 
agents  in  the  two  j)rincii)al  forms  of  this  disease,  pus  may  be  found  in  other  |)arts  of  the 
body.  The  most  common  surgical  .se(juels  of  pneumonia  occur  as  jK)st|)neunionic 
pyarthrosis,  which  has  been  wrongly  considered  a  rheumatic  affection.  These  lesions 
are  of  embolic  oi-  oi"  metastatic  orio-in. 


INFLUENZA,  OR  LA  GRIPPE. 

This  tlisease  has  assumed  prominence  in  medical  literature,  and  not  a  few  instances 
have  been  reported  of  surgical  sequels — abscesses,  purulent  ear  disease,  pyarthrosis, 
bone  lesions,  etc.     Even  necrosis  has  been  rejoeatedly  observed. 


MEASLES  AND  SCARLATINA. 

The  infectious  agent  in  these  affections  is  not  yet  recognized  and  their  surgical 
sequels  should  l)e  regarded  as  due  to  secondary  pyogenic  infections. 

Surgical  tuberculosis  appears  often  as  a  sequel  of  the  exanthemas.  In  the  lym])h- 
atics,  periosteum,  bones,  and  joint  cavities,  and  in  and  about  the  eye  and  ear,  mani- 
festations of  suppurative  disease  are  often  found.  It  is  believed  that  these  sequels  are 
likely  to  appear  when  the  eruption  has  been  incomplete.  Hyperplastic  thickening  of 
periosteum  and  neuralgic  pains  of  the  affected  parts  occur  without  suppuration,  hence 
the  rheumatic  character  which  Bonnet  and  others  have  wrongly  ascribed  to  these 
manifestations. 

While  the  absence  of  pus  takes  these  out  of  the  category  of  pyogenic  infections,  it 
nevertheless  leaves  them  still  as  surgical  complications  which  have  often  to  be  dealt 
with  by  mechanical  measures,  such  as  orthopedic  apparatus,  etc.;  while  more  or  less 
formidable  operations,  as  for  relief  of  ankylosis,  have  to  be  performed.  Postscarlatinal 
arthralgia  may  be  explained  as  a  local  ischemia;  so  may  acute  swelling  or  chronic  thick- 
ening. But  pus  is  an  expression  of  infection,  and  cannot  be  otherwise  regarded.  Retro- 
pharyngeal abscesses  and  a  peculiar  necrosis  of  the  alveolar  process  of  the  jaws, 
described  by  Salter,  are  among  the  various  serious  surgical  complications  of  scarlatina. 
Epiphyseal  separations  and  purulent  destruction  of  ribs  have  also  been  noted. 


TYPHOID  FEVER. 

Although  in  elaborate  treatises,  as  by  Liebermeister  and  ISIurchison,  there  is  no 
mention  of  bone  and  joint  complications  as  sequels  of  typhoid,  they  have,  nevertheless, 
been  recognized  by  surgeons.  Post-typhoid  hip  dislocations  have  been  reported 
by  several  German  surgeons.  Boyer  observed  spontaneous  dislocation  of  both  thighs 
after  what  he  called  "essential  fever,"  and  the  general  topic  of  spontaneous  luxations 
subsequent  to  typhoid  has  been  frecjuently  discussed. 

Those  affections  of  joints  formerly  considered  rheumatic  occur  much  less  often  after 
typhoid  than  after  dysentery.  Nevertheless,  post-typhoidal  arthralgia  and  myodynia 
have  been  recognized  by  several  French  writers.  Some  with  affected  joints,  supposed 
to  be  rheumatic,  have  later  been  discovered  to  be  suffering  from  genuine  typhoid  fever, 
and  it  has  been  afterward  recognized  that  the  joint  lesion  was  a  bizarre  expression  of 
the  typhoid  poisoning.  The  works  on  general  practice  call  attention  to  the  frequent 
complications  of  the  pleural  and  pericardial  serous  membranes  in  this  disease.  They 
say  little,  however,  about  the  implications  of  the  articular  serous  membranes,  though 
one  is  as  easy  to  explain  as  the  other.  Post-typhoidal  polyarticular  serous  arthritis  has 
been  described  by  more  than  one  writer.  Multiple  joint  abscesses  have  been  rarely 
seen.  Pus  has  been  known  to  collect  not  only  in  the  joints,  but  also  in  the  tendon  sheaths 
and  bursse.     The  lymph  nodes  are  also  frequently  affected,  and  cervical,  axillary,  and 


168  SURGICAL  DISEASES 

inguinal  abscesses  are  not  rare.  Post-typhoidal  pyarthrosis,  as  leading  to  spontaneous 
luxation,  has  had  a  medicolegal  interest,  for  luxation  has  been  known  to  occur  while 
raising  or  lifting  a  patient,  the  question  of  vioU-nce  being  subseciuently  brought 
into  court.  When  the  joint  disease  assumes  the  mono-articular  form  it  is  likely  to  ter- 
minate in  suppuration;  when  polyarticular,  pyarthrosis  is  less  common.  In  the  pus 
from  many  of  these  abscesses  ty])hoid  bacilli  may  be  recognized,  but  by  no  means  in  all. 
The  writer  has  found  them  in  a  case  of  abscess  in  the  abdominal  wall  occurring  during 
convalescence  from  typhoid  in  a  young  woman.  A  non-supj)urative  but  j)ainful  form 
of  periostitis  is  occasionally  observed.  I  have  never  seen  more  exquisite  tenderness 
nor  expressions  of  suffering  than  I  met  in  a  case  of  this  kind  in  a  boy  in  whom  the 
bones  of  ])oth  lower  extremities,  of  the  pelvis,  and  the  lower  spine  were  involved.  The 
slightest  jar  upon  the  floor  would  make  him  exchiim  with  pain,  and  to  minister  to 
his  ordinary  wants  was  a  distressing  task.  He  eventually  recovered  without  any  pus 
formation.  Deep  suppuration  in  bones  occasionally  occurs,  and  even  necrosis  with 
separation  of  sequestra. 

Thrombosis  and  thrombophlebitis  are  also  well-known  sequels  of  typhoid,  which 
may  lead  to  unpleasant  complications.  Typhoid  fever  appears  to  bear  a  pecuHar 
relation  to  the  growth  of  bones,  as  it  has  been  noticed  that  <lin-ing  its  course,  or  during 
convalescence,  they  show  an  extraordinarily  ra])id  growth  in  length,  even  to  the  extent 
of  1  Mm.  a  day.  This  is  probably  caused  by  the  irritation  of  the  typhoid  toxin  upon 
the  osteogenic  tissue,  since  hyperemic  areas  have  been  found  in  the  }:)one-marrow  of 
those  dying  of  the  disease,  and  bone  pains  are  a  frequent  accompaniment  of  the  disease. 
Typhoid  bacilli  have  the  power  of  remaining  latent  in  the  tissues  for  a  long  time  after 
cessation  of  active  symptoms,  and  have  been  found  alive  and  capable  of  active  growth 
seven  months  after  cessation  of  the  fever.  Remembering  the  multiple  ulcers  of  the 
lymphoid  tissue  which  characterize  the  intestinal  lesions  of  typhoid,  it  is  difficult  to 
explain  pyogenic  or  other  septic  infection  by  absorption  through  these  open  ports  of 
entry;  and  the  typhoid  bacilli  themselves,  entering  the  circulation  through  these  paths, 
may  be  carried  to  all  parts  of  the  body,  and  have  been  found  in  the  pia. 

A  large  amount  of  interest  has  attached  to  the  so-called  "surgery  of  typhoid  fever," 
which,  however,  has  been  permitted  to  include  only  abdominal  section  for  perforation 
of  intestinal  ulcers.  The  mortality  due  to  this  accident  is  nearly  70  per  cent. — ?'.  e.,  is 
formidable.  It  occurs  generally  during  the  third  week.  It  is  usually  preceded  by 
leukocytosis,  and  is  followed  by  profound  shock.  Operation  offers  almost  the  only 
hope.  It  has  been  successful  in  about  one  out  of  five  cases.  (See  Surgery  of  the 
Intestines.) 

Post-typhoidal  infections  of  the  biliary  and  pancreatic  ducts,  with  their  resulting  com- 
plications, play  a  conspicuous  part  in  the  etiology  of  biliary  obstruction.  They  are 
regarded  as  among  the  most  common  causes  of  acute  and  chronic  or  latent  disease  in 
these  passages. 

DIPHTHERIA. 

This  also  belongs  to  the  diseases  frequently  complicated  by  lesions,  aside  from  those  of 
laryngeal  obstruction  calling  for  surgical  relief.  Abscess  occurs  so  frequently  as  to  scarcely 
call  for  comment.  Here,  as  in  the  cases  of  scarlatina,  the  location  of  the  throat  lesions 
and  the  absorbing  powers  of  the  lymphadenoid  tissue  so  completely  involved  will  readily 
account  for  all  septic  or  pyogenic  manifestations  at  a  distance.  Multiple  abscesses 
have  been  found  in  the  liver,  the  spleen,  and  lungs,  in  and  around  bones,  betokening 
thereby  a  pyemic  manifestation.     Infectious  nephritis  is  also  common. 

Mann,  of  Denver,  has  communicated  to  me  personally  cases  of  embolus  of  the  femoral 
artery  with  resulting  gangrene  as  sequels  of  diphtheria,  as  well  as  instances  of  true 
diphtheria  of  the  penis,  established  by  bacteriological  diagnosis. 


MUMPS. 

The  infectious  character  of  this  disease  is  not  questioned,  although  not  definitely 
established.  Orchitis,  ovaritis,  stomatitis,  enlargement  of  the  tonsils  and  spleen,  and 
albuminuria   are    frequent   accompaniments  of  the  disease,  while  articular  and  peri- 


THE  PUERPERAL   STATE  109 

articular  toiiiplicalions  havr  been  iiolrd.  Bursal  absct'sses  and  pvarthro.scs  liave  also 
been  reported.  These  sur<j;i(al  eomjjlieations  have  been  regarded  as  rheumatoid  or 
rheumatic,  their  essential  sii:;iiificance  not  beinp;  recoirnizcd  until  recently. 


VARIOLA. 

The  \vrit(>rs  of  the  earli(>r  part  of  this  century  allude  fre(|Uently  to  the  rheumatoid 
complications  of  smallpox,  amonjjj  which  jnarthrosis  seemed  the  most  common  and 
most  serious.  The  various  arthropathies  are  the  most  interestinjij  of  the  surgical  com- 
plications of  this  disease.  The  joints  become  swollen,  red,  and  painful,  one  joint  after 
another  bein};  involved. 

INFECTIOUS  ENDOCARDITIS. 

The  individuality  of  this  condition  has  been  recofrnized  only  within  the  last  thirty 
years.  That  it  deserves  the  characterization  of  "nudi<jnant"  often  jijiven  to  it  is  well 
known.  It  is  an  infectious  disease  with  a  sj)ecial  localization  in  the  heart,  the  term 
cardiac  ft/phu.s-  being  very  expressive.  Although  so  ajijxirently  spontaneous,  it  is  usually 
a  secondary  lesion,  sometimes  a  primary  infection.  The  arthritic  manifestations  often 
assume  a  pyemic  character,  and  even  at  the  beginning  of  the  afl'ection,  as  Trousseau 
pointed  out,  there  are  frequently  severe  joint  pains. 


DENTAL  CARIES. 

Nearly  one  hundred  species  of  microorganisms  from  the  mouth  liave  been  studied 
and  identified  by  W.  D.  Miller,  who  has  clearly  established  that  dental  caries  is  due  to 
the  specific  action  of  some  of  these  parasites,  which,  gaining  entrance  into  the  dental 
tubules,  determine  fermentation  and  acid  profluction,  with  erosion  of  the  dental  struc- 
ture of  the  teeth  and  an  increase  in  softening  and  destruction.  In  this  way  the  teeth, 
as  already  indicated  in  Chapter  IV,  become  paths  of  infection  for  germs  which  may  travel 
but  a  short  distance,  causing  only  local  disturbance,  or  which  may  be  carried  to  other 
points  about  the  head,  producing  disturbance  in  the  antrum,  in  the  neighboring  bones, 
in  the  middle  ear,  and  not  infrequently  in  the  brain.  Abscess  in  the  brain  has  been 
distinctly  traced  to  caries  of  the  teeth.  Tuberculous  infection  is  also  common  through 
this  channel,  and  its  most  common  expression  is  probably  the  invasion  of  the  cervical 
lymphatics,  superficial  and  deep,  constituting  those  lymphatic  tumors  of  the  neck, 
formerly  known  as  scrofulous,  w^ith  their  disastrous  train  of  adhesions,  suppuration, 
erosion,  etc. 

SYPHILIS  AND  GONORRHEA. 

These  are  surgical  affections  whose  secondary  complications  in  the  way  of  abscesses, 
infarcts,  tumors,  etc.,  have  been  dealt  with  in  other  parts  of  this  work.  It  will  be  well  to 
group  all  of  these  infections  with  anthrax,  glanders,  etc.,  into  a  class  of  infections  which 
may  be  followed  by  tardy  or  late  surgical  sequels  that  may  call  for  more  or  less  radical 
operation.  In  the  case  of  gonorrhea  this  is  best  seen,  perhaps,  in  the  so-called  pus  tubes 
of  the  female  pelvis,  which  often  require  removal  years  after  the  date  of  the  primary 
invasion. 

Endocarditis  and  pyemia  are  occasionally  of  solely  gonorrheal  origin,  as  well  as 
peritonitis  by  extension  from  infected  pelvic  viscera. 


THE  PUERPERAL  STATE. 

This  is  seldom  followed  by  surgical  sequels,  save  in  the  instance  of  mechanical  lacer- 
ations demanding  plastic  repair,  or  of  septic  infections,  wdiich,  when  life  is  saved,  some- 
times lead  to  disastrous  consequences.  Puerperal  septicemia  is  in  no  respect  different, 
pathologically  speaking,  from  septicemia  due  to  any  other  presumably  streptococcus 


170  SURGICAL  DISEASES 

invasion;  and  the  predilection  which  streptococci  manifest  for  serous  membranes,  and 
especially  joints,  is  well  known.  Consequently  after  puerperal  fever  one  may  meet 
with  articular  or  peri-articular  abscesses,  affections  of  tendon  sheaths,  lymphatics,  etc., 
or  the  complication  may  assume  a  different  type,  the  veins  and  their  contents  being 
mainly  involved,  with  thrombosis,  infarct,  etc.,  for  its  immediate  results. 

There  is  probably  no  disease  of  known  or  suspected  germ  origin  which  may  not  be 
followed  by  disastrous  or  unexpected  surgical  comj)lications,  while  even  degenerative 
changes,  for  which  as  yet  no  theory  of  parasitism  has  been  invoked,  are  followed  by 
conditions  which  may  call  for  serious  surgical  measures,  hi  other  words,  ilir  .siirgiml 
complicationff  of  any  so-called  non-siirgiral  disease  may  loom  up  at  any  moment  in  any 
case. 


CHAPTER    XVI. 

POLSONINC;  BY  ANIMALS  AND  PLANTS. 

Certain  poisons  or  (Iclclcrions  sul)staiic('s  arc  iiitrodiucd  in  various  ways  into  tlio 
human  system  from  witliout,  some  of  which  j)ro(hR'e  only  symptoms  of  moderate  inten- 
sity, while  others  are  fatal.  It  is  authentically  stated  that  in  India  many  thousands  of 
individuals  lose  their  lives  every  year  as  the  result  of  the  bites  of  poisonous  snakes.  In 
1903  there  were  officially  reported  28, 104  deaths  from  this  cause.  Nothin<]f  approaching 
such  injuries  in  frecpiency  or  intensity  can  he  found  in  any  other  j)art  of  the  world. 
Animal  poisons  may  be  introduced  by  animals  of  many  s|)ecies.  The  poison  of  hydro- 
phobia has  been  described.  The  bites  of  the  mammalia  may  be  serious  and  may  be 
followed  by  septic  symptoms,  but  are  not  ordinarily  reti;arded  as  due  to  any  special  toxin 
secreted  by  the  animal.  A  number  of  reptiles,  however,  ]X)ssess  special  poi.ioN  (jlands 
which  are  connected,  in  most  of  them,  with  a  tooth  on  either  side  of  the  up|)er  jaw 
which  is  canal iculated,  and  serves  as  a  duct  through  which  the  poison  is  injected  when 
the  animal  inflicts  its  bite. 

SNAKE  BITES. 

The  principal  poisonous  serpents  in  North  America  are  the  rattlesnakes — of  which 
there  are  several  si)ecies,  usually  placed  at  eighteen — the  copperheacl.s,  the  vioccasovs, 
and  the  vipers.  Some  of  these  have  movable  poison  fangs,  some  fixed.  In  other  parts 
of  the  world  others  equally  or  even  more  poisonous  are  known. 

The  poison  gland  is  analogous  to  the  parotid  in  location  and  structure.  The  duct 
which  runs  through  it  is  so  dilated  as  to  contain  a  small  amount  of  the  peculiar  poison. 
The  amount  of  poison  contained  in  these  reservoirs  varies  from  eight  to  twelve  minims, 
and  is  secreted  somewhat  slowly.  It  seems  to  be,  in  some  cases  at  least,  a  ghicoside; 
in  others,  a  toxalbumin.  It  is  capable  of  being  preserved  either  dry  or  in  alcohol  or  in 
glycerin.  The  active  poisonous  principle  seems  to  pertain  to  a  globulin  or  to  a  peptone. 
Almost  all  of  these  venoms  are  innocuous  if  swallowed,  and  like  septic  infections  seem 
inoculable  only  through  the  tissues  and  the  circulating  fluids.  According  to  Mitchell, 
the  venom  of  the  rattlesnake  renders  the  blood  incoagulable,  paralyzes  the  walls  of  the 
capillaries,  and  facilitates  escape  of  leukocytes  into  the  tissues,  thus  making  actual 
hemorrhagic  swelling  occur;  while  the  red  corpuscles  rapidly  lose  shape  and  fuse 
into  irregular  masses  and  their  hemoglobin  is  dissolved  or  disappears.  This  poison 
seems  to  paralyze  both  the  respiratory  centre  and  the  heart.  Cobra  poison,  not 
containing  globulin,  at  least  to  a  great  extent,  does  not  produce  the  rapid  changes  of 
rattlesnake  poison. 

Symptoms. — A  snake  bite  is  like  a  hyjiodermic  injection  of  a  deadly  poison,  and 
symptoms  set  in  promptly.  These  are  both  local  and  general.  There  is  more  or  less 
local  pain,  with  swelling  and  discoloration,  which  are  due  to  effusion  of  blood.  They 
increase  in  intensity,  and  are  followed  by  vesication  and  necrosis  of  tissues — that  is, 
gangrene — if  the  patient  survive  for  some  time.  Constitutional  symptoms  are  not  long 
delayed,  and  are  characterized  by  severe  prostration,  including  cold,  clammy  sweat; 
feeble  and  rapid  pulse,  irregular  respiration,  etc.  When  patients  succumb  they  usually 
die  in  collapse.     The  pathological  changes  are  not  well-marked  or  characteristic. 

Treatment.— Treatment  of  snake  bite  must  be  prompt  if  it  is  to  be  successful. 
It  should  consist  of  incision  and  drainage  of  blood  from  the  part,  in  order  to  prevent 
diffusion  into  the  rest  of  the  body  by  means  of  the  returning  blood  and  lymph.  Bleed- 
ing should  be  facilitated  by  cups  "or  by  sucking  the  wound.  An  elastic  tourniquet 
should  be  applied  around  the  limb  near  "the  trunk,  the  site  of  the  wound  freely  incised, 
and  the  blood  worked  both  ways  toward  the  wound  by  "stripping"  the  member.  If 
there  be  any  known  antidote  to  snake  poison  it  consists  of  potassium  permanganate  or 
calcium  hypochlorite  (chloride  of  lime),  applied  locallv  in  solution,  the  former  sufficiently 

(171) 


172  SURGICAL  DISEASES 

strong  to  have  a  marked  color  and  capable  of  producing  local  irritation  (1  per  cent.). 
With  these  local  measures,  constitutional  stimulation  should  he  iiuhilged  l)y  means  of 
volatile  and  other  stimulants.  There  is  a  popular  fallacy  in  favor  of  inducing  alcoholic 
intoxication.  To  do  this  is  a  mistake.  Nevertheless,  alcohol  may  he  given  freely,  dosage 
being  lunited  not  by  amount  but  by  effect.  Strychnine,  digitalis,  atropine,  etc.,  will  often 
prove  serviceable.  The  tourniquet  should  be  gradually  released  after  being  in  use  for  two 
or  three  hours,  and  an  assistant  ready  to  antidote  the  poison  which  may  then  enter  the 
system  with  the  necessary  doses  of  stimulants  above  mentioned.  One-half  grain  of 
strychnine  may  be  administered  in  divided  doses,  it  apparently  being  an  antidote  to 
the  snake  venom.  There  is  much  reason  from  recent  experimentation  to  expect  benefit 
from  serum  therapy — i.  c,  by  injection  of  serum  from  immunized  animals  who  have 
been  fortified  by  increasing  doses  of  the  snake  poison.  Calmette  advises  the  use  of 
20  Cc.  of  serum  from  a  horse  which  has  been  immunized  by  cobra  poison.  He  believes 
the  active  poison  of  all  venomous  serpents  to  be  essentially  identical.  Good  results 
have  been  reported  even  after  an  interval  of  an  hour.  In  this  country,  however,  such 
treatment  will  be  called  for  so  seldom  that  there  is  not  the  hopeful  outlook  for  the  serum 
therapy  of  snake  bite  that  there  is  in  India. 


POISONING  BY  LIZARDS. 

A  large  lizard  found  in  the  southwestern  part  of  this  country  and  in  Northern  Mexico, 
known  as  the  Gila  Monster  (Heloderma  suspecium),  is  credited  with  being  a  poisonous 
animal.  The  probability  is  that  the  bite  is  fatal  to  some  of  the  lower  animals  and  may 
produce  more  or  less  serious  disturbances  in  man.  Nevertheless  there  is  little  real 
evidence  that  this  is  to  be  considered  in  the  same  category  with  the  venomous  serpents 
above  mentioned. 


POISONING  BY  SPIDERS  AND  SCORPIONS. 

Certain  species  of  spiders  are  venomous,  the  tarantula  being  the  best  known.  Certain 
scorpions  also  inflict  poisonous  stings,  and  centipedes  and  other  animals  occasion  at 
least  serious  local  disturbance  by  bites  or  stings.  These  insects  and  animals  seldom 
attack  unless  irritated  or  disturbed.  Tarantula  bites  are  occasionally  inflicted  in  the 
Northern  States  by  spiders  which  have  concealed  themselves  in  shipments  of  fruit, 
bunches  of  bananas  being  especially  likely  to  be  their  hiding  places.  The  injuries 
inflicted  by  these  animal  organisms  cause  local  pain,  considerable  swelling,  with  remote 
effects  on  the  nervous  system,  prostration,  restlessness,  etc.  They  are  seldom  fatal,  but 
may  cause  annoyance  and  serious  disturbance.  These  cases  are  to  be  treated  in  the 
same  way  as  bites  of  poisonous  serpents,  adapting  the  measures  and  the  energy  of  the 
treatment  to  the  severity  of  the  symptoms. 


POISONING  BY  WASPS,  HORNETS,  AND  BEES. 

Wasps,  hornets,  and  bees  are  capable  of  inflicting  severe  stings;  domestic  insects,  like 
mosquitoes,  bed-bugs,  etc.,  inflict  minute  wounds  which  sometimes  occasion  excessive 
annoyance.  Their  sting  is  followed  by  pain,  burning  sensation,  sometimes  intense 
itching,  and  more  or  less  swelling.  Enough  poison  is  deposited  to  produce  local  vaso- 
motor paralysis,  as  the  result  of  which  wheals  resembling  those  of  urticaria,  or  more 
extensive  swellings,  quickly  result.  If  the  sting  of  an  insect  has  been  broken  off  in  the 
flesh  it  may  remain  and  intensify  the  disturbance.  Two  or  three  injuries  of  this  kind 
create  local  disturbance,  but  there  are  some  instances  on  record  where  men  and  animals 
have  been  stung  to  death  when  attacked  by  swarms  of  these  insects,  death  apparently 
being  due  to  intensification  of  effect  owing  to  increased  dosage  of  poison.  If  a  sting 
occur  upon  loose  tissues,  like  the  eyelid,  or  upon  the  tongue  or  lips,  swelling  and  suffering 
may  be  extrem*'.     If  symptoms  of  depression  present,  they  should  be  combated  by 


IV)     I'OISOMXG  173 

.stiiiiuliiiits,  (liffusihlo  or  other,  and  hy  liypodcriiiic  iiicdicatioii  pro  rr  n<i(<i.      Local  dis- 
coiutort  may  Ih'  alleviated  l)y  i<'e,  l)V  iiieiitliol,  hy  eliloral  eaiii])lior,  etc.' 

Mdrii/  (>l  flir  loirfr  joniis  of  marine  aniin(t/.s-  are  ca|)al)le  ol"  iiiflicliiitj;  stiiif^s  hv  llieir 
rays,  or  inimite  injuries  in  other  ways,  which  <;ive  rise  to  j^reat  tein])orary  annoyance. 
The  .s{in(fin(/  ntitlr,  etc.,  is  an  instance  of  this  kind.  The  lesions  produced  in  this  way 
partake  of  tiie  nature  of  a  more  or  less  acute  dermatitis. 

ARROW  POISON. 

'i'he  arrow  'j)ni.s-nii  of  various  Indian  and  sava<;e  tribes  is  a  comj)osition  of  variable  and 
usually  imknown  nature.  It  is  compounded,  for  the  most  part,  from  vegetable  sub- 
stances, and,  if  one  may  judge  from  the  specimens  of  curare  sold  by  importing  houses, 
tiieir  strength  is  unreliable. 

While  some  of  these  preparations  are  made  by  the  natives  from  a  species  of  Strychnos 
growing  in  the  northern  part  of  South  America,  this  tree  is  not  in  universal  use  for  this 
purjjose:  in  the  East  Inclies  they  are  made  from  a  species  of  Upas  (the  deadly  Upas  of 
song  and  story).  Some  of  the  j)oisone(l  arrows  are  dij)j)ed  in  |)utrefying  blood.  A 
wound  made  by  these  is  not  necessarily  promptly  fatal,  but  would  tend  to  kill  by  setting 
up  septic  disturbance.  The  vegetable  |)oisons  have  the  property  of  paralyzing  the 
motor  nerves  and  the  circulation  to  such  an  extent  that  death  may  occur  within  a 
few  moments  after  injury.  All  of  these  poisons  are  innocuous  when  swallowed,  and 
game  killed  by  their  agency  may  be  eaten  without  fear  of  ill  results.  Arrow  poison  of 
the  vegetable  variety  which  is  not  fatal  within  a  few  hours  may  be  recovered  from  if 
stimulation  be  vigorous.     Artificial  respiration  is  a  factor  in  keeping  such  patients  alive. 


IVY  POISONING. 

In  the  vegetable  kingdom  there  is  one  kind  of  plant,  the  so-called  poison  ivy  (Rhus 
toxicodendron),  which  is  capable  of  producing  intense  dermatitis.  All  persons  are  not 
susceptible  to  this  poison — least  so  those  of  thick  skin  and  dark  hair.  It  is  generally 
those  of  blonde  type  and  thin  skin  who  seem  most  liable  to  its  irritation. 

The  active  agent  is  toxicodendric  acid,  and  it  is  capable  of  setting  up  an  intense  irri- 
tation of  the  eczematous  type,  with  a  large  amount  of  hyperemia  and  edema,  especially  of 
soft  tissues.  When  the  face  is  involved  the  eyelids  become  puffed  so  as  to  make  it  almost 
impossible  to  separate  them  for  purposes  of  vision.  Ivy  poisoning  is  usually  contracted 
by  contact  wath  the  plant.  Symptoms  supervene  generally  within  twenty-four  hours, 
and  in  well-marked  cases  do  not  subside  for  three  or  four  days.  The  itching  is  intoler- 
able, and  is  best  combated  by  strong  alkaline  solutions  or  brine.  A  dilute  bromine 
solution  sometimes  proves  beneficial.  Salt  and  soda  in  strong  solution  and  vigorous 
catharsis  are  also  useful.     Hypodermic  injections  may  be  necessary  to  induce  sleep. 

Certain  species  of  sumach,  particularly  the  genus  Cypripedium,  may  produce  similar 
sjTiiptoms,  usually  less  severe. 

'  Oil  of  lavender  is  a  pleasant  means  of  local  protection  against  mosquitoes,  etc.  Oil  of  tar  is  also  in  common 
use.  A  mixture  of  equal  parts  of  camphor  and  chloral,  with  menthol  dissolved  in  the  mixture  (camphor  and 
chloral  when  mixed  without  other  ingredients  quickly  form  a  dense  fluid  like  glycerin),  gives  great  local  relief 
from  the  itching  and  pain  of  insect  bites. 


CHAPTER   XVII. 

ACUTE  INTOXICATIONS,  INCLUDING  DELIRIUM  TRP:MENS. 

DELIRIUM  TREMENS. 

Delirium  tremens  as  an  expression  of  acute  or  subacute  alcoholic  poisoning  is  in  no 
essential  degree  a  surgical  condition.  This  form  of  toxic  delirium  may  occur  while  the 
individual  is  still  drinking  inordinately,  or  not  until  several  days  have  elapsed  after  active 
drinking  has  ceased.  It  is  jjrecipitated  in  many  cases,  where  otherwise  it  would  simply 
remain  imminent,  Vjy  surgical  injuries  and  operations.  In  one  in  whom  it  is  feared, 
the  surgeon  should  Ijecome  apj^rehensive  in  proportion  as  the  muscular  system  becomes 
unsteady  and  tremulous,  the  mind  disturbed,  and  the  individual  sleepless. 

Patients  in  a  well-marked  condition  of  delirium  tremens  may  become  so  uncontnjllable 
and  so  lost  to  sensation  of  pain  that  it  may  be  practically  impossible  to  enforce  the 
physiological  rest  which  their  surgical  condition  demands.  The  restraining  sheet  will 
answer  for  general  purposes,  but  the  strait-jacket  and  even  the  mo.st  carefully  applied 
plaster  splint  or  mechanical  restraint  will  not  always  be  sufficient  to  carry  out  the 
indication. 

Inwenuitv  iiiav  be  taxed  beyond  it.-^  limit  to  enforce  the  needed  rest,  for  patients  will 
tear  otl'  bamlages  and  injure  themselves  in  various  ways. 

Treatment. — The  loml  indirafions  are  in  the  direction  of  physiological  rest.  Con- 
stiiutionally  the  indications  are  in  two  directions:  Eirst,  to  keep  up  nutrition  and  excre- 
tion; secondlv,  to  properly  medicate.  Nutrition  is  difficult  unless  excretion  is  main- 
tained. Hot-air  baths,  laxative  enemas,  preferably  of  cold  water,  when  necessary, 
and  administration  of  a  fluid  and  easily  a.s.similable  diet  are  measures  of  the  utmo.st 
imp(jrtance.  Should  the  case  present  features  of  an  acute  alcoholic  gastritis,  stomach 
feeding  mav  be  abandoned  and  the  rectum  utilized  for  this  purpose.  Medication  should 
consi-st  mostlv  of  stimulants,  with  such  sedatives,  laxatives,  diuretics,  etc.,  as  may  be 
necessarv.  In  surgical  cases  it  is  not  wise  to  al)ruptly  de])rive  these  patients  of  the 
alcohol  which  they  have  so  abused.  Consequently  in  many  instances  a  mild  degree  of 
alcoholic  stimulation,  at  least  for  a  time,  should  be  continued.  Two  stimulants  rank 
higher  than  all  others  as  suVxstitutes  for  alcohol,  and  in  some  degree  antidotes  to  its 
effect.  These  are  strychnine  and  digitalis.  The  fonner  shotild  be  given  preferably 
subcutaneouslv;  the  latter  by  the  stomach  if  tolerated,  otherwise  by  the  rectum  or 
beneath  the  skin.  My  own  preference  for  the  use  of  digitalis  is  in  the  direction  of  large 
and  few  doses.  I  have  not  hesitated  in  many  instances  to  give  L5  Cc.  of  ordinary  tinc- 
ture, repeated  once  or  twice  at  intervals  of  a  few  hours,  and  then  to  discontinue  it.  The 
effect  is  to  brace  up  the  heart  and  to  equalize  the  circulation,  while  at  the  same  time 
it  acts  as  an  efficient  diuretic.  Adrenalin  may  be  necessary,  but  should  be  used  with 
discrimination. 

Of  the  .sedatives,  bromides,  chloral,  and  remedies  of  that  class  are  those  most  often 
resorted  to,  and  should  be  given  in  doses  sufficient  to  meet  the  s}Tnptoms.  They  are  all 
more  or  less  depressant,  and  stimulation  by  strychnine,  etc.,  is  necessary  even  while  they 
are  being  administered,  in  spite  of  the  apparent  physiological  antagonism  between  them. 
Opium  is  the  remedy  of  choice,  and  is  best  given  in  the  form  of  morphine  introduced 
beneath  the  .skin. 

The  first  indication  is  in  the  direction  of  ensuring  rest  and  .sleep,  even  at  the  expense 
of  inconvenience  or  misfortune  in  other  directions.  I  write  this  with  a  realizing  sense 
of  its  significance,  yet  with  positive  conviction  as  to  its  truth. 

L'pon  the  assumption  that  this  form  of  delirium  is  a  toxemia  of  complicated  type,  only 
benefit  can  accrue,  in  aggravatetl  cases,  from  a  free  venesection,  followed  by  intravenous 
infasion  of  a  pint  or  more  of  saline  .solution,  at  a  temperature  of  105°  F. 
(174) 


TOXIC  .\.\Tfsi:i"rics  175 


TRAUMATIC  OR  POSTOPERATIVE  MANIA. 

It  is  (liflicult  to  <listiii<j;uisli  tliis  loriii  of  iiiaiiia  rroiii  tlial  known  as  purrprrnl  nifniia, 
the  two  condilions  lit-iii^  essentially  similar.  This,  loo,  is  to  he  regarded  as  a  eonipli- 
eated  toxemia,  in  which  |)ro(lnets  of  defective  metabolism,  of  insnflicient  elimination, 
and  of  phafjoeytic  activity  minfi;le  in  a  hlood  whose  corpuscular  elements  are  already 
much  distin-hed  by  injury  or  hemorrhage.  Regarding  these  cases  from  a  .surgeon's 
standpoint,  and  carefully  avoiding  any  attempt  at  minute  explanation  of  the  j)lienoniena, 
such  cases  are  met  with  in  the  j)ractice  of  operating  surgeons,  as  in  the  experience  of 
obstetricians,  presenting  themselves  either  as  mild  forms  of  harmless  mental  aberration, 
or  assuming  almost  any  of  the  ty])es  of  insanity  as  made  out  and  classified  bv  experts 
in  that  subject.  From  the  mildest  mental  alienation  up  to  intense  and  even  homicidal 
or  suicidal  mania,  one  nuiy  meet  with  all  degrees  of  dej)arture  from  the  normal  standard. 
Bowel  wasiiing,  hot-air  baths,  hepatic  stimulants,  aiul  carefully  regulated  nutrition  will 
usually  restore  to  the  brain  its  natural  food  suj)ply,  and  hence  its  normal  function.  I 
have  repeatedly  seen  much  good  result  from  the  exhibition  of  small  doses  (0.30  to  0.50) 
of  potassium  iodide. 

TOXIC  ANTISEPTICS. 

As  stat(>d  above,  it  is  generally  recognized  that  in  p(>ople  of  peculiar  ifliosyncrasies  the 
administration  of  certain  drugs  ordinarily  considered  harmless  is  followed  by  more  or 
less  toxic  sym])toms.  Obviously  if  this  were  universally  the  case,  or  true  in  the  majority 
of  instances,  the  use  of  these  drugs  would  speedily  be  abandoned.  As  it  is,  it  is  w^ell  to 
have  in  mind  the  consequences  which  are  occasionally  known  to  ensue,  and  perhaps 
to  weigh  in  every  case  the  chances  as  to  Avhether  it  is  worth  while  to  use  a  given  substance 
of  known  occasional  toxic  power  as  against  another  which  is  not  known  to  possess  it. 

Of  the  less  active  antiseptic  agents,  borir  arid  is  considered  absolutely  innocuous,  yet 
is  known  sometimes  to  cause  intestinal  disturliance,  while  in  one  instance  serious  tcxxic 
effects  followed  its  use.  Napldhalin  will  sometimes  produce  vertigo  or  vasomotor 
symptoms,  especially  when  administered  internally  Many  of  the  antiseptic  materials 
used  are  more  or  less  irritating  to  the  skin,  and  such  local  expressions  as  eczema,  etc., 
provoke  little  comment. 

Iodine  is  a  drug  whose  activity  should  be  borne  in  mind.  Applied  upon  the  surface, 
it  tans  the  skin  and  does  no  good.  Injected  in  solutions  of  varying  strength  into  serous 
cavities  (for  example,  hytlnKcles,  etc.)  it  gives  rise  to  symptoms  which  may  be  alarming. 
Fatal  poisoning  following  its  injection  into  an  ovarian  cyst  has  been  reported,  and 
alarming  symptoms  have  been  produced  by  injection  of  the  ordinary  solution  into  a 
hydrocele  sac.  Much  of  the  virtue  ascril)ed  to  iodoform  is  creditefl  to  the  liberation  of 
free  iodine  by  its  decomposition.  Whether  or  not  this  be  true,  iodoform  is  one  of  the 
most  frequently  toxic  of  the  antiseptic  agents  in  ordinary  use.  In  mild  cases  it  produces 
headache,  restlessness,  wakefulness,  and  often  a  distinct  taste  of  iodoform  in  the  mouth. 
In  more  pronounced  degrees  of  poisoning  there  is  fever,  often  with  mental  derangement 
which  may  amount  to  deliriimi  or  even  to  acute  mania,  and  may  cause  well-founded 
suspicion  of  meningitis.  Death  after  its  use  has  repeatedly  occurred  from  syncope  or 
in  coma. 

Carbolic  acid  produces  unpleasant  effects,  both  upon  patient  and  operator,  or  with 
whoever  it  may  come  in  contact.  Aside  from  its  local  effect  upon  the  skin,  which  is 
most  unpleasant,  but  which  usually  passes  away  within  a  few  hours,  it  seems  to  affect 
especially  the  kidneys,  causing  often  temporary  albuminuria  with  discolored  urine, 
deranged  secretion,  and  sometimes  more  acute  forms  of  disturbance,  similar  to  those 
met  with  after  its  internal  use.  Carbolic  poisoning  was  observed  most  frequently  during 
the  era  when  Lister's  original  directions  were  scrupulously  followed,  and  at  a  time  before 
it  was  learned  that  it  is  much  better  to  remove  dirt  than  totry  to  antagonize  its  action, 
Eminent  surgeons  were  compelled  to  discontinue  its  use  because  of  its  unpleasant  effect 
upon  themselves  as  well  as  upon  their  patients. 

Among  the  powerful  antiseptic  agents  in  common  use  are  the  soluble  preparations  of 
mercury,  ordinarily  corrosive  svhlimafe,  in  solutions  of  varying  strength,  which  are  used 
for  irrigation,  douching,  etc.,  and  for  preparation  of  dressings.     An  intense  eczema 


176  SURGICAL  DISEASES 

may  follow  its  local  use,  and  symptoms  of  mercurial  poisoning  may  appear  in  individuals 
of  peculiar  susceptibility  to  this  drug.  Salivation,  intestinal  irritation,  and  other  phe- 
nomena of  mercurial  ])oisoning  have  been  produced,  with  the  result  that  the  solutions  and 
preparations  of  corrosive  sublimate  are  much  weaker  than  those  which  were  used  at 
first.  The  drug  eczema  produced  by  corrosivr  sublimate  interferes  with  one  of  the 
essentials  of  ideal  wound  healing— j".  e.,  physiological  rest.  The  area  involved  should 
be  protected  with  a  sterilized  powder  or  by  anointing  it  with  sterilized  ointment. 


PART  III. 

SURGICAL  PRINCIPLES,  METHODS  AND  MINOR 

PROCEDURES. 


CHAPTER    XVIII. 
DISTURBANCES  OF  BLOOD  PRESSURE;  SHOCK  AND  COLLAPSE. 

The  maintenance  of  the  normal  pressure  of  the  blood  is  a  material  factor  in  the 
welfare  of  surgical  cases.  Deviations  in  the  direction  of  lowered  pressure  constitute 
the  most  important  features  of  shock  and  collapse.  Prevention  of  loss  of  blooti  is  but 
one  of  several  complex  indications  in  prophylaxis  and  after-treatment. 

Blood  pressure  is  maintained  in  large  part  by  the  vasomotor  system  of  nerves,  whose 
prime  centre  is  in  the  gray  matter  of  the  fourth  ventricle,  with  subsidiary  centres  in  the 
spinal  cord  and  great  ganglia.  Stimulation  of  these  centres  causes  contraction  of  the 
peripheral  arterioles  and  increases  intravascular  pressure.  If,  however,  it  be  long- 
continued  or  excessive,  these  centres  become  exhausted,  vasomotor  paralysis  results, 
the  arterioles  dilate,  and  pressure  is  lowered. 

Three  factors  cooperate  to  maintain  this  pressure: 

1.  Regular  and  normal  rhythmic  heart  action; 

2.  Normal  vascular  contractility; 

3.  Normal  quantity  of  suitable  fluid  in  the  vascular  system. 

Departure  from  the  normal  in  any  one  of  these  factors  causes  perceptible  disturbance, 
but  when  in  all  three  of  them  it  may  prove  fatal.  Whether  this  be  caused  by  emotion, 
accidental  injury,  or  deliberate  operation  is  of  slight  concern,  as  the  effect  is  essentially 
the  same. 

The  pulse  will  usually  tell  its  own  story  to  the  experienced  observer,  but  scientific 
accuracy  in  measuring  blood  pressure  can  only  be  obtained  by  certain  instruments  of 
precision,  such  as  the  tonomrter  or  the  sphygvwvianometer,  consisting  of  an  air-containing 
armlet  which  encircles  the  arm,  a  bulb  by  which  the  pressure  of  air  can  be  regulated,  and 
the  whole  connected  with  a  manometric  gauge  and  mercury  tube.  These  instruments 
can  be  procured  of  the  dealers,  and  their  employment  during  an  operation  gives  the 
operator  a  continuous  record  of  the  blood  pressure,  by  which  he  may  judge  at  any  moment 
of  the  degree  of  shock. 

The  normal  blood  pressure  in  healthy  adults  is  130  to  140  INIm.  of  mercury  in  the  tube. 
In  children  it  ranges  from  90  to  110  Mm.  Females  have  an  average  lower  pressure  of 
10  Mm. 

Excitement  or  slight  stimuli  will  send  the  pressure  up  thirty  or  forty  points.  It  is  also 
higher  than  the  above  average  in  arteriosclerosis.  In  uremia  it  is  always  high.  In 
cases  of  intracranial  tension  it  is  also  high,  as  the  brain  alone  of  all  the  organs  of  the 
body  has  no  complete  vasomotor  apparatus  of  its  own;  when  it  needs  more  blood  this 
has  to  be  contributed  from  the  general  supply.  When  pressed  upon  by  a  clot,  depressed 
bone,  or  foreign  body  it  becomes  anemic,  and  on  effort  to  furnish  the  needed  blood 
from  other  parts  the  vascular  tonus  is  increased.  Cushing  has  shown  the  value  of  these 
estimations  in  cases  of  head  injury,  for  the  rise  of  blood  pressure  may  be  regarded  as 
an  indication  for  operation.  In  typhoid  fever  a  sudden  rise  of  pressure  is  associated 
12  (  177  ) 


17S  SURGICAL  PROCEDURES 

with  perforation,  or  perhaps  with  the  peritonitis  which  is  its  immediate  resiiU.     On 
the  other  hand,  in  this  disease  a  sudden  fall  of  pressure  is  an  indication  of  hemorrhage. 

The  course  of  events  in  surgical  shock  is  about  as  follows:  Injury  to  afferent  sensory 
nerves  acts  as  a  vasomotor  stimulus  after  it  reaches  the  centre  in  the  fourth  ventricle; 
a  reflex  impulse  is  then  sent  out  which  produces  arterial  contraction  and  raises  the  blood 
pressure.  When  the  abdomen  is  concerned  the  opening  and  handling  of  its  contents 
produce  the  same  result  through  the  splanchnic  centres.  If,  however,  the  stimulus  is 
excessive,  too  often  re])eatcd,  or  too  prolonged  the  vasomotor  grip  is  lost,  the  arterioles 
dilate,  and  the  blood  pressure  is  reduced.  A  severe  injury  to  any  part  of  the  body  may 
j)roduce  this  effect  without  the  preliminary  rise.  The  })opular  impression  that  a  patient 
"bleeds  to  death  into  his  own  veins"  has  this  to  justify  itself,  that  the  arterial  tonus  is 
lost  and  the  blood  is  pumped  through  the  arterioles  to  accumulate  in  the  capillaries  and 
veins,  especially  the  abdominal,  thus  overloading  the  right  side  of  the  heart  and  giving 
it  a  disproportionate  amount  of  work. 

Accompanying  these  circulatory  disturbances  are  others,  secondary  and  unavoidable, 
as  of  respiration,  which  becomes  rapid  and  enfeebled  in  proportion  to  the  degree  of  shock. 

Any  factor  which  tends  to  weaken  the  heart's  force  favors  both  jihenomena.  So 
important  is  the  respiratory  action  that  patients  die  from  cessation  of  respiration  rather 
than  from  impairment  of  the  circulation.  This  shows  the  imjiortance  of  maintaining 
artificial  respiration  in  cases  of  severe  shock. 

Gushing  and  Crile  have  studied  the  subject  exhaustively  in  animals.  They  have 
shown  that  certain  injuries  are  likely  to  be  followed  by  well-marked  reduction  of  blood 
pressure;  for  example,  those  of  the  brain,  the  interior  of  the  larynx,  the  abdomen  and 
testicle,  are  often  followed  by  a  marked  reduction  of  pressure  without  any  preliminary 
rise.  In  other  words,  vasomotor  paralysis  is  sometimes  an  almost  instantaneous  effect 
of  certain  injuries.  When  most  of  the  blood  is  collected  in  the  venous  system  and  the 
central  nervous  system  fails,  because  of  lack  of  blood  supply,  to  respond  to  those  normal 
stimuli  which  are  essential  to  heart  action  and  respiration,  the  heart  weakness  or  heart 
failure  is  due,  not  alone  to  failure  of  its  innervation,  but  to  its  reduced  output  and  its 
diminished  content  of  blood  on  the  left  side. 

Crile  has  shown  that  the  more  abundant  the  blood  supply  to  a  given  part  the  more  it 
contributes  to  production  of  shock;  hence,  the  value  of  cocainizing  the  interior  of  the 
larynx  and  the  nerve  trunks. 

Aside  from  emotional  causes — which  are  sometimes  inseparable  from  even  surgical 
cases — the  principal  agencies  in  the  production  of  surgical  shock  and  collapse  are  those 
which  make  a  sudden  and  deep  impression  through  the  medium  of  the  sensory  nerves 
upon  the  central  nervous  system  or  the  large  sympathetic  ganglia;  ultimately  upon  the 
latter  in  all  serious  cases.     Lo.s'.s"  o/  blood,  then,  need  not  phii/  a  reri/  important  role. 

Weakened,  anemic,  or  neurotic  |)atients  are  predisposed  by  virtue  of  these  conditions, 
and  also  the  young  and  aged.  Fright  combined  with  injury  increases  the  degree  of  the 
effect.  Crile  has  shown  that  trifling  lesions  of  the  interior  of  the  larynx  will  cause  symp- 
toms which  do  not  occur  in  animals  if  the  superior  laryngeal  nerves  be  divided  or  if  the 
parts  be  cocainized. 

The  upper  portions  of  the  abdomen  are  more  sensitive  in  this  resj)ect  than  are  the 
lower,  the  testicles  particularly.  The  skin  is  more  impressible  than  the  muscles  or 
tissues  beneath,  save  the  nerve  trunks,  which  are  very  sensitive;  the  bones  and  large 
joints  slightly  so.  After  shock  has  been  once  produced  further  injury  causes  a  dispro- 
jiortionate  lowering  of  blood  pressure. 

So-called  "concussion  of  the  brain"  is  essentially  a  condition  of  shock  following  injury 
to  this  particular  part  of  the  body.     (See  Head  Injuries.) 

Shock  and  hemorrhage  are  often  rloseli/  associated,  and  loss  of  blood  is  doubtless  a 
powerful  factor  in  the  production  of  the  former,  especially  in  those  already  reduced  or 
whose  blood  contains  a  lowered  percentage  of  hemoglobin.  There  are,  therefore,  great 
advantages  in  entrusting  an  assistant  with  the  duty  of  watching  blood  pressure  during 
serious  operations. 

The  terms  shock  and  collapse  are  nearly  interchangeable,  but,  by  common  consent,  the 
latter  is  usually  the  name  given  to  conditions  that  are  more  sudden  and  overwhelming. 
Shock  may  be  of  all  degrees — from  temjiorary  faintness,  from  which  the  patient  recovers 
within  a  few  moments,  up  to  a  condition  of  vital  depression  which  terminates  fatally, 
there  being  no  reaction  in  spite  of  all  efforts  to  produce  it. 


/)lSTURB.\Nri-:s  OF  HLOOn  PRKSSCRE  179 

Symptoms.  Tlicsc  vary  to  a  coiisidciahlc  cxtciil  acconliiif^  as  the  j)ati(>iit  is  or  is 
not  iiiidcr  a  ii;(MU'ral  aiicstlictic.  The  (Icscriptioii  of  fi/pr.s-  aiul  .si/niptoni.s  iiicliules  an 
I'xprcssioiilrss  face,  pallor  of  the  skin  and  mucous  nienihranes,  with  corresj)()n(ling  cold- 
ness of  the  same,  ?'.  c,  reduction  of  surface  circulation  and  heat;  dilated  puj)ils,  reacting 
slowly  to  light;  irr(>gularity  of  the  heart's  action,  with  a  weak,  irregular,  thready,  or 
almost  iiuperceptil)le  pulse;  irregular  resj)iration,  i.  p.,  irregular  both  in  rate  and  depth; 
mental  inactivity  and  apathy;  loss  of  voluntary  muscle  movement;  imj)airmcnt  of 
su|)erficial  sensibility;  reduction  of  body  tcm])erature;  and  nausea  or  actual  vomiting. 
'IMiesc  at  least  constitute  the  symptoms  and  form  the  aj)athctic  or  torpid  ly|)c  of  siiock. 

in  the  so-called  crcthistic  type  ('i^'avers)  the  jjaticnts  are  restless  and  excited,  uncon- 
trollable, witit  irregular  pulse  and  breathing,  often  with  dilated  pu|)ils. 

In  a  third  type,  described  by  Travers  as  the  driai/rd,  the  .symptoms  are  as  above 
detailed,  but  do  not  aj)pear  until  .some  hours  after  the  cau.se  which  has  produced  them, 
which  may  be  a  concealed  (internal)  hemorrhage.  The  delayed  type  is  also  seen  in 
those  who  escape  serious  accident  with  a  minimum  of  physical  harm. 

As  shock  lu'comes  more  pronounced,  mental  (lc])ression  deepens  into  coma,  or  mental 
excitement  sul)si(les  into  it;  the  surface  lu'comcs  colder  and  bathed  with  |)erspirafion, 
and  (Icatii  follows.  These  .symptoms  are  tho.se  generally  noted,  whether  following  injury 
to  the  head  and  denoting  so-called  concussion  of  the  brain,  lo.ss  of  blood,  wound  of  thi; 
abdomen  with  injury  to  the  viscera,  blows  upon  the  testicles,  gunshot  wounds  or  other 
accidents  which  are  causes  of  shock.  They  follow  also  after  perforation  of  the  bowel, 
as  in  typhoid  fever  or  appendicitis;  depression  following  the  receipt  of  bad  news,  or 
fright,  etc.;  in  other  words,  the  physical  condition  is  practically  the  same  no  matter  what 
the  exciting  cau.se. 

Diagnosis. — Shock  is  mainly  to  be  diagnosticated  from  fat  embolism;  concealed 
hemorrhage  as  well  as  pulmonary  edema  and  suj^pression  of  urine  are  to  be  suspected. 
It  is  uncjuestionable  that  many  jiatients  have  died  of  fat  embolism  in  whom  the  actual 
cause  of  death  has  not  been  ascertained,  yet  has  been  ascribed  to  shock.  (See  Fat 
Embolism,  Cha])ter  II.) 

Treatment. — The  treatment  of  shock  consists  essentially  in  measures  directed 
toward  raising  the  lowered  blood  pressure.  At  the  outset  reaction  should  not  be  estab- 
lished too  C(uickly,  lest  it  be  succeeded  by  overaction,  with  attendant  disasters  in  the 
shape  of  secondary  hemorrhage,  etc.  Patients  should  not  be  expected  to  swallow  nor 
act  as  they  would  under  other  circumstances.  They  should  not  drink  strong  li(|uors, 
for  the  irritating  fluid  may  escape  into  the  larynx  and  induce  coughing,  which  might 
prove  fatal.  The  same  is  true  of  inhalations  of  strong  volatile  stimulants,  like  ammonia. 
These  measures,  therefore,  should  all  be  resorted  to  with  great  care  and  discretion. 
Warm,  stimulating  drinks,  if  they  can  be  swallowed,  are  u.seful;  and  whisky,  brandy, 
etc.,  should  be  given  dilute  and  warm  rather  than  strong  and  cold.  External  heat  is 
advisable,  and  can  be  supplied  by  immersing  the  patient  in  a  bath-tub  of  warm  water, 
care  being  taken  to  keep  the  face  out  of  the  water.  When  this  is  not  at  hand,  bottles 
and  other  receptacles  for  warm  water  may  be  used,  but  with  caution,  since  too  much 
heat  has  been  the  cause  of  serious  burns. 

Numerous  drugs  have  been  recommended  in  the  treatment  of  shock.  There  are 
but  two  or  three  which  are  worthy  of  confidence.  Crile,  of  Cleveland,  subjected  a 
large  number  of  animals  to  tests  in  regard  to  the  effect  of  various  drugs  in  influencing 
blood  pressure.  He  found,  for  example,  that  alcohol  apparently  produces  more  depres- 
sion, and  in  deep  shock  is  dangerous.  Nitroglycerin  and  aniyl  nitrite  seem  to  increase 
shock  and  lower  pressure.  Digitalis  may  produce  a  temporary  rise  in  pressure,  but  in 
considerable  do.ses  impairs  or  arrests  respiration,  and  it  .seemed  to  him  that  cases  of 
severe  shock  treated  with  it  did  not  live  as  long  as  the  control  animals.  Strychnine 
has  been  one  of  the  main  reliances  in  the.se  conditions.  Crile  found  that  if  enough 
were  given  to  cause  increased  excitability  of  the  spinal  cord  it  raised  the  blood  pressure, 
while  small  doses  had  little  or  no  effect.  Pressure  was  raised  by  doses  large  enough  to 
produce  convulsions;  repeated  smaller  doses  had  little  effect,  tending  rather  to  increase 
shock. 

These  w^ere  the  experimental  results  in  the  treatment  of  shock,  and  are  to  be  distin' 
guished  from  what  may  be  done  with  the  same  drugs  in  the  way  of  fortification  and 
preparation  as  against  shock.  Thus  strychnine  always  exalts  susceptibility  of  the  cord 
of  the  medulla  and  digitalis  may  temporarily  supplement  its  use;  together  they  may  help 


1^0  SURdlCAL  PROCEDURES 

to  sustain  pressure  or  to  fortify  as  against  depressing  agencies.  They  are  like  whip  or 
spur  to  a  jaded  horse. 

Morphine  alone,  or  in  eonihination  with  ether  as  a  general  anesthetic,  reduces  sus- 
ceptibility to  shock,  and  appears  to  he  an  equalizer  of  pressure  and  a  tranquillizer  of  an 
excited  heart.  Nitroglycerin  and  the  nitrites  usually  fail  to  raise  or  even  sustain  pressure. 
Saline  injimon  antl  adrenalin  are  the  reliable  and  effieient  means  to  he  used  in  combating 
shock  and  collapse;  theij  always  raise  blood  pressure,  and  the  latter  is  the  most  powerful 
of  all  known  vasomotor  constrictors.  Adrenalin  always  produces  rise  of  blood  pressure, 
even  after  cocainization  of  the  medulla  and  cord  or  destruction  of  the  medulla,  division 
of  the  splanchnics,  or  arrest  of  the  heart  by  powerful  electrical  currents  (2300  volts, 
alternating).  Even  after  death  by  decapitation  and  an  interval  of  fifteen  minutes, 
adrenalin  salt  solution  thrown  into  the  veins  causes  a  rise  of  blood  pressure.  If  this  be 
combined  with  artificial  respiration  and  rhythmic  pressure  over  the  heart,  resuscitation 
is  possible  in  most  extreme  cases.  In  one  case,  reported  by  Crile,  a  human  heart  which 
had  sto]>])ed  beating  for  nine  minutes  was  made  to  resume  its  pulsation  for  thirty-two 
minutes.  From  all  this  it  will  appear  that  the  heart  stimulants,  so  called,  have  a  very 
limited  applicability. 

Crile  further  experimented  by  raising  the  atmospheric  pressure  surrounding  the 
animal,  and  found  that  blood  pressure  was  somewhat  exalted.  The  reverse  was  also 
found  to  be  true.  When  he  so  arranged  his  experiment  that  an  animal  inhaled  air 
under  increased  pressure  he  found  the  tendency  was  rather  to  impairment  of  heart 
action,  blocking  the  circulation  and  reducing  pressure.  Changing  the  experiment  and 
causing  the  animal  to  breathe  air  at  normal  pressure  while  the  body  was  under  increased 
atmospheric  pressure,  blood  pressure  was  notably  raised,  but  respiration  became  labored 
and  the  heart's  action  impaired.  After  death  the  heart  and  the  pulmonary  vessels  were 
found  engorged. 

This  has  its  practical  interest  because  it  concerns  not  alone  the  general  treatment  of 
shock,  but  the  management  of  those  cases  where  the  thorax  must  be  opened,  as  in  the 
surgery  of  the  heart,  the  lungs,  the  esophagus,  etc.,  and  the  mechanical  devices  recently 
suggested  for  maintaining  differences  of  atmospheric  pressure,  and  preventing  a  trau- 
matic collapse  of  the  lungs. 

These  experiments  also  suggested  the  so-called  "pneumatic  suit"  devised  by  Dr.  Crile, 
which  is  in  effect  a  double-layered  garment  of  rubber  cloth.  The  patient  is  enveloped 
in  the  suit,  which  can  be  inflated  with  an  ordinary  bicycle  pump,  so  that  pressure  is 
made  upon  the  surface  of  the  body,  and  at  the  same  time  evenly  distributed.  By  such 
pressure  accumulation  of  blood  in  the  venous  reservoirs  is  prevented,  and  the  emptying 
of  the  arteries,  especially  those  in  the  brain,  is  prevented.  This  is  a  more  perfect  and 
ideal  application  of  the  idea  underlying  the  practice  of  bandaging  the  extremities  or  rais- 
ing them,  in  extreme  conditions  of  shock;  the  former  requires  an  elaborate  and  expen- 
sive outfit,  while  for  the  latter  purpose  cotton  bandages  or  rul)ber  may  suffice.  The 
latter,  however,  must  be  used  with  great  caution  lest  pressure  be  overdone.  ^Yhen  the 
bandages  are  removed  they  should  be  taken  off  slow^ly.  and  from  one  limb  at  a  time, 
lest  the  change  be  too  abrupt. 

Two  other  expedients  are  of  the  greatest  value  in  conditions  of  this  kind;  the  first  is 
artificial  respiration.  This  cannot  be  carried  out,  as  is  done  on  experimental  animals, 
in  a  well-furnished  laboratory,  by  opening  the  trachea  and  making  connection  with  a 
pump;  it  must  be  effected  by  the  usual  methods,  coupled  with  the  aid  afforded  by  the 
improved  Fell  apparatus.  If  oxygen  can  be  administered  at  the  same  time  it  will 
enhance  the  effect. 

The  second  expedient  is  rhythmic  pressure  made  over  the  lower  part  of  the  thorax, 
or  beneath  the  ribs,  by  which  is  produced  a  stimulus  to  contraction  of  the  heart.  This 
may  be  made  .slowly  at  first,  but  may  approximate  a  rate  corresponding  to  a  .slow  pulse. 

The  temptation  is  to  use  the  adrenalin  solution  too  strong  or  in  too  large  doses.  It 
may  be  administered  in  doses  of  4  or  5  minims  in  a  small  syringeful  of  salt  solution,  but 
when  the  symptoms  are  profound  and  the  case  urgent,  300  to  500  Cc.  of  sterilized  salt 
solution,  containing  the  same  amount,  should  be  injected  beneath  the  skin  into  the 
subcutaneous  cellular  tissue  about  the  shouldcr-])la(le,  the  buttock,  behind  the  breast,  or 
into  a  convenient  vein.  !Much  larger  amounts,  even  up  to  1000  Cc,  may  be  used,  but 
the  adrenalin  should  never  be  mixed  until  just  before  using  it,  as  it  is  quickly  oxidized 
and  changed,  and  should  be  used  in  the  freshes':  possible  condition.     With  salt  solution 


DISTURB.{\ri:S  OF  BLOOD  PRESSURE  Igl 

coiitaiiiiiifj  1  to  ')(),()()()  ot"  aiirnialiii  and  coiitiiiiioii.sly  adiiiiiiistrivd,  Crilc  lias  kept  a 
(Iccapilatc'd  doi;  alivr  for  over  ten  hours — that  is,  the  heart  continued  its  action.  One 
may  at:;rce  with  liini,  tlicii,  in  tlie  statement  that  "cDiifrol  of  h/ood  pressure  is  ilie  eoiiirol 
of  life  itself." 

iSlathews,  atU-r  a  careful  study  of  the  osmotic  heliavior  of  hlood  phisma  and  sahne 
sohuions,  lias  shown  that  the  ordinary  salt  solution,  which  has  been  usually  made  in 
])ro|)()rtion  of  (i  to  lOtH),  is  not  the  best  which  can  he  used  for  purposes  of  saline  infusion. 
Many  observers  haw  ad<led  |)otassiuni  and  calcium  salts  to  such  a  mixture,  the  latter, 
especially,  because  of  its  jiroperty  of  increasinji;  the  coai;ulabili(y  of  the  blood. 

The  followinif  mixture  meets  the  indications  for  what  may  be  called  the  "balanced" 
physiological  solution:  Sodium  chloride  0.9,  potassium  chloride  0.03,  calcium  chloride 
0.()2,  water  100.' 

It  must  not  be  forgotten  that  indiscriminate  resort  to  intravenous  infusion  may  do 
great  harm.  It  is  a  minor  procedure  which  reciuires  skill.  When  the  lungs  are  congested 
from  the  irritating  effect  of  ether,  and  the  right  hcai't  is  embarrassed,  a  too  sudden 
Hushing  with  saline  solution  may  further  embarrass  it  or  even  check  its  activity.  So 
with  a  patient  in  the  Trendelenburg  posture,  the  intestines  are  crowded  uj)  against  the 
diajjliragm  and  its  natural  downward  ])lay  impeded,  though  the  brain  is  better  su[)j)lied 
with  blood  in  this  than  in  any  other  position. 

Much  may  be  done  in  the  way  of  lyrevention  when  shock  can  be  foreseen.  This 
includes  the  general  fortification  of  the  patient  by  overcoming  any  auto-intoxication  which 
may  have  been  previously  noticed,  by  improving  elimination,  and  by  stimulating  the 
heart's  action  with  strychnine,  digitalis,  cactus,  etc.  Atropine  is  especially  a  stimulant 
to  the  respiratory  centres. 

Once  the  ojX'ration  is  begun,  and  remembering  that  the  depressing  influences  which 
tend  to  reduc(>  blood  pressure  are  transmitted  through  the  afferent  nerves,  we  may  take 
advantage  of  Crile's  suggestions  and  temporarily  paralyze  them,  by  exposing  them  and 
injecting  directly  into  the  nerve  trunks  two  or  three  drops  of  1  per  cent,  cocaine  solution. 
This  should  be  done  before  division  of  the  main  trunks  and  at  a  point  above  the  line  of 
section.  It  is  possible  during  an  amputation,  by  taking  a  little  extra  time  and  pains, 
to  "block  ofif,"  as  it  is  calleil,  the  nerves  in  this  way  and  prevent  their  conveying  any 
depressing  sensation.  At  other  times,  as  in  operations  on  the  mouth,  and  especially  the 
larynx,  cocaine  solution  may  be  used  locally,  as  by  the  spray,  and  the  same  effect  pro- 
duced.    Cocaine  seems  to  be  a  protoplasmatic  poison  which  inhibits  nerve  action. 

In  the  description  of  the  treatment  of  shock  there  has  been  little  reference  made  to 
the  result  of  loss  of  blood  as  such.  In  cases  where  this  has  already  occurred,  or  cannot 
be  prevented,  it  should  be  atoned  for  by  the  infusion  of  saline  solution,  either  by  intra- 
venous introduction  or  by  hypodermoclysis,  i.  e.,  its  injection  into  the  loose  connective 
tissues  in  various  parts  of  the  body.  While  a  special  apparatus  has  been  devised  for  this 
purpose,  a  sterile  fountain  syringe  with  an  ordinary  aspirator  needle  will  be  found  to  be 
sufficient  for  nearly  all  purposes. 

The  erethistic,  or  extremely  restless  type  of  shock,  may  be  profitably  treated  by  small 
doses  of  morphine  given  subcutaneously. 

The  question  of  immediate  operation  or  delay  should  be  carefully  considered.  Shock 
is  often  alleviated  by  prompt  removal  of  mutilated  limbs  or  parts  whose  fragments,  while 
still  connected  with  the  trunk,  seem  rather  to  perpetuate  the  condition,  especially  if  the 
principal  nerve  trunks  are  cocainized.  In  serious  cases  intravenous  infusion  should  be 
practised. 

After  commencing  with  the  anesthetic,  Avhile  scrubbing  and  cleansing  the  field  of 
operation  it  is  advisable  to  scrub  an  arm  where  it  may  be  necessary  to  expose  a  vein,  or 
the  skin  at  several  points,  where  a  needle  may  be  entered,  so  that  there  may  be  no 
delay  for  this  purpose  should  infusion  or  hypodermoclysis  be  suddenly  required. 

'  To  the  fluid  for  hypodermoclysis  (salt  solution)  there  may  be  added  a  proportion  of  grape  sugar,  by  which 
much  is  gained  of  true  nutritive  value,  which  may  be  enhanced  by  the  addition  of  pure  pepsin  peptone  free  from 
albumose.  Thus  if  every  four  hours  there  be  injected  beneath  the  skin  100  Cc.  of  water  containing  2  grams  each 
of  grape  sugar  and  table  salt  to  4  grams  of  pepsin  peptone,  the  necessity  for  further  nourishment  may  be  almost 
obviated,  at  least  for  a  period  of  two  or  three  days  at  a  time;  as  for  instance  when  intense  nausea  of  severe 
peritonitis  prevents  the  ingestion  of  anything  possessing  food  value.  Cred^  recommends  for  the  same  purpose 
a  preparation  containing  soluble  albumin  in  the  strength  of  95  per  cent.,  with  traces  of  iron  and  salt.  This 
preparation  is  called  by  him  kalodol,  and  much  resembles  blood  albumin,  which  is  why  it  is  so  easily  assimilated. 
According  to  Cred^,  four  injections  of  kalodol  a  day  will  suffice  for  ordinary  needs. 


CHAPTER    XIX. 

ABSTRACTION    OF    BLOOD;    COUXTERIRRITATIOX;    PARACENTESIS; 
TRANSFUSION;   CATHETERIZATION;    SKIN   GRAFTING; 

BANDAGING. 

Abstraction  of  blood,  usually  of  venous  blood,  known  as  venesection,  was  a  practice 
frequently  indulged  in  years  ago.  At  one  time  in  the  history  of  medicine  it  seemed  to 
be  the  measure  regarded  as  a  panacea  for  all  ills.  The  reaction  from  the  period  of  exces- 
sive bloodletting  came  during  the  previous  century,  and  was  so  strong  that  the  practice 
was  for  a  oreneration  or  so  almost  abandoned.  The  eminent  surgeon  S.  D.  Gross  wrote 
a  paper  entitled  "Bleeding  as  a  Lost  Art."  Bloodletting  is  an  expedient  of  great  value 
in  a  somewhat  restricted  class  of  cases,  but  is  capable  of  afl'ording  such  relief  in  certain 
emergencies  that  jiractitioners  shoulfl  \)e  ready  to  resort  to  it  at  any  moment  when  it  may 
be  required. 

After  removal  of  a  certain  amount  of  fluid  blood  pressure  is  naturally  reduced  and 
at  the  same  time  equalized,  while  when  the  right  side  of  the  heart  is  overburdened  with 
its  task  it  is  thus  made  to  beat  more  easily  and  regularly;  thus  indirectly  there  may  be 
brought  about  a  subsidence  of  violent  heart  effort,  a  reduction  of  the  respiration  rate,  a 
lowering  of  temperature,  and  sometimes  a  diminution  in  the  activity  of  morbid  processes 
which  may  be  beneficial,  and  even  life-saving.  Even  after  moderate  bleeding,  say  a 
half-pint,  the  amount  of  urine  is  increased  and  the  proportion  of  solids  raised.  ]More 
air  is  taken  into  the  lungs,  and  oxygenation  is  thereby  nuich  ini])roved. 

The  indications  for  venesection  are: 
Excessive  vascular  tension. 

Intensity  of  pathological  tissue  activity  which  is  leading  to  serious  disturbances. 
The  removal  of  a  certain  proportion  of  toxic  material  from  the  blood. 

There  may  be  added  later  the  introduction  of  balanced  physiological  salt  solution 
as  recommended  in  the  treatment  of  shock,  and  of  some  of  the  acute  toxemias,  e.  g., 
delirium  tremens. 

The  effect  on  an  embarrassed  and  overfilled  right  heart  <jf  the  abstraction  of  blood 
is  prompt.  Nowhere  is  this  more  conspicuous  than  in  the  early  stages  of  pneumonia,  and 
in  some  cases  of  heart  failure  during  administration  of  an  anesthetic  where  a  dilated 
heart  seems  to  become  so  overfilled  as  to  be  iniable  to  emptv  itself.  In  profound  uremia, 
especially  in  puerperal  eclampsia,  the  relief  afforded  by  it  Is  usually  immediate  and 
permanent. 

VENESECTION. 

The  question  of  the  amount  of  blood  to  be  withdrawn  must  be  settled  at  the  time  and 
for  each  individual  case.  The  pulse  is  watched,  as  well  as  the  patient's  face;  the  best 
indications  when  to  cease  being  noted  in  this  way.  From  500  to  1000  Cc.  may  be 
removed  according  to  the  condition  of  the  patient  and  the  degree  of  emergency.  While 
the  operation  is  a  trifling  one,  it  should,  nevertheless,  be  performed  with  strict  aseptic 
precautions.  One  of  the  veins  at  the  bend  of  the  elbow,  usuallv  in  the  left  arm,  is  com- 
monly chosen,  although  in  rare  instances,  when  there  is  intense  cerebral  venous  conges- 
tion, the  external  jugular  may  be  selected.  At  the  elbow  the  median  basilic  vein  cros.ses 
the  brachial  artery,  being  separated  from  it  only  by  a  thin  prolongation  of  the  biceps 
tendon.  It  was  especially  in  opening  this  vein  at  this  point  with  the  old-fashioned 
lancet,  which  was  plunged  perpendicularly  to  the  surface  and  directly  into  the  vein,  that 
injury  to  the  artery  occasionally  occurred,  thus  leading  to  varicose  aneurysms  and 
aneurysmal  varices. 

The  skin  should  be  thoroughly  cleansed;  a  reasonably  tight  constriction  is  made  about 
the  middle  of  the  arm  by  a  bandage,  not  so  tight  as  to  completelv  occlude  the  radial 
(  182  )  ' 


COUNTKRIRRITA  TIOS  \  83 

pulse;  tlic  anil  is  allowed  to  liaiii:;  downwanl  and  the  |»atiriit  ('ncoiiraf];e(l  to  ^ri|)  some 
ohjcct  ill  order  to  better  fill  the  vein.  This  soon  heeoines  |)r()iiiinent,  after  which  an 
()l)li((iie  iiuisioii  is  made  throuffh  the  skin  above  it,  so  that  the  vessel  itself  is  exposed. 
Then  with  a  shar|)  bistoury  the  e.xternal  sm-face  of  the  vein  is  pricked  with  the  |)oiiit, 
and  a  cut  made  outward.  The  openinii;  in  the  skin  should  be  free;  tlu^  skin  may  be 
frozen,  or  in  very  sensitive  patients  local  anesthesia  may  be  first  produced  with  cocaine. 
By  ti<jhtening  and  releasing  the  grasj),  that  is  by  closing  and  ()])ening  the  hand,  the  How 
of  blood  may  be  hastened  When  it  is  time  to  cease,  the  bandage  should  be  removed 
and  an  aseptic  pad  be  applied  over  the  site  of  the  wound,  suitable  ))ressure  being  made, 
and  the  arm  kept  at  rest  for  two  or  three  days. 

When  the  jugular  or  some  other  vein  is  selected  the  procedure  is  essentially  the  same. 

Arteriotomy. — Arteriotomy,  or  the  oj)ening  of  an  artery  for  bloodletting  pur()oses, 
is  resorted  to  only  in  rare  instances,  and  in  an  emergency.  "^I'lie  temporal  artery  is  the 
one  usually  selected  because  of  its  accessil)ility  and  the  ease  with  which  its  outflow  can 
be  controlled  Its  position  is  determined  by  its  pulsation;  it  should  then  be  e.xpo.sed  by 
incision  through  the  skin,  and  ()j)ened  exactly  as  is  a  vein,  not  cut  tliroiujh,  lest  it  retract 
and  furnish  an  insufficient  amount  of  blood.  It  should,  however,  be  divided  and  tied 
before  ajiplication  of  the  dressings. 

Cupping. — By  the  application  of  "cups,"  blood  is  drawn  to  the  surface,  but  ordi- 
narily not  abstracted,  unless  the  surfaces  have  been  previously  scarified  or  incised.  f)rij 
cupping  has  the  eff(>ct  of  attracting  blood  to  one  |)ortion  of  the  body,  thus  drawing  it 
from  another  and  congested  part.  It  has  the  temporary  effect  of  a  venesection.  ru|)- 
ping  glasses  are  small  tumblers  which  are  rinsed  in  alcohol;  their  edges  are  wiped  and 
the  remaining  film  within  the  glass  is  ignited  from  a  candle  or  flame.  The  glass  is  then 
instantly  applied  to  the  affected  area.  The  oxygen  within  the  contained  air  is  sufficiently 
consumed  to  create  a  slight  vacuum  and  the  skin  quickly  becomes  congested,  being 
sucked  u|)vvard  into  the  glass.  These  cups  may  be  allowed  to  remain  for  a  few  moments, 
or  until  they  drop  oflf.  Care  should  l)e  exercised  with  alcohol  and  a  lighted  lamp  around 
a  patient  who  may  be  unconscious  or  excitable,  as  serious  burns  have  followed  careless- 
ness in  this  regard.  Small  vacuum  pumps,  like  the  Allen  surgical  pump,  have  been 
provided  for  this  purpose,  and  give  very  satisfactory  results. 

There  was  formerly  employed  for  the  purpose  of  wet  cupping  a  small  spring  instrument, 
containing  several  sharp  knives,  by  which  a  series  of  incisions  were  made  in  order  that 
blood  might  be  drawn.  This  instrument  cannot  be  kept  clean  and  is  not  used  at  present. 
When  wet  cupping  is  desired  the  part  should  be  scarified  with  a  sharp  knife  and  the  cup 
applied  as  above. 

Leeching. — Leeches  figure  largely  in  literature  of  the  past,  but  are  not  often  used, 
although  they  may  be  made  effective,  esjiccially  when  applied  behind  the  ears  in  cases 
of  cerebral  congestion.  The  American  leech  can  be  relied  on  only  to  abstract  about  a 
teaspoonful  of  blood,  while  the  Swedish  will  draw'  three  or  four  times  that  amount. 
The  region  to  which  they  are  ajiplied  must  be  washed,  and,  if  necessary,  shaved.  The 
part  should  then  be  smeared  with  milk,  blood,  or  sugar-water.  The  leeches  should  be  put 
in  a  basin  of  fresh  water,  after  which  they  are  placed  upon  a  dry  towel  for  two  or  three 
minutes.  Each  one  is  then  taken  up  in  a  small  glass  or  test-tube  and  inverted  over  the 
spot  chosen.  As  soon  as  the  animal  fastens  itself  upon  the  skin  the  glass  may  be  removed. 
Leeches  are  often  capricious  and  will  sometimes  wait  considerable  time  before  attaching 
themselves.  W'hen  full  of  blood  they  usually  relax  and  drop.  If  it  be  desired  to  remove 
them  a  little  salt  will  make  them  relax.  Leeches  should  never  be  applied  over  loose 
cellular  tissue  nor  over  superficial  vessels  or  nerves.  If  used  in  the  interior  of  a  cavity 
they  should  be  prevented  from  passing  too  far. 


COUNTERIRRITATION. 

Counterirritation  is  a  valuable  means  of  accomplishing  that  which  is  sometime^ 
induced  by  leeches — namely,  attracting  blood  to  the  surface  for  the  relief  of  deep 
congestion.  In  fact  it  comprises  more  than  this,  since  there  is  some  deep  influence 
exerted  through  the  medium  of  the  nervous  system;  it  not  only  equalizes  the  circulation, 
but  tranquillizes  a  disturbed  innervation.  The  milder  and  more  domestic  means  include 
the  use  of  the  so-called  rubefacients — hot  water,  mustard,  and  turpentine.     These  are 


184  SURGICAL  PROCEDURES 

of  little  use  in  surgical  conditions  which  call  for  coiiiitcrirritation;  their  use  should  be 
controlled  with  caution  lest  mere  counterirritation  he  converted  into  actual  burning. 

By  the  use  of  vesicafit'^  a  blister  is  produced,  /.  p.,  an  effusion  of  serum  and  lymph 
beneath  the  su{>erficial  anil  outside  of  the  deeper  layer  of  the  skin.  Mustard  and 
cantharis  are  the  princijjal  vesicants  in  common  use.  The  former  may  be  used  in  full 
strength,  in  which  ca.se  it  is  active,  or  it  may  be  reduced  with  wheat  flour  or  linseed  meal. 
To  bring  out  the  full  strength  of  mustard,  hot  water  should  not  be  ased  in  its  preparation, 
as  it  renders  it  almost  valueless.  A  mustard  paste  or  plaster  should  be  watched  at  inter- 
vals, and  it  should  be  removed  when  the  desired  effect  has  been  obtained — at  all  events, 
when  the  surface  to  which  it  has  been  applied  is  covered  with  vesicles. 

Cantharis,  or  Spanish  fly,  is  used  either  in  the  form  of  the  cantharidal  cerate  or  mixed 
with  collodion,  the  latter  l)eing  the  neatest  and  most  pleasant  preparation.  Several 
layers  are  painted  on  the  surface  where  its  effect  is  desired.  This  is  then  protected,  and 
vesication  will  be  found  to  have  been  produced  within  an  hour  or  two,  except  where 
the  skin  is  most  resistant.  The  .stronger  chemicals,  like  ammonia,  chloroform,  strong 
iodine,  and  nitrate  of  silver  solutions,  will  be  found  to  be  active  blistering  agents,  but 
should  be  used  with  caution. 

Two  other  methods  of  irritation  were  at  one  time  in  favor — namely,  the  seioti  and  the 
issue.  The  former  consisted  of  a  bundle  of  threads  or  a  wick,  drawn  into  a  large  needle 
with  a  lancet-shaped  point ;  the  skin  was  picked  up  into  a  fold,  the  needle  made  to  traverse 
it,  and  the  wick  was  thus  drawn  through  and  cut  off,  so  as  to  be  left  in  place.  The  issue 
was  made  by  drawing  a  l)lister  with  a  powerful  agent,  and  then  preventing  it  from  healing 
by  the  use  of  an  irritating  foreign  body.  These  procedures  have  been  abandoned  by 
the  medical  profession,  but  are  .still  in  vogue  among  veterinary  surgeons. 

The  Actual  Cautery. — In  some  one  of  its  improved  forms  the  Paquelin  cautery 
has  replaced  all  the  old  cruder  methods  of  cauterization.  ^Yhen  properly  employed  its 
counterirritant  effect  can  be  made  most  serWceable  for  the  relief  of  pain,  or  for  any 
desired  form  or  degree  of  counterirritation.  Applied  over  the  upper  abdomen,  with  the 
lightest  possible  touch,  in  such  a  way  as  to  deserve  the  term  ''flying  cautery,''  it  will 
sometimes  afford  great  relief  in  nausea  and  vomiting,  especially  when  these  s^Tnptoms 
are  purely  reflex. 

Used  over  the  course  of  the  larger  nerves  it  does  much  to  relieve  the  pain  of  neuritis; 
while  over  swollen  joints  and  swollen  testicles  it  affords  great  relief  from  the  pain  of 
chronic  arthritis  and  chronic  or  acute  epidid^^nitis.  In  deep-seated  congestions  and 
inflammations  ignipiaiciure  may  be  made  with  a  small  cautery  point,  by  plunging  it 
through  the  skin  into  the  underlying  tissues,  and  into  bone.  The  relief  of  tension 
as  well  as  the  counterirritation  will  give  great  relief.  ^Yhen  practised  in  this  manner 
local  or  general  anesthesia  may  be  used.  Except  when  thus  used  it  will  rarely  be  neces- 
sary to  do  more  with  it  than  to  disturb  the  exterior  of  the  skin.  \Yhen  skilfully  used 
this  can  be  done  with  the  production  of  very  little  pain. 

PARACENTESIS. 

Paracentesis  is  the  technical  name  given  to  the  act  of  tapping,  or  the  withdrawal  of 
fluid  from  any  of  the  closed  cavities  of  the  body.  It  includes  aspiration,  tapping, 
and  inrixicm. 

Aspiration. — By  aspiration  is  meant  the  removal  of  fluid  without  the  admission  of 
air;  it  comprises  the  use  of  a  suction  apparatus,  usually  known  as  an  aspirator,  which 
may  be  had  in  various  forms  and  sizes.  A  small  so-called  exploring  syringe  will  answer 
for  small  cavities,  while  for  large  collections  of  fluid,  such  as  may  be  met  with  in  the 
thorax,  more  elaborate  apparatus  is  used,  consisting  of  a  suction  pump  connected  by 
tubing  with  a  bottle  in  which  the  vacuum  is  produced.  By  another  tube  this  bottle  is 
connected  with  a  hollow  needle  used  for  the  withdrawal  of  the  fluid.  Absolute  asepsis 
should  be  observed,  even  in  this  minor  procedure.  The  skin  should  be  cleansed,  and 
the  needle,  instrument,  and  hands  should  be  sterilized.  The  pain  of  puncture  may  be 
prevented  by  use  of  the  freezing  spray,  of  cocaine  injected  locally,  or  by  touching  the 
skin  with  a  drop  of  pure  carbolic  acid.  The  vacuum  is  commonly  resorted  to  in  the 
removal  of  fluid  from  the  thorax,  the  spinal  and  the  cranial  cavities,  and  from  joints; 
also  in  small  collections  of  pus  in  any  part  of  the  body. 


TILW'SFUSION  AND  INFUSION  185 

Tapping. — Tappinj;;  means  a  scmicu  lial  similar  |)n)(('(liiit'  witli  a  larj^cr  instrument 
known  as  a  frocar  and  a  surroundinj^  c(iiiiiii/(i,  without  the  aid  of  (lie  vacuum.  J'rc- 
caution  should  Ik-  taken  in  every  rej^ard  that  the  instruments  and  the  |)arts  sliould  he 
sterilized. 

The  trocar,  inserted  in  the  cannuhi,  shouhl  he  phmj^ed  (|ui(kly  into  the  cavity  at  the 
site  selected.  Considerable  resistance  will  l)e  otVered  hy  the  skin.  It'  the  trocar  be 
small  it  is  cnouij;h  to  anesthetize  the  skin;  it"  larj^e,  a  small  incision  will  permit  of  its 
better  u.se.  The  instrument  makers  have  provided  cannulas  of  various  description.s,  to 
which  tubinij;  may  be  attached,  so  that  the  fluid  may  be  conducted  into  a  suitable  recep- 
tacle, and  wettinii;  the  patient  avoided.  It  is  well  to  draw  the  skin  aside  and  not  to  make 
the  instrument  j)ass  directly  into  the  cavity  to  be  tapped  unless  it  contain  |)us  and  it 
be  desired  to  keep  it  open.  If  this  j)recauti()u  is  taken  the  skin  will  cover  the  deep 
openinfj  after  it  slips  back  into  its  position,  and  will  act  as  a  valve  to  |)revent  leakage. 
In  this  way  infection  may  i)e  avoided. 

When  fluid  has  ceased  to  be  serous  and  has  become  purulent,  as  in  empyema,  it  is 
often  so  thick  that  it  will  not  flow  through  any  hollow  instrument.  In  such  an  event 
free  incision  should  be  made.  When  the  thorax  is  involved  incision  is  made  between 
the  ribs,  and  in  order  to  maintain  drainaf>;e  a  good-sized  drainage  tube  should  be  inserted. 
This  at  times  may  be  so  compressed  l)etween  the  ribs  that  an  inch  or  more  of  one  rib 
should  be  exsected  to  provide  again.st  this  possibility. 


TRANSFUSION  AND  INFUSION. 

Though  much  has  been  said  concerning  the  indications  for  these  procedures  no  explicit 
directions  have  been  given.  While  they  are  often  emergency  measures  they  are,  never- 
theless, frequently  practised.  In  well-regulated  institutions  the  conveniences  are  always 
at  hand  for  instant  resort  when  needed;  but  it  would  be  well  for  every  general  practitioner 
to  have  ready  at  all  times  the  few  things  that  are  required,  for  at  least  hypodermoclysis. 
In  country  practice,  however,  a  clean  fountain  .syringe,  a  suitable  aspirator  needle  (both 
carefully  sterilized),  some  boiled  water,  table  salt  (when  nothing  else  is  at  hand),  and 
soap  and  water  for  sterilization  of  the  operator's  hands  and  the  patient's  skin  are  all 
that  are  necessary.  In  every  outfit  there  should  be  a  needle  wdiich  may  be  used  for  this 
purpose.  It  may  be  carried  in  a  glass  tube,  always  sterilized,  and  ready  for  use.  No 
fountain  syringe  should  be  used  which  has  not  been  freshly  boiled,  except  in  an  emer- 
gency. Tablets  containing  common  salt  in  definite  amount,  so  that  a  solution  of  given 
strength  can  be  made  by  adding  them  to  a  definite  amount  of  water,  can  be  procured. 
With  such  a  needle,  a  few  tablets,  and  a  fountain  syringe  the  surgeon  is  prepared  for  any 
emergency. 

For  intravenous  infusion,  for  which  no  pressure  is  required,  an  ordinary  funnel,  with 
rubber  tubing  attached,  will  be  sufficient  without  the  use  of  a  rubber  bag. 

The  use  of  salt  solution  has  supplanted  the  iransjusion  of  blood.  This  requires  a  source 
of  blood  which  is  not  aUvays  at  hand  and  an  amount  of  attention  which  can  rarely 
be  given  in  emergencies;  moreover,  it  has  been  shown  that  the  injection  even  of  defibrin- 
ated  blood  is  a  dangerous  procedure,  because  of  liberation  of  hemoglobin  and  destruc- 
tion of  white  corpuscles,  with  the  liability  to  coagulation  of  the  blood  from  increase  of 
fibrin  ferment,  and  the  possible  death  of  the  patient.  Direct  transfusion  from  another 
person  into  the  veins  of  the  patient  is  also  difficult,  and  has  rarely  been  of  service. 

As  already  stated  in  the  chapter  on  Shock,  the  best  solution  for  infusion  is  composed 
of  calcium  chloride  2  parts,  potassium  chloride  3  parts,  sodium  chloride  9  parts, 
sterile  water,  1000  parts.  The  addition  of  one  part  of  sodium  bicarbonate  will  sometimes 
prove  of  advantage,  while  in  diabetic  cases  this  may  be  increased  to  three  parts  to  a 
thousand.  It  has  also  been  suggested  to  add  a  small  proportion  of  sugar,  even  up  to 
thirty  parts,  to  this  solution,  in  order  to  increase  osmotic  action  and  better  preserve  the 
red  corpuscles  from  injury.     It  is  supposed  also  to  give  a  certain  nutritive  value. 

When  the  fluid  is  injected  into  the  venous  system  all  that  is  desired  is  that  it  barely 
enter;  consequently  the  receptacle  containing  the  fluid  should  be  held  but  a  few  inches 
above  the  level  of  the  opening.  When  hypodermoclysis  is  practised  more  pressure  will 
be  needed  and  a  greater  difference  of  level  should  be  maintained.  In  the  veins  the 
amount  injected  should  not  exceed  100  Cc.  each  minute.     From  500  to  1500  Cc.  may 


186  SURGICAL  PROCEDURES 

be  used  altogether.  There  need  he  no  hesitation  in  introdueing  it  at  a  temperature 
considerably  above  the  body  normal,  and  in  eases  of  shock  it  may  be  introduced  even  at 
115°  F.  The  character  of  the  pulse  will  afford  the  indication  as  to  the  amount  of  fluid 
to  be  used  as  well  as  the  wisdom  of  repeating  the  measure  after  an  interval. 

For  intravenous  infusion  a  vein  in  the  arm  is  usually  exposed  and  the  needle  point 
carefully  inserted.  It  is  an  advantage  to  have  for  this  j)urpose  a  special  needle,  made 
with  a  blunted  extremity,  enlarged  a  little,  so  that  by  the  use  of  a  temj)orary  ligature  the 
vein  may  be  held  tightly  aroimd  the  cannula,  for  such  it  really  is,  and  the  escaj)e  of  fluid 
be  prevented.  After  withdrawal  of  the  needle  a  double  ligature  should  be  j)laced  for 
purposes  of  security.     The  limb  should  also  be  kept  at  rest  for  a  few  days. 

For  hi/podermoclj/sis  from  500  to  1000  Cc.  may  be  employed;  the  anterior  abdominal 
wall,  the  flank,  the  thigh,  and  the  retromammary  tissues  are  the  best  regions  in  which 
to  inject  the  solution.  Absorption  will  be  assisted  by  gentle  massage.  Local  anes- 
thesia by  the  freezing  spray,  or  by  cocaine,  will  rob  the  procedure  of  its  discomfort. 
Adrenalin  may  be  added  to  the  solution,  whose  formula  is  given  above,  in  emergency 
cases  where  it  seems  to  be  especially  needed.  In  instances  where  infusion  is  practised 
for  the  purpose  of  washing  out  the  blood,  i.  e.,  in  the  acute  toxemia  of  lu'cmia,  alcoholism, 
etc.,  nothing  of  the  kind  will  be  required;  but  in  conditions  of  lowered  blood  pressure, 
i.  e.,  shock,  it  will  prove  of  great  value,  as  already  indicated. 


CATHETERIZATION. 

Catheters,  as  such,  are  intended  for  the  withdrawal  of  urine  from  the  urinary  bladder, 
or  for  the  introduction  and  withdrawal  of  cleansing  fluids.  They  are  made  of  metal, 
glass,  gum,  and  silk,  or  other  similar  material,  in  various  sizes,  while  some  are  specially 
formed  or  bent  in  order  to  pass  more  easily  over  the  obstruction  offered  by  a  median 
prostatic  enlargement.  Various  forms  are  sold  in  the  surgical  depots,  from  which  the 
purchaser  may  make  a  choice.  Next  to  the  simple  tubular  forms  the  elbowed  or  Coude 
catheters  are  of  the  greatest  value. 

Catheters  should  be  sterilized  before  use.  Those  used  occasionally  should  be  cleaned 
after  use  and  dried,  while  those  in  daily  use  may  be  kept  in  an  antiseptic  solution  after 
cleansing.  The  cleansing  of  a  catheter  should  include  not  only  attention  to  the  exterior, 
but  also  removal  from  its  bore  of  all  clots,  debris,  etc.  Some  pressure  behind  the  fluid 
used  for  this  purpose  is  advisable.  A  clean  metal  or  glass  catheter  may  be  sterilized  in 
a  flame  just  before  use.  All  flexible  catheters  should  be  boiled  just  prior  to  their  inser- 
tion, or  they  should  be  taken  out  of  an  air-tight  receptacle  in  which  they  have  been 
kept  in  contact  with  some  antiseptic,  or  in  an  antiseptic  vapor.  For  the  latter  purpose 
paraforrn  offers  an  excellent  material,  as  there  is  given  off  from  it  formaldehyde  vapor, 
which  is  a  powerful  bactericide.  It  comes  in  crystals  and  in  tablets.  Rubber  catheters 
should  be  boiled  in  a  5  to  10  per  cent,  solution  of  ammonium  sulphate. 

The  urethra  should  also  be  cleansed,  especially  the  meatus,  in  either  sex.  Cases  of 
cystitis  may  be  directly  traced  to  infection  introduced  by  a  catheter,  the  result  being  the 
same  whether  the  germs  be  not  removed  from  the  instrument  or  are  carried  in  by  it 
from  the  anterior  urethra.  This  is  particularly  true  in  paralytics  who  have  no  power 
of  expelling  the  urine,  antl  in  prostatics  who  need  regular  catheterization. 

The  technique  of  using  the  metal  catheter  in  the  male  is  the  same  as  that  of  introducing 
a  sound.  A  lubricant  is  necessary  for  the  easy  introduction  of  the  instrument,  and  a 
sterilized  ointment  or  oil  will  serve  the  purpose.  Olive  oil,  mixed  with  iodoform,  as  often 
used,  is  not  sterile.  The  hands  of  the  operator  should  also  be  clean,  and  no  part  of  a 
clean  instrument  should  be  allowed  to  come  into  contact  with  any  portion  of  the  patient's 
surface.     On  this  account  the  parts  exposed  should  be  covered  with  sterile  towels. 

The  catheter  being  intended  to  afford  relief  with  the  least  amount  of  discomfort,  a 
smaller  instrument  may  be  used  than  would  be  inserted  were  it  meant  for  the  dilatation 
of  a  stricture.  Occasionally,  and  in  a  sensitive  patient  or  hyperesthetic  urethra,  a  little 
cocaine  solution  may  be  used  to  advantage,  especially  if  force  or  pressure  need  be  made 
in  order  to  overcome  spasm  of  the  cut-off  muscle.  The  metal  instrument  is  too  rigid 
in  some  cases,  while  the  gum  catheter  is  too  flexible.  Under  these  circumstances,  the 
silk  instrument  may  be  used. 

If  the  tip  of  the  instrument  be  kept  close  to  ^he  floor  of  the  urethra  it  will  rarely  catch 


SKI.\   (!R.\FTI\(i  1.S7 

in  any  fossa  or  lacuna,  |)arliciilarly  if  llic  si/c  has  hccn  correctly  chosen.  When 
apparent  ohstrnction  occurs  at  the  Irianj^uhir  litfaniciit  ihi-  instrument  should  he  witli- 
(Irawn  a  little,  tilted  differently,  or  lifti'd  a  little  so  that  it  is  made  to  liuj^  the  roof  of  the 
urethra  rather  than  to  ])ress  upon  its  floor.  \\\  a  little  manij)ulati<)n  of  the  end  of  the 
instrument  any  obstruction  at  the  neck  of  the  bladder  may  also  he  overcome.  A  sudden 
tlepression  of  the  outer  end  as  the  catheter  reaches  this  part,  or  a  little  pressure  hy  the 
finger  of  the  disengaged  hand  in  the  perineum,  will  give  much  hel]).  It  is  well,  occa- 
sionally, to  introduce  one  (iiig<>r  into  the  rectum  in  order  that  hy  it  the  instrument  may  he 
better  guided  along  its  course.  ()nly  in  cases  where  there  has  been  previous  disease  or 
where  uiisucc(>ssful  attempts  have  already  been  made  to  pass  an  instrument  will  much 
real  dilliculty  l)e  found;  that  is,  only  in  those  already  suil'ering  from  stricture,  or  from 
enlarged  prostate  with  the  difliculties  which  it  affords,  will  one  have  to  resort  to  inani|)u- 
lation  requiring  more  than  ortlinary  dexterity.  In  some  of  these  case.s  even  the  expert 
is  likely  to  meet  with  difficulty,  rarely  with  absolute  di.sap})ointment.  Should  it  be 
impossible  to  empty  a  distended  bladder  with  a  catheter  suprapiif/ic  puncture  with  the 
(i.tplraior  nrrdir  should  he  made. 

When  difficulty  is  experiiMiced  it  is  enhanced  by  sjxvsm  of  the  deep  muscles,  as  a  reflex 
from  the  soreness  produced  by  repeated  efforts  and  by  hemorrhage. 

Hemorrhage  from  this  source  is  rarely  of  serious  characti'r  and  quickly  ceases.  In 
certain  instances  where  it  is  aggravated  inuch  can  he  accom])lished  hy  leaving  the  catheter 
in  ffitu  for  a  few  hom-s,  or  even  for  two  or  three  days. 

False  passages  will  occur  sometimes  in  spite  of  at  least  ordinary  care,  and  are  always 
serious  in  their  nature.  Extravasation  of  urine  may  result,  with  more  or  less  disastrous 
con.sequences,  or  speedy  sejitic  infection  may  quickly  terminate  the  Hfe  of  the  individual. 
They  are  to  be  avoided,  as  far  as  ):)ossible,  by  the  use  of  instruments  of  large  rather 
than  of  small  size,  with  blunt  ti])s,  and  by  delicacy  of  manipulation.  For  this  j)urpose 
it  is  well  to  avoid  the  use  of  catheters  which  require  a  wire  stylet  for  the  maintenance  of 
their  proper  curve,  lest  dm-ing  manij^ulation  the  point  of  the  wire  may  work  injury. 
The  various  accidents  due  to  or  connected  with  catheterization  will  he  dealt  with  in 
their  proper  places  in  connection  with  the  surgery  of  the  uretlira  and  bladder. 

There  are  certain  constitutional  complications,  however,  which  deserve  mention. 
One  of  these  is  known  as  urethral  fever,  which  comes  on  usually  with  a  chill,  followed 
by  more  or  less  rise  in  temperature,  and  with  general  disturbance  of  the  system.  It  is 
to  be  regarded  as  a  manifestation  of  septic  intoxication,  the  hope  being  that  the  disturb- 
ance may  not  go  beyond  this  degree.  In  cases  that  have  once  suffered  from  this  intoxi- 
cation precautions  should  he  doubled.  The  deep  lu-ethra  should  he  irrigated  before 
and  after  the  withdrawal  of  the  urine,  the  patient  should  be  kept  in  bed,  and  urotropin 
and  quinine  may  be  administered  before  and  after  the  discharge  of  urine.  Much  may 
be  done  in  the  prevention  of  this  as  of  other  unpleasant  occurrences,  such  as  pain, 
excitement,  suppression  of  urine,  syncope,  etc.,  by  the  previous  use  of  cocaine  and  by 
due  regard  for  gentleness.  Should  a  septic  process  be  set  up  in  the  deep  urethra  it  may 
lead  to  sapremia  of  urethral  origin,  and  to  septicemia  and  pyemia.  Sejitic  complica- 
tions accompanied  by  any  local  indications,  such  as  swelling,  should  make  the  surgeon 
watchful  for  the  time  when  an  incision  must  be  made  for  relief  of  tension  or  escape 
of  pus. 

Postoperative  suppression  of  urine,  which  may  occur  even  after  catheterization,  may 
be  treated  by  giving  0.08  to  0.15  Cg.  of  sulphate  of  sparteine  every  three  or  four  hours 
(McGuire). 

SKIN  GRAFTING 

The  whole  method  of  skin  grafting  is  based  on  the  fact  that  if  epithelium  be  removed 
from  any  portion  of  the  body  and  ])lanted  on  favorable  soil  elsewhere  it  will  take  root 
and  grow,  reproducing  only  itself  and  no  other  kind  of  tissue.  It  is  closely  analogous 
to  sewing  seed  upon  a  favorable  soil,  or  even  to  sodding.  Furthermore  it  is  not  neces- 
sary that  epithelium  he  furnished  from  the  individual  upon  whom  it  is  to  be  implanted; 
it  may  come  from  another  of  the  same  species  or  even  from  a  different  species.  Thus 
the  skin  of  the  frog  has  been  used  for  grafting  upon  human  beings,  and  even  the  lining 
membrane  of  the  egg.  Nor  is  it  necessary  that  the  epithelial  cells  should  be  apparently 
alive  when  thus  employed.     Very  thin  shavings  of  human  skin  which  have  been  dried. 


188  SURGICAL  PROCEDURES 

or  have  been  kept  from  decomposing  by  some  antiseptic,  have  been  successfully  used; 
nevertheless  the  ideal  method  consists  in  taking  what  Ls  needed  from  the  individual 
who  needs  it. 

The  term  skin  grafting  is  now  applied  to  the  employment  of  very  thin  layers  of  the 
epidermis,  i.  e.,  as  thin  as  can  be  shaved  off  with  a  sharp  razor,  and  it  does  not  apply 
to  the  autoplastic  methods  of  skin  transplantation. 

Hamilton,  of  Buffalo,  and  Reverdin,  of  Geneva,  a  number  of  years  ago  independently 
discovered  that  minute  particles  of  healthy  skin  might  be  imjjlanted  ujxjn  healthy 
granuiatifjns  and  that  from  such  minute  grafts  epithelium  would  be  produced  and  a  fresh 
epidermal  covering  Ijc  afforded.  This  method  was  in  use  for  years  and  was  a  great 
advance  on  what  had  previously  Ijeen  done.  Then  Hamilton,  of  Edinburgh,  suggested 
the  use  of  thin  slices  of  clean  sponge,  in  order  that  thereby  a  trellis  might  l>e  offered  for 
the  growing  and  climbing  granulation  tissue;  this  sersed  a  gcjod  purpose  in  many  cavities. 
But  the  greatest  advance  came  when  Thiersch  demonstrated  that  large  areas  might  l)e 
covered  with  skin  shavings,  and  that  thus  in  a  few  days  there  would  l>e  accomplished 
that  which  took  weeks  or  months  by  older  methods.  His  original  plan  comprehended 
only  the  use  of  these  grafts  upon  granulation  tissue;  later  it  was  found  that  they  might 
be  applied  to  fresh  raw  tissue,  even  to  denuded  bone.  Thus  originated  the  so-called 
Thifrsch  methrxl  of  .shiii  grafting. 

The  surface  to  which  these  grafts  are  applied  must  be  thoroughly  cleansed  as  well  as 
the  surface  from  which  they  are  removed.  If  an  ulcerated  surface  is  to  l)e  prejjarecJ  for 
grafting  it  should  l^e  scrap>ed  thoroughly  with  a  sharp  spoon ;  all  sloughing  or  suspicious 
ti.ssue  should  be  carefully  removed,  and  all  oozing  allowed  to  subside.  Not  until  the 
surface  is  prepared  is  it  advisable  to  remove  the  grafts.  These  are  best  removed  by 
putting  upon  the  stretch  the  skin  of  the  selected  area,  so  as  to  render  it  taut  and  as 
nearly  flat  as  possible.  The  razor  used  for  the  purpose  should  be  sterilized  and  sharp. 
Salt  solution  may  be  allowed  to  drip  upon  the  razor  while  the  surgeon  is  using  it.  It 
Is  rarely  practicable  to  remove  a  strip  over  5  Cm.  wide  or  2.5  Cm.  long.  The  endeavor 
should  be  to  remove  only  the  superficial  layer  of  the  skin,  and  when  properly  done  this 
removal  should  be  followed  by  but  a  trifling  oozing  of  blood.  If  bleeding  be  profuse  the 
layer  removed  has  been  too  thick.  Grafts  of  sufficient  number  and  size  are  removed 
to  nearly  cover  the  desired  area.  The  more  completely  it  is  covered  the  more  acceptable 
will  be  the  final  appearance  of  the  surface.  If  the  grafts  adhere,  we  may  confidently 
rely  upon  their  furnishing  enough  fresh  epitheliimi  to  fill  in  the  irregular  defects  between 
the  edges.  The  grafts  when  cut  should  l>e  raised  with  a  razor  and  a  spatula  and  gently 
spread  out  upon  the  prepared  surface,  and  so  pressed  and  treated  that  no  air  bubbles 
are  retained  beneath  them.  If  the  surface  be  dr}"  enough  they  will  adhere  to  the  very 
thin  coagulum  of  blood  which  glazes  it,  and  after  a  few  moments  it  will  take  friction  to 
disturb  them. 

Should  the  margin  of  the  surface  to  Ix-  grafted  be  old  and  indurated  it  is  best  to  trim 
off  any  depression  that  exists,  so  that  the  new  skin  may  not  l>e  let  in  below  the  surface 
of  the  surrounding  skin. 

The  dressing  should  consist  of  a  layer  of  sterilized  oiled  silk,  gutta-percha  tissue,  or 
green  protective,  laid  on  in  strips,  in  order  that  excessive  fluid  may  escape  Ix'tween  them. 
A  little  antiseptic  jxtwder  may  be  dusted  upon  the  grafts,  if  such  Ijc  the  choice  of  the 
surgeon,  but  if  the  operation  has  been  properly  managed  this  will  hardly  be  necessary. 
Careful  regulated  pressure  should  be  made  outside  of  the  protective,  by  cotton  and  a 
suitable  dressing,  and  then  the  part,  if  a  limb,  may  V>e  bound  upon  a  splint  in  order  to 
ensure  physiological  rest.  Silver,  tin,  or  aluminum  foil  also  make  a  good  protective,  and. 
on  theoretical  principles,  are  even  lx"tter  than  the  textile  materials. 

Some  surgeons  leave  these  dressings  for  several  days.  I  have  found  it  an  advantage 
to  remove  them  within  thirty-six  hours,  as  sometimes  the  grafts  app>ear  to  be  macerated 
in  the  fluids  and  to  lose  their  first  cohesion  to  the  prepared  surface.  The  main  thing 
about  the  dressing  Is  that  .it  should  be  non-adhesive  and  restful.  After  three  or  four 
days,  when  the  grafts  have  completely  adhered,  any  ointment  dressing  may  be  used. 
It  may  happjen  that  only  a  portion  of  the  entire  number  of  grafts  sers^e  their  purpose,  and 
that  fjthers  fail  to  do  their  work.  Even  when  the  failure  has  l>een  apparently  consider- 
able it  will  often  be  seen  that  individual  epithelial  cells  have  adhered  and  later  will  grow. 
The  unhealed  portions  of  such  a  surface  now  fall  within  the  definition  given  earlier  of  an 
ulcer,  and  should  be  subjected  to  the  same  treatment. 


/>.i.v/>.i^7.\y/ 


189 


(ir;ittiii<^  may  l>»'  ic|M'a(ctl  asortfii  as  scciiis  (o  l)c  iircrssnrv.  The  best  surfaces  Iroin 
wliicli  to  lake  ti.e  jrral'ls  are  usually  the  outer  aspects  of  the  arms  and  thi<,'lis.  'i'lie 
places  from  which  they  are  removed  need  only  the  simplest  antise|)lic  dressin<rs.  If 
the  (grafts  have  been  of  siiflicient  thiimess  the  scars  left  hy  their  rennnal  are  scarcely 
permanent  and  rarely  disfijjurin<j. 

\Vi<;ht,  of  Brooklyn,  has  sufifgestcd  that  advantage  be  taken  of  th(>  properties  of 
hi<fh-fre(|ui'ncy  dischar<;es  from  a  suitable  ap|)aratus  to  secure  their  hemostatic  and 
coaifulant  etfect.  He  has  shown  that  such  electrical  discharge  will  clot  hlood  and  (H)agu- 
late  albumin,  tliis  etVect  beint;  jiartly  due  to  the  formation  of  nitric  acid  from  the  air.  In 
this  way  it  is  tlu-oretically  possible  to  so  seal  the  surfaces  as  to  fix  (drafts  firmly  in  place. 
The  a|)|)aratus  calls  for  a  pointed  electrode,  passed  at  a  distance  of  about  1  (^m.  above 
the  entire  surface,  until  the  clot  is  firm  and  reasonably  dry,  all  serum  that  is  expressed 
in  the  process  b(>ing  removed  with  sponojes.  Where  the  aj)paratus  can  be  ein[)loyed  this 
afi'ords  an  efiective  way  of  fixing  the  grafts  and  preventing  their  ('isplacement. 

Surface  epithelium  from  an  animal  source  may  be  used  when  necessary — as  from 
a  young  pig  after  it  has  left  the  packing-house,  a  young  calf,  or  some  smaller  animal. 
All  that  is  re(|uired  is  epiiliclium.  That  from  a  negro  will  reproduce  only  pigmented 
cells  like  the  original.  At  the  time  when  amputating  a  limb  about  which  there  is  still 
left  healthy  unbroken  skin,  shavings  may  l)e  removed  from  it  and  j)reserved  for  a 
week  or  two  between  dry  sterilized  towels  or  in  a  weak  antiseptic  solution;  these  may 
then  be  utilized  for  skin  grafting  during  the  ensuing  few  days. 


Fig.  30 


Figure-of-8  bandage  of  leg. 


Fig.  .31 


Fig.  32 


Velpeau'3  bandage. 


Ascending  spica  bandage  of  the  groin. 


BANDAGING. 


Bandaging  is  a  subject  now  taught  so  generally  by  actual  demonstration,  and  so 
simplified,  that  it  scarcely  seems  necessary  to  more  than  present  a  few  illustrations 
showing  how  simple  bandages  can  be  applied  in  the  most  effective  manner. 


190 


SURGIC.  \  L   PROCEDURES 


The  ])urposes  of  a  bandage  are  either  to  afford  means  of  retaining  splints  and  dressings, 
to  exert  pressure,  or  to  afford  physiological  rest.  After  every  operation  of  importance 
it  is  necessary  to  apply  and  retain  an  occlusive  and  aseptic  dressing,  under  which  the 
wound  may  heal  or  into  wliich  wound  discharges  may  be  received;  but  the  ideal  dressing 
affords  more  than  this — it  furnishes  support  and  rest. 


Fig.  33 


Fk:.  34 


i*pica  baniiage  of  shoulder. 

There  is  danger  in  the  injudicitnis  use  of  any  bandage,  as  by  the  exertion  of  undue 
pressure  it  may  interfere  with  wound  healing,  or  may  even  lead  to  gangrene.  If  applied 
loosely  at  the  extremity  and  too  tightly  above  it  will  lead  to  venous  obstruction  and 
possibly  secondary  hemorrhage.  Moreover  a  bandage  which  seems  projxrly  arranged 
may  become  so  tight  as  to  be  painful  and  even  unbearable  after  swelling  has  occurred. 
There  is  but  one  safe  rule,  and  that  is  to  take  note  of  the  apj>earance  of  the  part  as  well 
as  of  the  sensations  of  the  j^atient.     An  abdominal  bandage  may  have  been  placed  with 


iT-^.  35 


Third  roller  of  Desault's  bandage. 


a  projier  degree  of  snugness  at  the  conclusion  of  an  operation,  and  vet  be  altogether 
too  tight  when  the  abdomen  Ijecomes  distended  with  a  little  gas.  There  is  then  alwavs 
room  for  discretion  and  good  judgment  in  the  matter  of  bandaging.  It  may  be  neces- 
sary to  apply  a  banflage  quite  firmly  at  first  in  order  to  repress  hemorrhage,  with  the 
intention  to  relax  it  after  a  few  hours. 


y>'.l.\7;.ir,7.\7/ 


I'.ll 


A  s|)liiit  may  1)("  ;i  ncccssarv  teat  lire  in  a  siir;xi*:il  tlressiii^;  alter  amputating;  at  the  lower 
|)art  of  tile  lei;  it  is  advisable  to  hind  the  limt)  ii|)on  a  splint  in  order  that  the  necessary 
j)hysioloo;ieal  ri'st  may  l)e  thus  allorded.  'I'he  first  retpiisite  of  a  handat^e  is  not  its 
ap])earaiiee  hut  its  ettectiveness;  a  (hii'  re<;ard  for  the  esthetic  in  surgery  will,  however, 
dictate  tliat  it  he  made  as  j)rcsentahlc  as  possil)le. 


I'Ki.    M 


Vu:.  -M 


T-bandage. 


Kelly's  bandage  with  perineal  straps. 


For  the  roller  handages  of  cotton  cloth,  universally  in  use  twenty-five  years  ago,  there 
have  heen  suhstituted  handages  of  thin  gauze  or  crinoHne,  which  have  scarcely  body 
enough  to  he  applied,  as  was  the  roller,  or  else  of  flannel,  made  wider  and  necessarily 
thicker,  which- are  more  flexible,  comfortable,  and  applicable. 


Fig.   39 

y 


"A 


Barton's  head  bandage  as  employed  for  suspension  in  applying  plaster-of-Paris  bandage. 

Crinoline  impregnated  with  starch  is  also  in  general  use  and  makes  a  serviceable 
bandage  for  head  injuries.  When  prepared  with  plaster  of  Paris  it  is  capable  of  aft'ord- 
ing  absolute  support  and  even  rigidity. 


CHAPTER    XX. 

ANESTHESIA  AND  ANESTHETICS,  GENERAL  AND  LOCAL. 

To  Oliver  \\endell  Hcjlmes  we  owe  the  term  anesthesia,  as  generally  employed  and 
made  to  mean  insensibility  to  pain,  no  matter  how  produced.  A  more  strict  definition 
would  limit  the  term  to  conditions  comprisincj  not  only  insensibility  to  pain  but  loss  of 
consciousness  For  mere  loss  of  sensation  we  should,  strictly  speaking,  use  the  word 
auahjrsin.  This  is  a  distinction  with  a  difference.  Thus  I  have  on  rare  occasions  seen 
a  patient  under  chloroform  absolutely  oblivious  to  pain  but  perfectly  con.scious,  and 
chatting  intelligently  throughout  the  ojx'ration.  This  is  a  rare  phenomenon,  but  has 
been  noted  by  various  observers.  So  after  intraspinal  cocaine  injections  we  .secure  com- 
plete analgesia  of  the  lower  poiiion  of  the  body,  but  not  complete  anesthesia,  the  former 
being  what  we  are  most  anxious  to  produce. 

The  discovery  of  anesthesia  is  essentially  to  America's  credit.  Long,  of  Georgia,  had 
produced  anesthesia  by  ether  as  early  as  1S42;  Jackson,  of  Boston,  also  claims  credit 
for  the  discovery;  but  to  Morton,  a  dentist  of  Boston,  is  undoubtedly  due  the  honor  of 
having  introduced  it  for  surgical  purposes.  The  first  public  demonstration  of  its  proper- 
ties was  made  by  Morton  and  Warren,  October  l(i,  1S46,  in  the  Massachusetts  General 
Hospital.  Chloroform  seems  to  have  been  exploited  independently  by  Guthrie,  of 
Sackett's  Harbor,  N.  Y.,  and  Simpson,  of  Edinburgh,  in  1847.  It  is  a  curious  historical 
fact  that  the  patient  to  whom  Simpson  meant  first  to  administer  chloroform  in  his  clinic 
did  not  receive  it  because  of  some  failure  to  have  it  on  hand;  she  cook  ether  instead  and 
died,  presumably  of  the  anesthetic.  Had  she  died  under  the  influence  of  chloroform 
it  would  have  been  a  serious  setback  to  any  general  appreciation  of  its  merits.  Nitrous 
oxide  is  also  an  anesthetic  for  which  America  may  take  the  credit.  These  are  the  three 
drugs  ill  coininoii  use  today,  although  there  are  others  which  are  coming  into  general 
favor. 

It  can  be  .stated  as  an  axiom  that  when  a  surgeon  tries  to  abolish  human  sensibility, 
or  pa.ss  an  in.strument  through  the  human  skin,  he  introduces  elements  of  danger  which 
can  never  be  certainly  and  completely  controlled — that  is  to  say,  the  administration  of 
an  anesthetic  is  never  to  be  undertaken  as  a  trifling  matter,  but  should  be  entered  upon 
as  carefully  for  a  minor  procedure  as  for  a  dangerous  and  prolonged  operation. 

.\nesthetics  are  .sources  of  danger,  not  only  for  the  moment  while  they  are  in  use,  but 
because  of  the  disturbances  which  may  follow  in  their  train.  These  drugs  should  never 
be  administered  carelessly  nor  thoughtlessly,  nor  by  inex{X'rienced  individuals,  but  en- 
trusted to  the  wisest  and  the  most  discreet.  More  is  expected  of  the  anesthetizer  than 
that  he  shall  barely  keep  the  patient  alive;  he  should  be  .so  expert  as  to  keep  the  patient 
safely  on  the  side  of  complete  anesthesia  and  muscle  relaxation.  Nor  should  he  be 
willing  to  yield  to  the  im}X)rtunities  of  an  impatient  operator  who  may  be  continually 
appealing  to  him  to  crowd  the  anesthetic.  When  thus  given,  and  by  an  expert,  such 
p)ostanesthetic  distress  as  nausea,  vomiting,  coughing,  etc.,  may  be  avoided  So 
generally  are  these  facts  now  realized  and  appreciated,  that  in  many  of  the  large  hospitals 
a  regular  anesthetizer  is  employed,  whose  sole  duty  it  is  to  administer  the  anesthetic  for 
the  attending  surgeons.  The  management  of  an  anesthetic  has  much  to  do  with  the 
allied  subjects  of  the  preparation  of  the  patient,  the  management  of  shock  or  reduced  blood 
pressure,  and  the  status  hjmphaticus,  which  have  already  been  consiflered. 

Fatal  accidents  from  anesthetics  are  the  appalling  ones  which  have  generally 
occurred  in  cases  where  it  has  been  assumed  that  the  patient  is  in  good  condition,  and 
where  neither  preliminary  examination  nor  preparation  has  been  made.  In  the 
presence  of  unmistakable  cardiac  disea.se,  or  of  great  arterial  tension,  the  surgeon  may, 
by  foreseeing  the  possibility  of  trouble,  do  much  to  prevent  it;  but  when  an  apparently 
healthy  individual  is  placed  upon  the  operating  table  without  attention  to  these  matters 
it  may  happen  that  his  heart  will  stop  as  suddenly  and  unexpectedly  as  though  it  had  been 
transfixed.  In  other  words,  the  accidents  of  anesthesia  usuallv  occur  when  least 
(192) 


ETHER  103 

(•x|H'(t(Ml;  (til  the  iitlicr  liiiiid,  accidents  will  he  few  iiiHJ  far  between  when  all  eases 
are  handled  as  tiiou^h  |)n)inisinjr  to  he  si-vere  ones. 

The  odor  of  most  anesthetics  is  so  distastefiil  to  patients  that  thev  inhale  at  first  with 
(hfficultv  and  with  sii;ns  of  irritation.  Mnch  of  this  can  he  jruarded  aj^Minst  hv  sprayiiifij 
the  nasopharvnx  with  a  1  or  2  |)er  cent,  solution  of  cocaine.  Tiiis  expedient  will  make 
anesthesia  much  easier  for  them.  The  month  sliould  he  examined;  all  false  teeth  or 
foreign  bodies,  snch  as  pins,  chewinif-ffum,  etc.,  should  be  removed.  l'nj)leasant 
buniiuf;  of  the  .sensitive  mucosa  of  the  uo.se  and  lips  may  be  avoided  by  anointing  tlie.se 
parts  with  cold  ereani  Attention  should  be  given  to  the  avoidance  of  irritation  of  the 
eyes  or  the  careless  escape  of  an  anesthetic  into  the  conjunctival  sac;  with  a  struggling 
patient,  or  a  careless  administrator,  this  may  easily  happen. 

Ciremnstances  which  would  justify  the  administration  of  an  anesthetic  without  the 
con.sent  of  the  j>atient,  or  the  friends  or  parents,  occur  but  rarely;  still  in  an  emergency 
case,  with  a  j)atient  incompetent  to  decide  for  himself,  the  surgeon  must  assume  the 
responsibility,  in  which  in  all  probal)ility  the  law  will  sustain  him. 

The  anesthetizer  should  always  be  accompanied  by  an  assistant;  j)referably  in  the  ca.se 
of  a  female  patient,  by  a  female  nurse,  who  may  not  only  be  of  assistance  to  him  at  the 
time,  but  an  actual  protection  should  the  ])atient  experience  any  erotic  delusions  during 
or  after  her  period  of  anesthesia.  This  applies  equally  well  to  denti.sts  giving  nitrous 
oxide  for  the  extraction  of  teeth,  or  physicians  attending  ca.ses  of  accident,  convulsions, 
and  the  like. 

The  anesthetics  in  general  use  are  ether  and  chloroform.  If  statistics  alone  are 
appealed  to  it  can  be  easily  shown  that  ether  is  the  safer  of  the  two  by  a  large  ratio.  But 
the  recovery  of  consciousness  by  no  means  indicates  the  conclusion  of  the  period  of 
danger.  The  harm  which  chloroform  does  is  largely  done  promptly,  whereas  the 
unpleasant  effect  of  ether  lasts  through  a  much  greater  period,  and  the  statistics  which 
give  ether  an  advantage  are  in  many  respects  fallacious.  Chloroform  is  doubtless  the 
stronger  and  the  more  subtle  agent  of  the  two,  and  in  careless  hands  would,  in  all 
probability,  become  the  more  dangerous.  Bid  no  anesthetic  should  be  given  carelessly, 
and  no  one  should  give  it  who  cannot  give  it  properly.  There  may  be  emergency  cases, 
especially  in  the  rural  districts,  in  which  the  surgeon  may  have  to  act  in  the  capacity  of 
anesthetizer  and  operator  as  well,  and  where  he  may  have  to  transfer  the  inhaler  to 
some  lay  assistant  who  knows  nothing  of  the  action  of  these  drugs.  If  this  happen  it 
would  be  safer  to  use  ether. 

When  administered  by  a  thoroughly  competent  person  chloroform  is  the  safer  anesthetic 
of  the  two,  and  is  usually  to  be  preferred.  So  largely  does  the  personal  equation  figure 
in  this  consideration  that  it  seems  unnecessary  to  reproduce  here  statistical  tables  in 
regard  to  its  efficiency. 

ETHER. 

The  writer's  intention  is  to  confine  his  views  on  anesthesia  to  the  practical  application 
of  certain  drugs  whose  chemistry,  materia  medica,  and  ordinary  therapeutic  properties 
are  appropriately  treated  of  in  other  w'orks. 

Ether  anesthesia  has  by  some  been  considered  to  be  simply  one  form  of  carbon  dioxide 
poisoning;  that  it  may  be  all  of  this,  in  certain  cases,  may  be  granted;  but  it  is  certainly 
something  more,  as  is  shown,  among  other  things,  by  the  peculiar  odor  which  persists  in 
the  breath  of  the  patient  for  hours  or  even  for  days  after  its  use.  Various  ways  of  ad- 
ministering it  have  been  recommended.  Some  give  it  well  diluted  with  air,  and  some  give 
it  as  strong  as  a  patient  can  possibly  bear  it,  and  from  the  outset.  Some  keep  mixing 
air  with  the  vapor,  while  others  have  devised  inhalers,  by  which  the  same  ether-ladened 
air  is  breathed  over  and  over  again.  These  latter  produce  a  certain  degree  of  the  carbon 
dioxide  poisoning  above  alluded  to,  and  are  not  ideal  even  if  effective. 

Even  when  well  diluted  with  air  the  vapor  of  ether  causes  irrhation  of  the  air  passages, 
in  both  the  nose  and  throat,  and  leads  quickly  to  a  sensation  at  first  of  oppression  and 
then  almost  of  suffocation,  which  is  trying  to  the  self-control  of  intelligent  patients  and 
disturbing  to  those  having  little  or  none.  An  inhaler  saturated  with  ether  should  not  be 
pressed  tightly  over  the  patient's  face,  as  it  is  likely  to  produce  struggling  to  such  an 
extent  that  w-eakened  bloodvessels  may  give  way  and  by  their  rupture  produce  serious 
disturbance. 
13 


194  SURGICAL  PROCEDURES 

The  first  momentary  period  of  irritation  having  .snl)si<le(l,  there  will  Hkely  follow  a 
few  dee])  inspirations,  and  then  |)erha})s  a  fixation  and  iinmohility  of  the  chest,  so  that 
for  half  a  minute  or  a  minute  it  would  seem  as  thouj^h  the  patient  had  jorgotirn  to  breathe 
(Hare).  But  deej)  respiration  is  quickly  reestablished,  or  may  he  stimulated  by  slap- 
ping the  chest,  by  a  few  movements  at  artificial  res  [)i  rat  ion,  or  at  least  by  compressing 
the  thorax.  Then  follows  the  period  of  "primary  anesthesia,"  so  called,  or  a  period  of 
excitement,  during  which  the  patient  may  rave  or  become  quite  disturbed,  and  in  a  manner 
sometimes  quite  at  variance  with  his  ordinary  temperament.  As  this  period  subsides 
the  state  of  complete  anesthesia  begins,  and  when  muscular  relaxation  is  complete,  oi 
even  before,  the  surgeon  may  commence  his  work.  The  respiration  under  complete 
anesthesia  is  usually  deeper  and  sometimes  more  rapid  than  in  health,  while  as  the 
muscles  become  more  relaxed  a  positively  stertorous  breathing  is  noted,  along  with  an 
increase  in  flow  of  saliva,  due  to  the  irritation  of  the  ether  vapor.  As  anesthesia  passes 
into  complete  narcosis,  and  this  into  asphyxia,  the  color  of  the  surface,  especially  of  the 
face,  changes  to  a  cyanotic  hue,  the  skin  becomes  moist  and  clammy,  and  the  pulse, 
which  had  been  accelerated,  fails.  The  blood  also  becomes  exceedingly  dark  from 
lack  of  oxygen.  Under  these  circumstances  the  heart  may  continue  to  beat  feebly  for 
a  short  time  after  respiration  has  ceased.  As  Hare  puts  it:  "In  producing  its  effects 
ether  first  attacks  the  perceptive  and  intellectual  cerebral  centres,  next  the  sensory  side 
of  the  spinal  cord,  next  the  motor  side  of  the  cord,  then  the  medulla,  and  with  this  last 
depression  death  ensues." 

Ether  is  more  pungent  and  less  agreeable  to  l>reathe  than  chloroform,  but  the  chief 
advantage  usually  connected  with  its  use  is  its  supposed  factor  of  safety. 

On  the  other  hand,  the  accidents  which  are  due  to  ether  are  in  a  large  measure  those 
common  to  the  use  of  any  anesthetic  agent.  Among  the  most  prominent  is  arreftt  of 
respiration,  which  may  be  caused  either  by  mucus  or  some  foreign  body  in  the  air  passages, 
or  by  the  tongue  dropping  back  in  the  pharynx,  and  the  impediment  to  respiration 
thereby  offered.  When  the  cause  of  the  difficulty  is  ascertained  it  is  usually  easily 
removed.  Should  great  pallor  accompany  these  symptoms,  then,  it  is  usually  because 
the  heart  as  well  is  at  fault,  and  vigorous  stimulation  of  this  organ  should  be  promptly 
instituted. 

An{)th(>r  disadvantage  pertaining  to  ether  results  from  the  irritation  which  its  vapor 
produces  in  the  bronchi  and  lungs,  or  in  the  kidneys  during  its  elimination.  From 
the  former  may  result  bronchitis,  congestion,  or  even  pneumonia;  the  latter  more  often 
of  the  catarrhal  type  than  of  the  croupous.  As  the  result  of  renal  irritation  there  may 
be  temporary  albuminuria,  or  the  congestion  resulting  may  assume  so  serious  a  type  as 
to  produce  absolute  suppression  (anuria),  which  is  practically  always  fatal.  Ether  is 
said  to  be  particularly  undesirable  in  cases  of  diabetes,  because  of  the  resulting  aceto- 
nuria.     Patients  have  even  been  known  to  pass  from   anesthesia   into  diabetic  coma. 

It  has  been  found  that  complications  are  more  common  in  males  than  in  females,  but 
more  severe  in  the  latter.  Vomiting  following  the  use  of  ether  is  a  frequent  and  most 
un])leasant  sequel.  It  is  to  be  prevented  by  previous  lavage,  as  well  as  by  the  same 
measure  at  the  conclusion  of  the  operation.  It  will  rarely  subside  when  present  until 
the  ether  vapor  has  been  eliminated.  So  far  as  it  is  possible  to  sup])ress  it  with  drugs 
probably  2  Gm.  doses  of  chloral  and  one  of  the  bromides,  with  a  little  laudanum,  given 
by  the  rectum  in  salt  solution  or  a  little  starch-water,  will  give  the  best  results. 

As  already  stated,  it  was  formerly  held  that  anesthesia  was  carbon  dioxide  poisoning, 
plus  something  else  which  was  vaguely  described  by  different  authorities;  much  clearer 
notions  now  prevail  regarding  the  mechanism  of  anesthesia.  A  few  years  ago  Meyer 
and  Overton  concluded  that  anesthesia  is  produced  by  solution  of  the  fatty  constituents 
of  the  cells  by  the  anesthetic  absorbed,  this  being  true  at  least  with  chloroform  and  ether, 
both  of  which  are  solvents  of  fat.  The  absorbability  of  the  anesthetic  varies  with  the 
blood  temperature,  this  varying  widely  between  the  cold-blooded  and  warm-blooded 
animals.  They  estimate  that  1  part  of  ether  to  400  parts  of  serum  is  necessary  for 
complete  anesthesia  in  man,  while  one  part  in  4500  to  GOOO  parts  is  a  sufficient  propor- 
tion of  chloroform.  According  to  these  views  the  dissolved  fat  is  not  removed  from 
the  cells,  and  no  satisfactory  explanation  yet  accompanies  this  theory,  even  assuming  its 
accuracy. 

Of  no  small  importance  are  the  experiences  of  Snel,  who  found  that  anesthetics  decrease 
the  bactericidal  properties  both  of  the  blood  and  of  the  tissues,  but  that  this  power  is 


cUl.oh'OFnuM  ]95 

(jiiickly  rf(()V(Tc<l  iiltcr  the  cliiiiiiijitioii  of  the  jiiicstlictic.  lie  t'liniislics  reason  for  tlic 
theory  that  the  thus  lowered  resistance  of  tlie  hirij^s  is  an  important  factor  in  the  pro- 
(luetion  of  the  pneumonia  which  occasionally  follows  operations. 

There  is  a  helief  that  ether  is  more  irritating;  to  the  kidneys  than  chloroform.  This, 
however,  does  not  s(>ein  to  he  justified  by  evich-nce,  neither  is  the  prejuchce  against  the 
u.se  of  ether  durin<;  the  existence  of  albuminuria  or  in  the  j)re.senoe  of  easts.  In  the  |)res- 
ence  of  a  hi<;h  degree  of  albuminuria  any  anesthetic  is  dangerous,  and  here  ether  would 
be  the  less  desirable  of  the  two.  Nevertheless  in  ordinary  mild  albuminuria  one  need 
not  fear  to  give  ether. 

About  twenty  years  ago  it  was  suggested  that  ether  anesthesia  could  l)e  induced  by 
passing  its  rapor  into  the  colon  thronr/li  an  ordinarij  rrrfa/  tiihr.  There  are  many  (obvious 
reasons  why  it  would  be  of  great  advantage  if  anesthesia  could  be  safely  practised  in 
this  way,  not  only  in  oj)erations  about  the  face  and  head,  but  becau.se  of  the  avoidance 
of  pulmonary  and  gastric  irritation. 

The  method  was  to  thoroughly  empty  the  colon  and  then  connect  a  rectal  tube  with 
a  receptacle  containing  ether,  which  was  placed  in  warm  water  anri  the  vapor  passed 
into  the  intestine.  It  was  found  that  patients  could  be  readily  anesthetized  in  this 
manner,  but  unfortunately  it  was  also  found  that  a  considerable  degree  of  intestinal 
irritation  was  j)roduced. 

The  writer  recalls  one  case  in  wjiich  this  methofl  was  practised,  which  terminated 
fatally  within  twenty-four  hours  after  the  operation,  where  tlie  autopsy  disclosed  a  violent 
degree  of  acute  colitis.^ 


CHLOROFORM. 

It  is  important  that  pure  chloroform  should  be  secured  for  anesthetic  purposes.  It 
shoukl  be  kept  in  dark  bottles,  and  in  the  dark,  as  it  is  liable  to  undergo  decomposition 
in  the  presence  of  sunlight.  It  is  less  volatile  than  ether,  and  mixtures  of  the  two  drugs 
are  not  stabile,  since  the  ether  is  likely  to  evaporate  first.  In  its  anesthetic  effects  it 
resembles  ether,  acting  first  upon  the  perceptive  and  last  upon  the  motor  centres. 

The  British  Chloroform  Committee  estimate  that  from  1  to  2  per  cent,  of  chloroform 
in  the  inspired  air  is  sufficient  for  anesthetic  purpo.ses,  and  may  be  safely  used;  that 
5  per  cent,  is  more  than  adequate,  and  that  anything  stronger  than  2.5  per  cent,  is 
dangerous. 

The  effect  of  chloroform  upon  the  heart  is  to  quicken  and  then  slacken  it.  The  former 
action  is  due  to  a  depression  of  the  vagus  centre,  while  subsequent  slowing  is  due  partly 
to  vagus  stimulation  and  partly  to  direct  weakening  of  the  heart  muscle.  While  chloro- 
form does  not  materially  affect  the  excitability  either  of  the  vagus  or  accelerator  nerves 

■  Ether  Narcosis  by  the  Rectum. — Cunningham  and  Lahey  have  revived  the  almost  abandoned  method  of  rectal 
ether  narcosis,  after  improving  the  technique.  The  rectal  tube  is  introduced  for  ten  to  fifteen  inches  and  ether 
vapor  is  then  forced  in  until  considerable  gas  is  pressed  around  the  rectal  tube,  keeping  the  forefinger  in  the  rectum 
opposite  the  tube  until  it  causes  pain  and  hastens  the  expulsion  of  the  rectal  gases.  It  is  essential  that  the  rectum 
be  distended  to  the  point  of  keeping  closed  around  the  tube,  since  unless  the  gas  normally  in  the  bowel  be 
first  removed  the  patient  absorbs  the  ether  much  more  slowly,  presumably  because  of  its  dilution.  At  the 
first  introduction  of  the  ether  vapor  the  patient  may  feel  a  natural  discomfort  and  desire  to  defecate,  but  in 
a  short  time  this  sensation  disappears;  the  breath  becomes  ether-ladened  in  from  one  to  five  minutes,  he  becomes 
drowsy,  the  breathing  stertorous,  and  he  passes  into  complete  surgical  narcosis  without  any  excitement. 

The  apparatus  used  consists  of  a  bottle  seven  inches  in  height,  of  which  five  inches  are  used  for  ether  space 
and  the  balance  for  vapor.  The  afferent  tube  which  leads  to  the  bottom  of  the  ether  ends  in  a  bulb,  with 
small  perforations,  so  that  the  air  escapes  in  several  bubbles.  This  bottle  is  placed  in  a  water-bath  at  a  tem- 
perature between  80°  and  90°.  By  keeping  the  ether  warm,  without  boiling,  the  air  forced  through  it  is  more 
easily  saturated. 

The  same  care  must  be  given  to  see  that  the  tongue  does  not  fall  over  the  larynx  as  when  ether  is 
given  by  the  mouth.  Should  narcosis  be  too  pronounced  the  tube  should  be  disconnected  and  ether  gas 
forced  out  of  the  bowel  by  abdominal  massage.  O.xygen  may  be  given  through  the  same  tube  if  desired, 
while  artificial  respiration  and  stimulation  are  practised  as  usual  when  needed.  After  completion  of  the 
operation    the    ether    vapor    should    be    completely    expelled    by    pressure. 

The  advantages  of  the  method  are  that  but  a  small  amount  of  ether  is  used,  there  is  no  .stage  of  excitement, 
vomiting  is  rare,  bronchial  secretion  is  prevented,  and  recovery  is  rapid.  It  has  been  shown  that  six  volumes 
per  cent,  of  ether  are  required  in  the  blood  for  the  production  of  complete  anesthesia.  The  rapidity  with 
which  the  latter  can  be  produced  depends  upon  the  rapid  production  of  this  percentage.  This  result  is  attained 
more  readily  by  the  rectum  than  by  the  lungs.  For  the  production  of  narcosis  by  this  method  the  rectum 
should  be  previously  and  thoroughly  emptied. 


196  SURGICAL  PROCEDCRES 

its  main  effect  is  on  the  strength  of  the  heart  afiioii.  and  is  less  marked  on  the  auricles 
than  on  the  ventricles.  Ether  has  a  more  marked  tendency  to  raise  blfKKJ  pressure  than 
chloroform,  while  the  latter  is  likely  to  be  more  responsible  for  sudden  falls  in  blood 
pressure  even  after  its  administration  has  ceased. 

The  question  of  the  relative  dangers  of  the  two  drugs  has  engaged  the  attention  of 
investigators  the  world  over,  and  one  of  the  side  questions  to  l)e  discu.s.sed  is  whether 
chloroform  kills  by  arresting  the  circulation  or  the  respiration.  Chloroform  produces 
a  fall  in  blood  pressure  (see  Chapter  XVIIj  but  as  long  as  the  Ijhjod  pressure  within  the 
brain,  and  esjiecially  the  medulla,  is  maintained  this  effect  is  of  .secondary  importance; 
but  when  the  respiratory  centres  lack  their  natural  stimulus,  and  respiration  becomes 
irregular,  then,  as  it  were,  the  patient  "bleeds  into  his  own  ve.s.sels."  It  is  under 
these  circumstances  that  adrenalin  produces  its  most  marked  and  prompt  effect. 

The  first  effect  of  chlorofonn  inhalations  is  to  raise  blorxl  pressure,  but  this  is  soon 
followed  by  lowered  tension.  The  pupils  may  dilate  .slightly  at  first,  but  usually  contract 
and  remain  contracted  during  anesthesia.  When  they  dilate  suddenly  means  should 
be  adopted  to  avert  the  danger  threatened,  as  the  relaxation  of  the  iris  is  the  first  visible 
relaxation  of  death.     While  the  pupils  react  to  light  there  is  little  danger.' 

Death  from  chloroform  usually  occurs  when  it  Is  assumed  that  no  accident  Is  likely 
to  hap|)en,  as  when  it  is  given  to  an  athlete,  or  to  drunkards  who  are  suppo.sed  to  be 
secure  from  any  reflex  influences.  Patients  with  weak  hearts  can  be  conducted  safely 
through  a  prolonged  anesthesia  if  there  be  time  to  prepare  them.  (See  chapter  on  the 
Preparation  of  Patients.) 

The  after-dangers  of  chlurofurm  are  smaller  than  those  of  ether,  due  in  part  to  the 
fact  that  a  much  smaller  amount  of  the  drug  suffices;  in  other  words — that  it  is  the 
stronger. 

After  anesthesia  has  been  produced  and  the  patient  is  unconscious  it  requires  but  small 
additional  amounts  to  maintain  unconsciousness,  as  it  is  necessary  to  add  only  as  much 
as  may  be  required  to  replace  what  is  lost  by  evaporation  and  exhalation.  It  is  some- 
times advantageous  to  commence  with  nitrous  oxide  gas,  for  there  are  fewer  unpleasant 
reflexes,  less  salivation,  and  le.ss  disturbance  of  every  kind.  Shallow  breathing  may 
he  improved  at  almost  any  time  with  a  jeiv  drops  of  ether. 

Many  anesthetizers  have  a  habit  of  testing  the  degree  of  anesthesia  by  touching  the 
cornea  with  their  fingers.  A  piece  of  sterile  gauze  will  prove  equally  effective  and  less 
irritating. 

When  the  ma>k  upon  which  chloroform  or  ether  is  given  is  held  over  the  face  free 
salivation  will  frequently  l>e  excited,  and  the  patient  will  l^e  tempted  to  swallow  as  well 
as  inhale.  In  this  way  the  vapor  of  the  anesthetic  is  taken  into  the  stomach  as  well  as 
into  the  air  passages,  and  when  the  stomach  is  empty  this  comes  into  direct  contact  with 
the  gastric  mucosa.  This  may  produce  not  only  irritation,  but,  in  extreme  cases,  gas- 
tritis. It  has  been  suggested  that  to  allow  the  patient  to  drink  a  quantity  of  water  at 
intervals  before  taking  the  anesthetic,  and  especially  a  half-pint  or  more  immediately 
before  Ijeginning  it,  will  be  to  permit  of  absorption  and  dilution  of  the  anesthetic  vapor 
without  their  causing  this  irritation. 

The  simplest  method  of  administering  chloroform  is  up)on  an  ordinary  mask,  the  cover- 
ing of  which  should  be  thin  in  order  to  permit  of  easy  play  of  air.  By  this  method  a 
patient  can  always  be  anesthetized,  but  with  a  waste  of  the  anesthetic  and  with  absolute 
uncertainty  as  to  the  proportion  of  chloroform  vapor  in  the  inspired  air.  A  variety  of 
expedients  have  been  suggested  in  time  past,  and  chloroform  inhalers  of  various  patterns 
are  constantly  up)n  the  market.  The  Junker  inhaler,  introduced  some  twenty-five 
years  ago,  was  a  great  improvement  u|x>n  its  predecessors,  hm  only  recently  has  a  really 
scientific  measuring  inhaler  been  placed  before  the  profession.  This  is  the  one  de- 
vised for  and  introduced  by  a  committee  of  the  British  Medical  Association,  and  is  the 
result  of  the  study  and  ingenuity  of  Prof.  Vernon  Harcourt.  It  has  already  been  stated 
that  more  than  2  per  cent,  of  chloroform  vapor  in  the  inhaled  air  is  dangerous.  The 
Harcourt  apparatus  consists  of  a  two-necked  bottle,  nearly  filled  with  chloroform,  into 
which  are  dropped  two  colored  glass  beads,  which  sen'e  to  indicate  when  the  temperature 
is  between  5.5°  and  59°  F.     If  the  temperature  be  below  55°  F.,  both  l>eads  will  float; 

•  Lehmann  believes  it  is  a  bad  sign  when  a  patient  who  i.«  taking  an  anesthetic  keeps  the  eyes  partially 
or  completely  open,  or  frequently  reopens  them  after  being  under  the  influence  of  the  drug.  He  holds  it  to  be 
a  premonitory  s>-inptom  of  more  or  less  serious  complications. 


CHLOROFORM 


107 


Fi<: 


if  it  In-  above  ')i)°  F.  both  will  sink.  If  the  foniicr,  (lie  iMoportioii  of  clilorofonu  will  he 
below  that  iiulicated  by  the  pointer;  if  the  latter,  it  will  be  greater.  Inasnuu-h  as  during 
inhalation  the  chloroform  is  cooled  by  evaporation,  it  is  necessary  to  occasionallv  place 
the  warm  hand  over  the  bottle  until  the  blue  bead  has  sunk  and  the  red  bead  is  beginning 
to  sink,  indicating  that  the  tem|)erature  is  again  approaching  ")')°  F.  A  sto])C()ck  is  so 
coustructi'd  tiiat  when  the  pointer  is  at  one  end  of  the  arc  the  maximum  amount  of  chloro- 
form which  may  be  taken  up  is  2  per  cent.;  when  the  |)ointer  is  at  the  o.p|)o.site  end,  the 
patient  breatluvs  only  |)ure  air.  There  are  valv(>s  which  |)reveut  the  entrance  of  expired 
air  into  the  apparatus,  and  which  show  whether  the  stojK-ock  is  working.  'J'liey  also 
show  the  character  of  the  resj)iration.  Administration  is  begun  with  the  pointer  at  0.2, 
and  while  it  may  require  2  per  cent,  of  vapor  to  produce  narcosis,  i.  c,  the  complete 
and  final  stage  of  anesthesia,  it  will  take  scarcely  more  than  1  per  cent,  to  maintain 
it.  The  mouth-piece  has  an  expiratory  valve,  and  the  apparatus  can  l)e  held  in  any 
position,  but  should  be  kej)t  nearly  vertical.  The  mask  is  fitted  with  an  air  cushion, 
which  can  be  molded  in  hot  water  so  as  to  fit  the  patient's  face.  Buxton,  who  is  tlie 
leading  autiiority  on  anesthetics  in  London,  has  abandoned 
all  other  apparatus  for  this.  While  he  is  a  most  skilled 
expert,  he  has  shown  that  by  means  of  this  apparatus 
chloroform  can  be  given  with  almost  absolute  safety. 

Aside  from  the  danger  and  discomfort  pertaining  to  the 
use  of  chloroform  in  apartments  lighted  or  heated  with 
natural  gas,  there  is  another  similar  danger  in  connection 
with  ordinary  city  illinninating  gas.  In  the  presence  of 
a  flame  produced  by  the  latter  the  vapor  of  chloroform 
is  broken  up  not  only  into  chlorine  and  hydrochloric 
acid,  but  into  a  carbon  oxychloride,  known  also  as  pJios- 
gnic,  which  is  toxic  and  produces  a  sense  of  suti'ocation  by 
producing  decomposition  within  the  blood.  A  fatal  occur- 
rence of  this  kind  led  to  experiments  on  animals  by  an 
Italian  observer,  which  showed  that  the  substance  pro- 
duced rapid  disintegration  of  hemoglobin,  which  fell 
rapidly  to  40  per  cent.,  and  that  accompanying  this  there 
was  suppression  of  urine  with  convulsions. 

Unless  chloroform  be  given  by  one  familiar  with  its  use, 
it  is  best  given  from  a  dropping  bottle.  If  this  be  so  ar- 
ranged that  it  will  discharge  but  one  drop  at  a  time,  and 
the  anesthetizer  so  administer  it  as  to  allows  perhaps  one 
drop  to  fall  each  second,  the  patient  will  at  no  time  get  an 
overdose,  nor  will  there  be  struggling  or  choking.  Irregu- 
larity of  breathing  is  usually  the  result  of  insufficient  air, 
and    the    mask  should   be  at  once  removed,  so   that  the 

patient  may  take  one  or  two  deep  inspirations.  When  the  cornea  is  insensitive  the 
patient  will  stand  almost  any  manipulation  except,  perhaps,  stretching  of  the  sphinc- 
ters. When  the  sphincter  can  be  stretched  without  provoking  any  effect  except  a  pro- 
longed inspiration,  then  the  patient  is,  in  all  probability,  completely  relaxed  and  ready 
for  any  procedure.  W^hen  the  breath  becomes  stertorous  the  mask  should  be  removed 
even  though  the  cornea  be  sensitive.  It  will  quickly  lose  its  sensitiveness  again  within  a 
few  seconds.  Proper  breathing  must  he  maintained.  Free  supply  of  air  is  important  above 
all  other  things,  and  it  is  better  that  the  surgeon  should  wait  rather  than  the  anesthetizer. 

Additional  safety  in  the  use  of  chloroform  may  be  afforded  by  the  simultaneous  use 
of  oxygen  gas,  by  which  cyanosis  is  usually  avoided  and  vomiting  often  prevented.  It 
may  be  safely  used  with  chloroform,  but  not  with  ether.  If  ozonized  air  be  conducted 
into  anhydrous  ether  it  forms  a  thick  liquid,  probably  ethyl  peroxide,  which  exjilodes 
if  heated  (Hare).  It  is  a  mistake  to  so  manage  the  administration  of  chloroform  with 
oxygen  that  the  patient  receives  no  pure  air.  Oxygen  is  of  great  value,  but  it  is  not 
physiologically  breathed  in  its  pure  state.  When  the  gas  is  allowed  to  bubble  through 
a  bottle  of  chloroform,  carrying  with  it  the  vapor,  no  idea  can  be  formed  as  to  relative 
percentages.  A  better  way  is  to  administer  the  chloroform  upon  a  mask,  and  the  oxygen 
by  a  tube  from  a  wash-bottle  filled  with  water  and  passed  into  the  nostril  under  the 
edge  of  the  inhaler  (Hare). 


Harcourt  inhaler. 


198  SURGICAL  PROCEDURES 

Gwathmey  ha.■^  imriMlucfd  a  niodification  of  the  well-known  standard  Junker  inhaler, 
by  which  oxygen  and  chloroform,  or  nitrous  oxide  and  ether,  may  be  given  together, 
or  by  which  any  desired  combination  can  be  effected.  Its  special  advantage  is  the 
same  as  the  Harcourt  apparatus,  that  the  {x*rcentage  of  chloroform  or  ether  vapor  can 
be  estimated  or  controlled.  So  far  as  the  administration  of  chloroform  with  oxygen 
is  concerned,  Roth  has  shown  that  oxygen  df>es  not  decompose  the  ciiloroform,  but 
diminishes  the  danger  of  its  administration. 

Gwathmey  refers  to  the  advantage  of  keeping  an  open  airway  by  turning  the  head  a 
little  to  one  side  and  pressing  the  jaw  well  forward;  he  also  advises  that  when  the  ane.s- 
thetic  is  removed  from  the  face  it  is  well  to  replace  its  odor  by  some  other  |)erfume,  such 
as  cologne  or  smelling  salts,  as  it  is  presumed  that  the  olfactory  nerve  is  responsible  for 
the  initial  s^-mptoms  of  nausea  and  gastric  distress. 

In  some  States  natural  gas  Is  used  as  fuel,  usually  in  open  fireplaces  or  stoves.  AVhen 
chloroform  is  administered  in  a  room  thus  heated,  or  even  lighted  by  natural  gas,  for- 
maldehyde gas  is  the  result  of  a  mutual  decomposition,  and  this  is  exceedingly  pungent 
and  irritating,  and  will  soon  produce  violent  coughing  in  all  who  are  present  in  the  room. 
It  may  be  imjxjssible  to  avoid  this,  but  natural  gas  flames  should  l>e  extinguished  and 
some  other  source  of  illuiaiiiation  slimild  \)v  de]>en(led  ujmju  when  practicable. 


A.  C.  E.  MIXTURE. 

Lnder  this  term  are  known  various  mixtures  of  alcohol,  chloroform,  and  ether,  the 
intent  l>eing  to  counteract  the  depressing  influence  of  chloroform  by  alcohol  and 
ether.  It  may  be  said  of  every  mixture  of  anesthetics  that  it  is  no  less  dangerous  than  its 
strongest  constituent.  Thus  a  mixture  of  chloroform  and  ether  should  be  given  with  as 
much  precaution  as  pure  chloroform. 

Mixtures  of  this  kind  should  be  made  fresh  for  each  administration,  as  the  most  vola- 
tile ingredient  may  evaporate  in  unknown  amount  and  thus  change  the  pro|X)rtions. 
This  is  true  of  the  mixture  even  after  it  is  poured  ujxtn  the  inhaler,  and  the  patient  will 
thus  be  subjected  to  a  chloroform  mixture  of  varying  strength. 

The  administration  of  ether  for  a  few  seconds  during  chloroform  anesthesia  will 
often  prove  beneficial  in  regulating  or  deepening  inspiration,  but  it  would  be  l>est  to 
have  the  two  drugs-  separate,  and  use  the  ether  as  it  may  seem  called  for,  rather  than  to 
rely  upon  any  such  mixture.  ^Moreover  the  vapor  of  alcohol  is  of  itself  irritating  and 
undesirable. 

ETHYL  BROMIDE. 

For  operations  of  but  short  duration  ethyl  bromide  offers  some  advantages,  in  that  its 
effects  quickly  pass  away  and  that  there  are  few  unpleasant  sequels.  Indeed,  patients 
may  take  it  for  a  few  minutes  with  almost  as  little  disturbance  as  is  produced  by  nitrous 
oxide;  nevertheless  it  cannot  Ix"  regarded  as  being  as  free  from  danger  as  was  originally 
claimed.  Only  a  pure  preparation  should  be  used.  When  given  as  ether  is  usually 
given,  upon  a  cone  or  mask,  complete  anesthesia  may  often  be  produced  within  one 
minute.  It  can  hardly  be  relied  upon  to  produce  muscular  relaxation  and  it  frequently 
causes  great  congestion  of  the  face  and  head,  consequently  it  is  not  as  convenient  for 
short  operations  on  the  nasopharynx  as  its  other  good  qualities  might  render  it.  It  is 
not  unpleasant  to  take,  and  ordinary  ether  anesthesia  may  well  be  begun  with  it. 


METHYLENE  BICHLORIDE. 

For  a  number  of  years  this  anesthetic  agent  was  in  favor,  especially  in  Great  Britain, 
where  it  was  warmly  advocated  by  Spencer  Wells.  Its  odor  is  agreeable,  its  action  rapid, 
and  recovery  from  its  effects  is  usually  prompt.  But  it  proved  to  be  unsafe,  since  it  was 
found  that  the  substance  commonly  used  under  this  name  was  really  chlorofomi  diluted 
with  one-fifth  of  methyl  alcohol,  while  the  genuine  methylene  bichloride  was  found  by 
experiment  to  be  a  dangerous  substance,  and  its  use  has  been  discarded. 


1  ()L.  1  TILh:  .  1 SESTIIETK 'H  ] 99 


ETHYL  CHLORIDE. 

This,  like  every  other  i\v\\^  used  for  the  purpose,  should  be  used  in  perfectly  pure 
form.  While  this  can  be  obtained  from  manufacturers  in  this  country,  there  seems 
to  be  a  tendency  to  rely  uj)on  the  imported  |)rej)aration  sold  here  under  the  name  of 
Kelene.  For  certain  short  operations,  such  as  those  u])on  the  eye,  nose,  and  throat, 
and  for  children,  it  has  many  advantafjes  and  appears  to  be  a  reasonably  safe  dru^  for 
the  purj)ose.  (\)nsciousness  is  (juickly  recovered  after  its  use,  and  the  aftcr-efl'ects  are 
slifjht.  It  is  in  ifcneral  use  preparatory  to  one  of  the  stronger  anesthetics,  like  ether  or 
chloroform,  and  affords  a  means  of  puttinj;  ])aticnts  under  the  relaxinfj  effect  of  citiicr  of 
these  druifs.  It  should  be  administered  upon  a  cone  or  mask,  from  which  evaporation 
should  not  occur  too  easily,  because  it  is  extremely  volatile.  In  the  hands  of  one  accus- 
tomed to  its  u.se,  operations  of  consitlerable  magnitude  and  duration  may  be  success- 
fully maintained.  A  special  valveless  mask  lias  been  devised  for  its  use,  consisting 
of  a  rubber  mouth-piece  which  can  be  snugly  fitted  to  the  face,  and  a  movable  tube  over 
which  two  or  three  layers  of  gauze  may  be  stretched,  upon  which  the  ethyl  chloride  is 
allowed  to  drop  or  is  ejectcMl  from  the  tube  in  which  it  is  sold.  Sonu'times  the  expired 
air  will  freeze  upon  this  gauze.     This  is  of  no  disadvantage. 

Local  Use. — ( )n  account  of  its  extreme  volatility,  chloride  of  ethyl  afiords  a  ready  means 
of  producing  local  anesthesia.  It  boils  at  o()°  F.,  and  when  the  tube  containing  it  is 
held  in  the  hands  and  its  cajiillary  tip  is  opened  it  issues  in  the  form  of  a  fine  spray,  which 
being  directed  upon  the  part  to  be  desensitized  first  chills  and  then  freezes  it.  Whether 
this  part  be  skin  or  mucous  membrane  the  effect  is  the  same.  As  soon  as  the  desired 
area  is  covered  with  a  thin  layer  of  small  frozen  crystals,  looking  like  hoar-frost,  the  sur- 
face is  anesthetized  and  the  necessary  instruments  may  be  used.  Blowing  on  the  part 
to  be  anesthetized  will  favor  evaporation  and  shorten  the  time  necessary  for  the  j)urpose. 

The  purposes  to  which  this  drug  may  thus  be  used  are  numerous  and  obvious.  For 
instance,  in  dentistry  it  will  do  much  to  allay  the  pain  of  tooth  extraction;  in  genito- 
urinary surgery  such  operations  as  incision  of  the  prepuce,  the  cauterization  of  venereal 
ulcers,  and  circumcision  may  be  done  with  little  or  no  pain.  The  .small  operations 
required  in  various  skin  di.seases,  the  incision  of  small  abscesses,  the  use  of  caustics 
wherever  they  may  be  needed,  may  all  be  made  easy  under  its  effect;  while  in  cases  of 
neuralgia,  stings,  bites,  etc.,  it  will  often  alleviate  the  s}Tnptoms.  The  skin  m.ay  also 
be  anesthetized  in  this  way  before  the  introduction  of  the  needle  through  which  anti- 
toxins are  injected  or  hypodermoclysis  practised.  Before  venesection  or  before  exj)lor- 
atory  puncture  it  may  also  be  used. 

Somnoform. — This  agent,  composed  of  ethyl  bromide  0  parts  methyl  chloride  35 
parts,  and  ethyl  chloride  60  parts,  was  introduced  by  Rowland,  of  Bordeaux,  as  a  con- 
venient means  of  producing  an  analgesic  condition,  i.  e.,  something  between  complete 
ane.sthesia  and  conscious  sensibility.  The  dose  is  about  5  Cc.,  to  be  sprayed  upon  a  tightly 
fitting  mask.  The  patient  should  be  told  to  breathe  and  swallow  as  naturally  as  possible, 
and  the  eflfect  is  obtained  within  a  few  seconds.  The  agent  is  so  speedy  in  producing  its 
efifects  that  it  is  sometimes  difficult  to  tell  when  the  proper  degree  of  unconsciousness  has 
been  secured.  A  patient  may  be  directed  to  hold  up  an  arm  in  order  that  when  it  drops  the 
surgeon  may  proceed.  There  is  neither  cyanosis  nor  corneal  reflex,  and  nausea  does  not 
usually  occur.  The  essential  point  of  administration  is  the  exclusion  of  air.  Twenty 
seconds  of  administration  will  give  from  one  to  two  minutes  of  anesthetic  effect,  during 
which  various  brief  operations  can  be  performed.  By  proper  management  this  period 
can  be  lengthened  many  times. 

Petroleum  Ether.— Petroleum  ether  was  introduced  by  Schleich  for  the  purpose  of 
diluting  chloroform.  By  itself  it  has  a  weak  anesthetic  power,  and  seems  to  po.sse.ss 
some  dangers  of  its  own  in  the  way  of  depressing  the  heart's  action  and  producing  con- 
vulsions. 

OTHER  VOLATILE  ANESTHETICS. 

Schleich  was  among  the  first  to  demonstrate  that  the  retention  of  an  anesthetic 
within  the  body  depends  upon  its  boiling  point.  W.  Meyer  carried  Schleich's  views 
still  farther  and  showed  the  at  least  theoretical  value  of  an  anesthetic  mixture  whose 


200  SURGICAL   PROCEDURES 

boiling  {xjint  was  that  of  the  normal  l)loo(l  tempt'rature.  If  the  evaporating  }X)int 
be  much  higher  than  the  blood  it  is  volatilized  too  easily,  while  if  it  be  h^wer  it  reduces 
bodv  temperature  as  it  evaporates.  After  considerable  experimentation  Meyer  recom- 
mended a  mixture  by  volume  of  chloroform  3  parts,  ether  2  parts,  and  ethyl  chloride 
1  part,  and  introduced  this  mixture  under  the  name  of  anesthol.  This  composition 
does  not  seem  to  have  met  with  great  favor  as  yet,  although  it  has  theoretically  much 
to  commend  it,  as  it  seems  slower  in  action  and  but  little  more  satisfactory'  in  other 
respects. 

NITROUS  OXIDE  GAS. 

This  is  by  all  means  the  most  rapid  general  anesthetic  in  use.  Patients  can 
be  placed  under  its  influence  in  from  twenty-five  to  sixty  seconds.  For  a  long 
time  its  emplo\-ment  was  confined  to  dental  practice,  but  it  is  now  in  general  use  by 
surgeons,  as  a  yjreliminary  to  the  use  of  ether  or  as  the  sole  anesthetic  agent.  When 
managed  profjerly  patients  can  Ix-  kept  for  a  half-hour  or  even  an  hour  under  its  influence. 
Two  disadvantages  attend  its  administration:  (1)  It  is  difficult  to  completely  relax 
the  muscles  and  so  maintain  them  that  no  difficulties  are  placed  in  the  ojxrator's  way, 
e.  g.,  in  certain  operations  upon  the  abdomen  where  muscle  rigidity  delays  and  makes 
difficult  the  operation.  (2)  The  use  of  nitrous  oxide  alone  so  far  impairs  proper  oxy- 
genation of  the  blood  that  this  fluid  becomes  dark  or  almost  Vjlack  and  frequently 
obscures  the  field  of  operation.  These  difficulties,  especially  the  latter,  can  be  over- 
come bv  the  skilful  simultaneous  use  of  oxygen  gas,  by  which  the  blood  is  kept  well 
oxygenated,  and  by  which  the  deep  stupor  of  nitrous  oxide  poisoning  can  be  made 
so  safe  that  it  can  be  prolonged  to  the  degree  necessary  to  afford  relaxation. 

Nitrous  oxide  anesthesia  is  thus  proved  to  be  something  more  than  mere  asphyxia, 
or  it  would  be  completely  counteracted  by  oxygen.  Suitable  apparatus  can  now  be 
procured  bv  which  both  gases  can  be  blended  together  as  desired;  considerable  experi- 
ence, however,  is  necessary  for  their  successful  use.  It  is  generally  stated  that  nitrous 
oxide  alone  should  not  be  given  to  persons  with  fatty  hearts  or  atheromatous  vessels. 
From  a  brief  period  of  nitrous  oxide  anesthesia  patients  usually  recover  within  a  few 
minutes  and  without  after-effects;  still,  relaxation  of  the  sphincters  may  occur.  After 
its  prolonged  use  there  may  be  considerable  headache  and  vertigo. 

THE  CHOICE  OF  AN  ANESTHETIC. 

This  will  depend  upon  who  is  to  l>e  the  anesthetizer  as  well  as  upon  the  actual  condition 
of  the  patient.  If  an  inexperienced  person  is  to  administer  the  anesthetic,  ether  is  safer 
than  chloroform,  though  slower.  Dn  the  other  hand,  when  given  by  an  expert,  and 
after  due  preparation  of  the  patient,  chloroform  is  ordinarily  preferable.  The  latter 
is  especiallv  indicated  in  the  young  and  aged,  as  well  as  in  those  who  have  bronchitis 
or  chronic  cough,  and  those  who  have  advanced  renal  diseases  or  atheroma,  because  it 
is  not  likely  to  produce  such  high  arterial  tension. 

Ether  should  never  be  given  near  an  unprotected  flame,  and  lamps  or  gas-jets  should 
be  held  above  the  level  of  the  oj>erating  table,  as  the  vapor  of  ether  is  heavier  than  air 
and  will  tend  to  sink.  The  disadvantages  of  chloroform  where  natural  gas  is  in  use 
have  already  been  mentioned. 

Efforts  should  be  made  to  prevent  struggling,  as  in  the  violence  of  this  unconscious 
act  an  overtaxed  heart  might  yield,  or  at  least  undergo  dilatation.  Chloroform  is  notably 
less  likelv  to  be  followed  by  nausea  and  vomiting  than  ether,  and  yet  nausea  cannot 
always  be  prevented.  There  can  be  no  doubt  that  morphine,  alone  or  with  atropine, 
may  be  given  with  advantage  to  most  patients  before  administration  of  a  general 
anesthetic.  The  treatment  of  postanesthetic  nausea  has  V)een  referred  to  in  the  chapter 
on  the  Preparation  and  After-care  of  Patients.  By  general  consent,  chloroform  is  the 
anesthetic  of  choice  during  lalxjr. 


TlIK  DAXGERS  OF  AND  ACCIDENTS  FROM  ANESTHETICS 


201 


THE  DANGERS  OF  AND  ACCIDENTS  FROM  ANESTHETICS. 


The  principal  (laiijj<'rs  from  any  of  the  volatile  anesthetics  come  from  interference  with 
circulation  and  with  respiratit)n.  The  heart  may  fjive  rise  to  alarm  by  fjradual  failure  in 
strcngtli,  while  the  pulse  becomes  more  rapid  and  irre<:;ular.  or  by  sudden  and  apparently 
complete  rc.'tsdtion  of  aciirifi/.  When  flic  pupils  .siuldnili/  dilate  and  do  not  react  to  lif^ht 
danjjcr  is  close  at  hand,  if  it  have  not  already  manifested  itself,  and  then  is  the  time  to 
discontinue  the  anesthetic  and  resort  to  vitjjorous  methods,  which  may  include  artificial 
resj)irati«)n,  but  must  include  attention  to  the  heart.  It  is  customary  to  use  injections 
of  strychnine,  which  arc  often  too  weak  or  too  small  to  be  of  service,  nothiufj  less  than 
oV  ^•'".,  which  may  be  rej)eatc-d  in  a  few  moments,  will  be  of  any  service.  If  ,  ^f,  to  ,  J^,  (Jr. 
of  atro|)ine  be  given  with  the  strychnine  it  will  prove  a  much  more  efi'ective  stimulus. 
It  is  right  and  proper  to  administer  these  drugs  in  this  emergency,  but  still  more  reliable 
measures  are  at  hand. 

Sudden  stoppage  of  the  heart,  being  the  most  disastrous  accident  during  or  after  anes- 
thesia, has  attracted  no  small  amount  of  attention  on  the  part  of  experimenters.  An 
active  massage  of  the  heart  seems  to  furnish  the  basis  for  all  the  newer  methods  of  treat- 
ing it,  all  of  which  are  accomj)anied  by  artificial  res]>iration.  Some  of  Crile's  work 
in  this  connection  was  alluded  to  in  the  chapter  on  Blood  Pressure  and  Shock. 


Showing  how  proper  traction  on  the  tongue  pulls  on  the  epiglottis.     (Hare.) 

Numerous  investigators  have  revived  the  hearts  of  experimental  animals  by  massage 
and  saline  injections,  and  Crile  has  shown  the  advantage  of  adding  adrenalin  to  the 
latter.  It  is  better  to  begin  the  efforts  while  the  heart  is  still  feebly  beating  than  to  wait 
until  it  has  ceased.  Ordinarily  this  massage  should  be  made  through  the  intact  thorax, 
but  the  time  is  coming  when  it  will  be  esteemed  life-saving  either  to  open  the  abdomen 
and  massage  the  heart  through  the  diaphragm,  or  to  open  the  thorax  and  do  it  directly. 
The  former  can  be  done  during  almost  any  abdominal  operation.  The  greatest  obstacle 
to  success  has  been  the  formation  of  clots  in  the  cardiac  cavities.  These  are  fomied 
within  a  few  moments  after  the  heart  has  cea.sed  to  act. 

Massage  of  the  heart,  coupled  with  the  use  of  adreualin,  will  prove  of  service. 

Approaching  cardiac  weakness  is  always  indicated  by  failure  of  capillary  circulation, 
which  may  be  easily  and  instantly  estimated  by  making  pressure  upon  the  finger-nails. 
The  rapidity  with  which  the  blood  will  return  to  give  them  a  natural  appearance,  after 
such  pressure  is  made,  will  be  the  index  as  to  whether  or  no  stimulation  is  necessary. 
Tardiness  in  return  of  color,  or  absence,  is  a  better  indication  of  the  approach  of  shock 
than  is  coldness  of  the  no.se  or  moisture  of  the  skin.  It  often  precedes  acceleration  of 
the  pul.se. 


202 


SURGICAL  PROCEDURES 


Respiration  may  be  interfered  with  hi/  a  varirtij  of  raiisrs.  Not  iiifrcciucntly  the  tonouc 
is  allowed  to  drop  backward  into  the  j)harvnx  as  the  patient  lies  upon  his  hack,  whfch, 
by  its  pressure,  causes  the  epiglottis  to  fall  backward  upon  and  close  the  glottis.  The 
indication  here  is  to  lift  the  tongue  forward  and  carry  the  epiglottis  upward  so  as 
to  restore  the  air  channel.  Extension  of  the  head  and  lieck  will  accomplish  much  in 
this  direction,  as  well  as  holding  the  lower  jaw  forward  and  upward  bv  well-regulated 
pressure  exerted  behind  the  angle  and  at  the  same  time  by  upward  and  forward  traction 
upon  the  hyoid  bone.  But  when  it  is  necessary  in  cases  of  emergency  to  carry  out  this 
maneuver  forcibly  and  extensively,  then  the  tongue  should  he  drawn  upward  and  forward 
in  the  direction  indicated  in  Figs.  41  and  42. 

Tongue  forceps  are  often  resorted  to  for  this  purpose,  and  can  be  procured  in  various 
forms  and  shapes.  To  the  writer  their  employment  has  always  .seemed  far  more  bar- 
barous than  the  much  simpler  expedient  of  passing  a  curved  needle,  armed  with  silk, 
through  the  tongue  in  either  direction,  3  to  5  Cm.  back  of  its  tip.  The  suture  thus  drawn 
through  is  knotted  and  made  into  a  loop,  and  may  be  employed  through  a  long  operation 
to  make  all  the  traction  that  will  be  required.  This  really  makes  the  tongue  less  sore 
J  nd  produces  less  su-ellincj  and  after-discomfort  than  does  the  use  of  forceps 

Respiration  may  also  be  impeded  or  suddenly  checked  by  the  presence  of  a  foreign 
body.  This  may  possibly  be  a  plate  which  the  anesthetizer  has  failed  to  require  the 
patient  to  remove,  or  it  may  be  material  ejected  from  the  stomach;  this  latter  is  especially 


Fig.  42 


Showing  how  dragging  the  tongue  over  the  teeth  fails  to  pull  on  the  epiglottis.    (Hare.) 


likely  to  happen  when  emergency  has  required  anesthesia  without  due  preparation. 
When  this  happens  the  fingers  should  be  passed  behind  the  epiglottis  and  the  obstruct- 
ing body  removed.  In  rare  instances  some  portion  of  food  may  have  been  so  impacted 
in  the  glottis  as  to  completely  obstruct  it.  If  such  an  emergency  arise  the  trachea  should 
be  opened  and  relief  thus  aft'orded.  Only  in  this  way  can  life  be  saved.  Embar- 
rassment of  respiration  is  caused  at  other  times  by  the  patient  apparently  "forgetting 
to  breathe"  or  by  his  taking  such  shallow  inspirations  that  nothing  is  accomplished. 
This  may  be  combated  in  several  ways.  In  the  former  instance  the  u.se  of  ether  or 
injections  of  atropine  will  frequently  afford  the  necessary  stimulus  to  the  respiratory 
centres.  In  the  latter  class  of  cases  especially  the  most  valuable  expedient  is  the  dila- 
tation of  the  sphincter  ani,  which  may  be  stretched  with  a  speculum,  or  with  the  fingers. 
Long-drawn,  even  gasping  inspirations  may  follow  this  expedient. 

Finally  in  certain  cases  artificial  respiration  will  be  required,  combined  with  rhythmical 
traction  upon  the  tongue.  The  tongue  should  be  grasped,  or  controlled  by  a  suture,  and 
retracted  from  the  mouth  at  the  rate  of  at  least  sixteen  times  a  minute,  while  the  chest  is 
compressed  at  the  same  rate,  the  traction  being  made  at  the  moment  of  relaxation  of 
chest  pressure.  Tongue  traction  alone  will  sometimes  renew  respiratory  movements 
in  extreme  eases. ^     Figs.  43  and  44   from  Hare,  show  the  combined  manipulation  of 

'  Freudenthal  has  called  attention  to  the  extreme  irritability  of  both  surfaces  of  the  epiglottis,  and  advises 
to  pass  the  index  finger  liown  upon  it,  irritating  it  by  friction.  This  causes  a  powerful  rePex  efTect,  a.*  the  glos.«o- 
oharyngeal  supplies  its  anterior  surface  and  the  inner  branch  of  the  superior  laryngeal  its  posterior  surface 


THE   D.WdEh'S  OF   AM)   ACCIDK.MS   FliOM    A  \ KSTII IITK'S 


203 


iiivcrtinu;  llic  |);i(iciit  in  order  tluil  thf  liraiii  iii;iy  iiol  hck  for  Mood  .sii|t|»l\    mikI  carrNiiif^ 
out  iirtilicial  respiration. 

While  these  measures  are  to  l)e  re<;arded  as  enier<feney  expechcnts,  they  will  ol'leii 
need  to  he  suppleiiieiited  by  others,  the  use  of  adrenalin  ami  of  salt  solution,  either 
beneath  the  skin  or  in  the  veins,  and  the  use  ol"  the  ("rile  pneuniutie  rubber  .suit 
described  in  the  eha|)ter  on  Shock. 


l'l<:.   13 


Showing  inversion  of  patient  and  metliod  of  performing 
artificial  respiration  simultaneously.     (Hare.) 


Same  as  I'ig.  43. 


There  is  a  delay  in  the  management  of  the  patient  after  the  conclusion  of  an  oj)erati()n 
which  is  too  often  neglected — namely,  prevention  of  such  exposure  as  shall  produce  a 
sudden  checking  of  perspiration.  The  patient  should  be  wrapped  in  several  thick- 
nesses of  blanket,  leaving  only  the  face  exposed;  and  only  when  fully  conscious  should 
he  be  uncovered  gradually  and  well  dried  with  a  bath  towel.  Such  procedure  takes 
away  much  of  the  danger  of  congestion  of  the  lungs,  or  of  the  kidneys,  which  may  cause 
serious  disturbance  should  they  occur. ^ 

1  The  following  is  quoted  from  a  recent  journal  article  by  an  unknown  writer: 

Acid  Intoxication  after  Anesthetics. — Occasionally  some  surgeon  reports  a  case  of  peculiar  rapid  fatal  toxemia 
after  a  prolonged  operation,  the  cause  of  which  is  obscure.  We  have  also  heard  of  this  trouble  after  parturition, 
during  which  chloroform  was  given  for  a  prolonged  period,  and  the  ultimate  cause  of  the  violent  symptoms  has 
been  unknown.  Now  we  are  beginning  to  believe  that  anesthetics,  especially  chloroform,  can  produce  a  destruc- 
tive effect  on  the  liver  and  kidney  cells  very  similar  to  iihosphorus  poisoning.  In  many  cases  a  peculiar  idiosyn- 
crasy seems  nece.ssarv  to  explain  the  toxic  effect,  but  certain  predisposing  causes  have  been  noted,  f.f/.,  hemorrhage. 
The  svmptom-complex  makes  its  appearance  from  a  few  hours  to  a  few  days  after  the  anesthesia,  and  consi.-ts  of 
vomiting,  restlessness,  delirium,  convulsions,  coma,  irregular  breathing,  cyanosis,  and  icterus  in  varymg  degree. 
The  disease  as  described  bv  Bevan  and  Favill  is  a  hepatic  toxemia,  resulting  from  acute  fatty  degeneration  of  the 
liver,  and  seems  to  be  a  clinical  entity.  It  is  characterized  by  an  acid  intoxication,  acetone,  diacetic  acid,  and 
beta-oxvbutvric  acid  being  found  in  the  blood  and  urine.  Several  clinical  varieties  must  receive  renewed  interest 
in  the  light  of  this  investigation.  First  is  acute  yellow  atrophy  of  the  liver,  many  cases  of  which  occur  after 
chloroform  anesthesia.  Next,  the  rapi.l  death  after  abdominal  operations,  which  have  hitherto  been  attributed 
to  intestinal  toxemia;  and  lastly,  certain  fatal  cases  of  nephritis  after  operation  need  a  more  careful  .study. 


204 


SURGICAL  PROCEDURES 


ARTIFICIAL  RESPIRATION. 


All  foreign  bodies  should  be  removed  from  the  mouth  and  })harvnx.  If  the  patient 
have  been  in  water  he  should  be  suspended  head  downward,  in  order  that  the  water  may 
escape  bv  gravity  from  the  lungs.  In  all  of  these  methods  rhythmical  traction  upon  the 
tongue  will  be  found  a  valuable  aid  in  the  procedure. 

Si/lvester's  method  utilizes  the  arms  as  levers  by  which  to  expand  the  thorax,  t)y  means 
of  the  muscles  which  pass  between  them  and  the  chest.  Tlie  i)atient  is  laid  on  his  back, 
the  shoulders  somewhat  elevated  and  the  head  thrown  backward.  The  forearms  are 
seized  just  below  the  elbows  and  carried  ujnvard  over  his  head,  by  which  movement 
the  chest  is  expanded;  here  they  are  held  about  two  .seconds,  and  then  brought  down 
to  the  side  of  the  chest  and  actual  compression  of  the  thorax  made  with  them,  for  the 
same  period  of  time.  When  the  chest  is  compressed,  an  assistant  may  also  press  the 
liver  upward  and  thus  help  to  empty  the  lungs.  The  intent  is  to  make  from  sixteen  to 
eio-hteen  of  these  movements  in  a  minute.  In  children  the  movements  are  made  more 
rapidlv,  and  in  infants  considerably  more.  It  is  usually  necessary  that  traction  be  made 
upon  the  feet  to  prevent  pulling  the  body  upward  when  the  arms  are  moved  to  expand 
the  thorax.  If  the  manipulations  can  be  carried  out  upon  a  table  who.se  feet  can  be 
somewhat  elevated  this  will  also  helj),  as  the  blood  is  thereby  induced  to  enter  the 
cranium. 

Mar.<ihall  llalVs  method  is  to  roll  the  patient  from  his  back  on  to  his  side,  the  upper- 
most arm  being  utilized  to  make  pressure  upon  the  side  of  the  thorax  in  order  to  expel 
air.  Then  the  body  is  rolled  over  on  to  the  back,  by  which  movement  the  chest  is 
expanded.     This  method  is  not  nearly  as  efficient  as  that  mentioned  above. 

Fig.  45 


Fell's  apparatus  for  forced  or  artificial  respiration. 

In  case  of  drowning  Hoicard'^-  method  is  cpiite  ajiplicable.  The  maneuvers  are  as 
follows : 

1.  Turning  the  patient  upon  the  face,  with  a  large  firm  roll  under  the  stomach  and 
che.st,  and  jirotecting  his  mouth  from  the  surface  upon  which  he  is  lying,  press  with  full 
weight  two  or  three  times,  for  four  or  five  seconds,  each  time  upon  his  back,  so  that  the 
water  is  expelled  from  his  lungs  and  stomach. 

2.  Then  quicklv  turn  him  face  upward  with  the  roll  beneath  his  back,  with  his  head 
hano-ino-  downward  and  his  hands  above  his  head.  The  operator  then  kneels  astride 
over  the  patient,  with  the  hips  between  his  knees,  and  grasps  the  lower  part  of  the 
patient's  chest  firmly,  bracing  his  own  hands  with  his  elbows  firmly  against  his  own  hips. 
With  his  full  weight  he  then  makes  pressure  upon  the  patient's  chest,  compressing  it 
laterallv  for  two  or  three  seconds,  gradually  leaning  forward  while  doing  this,  and  then 
with  a  sudden  jerk  pushing  himself  backward  The  intent  here  is  to  imitate  the  ordinary 
respiration  rate  as  above,  or  perhaps  a  little  less  often.  This  may  be  continued  for  a 
half-hour  or  even  for  an  hour,  sometimes  with  eventual  success. 

There  should  be  also  massage  of  the  heart,  in  addition  to  traction  upon  the  tongue. 
Artificial  assistance  should  not  be  discontinued  until  the  patient  is  breathing  regularly 
and  sufficiently  without  help.     In  Fig.  45  is  represented  the  Fell  apparatus  for  making 


LOCAL   AXESTHESIA  205 

f()rc('<l  iirlilicial  rcs]>irati(»ii,  this  Ix-iiiif  a  t^rcal  iiii|)r(i\ciiiciit  on  the  so-called  iiioutli-lo- 
iiioutli  inflation.  riif  essential  feature  of  it  is  a  bellows,  by  wliicli  the  air  is  forced  into 
the  lungs,  throu<;h  a  inoutli-|)iece  made  to  fit  tif^htly  over  the  face,  or  throufjh  a  trache- 
otomy tube.  In  accident  cases  other  measures,  such  as  artificial  warmth,  etc.,  sfiould 
be  employed. 

MORPHINE  AND  SCOPOLAMINE. 

Morphine  offers  no  little  aid  in  tiic  production  of  anesthesia  in  many  cases.  Those 
patients  who  are  ti'rrified  by  the  thought  of  operation,  and  w  ho  are  in  a  semihysterical 
state  when  anesthesia  is  begun,  may  be  greatly  tran(|uilli/,e(l  by  a  hypodermic  injection 
of  0.01  to  0.01 .")  of  morphini',  fifteen  or  twenty  minutes  |)reviously.  (iiven  in  this  way 
it  acts  as  a  hi'art  tonic  and  general  ecjualizer  to  the  circulation.  If  a  .small  do.se  of  atro- 
pine be  added  the  efiect  upon  the  respiratory  centres  is  much  enhanced.  Again,  in  tho.se 
cases  where  anesthesia  is  begun  without  it,  and  patients  prove  very  rel)ellious,  it  will 
have  the  .same  happy  effect.  The  only  objection  to  its  use  is  the  nausea  which  may 
thereby  be  produced.  There  is  no  way  by  which  to  dissociate  this  from  the  nau.sea  due 
to  the  anesthetic,  elsewhere  considered  under  the  lieading  of  the  After-care  of  Patients. 

Patients  can  rarely  be  so  com])letely  ])Ut  inider  the  influence  of  morphine  as  to  justify 
its  use  alone. 

Scopolamine. — The  (Jermans  .sell  under  this  name  an  alkaloid  made  from  the 
Solanaceje,  which  seems  to  be  identical  with  the  hyo.s-ci/atnine  of  the  U.  S.  Pharmacopa'ia. 
Schneiderlin,  in  1900,  published  a  method  of  producing  anesthesia  with  little  discom- 
fort by  using  it  combined  with  morphine.  The  mixture  seems  more  effective  than  either 
alkaloid  alone,  but  is  rather  slow  in  action.  On  the  day  preceding  the  operation  a 
trial  dose  of  0.02  of  morphine  and  0.008  to  0.01  of  .scopolamine  may  be  given.  This 
will  demonstrate  the  susceptil)ility  of  the  patient  to  the  mixture.  One  hour  and  a  half 
before  the  operation  this  dose,  or  a  larger  one,  should  be  administered,  and,  if  necessary, 
another  one  of  smaller  size  fifteen  minutes  l)efore  the  time  of  operation. 

According  to  this  method  an  interval  of  sixty  to  eighty  minutes  should  elap.se  fjetween 
the  first  do.se  and  the  operation  it.self.  When  anesthesia  is  thus  produced  it  la.sts  from 
three  to  several  hours.  Others  have  advised  to  divide  the  dose  into  three  injections, 
giving  the  first  about  two  and  one-half  hours,  the  second  one  and  one-half  hours,  and 
the  third  one-half  hour  before  operating.  In  some  cases  this  has  produced  complete 
and  .satisfactory  anesthesia;  in  .some  it  has  not  been  complete,  while  in  others  .serious 
symptoms  have  been  produced.  The  .statement  that  each  alkaloid  counteracts  the 
dangerous  effects  of  the  other  is  not  substantiated;  it  is  probable  that  the  combined  effect 
is  greater  than  would  be  that  of  either  u.sed  alone.  This  mixture  should  rarely  be  used, 
save  in  those  cases  where  general  anesthesia  is  inadvisable,  and  where  there  are  diffi- 
culties, even  about  the  employment  of  local  anesthetics. 


LOCAL  ANESTHESIA. 

The  use  of  ethyl  chloride,  as  the  most  volatile  of  the  ordinary  drugs,  by  which  chilling 
or  freezing  of  the  skin  may  be  produced,  has  been  already  mentioned.  Other  agents 
which  chill  or  freeze  may  be  used,  e.  cj.,  a  spray  of  common  ether  or  of  rhigolene,  or  the 
local  api)lication  of  ice  and  salt. 

Liquid  Air. — Liquid  air,  when  available,  affords  an  excellent  means  of  benumbing 
sensibility,  since  one  or  two  very  light  applications,  tw^o  or  three  minutes  apart,  admi- 
rably .serve  the  purpose.  It  is,  however,  rarely  available  and  should  be  u.sed  with  great 
caution. 

Cocaine. — ( )f  the  local  anesthetics  cocaine,  or  .some  of  its  compounds  or  suKstitutes, 
will  give  the  be.st  results;  although  it  is  said  that  injections  of  pure  water,  if  sufficiently 
bulky,  will  also  answer  the  purpo.se  of  a  local  anesthetic.  Cocaine  has  marvellous 
properties  upon  mucous  surfaces  or  in  the  tissues,  but  none  upon  the  unbroken  skin, 
Where  the  parts  to  be  operated  are  covered  with  skin  it  is  necessary  to  inject  the  drug 
with  a  hypodermic  sjTinge,  as  in  the  ca.se  of  all  deeper  tissues.  About  the  eye,  the  drug 
is  used  in  from  1  to  4  per  cent,  .strength;  in  the  nasopharynx,  from  2  to  4  for  ordinary 
purposes;  about  the  genitals,  2  to  5  per  cent.;  beneath  the  skin,  ordinarily  in  strength  of 


206  SURGICAL  PROCEDURES 

1  to  2  })er  cent.  In  operations  up)on  the  nasopharynx  and  larynx  it  is  often  aflvisable 
to  make  a  local  application  of  a  small  amount  of  an  almost  saturated  solution,  by  which 
a  more  complete  effect  is  gained. 

Cocaine  is  not  ivithoiit  datigerou.s-  toxic  pmjx-rtic.s-,  to  which  some  persons  are  jieculiarly 
susceptible.  It  will  seriously  disturb  heart  action  in  some;  in  others  produce  vertigo 
and  mild  delirium,  and  in  still  others  j^culiar  erotic  symptoms.  Warm  solutions  are 
more  quickly  absorbed  than  cold  ones.  The  use  of  more  than  0.06  (1  grain)  should  be 
avoided. 

When  the  skin  alone  is  to  be  anesthetized  the  injection  should  be  made  into  and 
not  beneath.  The  nearer  the  cocaine  solution  is  dejx)sited  to  the  principal  nerve  trunk 
or  branches  the  more  promising  will  be  its  effect. 

The  use  of  cocaine  in  ojx'rations,  under  general  anesthesia,  for  the  prevention  of  those 
depressing  influences  which  cause  lowered  Ijlood  pressure  and  shock,  has  been  alluded 
to  in  the  chapter  on  Shock.  For  instance,  it  is  well  to  spray  the  larynx  after  opening  it 
and  before  making  further  operation  u|X)n  it;  while  in  all  major  operations  in  which 
large  nerve  trunks  are  exposed  or  divided,  e.  y.,  amputations,  etc.,  the  injection  into  the 
nerse  trunks  of  a  few  drops  of  2  or  3  Y>eT  cent,  cocaine  solution  prevents  this  kind  of 
disturbance. 

For  small  and  localized  operations  the  direct  injection  of  cocaine  into  and  around 
the  area  involved  will  prove  sufficient.  It  Is  rarely  necessarv  to  use  for  this  purpose  a 
solution  stronger  than  1  or  2  per  cent.,  especially  if  it  is  deposited  drop  by  drop  around  the 
entire  margin  of  the  area  and  if  the  part  have  been  previously  made  Vjloodless  by  pressure, 
as  bv  the  Esmarch  rubber  bandage.  But  when  extensive  operations  are  to  be  under- 
taken the  method  of  "  hlorking,"  so  called,  should  be  carried  out.  This  consists  in 
cocainizing  the  principal  nerve  trunks  which  supply  the  part,  for  which  purpose  an 
accurate  knowledge  of  regional  neural  anatomy  is  necessary,  with  the  intent  to 
inject  into  or  closely  around  the  nerve  trunks  a  few  drops  of  a  1  or  2  j^er  cent,  solution. 
Working  in  this  way  by  combination  of  injection,  then  of  incision,  by  which  the  nerAe 
trunks  are  better  expo.sed  and  more  fully  protected  in  order  to  be  more  completely 
injected,  and  then  proceeding  farther  with  the  operative  part,  extensive  operations  have 
been  and  may  be  done;  such  for  instance  as  amputations^  not  alone  of  the  limbs  but 
even  of  the  shoulder  girdle,  removal  of  large  tumors,  etc.  In  this  way,  for  example, 
Kocher  now  removes  most  of  the  goitres  which  he  attacks.  The  es.sential  feature  of 
this  work  is  to  first  get  the  cocaine  inside  of  the  nerve  sheaths.  In  this  way  a  minimum 
of  the  drug  is  used  with  a  maximum  of  effect.  Nevertheless  when  a  large  nerve  trtmk 
Ls  thus  to  be  paralyzed  temporarily  it  is  best  to  inject  the  solution  directly  into  it  a.s-  urll 
as  around  it  inside  the  sheath.  Cocaine  is  a  temporary  protoplasmic  poison,  and  for  the 
time  being  shuts  off  the  afferent  power  of  the  nerve.  One  advantage  of  this  method 
is  the  avoidance  of  shock  as  well  as  of  pain.  Another  method,  devised  by  Schleich, 
is  to  be  preferred.  He  uses  three  different  solutions,  of  which  the  second  Ls 
commonly  used.  Tablets  for  making  these  solutions  can  now  be  obtained.  In  order 
to  secure  the  best  effect  with  them  the  parts  should  be  made  bloodless.  The  solution  is 
deposited  subcutaneously  in  a  series  of  drops  around  the  margin  of  the  area,  and  then 
massage  may  be  made  to  distribute  the  fluid  more  uniformly  in  the  tissues.  When  the 
tissue  to  be  operated  upon  is  inflamed  the  injections  should  be  made  first  into  the  healthy 
area  on  the  proximal  side. 

Schleich's  formulas  are  as  follows : 

No.  1. 
Cocainse  hydrochloridi  ......  .200  (gr.  iij). 

Morphinff  hydrochloridi  ......  .  02.5  (gr.  |). 

Sodii  chloridi .200  (gr.  iij). 

Aquse  de.stillat« ad     100.000  (f  5 iiiss) 

No.  2. 
Cocain*  hydrochloridi  ......  .  100  (gr.  Ls.?). 

Morphinif  hydrochloridi         ......  .02.5  (gr.|). 

Sodii  chloridi .200  (gr.  iij). 

Aqua-  destillatse ad  100.000  (f  Siiiss). 

No.  .3. 
Cocainsp  hydrochloridi  ......  .010  (gr.  A). 

ilorphina  hydrochloridi         ......  .00.5  (gr.  |). 

Sodii  chloridi -200  (gr.  iij). 

Aquse  destillatse ad  100.000  (f  oiiiss). 


INTRASPI.\AL   ('(H'MMZATION  207 

Various  .sul).stitutes  for  cocaiiu*  arc*  now  on  the  market.  Some  of  tlicso  are  .soluble 
and  .some  in.soluble.  Eucainr  is  most  commonly  used,  especially  in  form  known  as 
curaiiif  B.,  or  hrta-r  lira  inc.  It  is  weaker  than  cocaine,  especially  so  in  toxic  |)roperties, 
and  .solutions  of  twice  the  stren«;th  can  he  u.sed,  often  with  satisfaction,  and  almost 
always  without  dan^'er.  l^'or  urethral  and  eye  work,  r.  (/.,  it  answers  the  j)urposc;  never- 
theless, it  will  sometimes  j)r()ve  disappointinfj;.  OrflKiJonu  is  a  crvstalline,  s|)arinfjly 
.soluble  artificial  product,  which  is  too  li<:;ht  and  too  coherent  to  be  generally  .serviceable. 
It  often  ijjives  satisfaction  mi.xed  with  other  powders  or  in  ointments,  and  it  i.s  usually 
free  from  toxic  j)roperties.  Ncrraniii  is  another  laboratory  product,  not  equal  in  activity 
to  cocaine,  but  almost  free  from  unpleasant  projx'rties.  Anrsthesin  is  another  similar 
|)roduct,  which  is  practically  free  from  physiological  proj)erties  save  that  it  acts  as  a 
local  anesthetic.  The  latter  may  be  emj)loyed  for  inliltration  anesthesia  in  the  follow- 
ing proportion,  recommended  by  Dunbar: 

Aiu'sthcsin  hydrochloride         ......  0.250 

Sotliuin  c'liloride     ........  O.l.oO 

Morphine  liydrocliloride           ......  0.00.')  to  0.01.5 

Water          " 100.000  Cc. 

Stovaine  and  alypin  are  among  the  latest  synthetic  substitutes  for  cocaine.  The 
latter  .seems  to  offer  promise  of  usefulness. 

Adrenalin  may  be  added  to  any  of  these  solutions  in  proportion  of  1  per  cent,  of  a 
1  to  1000  solution,  and  will  have  a  beneficial  effect  in  all  cases. 


INTRASPINAL  COCAINIZATION. 

The  intraspinal  injection  of  remedies  was  first  suggested  by  Corning,  of  New  York, 
in  1885;  it  remained,  however,  for  Bier  to  perfect  the  technique  in  1899,  and  to  make  it 
so  popular  that  the  same  maneuver  has  been  practised  for  various  other  purposes;  as,  for 
instance,  for  withdrawal  of  cerebrospinal  fluid  in  cases  of  hydrocephalus,  etc.,  or  the 
injection  of  tetanus  antitoxin.     (See  chapter  on  Tetanus.) 

The  intent  in  this  use  of  cocaine  is  to  spread  the  solution  over  the  surface  of  the  cord 
and  beneath  the  arachnoid.  For  this  purpose  a  needle  about  4  inches  in  length,  with 
a  point  not  too  sharp,  preferably  gold  or  platinum  plated,  is  used;  with  this  also  a  .syringe 
which  will  hold  2  to  4  Cc,  which  can  be  firmly,  yet  easily,  attached  to  the  needle.  The 
accompanying  illustration  (Fig.  46)  will  give  an  idea  of  the  technique.  The  patient 
should  be  seated  leaning  forward  so  as  to  curve  the  back  and  open  the  intervertebral 
spaces.  A  sterilized  towel  is  stretched  tightly  across  the  back  from  one  iliac  crest  to 
the  other;  its  upper  edge  should  then  pass  just  over  the  spinous  process  of  the  fourth 
lumbar  vertebra.  The  injection  is  usually  practised  between  the  second  and  third  lum- 
bar spines,  or  between  the  third  and  fourth;  the  latter  having  been  identified,  the  former 
are  easily  made  out.  The  needle  is  entered  about  1  Cm.  to  the  right  of  the  middle  line 
and  passed  forward,  inward,  and  upward,  to  a  depth  of  7  or  8  Cm.  in  the  ordinary 
adult,  until  the  resistance  offered  by  the  tissues  is  felt  to  have  been  passed  and  the  point 
to  have  entered  a  cavity.  If  the  needle  has  been  passed  alone  the  escape  of  a  drop  or 
two  of  cerebrospinal  fluid  will  indicate  that  the  spinal  canal  has  been  entered;  if  the 
syringe  is  attached  to  the  needle  the  piston  should  be  withdrawn  in  order  to  show  the 
same  result.  It  is  possible  to  practise  this  operation  with  a  patient  in  the  recumbent 
position,  but  it  is  done  more  easily  as  above  outlined.  The  skin  may  be  frozen  by  the 
freezing  spray,  or  may  be  anesthetized  by  the  local  injection  of  cocaine  solution  with 
the  ordinary  hypodermic  syringe. 

It  is  astonishing  what  beneficial  effects  can  be  gained  from  the  use  of  a  small  amount 
of  cocaine.  It  is  rarely  necessary  to  u.se  more  than  0.03  {h  grain)  of  pure  cocaine  in 
order  to  procure  analgesia  of  the  entire  lower  part  of  the  body. 

Beta-cocaine  or  tropacocaitie  may  be  used  for  the  same  purpose,  in  double  this  amount, 
but  they  do  not  give  as  reliable  results.  Morton,  of  San  Francisco,  has  suggested  that 
jGr.  powders  of  cocaine  be  wrapped  in  such  a  way  that  they  can  be  repeatedly  sterilized 
by  a  heat  of  200°  F.,  and  that  one  of  these  be  dropped  into  the  syringe  barrel,  that  this 
be  attached  to  the  needle,  and  the  cocaine  it.self  .  be  dissolved  in  the  cerebrospinal 
fluid  withdrawn  through  the  latter,  and  then  thrown  back  again.     This  is  probably 


208 


SURGICA  L   P  ROC  ED  URES 


the  neatest  and  most  seniceable  method  yet  devised,  and  its  originator  has  assured  the 
writer  that  with  1  Gr.  of  tropacocaine  used  in  this  way,  thrown  into  the  spinal  canal 
with  considerable  force,  i.  e.,  in  such  a  way  as  to  more  completely  distribute  it,  he  has 
been  able  to  practise  oj)erations  even  upon  the  tongue  with  little  or  no  pain  to  the  patient. 
The  solution  used  for  this  pur[}osc  should  be  sterilizt^d,  also  the  needle,  the  syringe,  the 
patient's  skin,  and  the  ojx-rator's  hands.  The  water  with  which  the  cocaine  solution 
is  made  should  be  first  pure,  then  measured,  and  the  solution  made  in  such  strength  that 
not  more  than  the  amount  indicated  above  will  }>e  used.  This  should  then  be  again 
heated,  but  not  quite  to  the  boiling  point,  .since  cocaine  .solutions  are  impaired  by  too 
much  heat. 

The  advantages  of  intraspinal  anesthesia  are  many  and  obvious,  and  were  it  not 
for  di.sadvantages  this  method  would  have  supplanted  all  others  for  certain  work. 
It  i-,  however,  by  no  means  free  from  danger,  Ijoth  from  the  maneuver  and  from  the 


Fig.  40 


drug  itself.  Careles.sne.ss  in  its  introduction  may  lead  to  septic  meningitis,  while  the 
drug  it.self  may  produce  considerable  and  even  serious  or  fatal  disturbance,  though  the.se 
ca.ses  are  rare.  It  has  been  claimed  that  2  per  cent,  of  the  ca.ses  in  which  this  method 
has  been  employed  have,  in  consequence,  terminated  fatally.  The  immediate  effects 
are  largely  confined  to  the  stomach  and  the  nei^ous  .system,  and  include  nau.sea,  inten.se 
headache,  and  profound  depression.  The  remote  effects  are  less  positive,  but  have  fjeen 
.stated  to  include  serious  changes  in  the  cord  itself.  It  is  often  a  disadvantage  to  have 
the  patient  mentally  con.scious  of  what  is  going  on,  even  though  oblivious  to  pain.  Ina.s- 
rauch  as  cocaine  produces  analgesia  rather  than  anesthesia,  nervous  patients  will  be 
likely  to  mistake  the  general  .sensation  of  lifting  a  limb,  or  manipulating  it,  for  actual 
pain.  There  are  not  a  few  cases  where  chloroform  and  ether  are  so  plainly  contra- 
indicated  that  if  it  were  possible  to  u.se  any  other  agent  with  safety  this  would  offer  a 
valuable  substitute. 

The  effect  desired  is  not  produced  immediately,  but  comes  on  slowly,  after  the  expira- 
tion of  ten  to  twelve  minutes.  As  grdinarily  used,  anesthesia  of  the  surface  will  be  pro- 
duced up  to  the  height  of  about  the  waist.     Should  it  be  desired,  however,  to  increase 


I.\Th'.\Sl'I\M.   COCMMZAIION  209 

or  ciiliaiicc  tlic  cllVct  llic  solution  iiii^lit  Ix-  injected  helweeii  some  of  (lie  dorsal 
vertehne,  altlioii<fli  at  this  point  it  will  re(|nire  more  skill  to  inlrodnce  the  needle,  and  the 
operator  siionld  he  eantions  not  to  injure  the  eord.  Below  the  second  Inmhar  vertehra 
the  cord  breaks  up  into  its  se<^ments  and  the  j)atient  would  he  almost  exem|)t  from  this 
danijer.  It  is  occasionally  necessary  to  tran((uillize  the  ])atient's  fear  by  usinj;  morphine 
suhcutaiu'ously  at  the  same  time.  It  is  a  (juestion  whether  this  can  he  safely  coml)ined 
with  cocaine  for  the  subarachnoid  injection.  Failing  iti  this  it  may  be  neee.ssary  to 
supplement  the  u.se  of  cocaine  with  ether  or  chloroform. 

The  intraspinal  injection  of  normal  saline  solution,  or  even  of  j)ure  water,  has  been 
shown  by  l^deii  to  be  almost  as  effective  in  some  cases  as  the  cocaine  solutions.  Bier 
has  larjiely  modified  his  statements  about  the  value  of  intrasj)inal  cocaine  injections,  and 
s|K'aks  of  tlii'iu  as  more  dan<jer()us  than  he  had  first  appreciated.' 

'  Miiijiiesium  Suits  ax  Local  A  ncslhctics.  Six  years  ago  Mcit/.er  discovercil  that  iiiaKiic.xiuni  salt^^  have  the  property 
of  inhih)itini2  functicnial  activity  in  nerve  tissue,  and  in  Deceniher,  1899,  he  announced  that  the  intracerebral 
injection  of  niaRnesiuni  sulphate  in  a  rabbit  cau.sed  paralysis  without  previous  convulsion.s.  He  has  recently 
announced  the  local  anesthetic  effect  of  small  doses  of  a  25  per  cent,  solution  of  magnesium  sulphate,  an  effect 
which  lasts  from  one  to  two  hours.  It  is  the  magnesium  "ion"  which  po.ssesses  the  anesthetic  property,  since  the 
chloride  and  the  liromides  give  the  same  effects. 

These  salts  have  this  advantajje  over  other  local  anesthetics  that  there  is  no  i)riniary  pcrifxl  of  excitation.  More- 
over, applied  locally  to  nerve  trunks  they  have  the  effect  of  "blocking"  thcni;  and  when  appliefl  to  the 
sciatic,  pneumogastrir,  and  other  nerves,  temporarily  abolish  their  power  of  coiKhiotiiig  iiifluences,  either  motor 
or  sensory.  This  effect  is  ajiparently  tlue  to  the  fact  that  the  magnesium  normally  present  in  the  tissues  constantly 
e.xercises  an  inhibitory  power  over  them,  and  that  when  thus  api)lied  from  without  they  merely  exaggerate  the 
condition  already  present;  thus,  if  this  he  true,  affording  an  ideal  anesthetic. 

In  December,  190.5,  Meltzer  read  a  paper  before  the  New  York  Academy  of  Medicine,  announcing  success  with 
intraspinal  injection  of  magnesium  sulphate  in  2.5  per  cent,  .strength.  Elake,  of  New  York,  promptly  made  u.se 
of  the  suggestion  in  a  child  with  tetanus.  Two  injections  of  antitoxin  had  been  made  into  the  cervical  cord  on 
succes.sive  days,  with  apparently  no  effect.  He  then  made  lumbar  puncture  and  a  subdural  injection  of  mag- 
nesium sulphate,  giving  1  Cc.  of  2.5  per  cent,  .solution  for  every  twenty-five  pounds  of  body  weight,  administering 
it  every  thirty-six  hours,  employing  four  doses.  The  effect  was  marked,  in  immediate  control  of  convulsions, 
which,  however,  was  not  permanent;  hence  the  repetition  of  the  doses.  How  much  influence  the  previous  anti- 
toxin had  produced  does  not  appear. 

Meltzer  suggests  that  the  best  time  for  an  operation  is  three  or  four  hours  after  a  .spinal  injection.  He  reports 
four  ca.ses  thus  operated,  in  one  of  which,  after  the  operation,  the  patient  passed  into  a  period  of  deep  general 
anesthesia,  in  which  he  remained  for  five  hours,  the  pulse  keeping  up,  the  respirations  falling  to  ten  per  minute. 
In  this  case  another  spinal  puncture  was  made,  .some  of  the  .spinal  fluid  let  out,  and  the  spinal  cavity  treated  by 
repeated  irrigations  with  sterile  salt  solution. 

Meltzer's  few  but  important  experiences  indicate  that  at  least  three  or  four  hours  should  be  allowed  to  elajise 
after  the  introduction  of  the  magnesium  solution.  He  advises  1  Cc.  for  every  twenty-five  pounds  of  body  weight, 
for  intraspinal  injection,  which  causes  not  only  nnahiesia  but  temporary  paralysis  of  the  legs,  .sensation  and  motion 
returning  in  from  eight  to  fourteen  hours,  with  possible  retention  of  urine  for  a  day  or  two.  requiring  the  use  of 
the  catheter. 

Doses  a  little  larger  than  the  above,  he  thinks,  would  permit  the  performance  of  extensive  operations  in  the 
abdominal  cavity,  or  even  higher  up,  without  the  aid  of  a  general  anesthesia.  He  is  inclined  to  think  that  it  would 
be  preferable  not  to  wait  four  hours,  but  to  operate  within  about  two  hours  after  injection,  with  the  aid  of  a 
R-n-ll  amount  of  chloroform,  the  operation  to  be  followed  by  another  puncture,  with  the  removal  of  at  lea.st  as  much 
fluid  as  was  introduced,  and  irrigation  with  sterile  salt  solution,  finally  leaving  some  of  it  within  the  canal. 

14 


PAKT   IV. 
INJURY  ANT)   rvEPAIR. 


CHAPTER    XXL 

WOUNDS  AND  THEIR  REPAIR. 

Thk  old  classific-jiliori  of  wounds  dividos  tlicin  into  ronfii.srd,  lareratrd,  pHiirtiiird, 
and  {nri.srd.  For  descriptive  purposes  these  adjectives  are  self-sufficient;  tliev  can  be 
criticised  only  in  case  the  injuries  dirt'er  in  character.  The  adjectives  tiius  employed 
allude  to  the  character  of  the  injury  as  well  as  to  its  cause,  but  no  nieanino;  should  l)c 
conveyed  by  any  of  them  other  than  to  indicate  a  severance  of  continuity  in  tissues. 
In  either  case  cells  are  rudely  torn  apart.  But  whether  the  injury  be  subcutaneous  and 
tiie  tearini>;  make  a  rai^j^ed  surface;  or  whether  the  wound  be  an  open  one,  with  the  ])ossi- 
bility  of  introduction  of  germ-laden  air  and  grosser  impurities,  even  though  the  surfaces 
separated  present  an  even  plane,  as  in  an  incised  wound;  or  a  channel  or  tunnel,  as 
when  made  by  a  pointed  instrument  or  a  gunshot  missile,  the  principle  is  the  same,  and 
the  same  processes  of  repair  are  brought  to  work  to  undo  the  harm.  There  is  but  one 
natural  method  of  re])air,  and  that  includes  the  exudate,  or  the  utilization  of  the  fluid 
portion  of  the  blood  already  poured  out,  and  the  activity  of  cells,  those  which  lie  in  the 
vicinity  and  those  which  are  furnished  from  a  distance,  i.  e.,  leukocytes  and  wandering 
corpuscles.  It  is  of  advantage  to  have  the  injury  subcutaneous  and  protected  from 
contact  with  the  air,  yet  extensive  injuries  of  this  kind  are  often  much  longer  in  healing 
than  those  inflicted  by  the  surgeon's  knife,  when  the  parts  can  be  brought  into  complete 
apposition  with  each  other  by  sutures. 

It  is  the  writer's  intent  to  simplify  the  description  of  the  healing  processes  and  to  insist 
that  it  is  always  the  same,  not  modified  in  character  but  in  duration  and  extent,  accord- 
ing to  the  nature  of  the  injury. 


CONTUSION. 

The  term  contusion  implies  a  subcutaneous  injury  of  varied  extent,  in  which  laceration 
cannot  be  left  out  of  consideration.  Even  in  the  mildest  contusion  mechanical  harm 
has  been  done,  permitting  a  dilatation  of  the  vessels  and  the  escape  of  fluid.  Should 
this  occur  in  linear  form,  as  by  a  whip-lash,  there  may  be  what  is  called  a  wheal.  In 
loose  tissues  swelling  occurs  more  easily,  as  in  the  eyelid,  the  scrotum,  etc.  Injuries  of 
severity  will  produce  laceration,  at  least  of  capillaries  if  not  of  arterioles,  and  the  result  is 
the  escape  of  an  amount  of  blood  which  will  infiltrate  the  surrounding  tissues  and  dis- 
color them  and  produce  an  extraimsaiion  or  ecchymosis.  The  blood  barely  escapes  and 
coagulates  before  its  absorption  begins.  The  fluid  portion  disappears  before  the  solid, 
and  the  pigment  is  usually  the  last.  There  results  a  black  and  blue  .fpof;  the  color  when 
near  the  surface  is  at  first  indigo  or  purple,  and  fades  out  through  bluish  and  greenish 
tints  into  a  yellow,  which  may  not  disappear  for  two  or  three  weeks.  Should  blood 
collect  in  a  cavity  or  in  large  amount  the  mass  is  called  a  hematoma;  this  is  especially 
common  in  the  pelvis  and  in  the  cranial  cavity.  Should  a  vessel  wall  give  way  from 
weakness  caused  by  di.sease  instead  of  by  accident  the  result  is  the  same. 

(211) 


212  IX JURY   AND  RJiPAIR 

Coaiused  wounds  of  the  surface  often  cover  excessive  and  even  fatal  injuries  within, 
as  when  a  heavy  object  falls  upon  or  injures  the  abdomen  or  a  limb.  The  skin  is 
resistant,  and  the  writer  has  seen  a  limb  pulpified  bv  bein^  run  over  bv  a  heavv  car,  the 
skin  Ix'ing  but  slightly  torn.  In  such  accidents  exploratory  incisions  are  imperative. 
Belter  results  will  follow  ojx*ning  the  abdomen  in  cases  of  severe  contusion,  for  the 
purpose  of  exploring  the  viscera,  than  will  follow  the  "let-alone"  jK)licy  of  waiting  for 
something  serious  to  ap{)ear. 

An  outpour  of  blood  should  be  expected  in  every  contusion,  save  the  most  trifling, 
while  clot  formation  may  ensue.  Whether  the  clot  will  be  absorbed  or  require  the  aid 
of  the  surgeon  will  depend  upon  its  .size,  its  location,  and  its  liaVnlity  to  infection.  Clot 
in  some  locations,  e.  g.,  pressing  upon  the  brain  or  spinal  cord,  may  justify  extensive 
operation  for  its  removal. 

Pain  produced  hy  contusion  Ls  variable.  When  nerve  trunks  of  considerable  size  have 
been  injured  pain  is  frequently  aggravated.  In  general  it  is  proportionate  to  the  amount 
of  swelling,  /.  e.,  to  the  density  or  laxity  of  the  injured  tissue.  When  exudate  occurs 
beneath  unyielding  membranes,  for  instance  the  periosteum  and  the  capsules  of  certain 
organs,  the  pain  may  W  severe.  The  appearance  of  discoloration  is  proportionate  to 
the  depth  of  the  injury  and  the  amount  of  hemorrhage  The  time  of  its  appearance  will 
depend  upon  the  distance  from  the  surface;  after  fracture  of  the  neck  of  the  femur  it 
may  not  be  ob.served  for  several  days.  The  general  condition  of  the  patient  will  depend 
greatly  upon  his  temperament.  When  there  has  been  considerable  extravasation  the 
release  of  the  fibrin  ferment  may  produce  a  mild  rise  in  temperature. 

Treatment. — So  long  as  air  or  other  infection  can  be  excluded  the  treatment  of 
contusions  is  simple.  Cleanline.ss  of  the  injured  parts  should  be  enjoined;  aho 
physiological  rest,  by  their  confinement  within  dres.sings  or  splints,  or  by  placing  the 
patient  in  bed.  An  antiseptic  application,  dry,  waterA%  or  in  ointment  form,  should  be 
applied  upon  a  surface  which  has  V)een  abraded.  Differences  of  opinion  exist  as  to  the 
respective  values  of  heat  and  cold.  ^^  hen  the  case  is  seen  early,  Vjefore  much  swelling 
has  occurred,  the  exudate  may  be  limited  by  the  application  of  cold  dressings;  whereas 
if  seen  after  the  swelling  is  at  its  height  the  use  of  moist  heat  may  favor  a  more  speedy 
re-absorption.  The  effect  of  extremes,  either  of  heat  or  cold,  is  sedative,  although  hot 
applications  afford  more  relief  than  do  those  of  ice.  Of  domestic  remedies  in  use  among 
the  laity  it  may  be  said  that  those  which  have  any  value  owe  it  to  the  alcohol  which  they 
contain.  Elastic  constriction  will  reduce  the  amount  of  exudate  and  assist  in  the  ab- 
sorption of  that  already  present.  It  is  a  measure,  however,  to  be  used  with  great  caution 
lest  venous  return  be  interfered  with  and  edema  or  gangrene  be  the  consequence.  A 
joint  tensely  distended  with  fluid  as  a  result  of  comVjined  contusion  and  laceration,  called 
a  sprain,  may  be  emptied  by  aspiration,  but  this  should  be  used  only  under  antiseptic 
precautions.  Finally  any  collection  of  blood  which  fails  to  disappear  may  be  incLsed 
and  cleaned,  its  cavity  mopped  out  with  compresses,  and  its  surface  made  to  come  in 
contact  by  pressure.  In  hematomas  and  large  extravasations  of  blood,  sometimes  in 
joints,  but  rarely  in  the  pleural  or  peritoneal  cavities,  this  method  may  also  be  used. 


LACERATED  WOUNDS. 

Lacerated  wounds  differ  from  contused  in  the  character  of  the  tears  in  the  tissues 
affected  and  in  the  exposure  to  infection  by  contact.  They  vary  in  extent  and  severity. 
Not  infrequently  tissues  or  organs  of  the  greatest  imjwrtance  are  lacerated,  e.  g.,  the 
globe  of  the  eye,  the  liver,  the  intestines.  The  term  laceration  itself  implies  such 
open  injury  that  part  of  it  may  be  exposed  to  infection.  The  first  danger  is  from  hemor- 
rhage. This  may  subside  spontaneously,  or  may  have  been  checked  Vjy  some  first  aid,  or 
may  prove  nearly  fatal  by  the  time  the  patient  is  seen  Vjy  the  surgeon.  The  first  measure 
will  V>e  hemosiasis  by  the  readiest  and  most  effective  measures  at  hand.  This  may  mean 
the  application  of  compresses  or  of  a  tourniquet,  or  even  of  manual  pressure,  until 
surgical  procedures  can  be  instituted.  .Shock  should  be  treated  by  lowering  the  head  and 
raising  the  extremities,  or  bandaging  the  latter,  and  the  subcutaneous  arlministration 
of  morphine  or  atropine.  Emergency  treatment  of  these  cases  should  include  removal 
of  foreign  bodies,  and  such  cleanliness  and  attention  to  antisepsis  as  may  be  po.ssible  at 
the  time.     Support  of  the  injured  part  should  be  effected  temporarily  until  dressings 


PrMCTVRED  WorXDS  213 

call  !)(•  scientifically  applied.  11' cane  siij^ar  will  kecj)  IVnit  and  meat  rnmi  (lec(ini|)(».sili(»ii 
it  will  have  the  same  etlect  in  human  tissues,  and  a  laceration  with  or  without  com- 
pound fracture  of  bone  may  he  fille*!  with  <,'ranulate(l  suj^ar  until  a  suitahle  dressinj^ 
can  he  applic(l. 

The  surgical  Ircatmcnt  of  laceration  should  include  the  i'ollowinif  measures:  Ilniio- 
Masin;  the  iriiioral  oj  /'orcK/ti  hod ic.f,  as  wvW  as  of  tissue  which  is  so  injured  as  to  make 
repair  impossible  or  even  (piestionable;  a  careful  .stiiclij  of  nerve  .^tupphj,  in  order  to  be 
sure  that  no  nerve  suture  should  1k>  made;  a  similar  study  oj  vinsrles  and  trjidon.s,  in 
order  that  tendon  suture  may  be  ])romptly  made;  careful  anfi.iep.s-i.s-  throufihoiit,  asej)sis 
bein*;  impossible;  closure  of  the  wound  by  buried  and  superficial  sutures,  and  such 
drainaije  tubes  or  outlets  as  may  permit  free  escape  of  whatever  products  of  inflamniati<»n 
or  disinte<;ration  may  result.  There  should  also  be  provision  for  j)hysi()lof^ical  rest  of 
the  injured  parts  as  well  as  of  the  j)atient's  mind  and  body. 

When  lart:;e  areas  of  skin  or  deej)  tissues  are  destroyed  or  torn  away,  as  in  scalj)  wounds, 
avulsion  of  liml)s  or  p;irts  of  limbs,  it  may  be  necessary  to  retain  that  which  can  be  saved 
and  to  remove  that  which  would  slouijh  if  left  to  it.self,  thereby  providing  for  flaps  of 
skin  by  which  the  wound  may  subsequently  l)e  c-overed,  or  leaving  them  in  ea.se  removal 
of  a  part  must  be  made. 

Everything  which  has  vitality  should  be  spared;  on  the  other  hand,  that  which  has 
lo.st  its  vitality  should  be  removed  at  once,  "^riius  am|)utations  may  be  sometimes  called 
for  because  of  extensive  laciM'ations  with  destruction  of  vascular  and  nerve  supply,  even 
though  the  bones  be  uninjured. 

In  cases  where  the  (juestion  of  viability  of  tissues  cannot  be  ])romptly  decided  it  is 
best  to  keej)  the  injured  part  immer.sed  in  water  as  warm  as  can  be  borne.  In  hospitals 
the  entire  body  may  be  kept  immersed  for  days.  By  the  use  of  warm  water  parts  which 
have  been  seriously  injured  may  be  restored.  Ulcerations  which  are  seen  after  the 
sloughing  process  has  begun  can  be  best  treated  by  immersion  or  by  the  application  of 
brewers'  yeast  upon  compresses  or  cotton.  No  other  substance,  perhaps,  will  .so  quickly 
clear  up  an  indolent  or  foul  surface  as  this;  it  hastens  the  time  of  .separation  of  all  that  is 
dead  or  dying  and  restores  healthful  activity  to  the  surrounding  tissues. 

Extensive  lacerations  leave  frequent  opportunity  for  operations  by  which  function 
may  be  restored  or  improvement  affected. 


PUNCTURED  WOUNDS. 

The  essential  features  of  punctured  wounds  are  sufficiently  indicated  by  the  descriptive 
name;  but  harm  may  be  done  through  a  small  external  opening.  An  important  sui)- 
variety  of  punctured  wounds  is  inflicted  by  gunslioi  missiles,  which  will  receive  con- 
sideration by  themselves.  Injury  to  imjjortant  vessels  may  lead  to  serious  hemorrhage; 
while  injuries  to  nerve  trunks  may  be  followed  by  paralysis  of  .sensation  and  motion,  or, 
as  in  the  ca.se  of  a  sympathetic  trunk,  by  the  well-known  consequences  of  division  of 
vasomotor  nerves,  e.  g.,  in  the  neck.  When  the  punctured  wound  bleeds  freely  and 
externally  it  may  be  assumed  that  some  large  ves.sel  has  been  injured.  When  it  bleeds 
into  one  of  the  cavities  of  the  body  delay  in  recognition  may  occur.  This  is  true  of  a 
puncture  of  the  skull  by  w^hich  the  middle  meningeal  artery  or  one  of  the  sinuses  is 
wounded,  when  the  symptoms  of  brain  pressure  may  tardily  or  rapidly  appear.  In 
the  chest  the  intercostal  or  internal  mammary  artery  may  be  so  injured  as  to  bleed  into 
the  pleural  cavity  and  cause  death.  A  puncture  of  the  heart  frecjuently  leads  to  fatal 
hemorrhage  into  the  pericardial  cavity,  and  in  the  abdomen  puncture  of  the  various 
viscera  has  led  to  consequences  beyond  help  save  when  prompt  relief  could  be 
afforded. 

The  dangers  attending  punctures  pertain  to  the  introduction  of  infectious  material 
w^hich  may  produce  sepsis  or  may  slowly  produce  tetanus.  No  ordinary  weapon  or  tool 
is  clean  in  a  surgical  sense,  while  a  rusty  nail  is  even  less  so.  It  will  be  seen,  therefore, 
that  the  danger  inherent  in  such  a  case  is  not  to  be  measured  by  either  the  size  or  the 
depth  of  the  wound. 

In  dealing  with  these  cases  the  first  attention  is  to  be  given  to  hemorrhage.  Obviou.sly 
punctures  in  certain  regions  are  much  more  likely  to  be  followed  by  hemorrhage,  and 
any  puncture  in  the  vicinity  of  one  of  the  large  vessels  should  be  managed  with  caution. 


214  INJURY  AND  REPAIR 

especially  if  the  surgeon  ascertain  that  it  had  l)le(l  profusely  when  first  inflicted.  Such 
a  puncture,  when  seen  a  few  hours  later,  may  have  become  occluded  by  clot,  or  a  con- 
siderable hematoma  may  have  formed  beneath  the  skin.  It  is  safe  to  ])resume  that 
there  is  more  danger  of  se])tic  infection  than  can  accrue  from  later  attention,  and  it  would 
be  advisable  in  such  cases  to  anesthetize  the  patient  and  hiy  open  the  parts  freelv 
under  full  aseptic  ])recautions,  in  order  that  the  clot  be  turned  out  and  anv  bleeding 
vessel  secured.  A  brief  study  of  such  a  case  will  decide  the  ((uestion  of  injury  to  the 
principal  nerve  trunks.  A  princijml  nerve  which  has  been  injured  or  divided  should 
be  carefully  sought  for  and  its  ends  freshened  and  sutured.  This  is  true  also  of  any 
tendon  whose  function  is  evidently  lost.  If  the  thorax  have  been  punctured  and  the 
physical  signs  indicate  the  presence  of  fluid,  i.  p.,  blootl  in  the  pleural  cavity,  it  should 
be  incised  and  the  blood  withdrawn.  This  method  should  also  Ijc  applied  to  punctures 
of  the  heart.  These  measures  will  l)e  more  completely  dealt  with  in  treating  of  the 
surgery  of  the  chest  and  its  contents. 

Punctured  wounds  of  the  abdomen  may  give  rise  to  great  anxiety.  If  none  of  the  viscera 
have  been  injured  they  may  be  let  alone,  l)ut  if  doubt  exists  as  to  the  safety  or  injury  of 
any  of  them  the  abdomen  should  be  opened.      (See  Surgery  of  the  Abdomen.) 

Treatment. — For  emergency  purposes  antiseptic  occlusion  is  the  best  procedure, 
and  all  punctures  infiieted  by  ragged  and  infectious  materials,  as  rusty  nails,  should  be 
treated  by  free  incision,  with  thorough  cleansing  and  packing  with  antiseptic  material, 
that  the  wounds  may  heal  by  granulation. 

INCISED  WOUNDS. 

Incised  wounds  are  those  inflicted  by  a  sharp  object  which  divides  the  tissues  abruptly 
and  with  a  minimum  amount  of  disruption.  They  invariably  bleed,  sometimes  seriously, 
even  to  a  fatal  degree,  the  hemorrhage  in  such  ca.ses  Ijeing  due  to  severance  of  large 
vascular  trunks.  Like  contused  wounds  they  vary  as  infinitely  in  extent  as  in  locality. 
According  to  their  locality  and  dimensions  important  structures  may  be  severed,  e.  g., 
the  trachea,  the  large  nerve  trunks  of  the  body,  the  tendons,  etc.,  while  visceral  and  joint 
cavities  may  be  more  or  less  widely  opened.  When  death  occurs  soon  after  injury  it  is 
generally  from  hemorrhage.  They  are  attended  by  the  same  dangers  of  septic  infection 
as  are  punctures,  especially  when  there  is  neglect  in  the  emergency  dressing.  Should 
the  pleural  cayity  be  opened  there  may  be  collapse  of  the  lung. 

Hemostasis  is  the  paramoimt  indication  in  all  incised  wounds  which  Ijleed  seriously. 
Hemorrhage  is  to  be  controlled  temporarily  by  any  expedient,  later  by  ligation  or  suture, 
or  both.  The  remarks  above  in  relation  to  possible  injury  to  vessels  and  nerves  are  of 
equal  force  in  this  consideration.  Every  divided  nerve  trunk,  as  well  as  every  severed 
tendon,  should  be  reunited  by  suture.  If  a  joint  have  been  opened  it  should  be  clean.sed 
and  drained,  even  though  the  incision  be  closed.  Should  there  be  injury  to  any  of  the 
viscera,  the  wound  may  be  enlarged  in  order  that  ex])loration  may  be  made  and  suitable 
remedies  applied.  This  is  true  of  every  })unctured  or  incisetl  woimd.  No  hesitation 
need  be  felt  about  enlarging  it  so  as  to  jx'rmit  of  investigation.  Hemorrhage  having  been 
checked  and  all  required  attention  having  been  given,  the  closure  of  an  incised  wound 
may  be  made  partial  or  comjjlete  according  to  its  condition.  If  fresh  and  clean  it  may 
be  almost  completely  reunited,  using  deep  and  buried  sutures  in  order  to  bring  into 
contact  its  deeper  portions,  while  superficial  sutures  will  suffice  for  the  skin.  Drainage 
may  be  by  tubes  or  gauze  or  by  loose  suturing  of  the  surface ;  but  no  incised  wound  whose 
surfaces  have  become  contaminated  should  be  completely  closed  by  primary  suture 
until  all  such  surfaces  have  been  freely  cut  away  and  appear  healthy  and  iminfected. 
An  old  infected  and  gaping  incised  wound  may  be  cleaned  by  the  application  of  brewers' 
yeast,  and  when  granulating  it  may  be  closed  secondarily  with  sutures,  by  which  gran- 
ulating surfaces  are  brought  into  close  contact. 

Of  wounds  in  general  it  may  be  said  that  there  are  mixed  types  as  well  as  illustrative 
examples.  Thus  a  wound  made  by  a  hatchet  or  axe  may  partake  of  the  nature  of  con- 
tusion and  of  incision.  In  instances  where  personal  violence  has  been  applied  multiple 
wounds  of  varied  character  may  complicate  the  case.  The  statements  made  above 
pertain  to  their  conventional  and  common  characteristics.  Treatment  which  would  be 
proper  in  one  case  may  be  impossible  in  another.     Inhere  is  always  room  for  discretion 


RKPMIx    OF    W'OCXDS  215 

aM«l  j^dod  iii(l<:;iiii-iil,  (lu)ii<ili  then-  ;irc  l'iiii(l;iiiiciitiil  rules  which  applv  (o  all  cases,  and 
iiieliide  t'xact  heiiiostasis,  siir<j;ieal  eleaiiliiiess,  i-e|)air  of  severed  nerves  and  tendons, 
removal  of  lori'ign  luulu's  and  involved  tissue,  and  the  eiiroreenient  of  physiological  rest. 

REPAIR  OF  WOUNDS. 

The  j)roc(>ss  of  r(>j)air  is  CNscniinlhi  ihr  same,  being  modified  only  by  the  needs  of  the 
wound  and  the  tissues  involved,  and  by  their  environment.  Whether  soft  tissues  or 
bones  are  being  re|);iire(l  the  ditVerenees  are  apparent  rather  than  real,  as  bony  tissue 
is  temporarily  decalcified,  and  then,  as  soon  as  the  ])rocess  permits,  is  once  more  stiffened 
by  deposition  of  calcium  salts. 

The  process  of  repair  should  be  begun  immediately  after  the  cessation  of  the  disturb- 
ance which  has  |)roduced  the  wound,  and  as  soon  as  the  bleeding  is  checke<l.  It  may  be 
materially  influenced  and  retarded  by  the  |)resence  of  bacteria  or  other  foreign  bodies, 
but  its  character  remains  unchanged.  Healing  has  been  described  as  occurring  by 
priinarij  union,  or  by  "the  first  intention,"  and  by  fjranulatiov,  or  the  "second  intention." 

Wounds  which  have  been  permitted  to  remain  clean,  with  their  edges  brought  together 
so  that  the  surfaces  are  in  contact,  are  healed  with  a  mininnnn  of  waste  of  rej)arative 
material,  the  process  being  as  follows:  The  small  vessels  are  occluded  with  thrombi 
up  to  the  first  collateral  branches;  the  leukocytes  Ijcgin  to  penetrate  the  film  of  blood, 
which,  having  coagulated,  serves  as  a  cement  to  helj)  hold  the  surfaces  together.  By 
their  proliferation  and  more  complete  organization  the  gaj)  between  the  surfaces  is  bridged 
with  both  fil)rous  and  capillary  bloodvessels,  and  within  .'-ixty  or  seventy  hours  the  clot 
has  beconu>  largely  replaced  by  organized  cells.  Meantime  from  the  endothelial  cells 
of  the  vessels  and  vascular  spaces,  as  well  as  from  the  fixed  cells  of  the  connective  tissue, 
the  .so-called  fibroblasts  are  formed,  which  are  later  converted  into  connective  tissue. 
Many  of  the  cells  which  have  wandered  to  the  scene  of  activity,  or  have  been  there 
reproduced  in  unnecessary  numbers,  disa])pear  again,  either  into  the  circulation  or  they 
serve  as  food  for  the  fibroblasts.  Branching  cells  attach  themselves  more  intimately, 
and  thus  the  original  clot  is  completely  converted  into  fibrous  and  connective  tissue,  and 
this  becomes  a  scar,  which  extends  as  deeply  as  did  the  original  injury.  New  ca])illaries 
are  rapidly  formed  by  a  budding  process,  and  su])ply  the  j)abulum  ref|uircd  for  nourish- 
ment of  the  new  cells.  By  fusion  or  amalgamation  of  neighboring  vascular  buds  com- 
plete new  vessels  are  formed,  extending  through  the  new  tissue  from  one  side  to  the  other, 
while  around  them  the  fibroblasts  or  connective-tissue  elements  arrange  themselves. 
From  this  it  wall  appear  that  the  coagulum  which  forms  within  a  wound  is  desirable  as 
a  scaft'olding  upon  which  the  process  of  repair  may  be  begun.  But  it  is  desirable  that 
this  coagulum  should  be  small  in  amount,  in  order  that  these  processes  may  not  be  too 
long  delayed;  hence  the  advisability  of  removing  all  clots  within  a  wound  when  closing 
it,  and  preventing  the  formation  or  leaving  of  dead  spaces  in  the  tissues  in  which  blood 
clots  may  collect. 

The  process  of  granulation  is  not  dissimilar  to  that  described  al)ove,  save  only  in  its 
gro.ss  ajjpearances.  Granulations  consist  of  vascular  buds  surrounded  by  leukocytes 
and  lightly  covered  by  them,  while  around  the  base  of  each  bud  epithelioid  and  spindle 
cells  arrange  themselves,  these  fixed  cells  organizing  themselves  more  and  more,  as  the 
wound  fills  up,  with  the  more  superficial  layers  of  granulations.  In  time  they  are  con- 
verted into  a  dense  fibrous  tissue  which  forms  later  what  is  known  as  the  scar.  As 
before,  also,  the  spaces  between  the  young  capillary  loops  are  filled  with  large  nucleated 
cells  derived  from  the  fixed  cells  of  the  tissue,  and  from  the  endothelial  lining  of  the 
newly  formed  vessels.  Thus  fibroblasts  are  produced  in  each  case,  and  are  often  more  or 
less  mingled  with  giant  cells,  especially  if  some  foreign  body,  such  as  a  silk  ligature,  be 
embodied  in  the  tissues.  The  particular  function  of  the  leukocytes  seems  to  be  the 
removal  of  red  corpuscles  and  fibrin  from  the  original  clot. 

The  granulation  tissue  thus  constituted  by  capillary  loops  and  proliferating  cells  con- 
stitutes the  basis  of  all  wound  repair.  Later  this  tissue  assumes  more  of  the  fibrous 
and  less  of  the  cellular  chai-acter,  while  the  fibroblasts  arrange  themselves  in  accordance 
with  the  mechanical  requirements  of  the  tissues  and  the  stress  or  strain  placed  upon 
them.  This  tissue  is  at  first  vasc-nlar,  but  as  it  condenses  its  capillaries  become  less 
numerous  and  smaller,  and  the  final  white  fibrous  scar  is  usually  almost  bloodless. 


216  INJURY  AND  REPAIR 

When  tluMV  has  been  loss  of  skin,  or  wlicn  skin  cdffcs  are  not  hronght  together,  tlie 
(leej)er  ))r()cess  of  grannlation  needs  an  epitheHal  covering,  which  cannot  l)e  afforded  hy 
niesohhistic  or  endothelial  cells.  The  formation  of  an  epithelial  or  epidermal  covering 
is  a  process  ])ecMliar  to  ej)itlielial  tissne  alone,  and  takes  place  mainly  from  the  cells  of 
the  rete  Malpighii. 

Epithelial  elements  of  the  skin  will  afford  a  large  amount  of  covering,  and  yet  even  their 
activity  sometimes  is  insufficient  and  has  to  be  atoned  for  by  skin  (jvajting.  Should  the 
granulating  surface  be  small,  and  so  situated  that  the  fluid  upon  its  surface  may  dry  by 
evaporation,  there  will  result  a  crust  or  scab,  which,  while  it  conceals  from  observation 
what  is  going  on  beneath,  serves  as  an  admirable  protection,  beneath  which  j)roliferation 
of  epithelium  takes  place.  A  spontaneous  detachment  of  the  scab  may  take  j)la<-e 
when  this  process  is  complete,  and  with  the  loosening  of  the  crust  it  is  ap])arent  that 
repair  has  become  complete.     This  is  known  as  hculiny  under  a  scab  or  under  a  rrus-t. 

Two  clean  and  healthy  granulating  surfaces  may  be  so  })laced  in  contact  with  each 
other  as  to  blend  together  by  exactly  the  same  process  as  that  by  which  granulations 
are  first  formed.  This  is  called  secondary  adhesion,  or  by  the  older  writers  the  ''third 
intention.''  Advantage  is  taken  of  this  possibility  in  the  application  of  what  are  called 
secondary  sutures,  which  may  be  placed  some  days  before  they  are  utilized,  with  the 
intent  to  bring  together  surfaces  so  soon  as  they  shall  ])resent  granulations. 

One  of  the  most  interesting  of  all  healing  processes  is  that  by  which  severed  tissues, 
when  promptly  replaced,  often  reestablish  vascular  conimimication  and  grow  again  in 
a  satisfactory  manner.  Thus  a  severed  ear,  nose,  or  finger-tip  may  be  replaced,  and, 
if  carefully  held  in  situ,  the  parts  being  kept  at  rest,  will  prevent  disfigurement  and 
the  loss  of  important  tissues.  In  these  cases  the  severed  tissue  remains  passive  several 
days  until  it  has  become  vascularized.  Meantime  its  nutrition  seems  to  be  maintained 
through  the  medium  of  the  living  tissues  to  which  it  has  been  affixed,  probably  by 
absorption  of  their  blood  plasma. 

Two  human  tissues  are  essentially  non-vascular,  the  cornea  and  cartilage.  The  former 
appears  to  be  nourished  by  cellular  interspaces  which  may  admit  leukocytes  from  the 
surrounding  tissues,  and  through  these  proliferation  and  vascularization  occur;  while 
a  scar  in  the  cornea  remains  permanent,  and  the  new  tissue  by  which  repair  is  brought 
about  never  becomes  transparent  like  the  cells  composing  the  cornea  proper.  In  car- 
tilage scar  tissue  is  produced,  as  in  other  tissues,  by  a  similar  jirocess,  in  sjiite  of  the 
extent  of  the  cartilaginous  layer  and  its  non-vascularity.  In  general  the  more  specialized 
a  tissue  the  less  completely  does  it  heal,  and  the  specialized  tissues,  like  the  retina,  etc., 
seem  to  be  incapable  of  reproducing  themselves.  I>ow  down  in  the  animal  scale  some 
parts  can  be  more  or  less  reproduced.  In  the  ascending  forms  there  is  less  tendency  in 
this  direction;  in  man  there  is  little  reproduction  of  an  original  tissue,  scar  tissue  taking 
the  place  of  most  of  that  which  has  been  lost.  An  ap]xirent  excei:)tion  to  this  is  seen  in 
the  osseous  system,  where  a  large  amount  of  bone  may  often  be  reproduced.  Epithelium, 
also,  w^iether  on  the  external  or  internal  surfaces  of  the  l)ody,  can  regenerate  itself  in 
large  degree  and  amount.  From  every  small  island  or  mass  of  epithelial  cells  which 
can  be  retained  new  cells  may  thus  be  reproduced;  hence  ac-crues  the  advantage  of  leav- 
ing such  epithelial  collections  whenever  ])ossible,  and  wherever  they  may  be  beneficial. 
If  upon  a  burnt  area  it  happens  that  epithelium  has  not  been  completely  destroyed, 
new  skin  may  be  confidently  looked  for  from  each  clump  of  epidermal  cells.  It  should 
be  remembered,  however,  that  with  the  epidermization  of  a  surface  under  these  circum- 
stances merely  an  epithelial  covering  is  secured.  The  distinctively  dermal  appendages, 
such  as  hair,  sweat  glands,  and  sebaceous  glands,  are  not  reproduced.  If  the  highest 
ideal  results  are  to  be  secured  in  any  case  the  parts  must  be  jiut  in  the  most  favorable 
condition,  which  means  early  surgical  attention  to  every  wound. 

INJURIES  TO  VESSELS. 

Bloodvessels  are  subject  to  contusion,  to  laceration,  and  to  incision.  They  may  be 
contused  by  superficial  blows,  compressed  against  underlying  bone,  torn  in  the  replace- 
ment of  old  dislocations,  or  punctured  or  incised  by  accidental  or  homicidal  injuries. 
A  vessel  which  is  not  abruptly  divided  but  is  seriously  injured  will  usually  sustain  a 
separation  of  its  internal  and  middle  coats,  which  curl  up  within  the  external  coat, 


INJURIES  OF  NERVES  217 

occlude  tlic  cliamicl,  and  lead  to  llinniilxi.sis.  A  vessel  t  li us  occluded  inav  tend  to  fjaiif^reiie 
of  the  |)arts  supplied  hy  it  or  to  ii  temporary  isciieiuia,  with  iiunihiiess  and  pallor  if  an 
artery,  or  to  passive  edema  if  a  vein.  In  eases  of  such  injury  it  is  always  hoped  that  the 
blood  su|)ply  will  he  proxided  through  the  collateral  circulation.  If  a  vessel  he  torn 
or  cut  across  there  may  result  a  hematouia  which  may  lead  to  immediate  prostration, 
from  hemorrlia<;e,  and  to  jjanjirene  by  stoj)pin<f  the  blood  supply.  Such  blood  tumor 
rarely  i)ulsates,  but  may  cause  extreme  |)ain.  The  character  and  the  size  of  the  swelling 
will  depend  upon  the  ti.ssues  which  surround  the  injured  vessel.  Cessation  of  the  j)ulse 
on  the  distal  side  of  an  injury  nearly  always  implies  temporary  occlusion.  Trainiiatir 
(inriiri/.siii  may  be  j)rodueed  by  lateral  injury  to  an  arterial  trunk,  by  which  its  continuity 
as  such  is  yet  not  completely  disrupted. 

If  a  lar>;e  outpour  of  blood  has  occurred  it  will  be  safer  to  incise  ami  turn  out  the  clot 
and  secure  the  injured  vessel.  In  milder  cases  the  sur<reon  should  do  all  that  he  can  by 
rest  and  bv  position  to  favor  restoration  of  blood  circulation.  After  the  subsidence  of 
acute  sym|)toms  massatje  and  ijentle  motion  will  serve  to  j)romote  absorption  of  the 
escai)e(l  blood.  Cases  will  occasionally  occur  in  which  the  principal  arterial  trunk  of  a 
limb  should  be  tied,  hopinif  thereby  to  .save  the  member.  Amputation  may  be  the  last 
resort  when  gangrene  is  impending. 

Injury  to  the  rcifi.t  is  of  a  less  serious  nature  in  so  far  as  immediate  consequences  are 
concerned;  nevertheless  a  punctured  woimd  or  a  large  vein  is  always  a  serious  matter. 
The  pressure  of  the  blood  may  produce  gangrene,  or  cause  so  large  a  hematoma  that  it 
should  be  incised. 

Fine  silk  sutures  may  be  a])plied  to  wounded  vessels,  arteries  or  veins,  when  they 
have  been  partially  severed. 

The  healing  process  in  all  the.se  cases  is  essentially  the  same.  It  may  mean  the  for- 
mation of  a  clot  in  or  around  a  ve.s.sel,  followed  by  absorption  of  its  principal  portion  and 
organization  of  what  remains.  A  vessel  itself  which  has  once  been  occluded  by  thrombus 
will  usually  remain  closed,  a  cord  of  fibrous  tissue  taking  its  place.  Only  in  rare 
instances  is  continuity  of  the  blood  channel  preserved  or  regained.  In  such  cases  the 
collateral  circulation  afi'ords  the  life-saving  feature.  The  granulations  which  intrude 
themselves  into  the  clot  gradually  substitute  tissue  for  coagulum,  the  conversion  begin- 
ning promptly,  but  often  occupying  weeks  for  its  completion. 

Lymph  vessels  may  be  lacerated  in  almost  any  injuries  and  more  or  less  lymph  escape 
with  the  blood.  When  the  skin  is  torn  from  the  underlying  parts  lymph  collects  in  the 
cavity  thus  made,  while  its  wall  may  undergo  more  or  less  organization,  and  formation 
of  a  lymph  cyst  results.  Should  one  of  these  connect  with  a  good-sized  lymph  duct, 
as,  for  instance,  in  the  neck  the  thoracic  duct,  then  lymph  cysts  of  considerable  size 
might  form.     Should  these  rupture  or  be  opened  lymph  fistulje  might  result. 


INJURIES  OF  NERVES. 

B}  small  hemorrhages  into  a  nerve  sheath  nerve  function  may  be  either  temporarily 
or  permanently  disturbed.  A  compression  too  long-continued  may  lead  to  degeneration 
within  the  nerve  fibers.  Providing  this  do  not  occur  there  may  be  complete  restoration 
of  function,  or  there  may  result  chronic  neuritis,  with  pain  and  irritation.  A  later  con- 
■sequence  of  all  nerve  injuries  is  more  or  less  serious  disturbance  of  sensation,  while  still 
later  parts  supplied  by  the  affected  nerves  may  undergo  more  or  less  atrophy,  as  well 
as  spastic  contraction,  by  which  loss  of  function  and  deformity  are  produced. 

There  is  a  form  of  nerve  injury  which  is  due  to  the  temporary  pressure  of  the  elastic 
tourniquet,  frecjuently  applied  around  limbs  previous  to  operations,  or  to  pressure  which 
is  made  by  crutch  handles  upon  the  axillary  plexus,  and  called  crutch  paralysis.  Limbs 
carelessly  allowed  to  hang  over  the  edge  of  the  operating  table  during  prolonged  operations 
also  have  suffered  in  the  same  way.  Such  lesions  are  of  the  character  of  a  contusion, 
but  are  often  followed  by  paresis,  paralysis,  and  by  various  sensory  disturbances. 

Injury  to  a  nerve  trunk  having  been  recognized  by  a  study  of  the  local  features  of 
a  given  case  requires  special  treatment  in  case  laceration  or  more  localized  division 
can  be  assumed.  The  nerve  known  to  be  lacerated  and  torn  across  should  have  its  ends 
freshened  and  be  reunited  by  fine  catgut  sutures;  also  a  nerve  trunk  known  to  be  punc- 
tured or  divided.     Such  injury  is  not  necessarily  inflicted  from  without,  as  it  may  be 


218  INJURY  AND  REPAIR 

prodiiccMl  l)y  ;i  fra<fm('ii(  of  hoiu';  in  this  case  the  ojK'ratioii  should  he  directed  toward  the 
hone  as  well  as  toward  tlie  nerve  trunk  itself.  A  divided  nerve  trunk,  if  neatly  sutured, 
heals  by  the  orj^anization  of  hlood  clot,  as  in  other  instances,  actual  nerve  coniinunication 
being  made  across  the  intervening  clot  hy  a  ])roeess  of  regeneration  or  n'duplication  of 
the  true  nerve  elements,  the  perij)heral  neurilemma  playing  an  ini])ortant  part.  Auto- 
genetic  [)()wer  decreases  with  tlie  age  of  the  individual.  By  careful  nerve  suturing 
disability  may  be  prevented. 

Even  months  after  injury  much  can  be  accom|)lished  by  nerve  suture  ]:)roj)erly  ])er- 
formed.  Symptoms  similar  to  those  of  division  may  occur  when  a  nerve  trunk  is  sm- 
rounded  and  compressed  by  l)one  callus  after  fracture,  as  when  th(>  ulnar  nerve  is  thus 
caught.  If  too  long  a  time  have  intervened  it  may  be  necessary  to  exsect  the  injured 
])ortion  and  then  bring  the  ends  into  aj)position  by  sutures.  Other  methods  of  atoning 
for  these  nerve  injuries  by  nerve  grafting,  etc.,  will  be  described  in  the  chapter  on  Surgery 
of  the  Peri|)heral  Nerves. 

Neuritis  may  be  overcome  by  counterirritation,  preferably  with  the  actual  cautery, 
i.  e.,  the  "flying  cautery,"  by  massage,  and  by  galvanization.  The  pain  in  many  of 
these  cases  can  l)e  mitigated,  if  not  completely  relieved,  by  the  .7"-rays,  or  by  the  high- 
fre(|uency  current.  In  some  cases  nerve  elongation  may  be  brought  to  bear  and  a  tender 
and  irritable  nerve  be  thus  brought  under  subjection. 

INJURIES  TO  MUSCLES  AND  TENDONS. 

Lacerations  or  divisions  of  muscles  are  usually  repaired  at  first  by  fibrous  tissue,  the 
result  of  organization  of  a  clot.  Later  a  true  muscle  regeneration  takes  place  and  muscle 
scar  finally  disa])pears.  Atrophy  of  a  muscle  is  not  a  sign  of  injury  directly  to  itself, 
but  often  results  from  injury  to  the  nerve  which  supplies  it;  for  example,  the  circumflex 
nerve  may  be  injured  in  shoulder  dislocations,  while  the  deltoid  muscle,  which  is  supplied 
by  it,  sjX'edily  undergoes  atrophy. 

Muscle  fibers  may  be  torn  by  violent  exertion.  Such  an  accident  may  be  followed  by 
pain  and  loss  of  function.  An  interval  can  often  be  telt,  even  from  the  outside,  between 
the  torn  muscle  ends.  The  injury  will  ])ro(luce  considerable  hemorrhage.  The  amount 
of  function  regained  in  a  muscle  will  (le])en(l  to  some  degree  on  the  extent  of  its  injury. 
If  it  have  been  injured  by  an  incised  wound  it  will  depend  upon  the  way  in  which  it  is 
brought  together  after  an  o{)en  incision.  The  origin  and  insertion  of  such  a  muscle 
should  be  a})j>roximated  by  proper  position,  and  so  maintained  by  the  dressings,  in 
order  that  perfect  rest  may  be  more  easily  maintained.  When  a  ])()rtion  of  the  fascia 
or  a[)oneurosis  is  torn  the  muscle  fiber  may  protrude  and  form  a  hernia  of  muscle. 

Tendons  often  suffer  from  contusion,  in  consequence  of  which  they  may  become 
adherent  within  their  tendon  sheaths;  this  leads  to  stiffness  of  the  part  and  more  or  loss 
loss  of  function.  Sometimes  they  calcify,  as  d(H\s  the  adductor  magnus  tendon  in  the 
formation  of  the  so-called  rider's  hone.  The  tendon  most  frecjuently  injured  is  that  of 
the  quadriceps,  near  the  knee. 

If  it  can  be  decided  that  a  tendon  has  been  divided  or  torn  across  its  ])rompt  reunion 
by  suture  should  be  always  prat-tised.  Also  a  divided  muscle,  if  exposed,  should  be 
drawn  together  with  sutures,  chromic  or  hardened,  so  as  to  make  them  more  reliable. 
Tears  of  aponeuroses  and  fascia^  should  also  be  sutured.  Tendon  suturing  is  nearly 
always  successful,  especially  if  it  can  be  done  in  a  cleanly  manner;  while  tendon  grafting 
is  a  measure  which  may  be  reserved  to  overcome  the  conse(|uences  of  injuries  to  muscles 
and  tendons  not  disposed  to  repair. 

INJURIES  TO  BONES. 

Aside  from  simple  and  compound  fractures,  which  are  essentially  bone  woimds,  there 
may  be  seen  hemorrhages  l)eneath  the  periosteum  or  in  the  immediate  vicinity  of  bones, 
which  are  usually  small  in  amount,  yet  may  cause  considerable  disturbance.  The 
traumatic  henuitoma  of  the  scalp  which  often  follows  delivery  is  an  illustration  of  an  injury 
of  this  class,  the  periosteum  itself  being  sometimes  separated.  Collections  of  blood  under 
these  circumstances  which  fail  to  disappear  by  absorption  may  be  in(  iscd  and  the 
contained  clot  turne«l  out. 


PLATE  X, 

FIG.  1 


Young  Granulation  Tissue  Following  Burn,    a,  aa,  thin-walled  capillaries.     Large  nuclei,  fibroblasts, 

horseshoe  nuclei,  leukocytes.      X  250. 
FIG.  2 


■^<&^^* 


Young  Scar.     Numerous  capillaries  parpendicular  to  surface.     Spindle  elements,  fibroblasts 
considerably  smaller  than  in  Fig.  1.      X  250. 

FIG.  3 


#.^z 


Mature  Scar.     Dense  fibrous  connective  tissue  with  a  few  fibroblasts.     At  a,  a  small 

bloodvessel.      X  250. 

Granulation  Tissue  organizing  into  Cicatricial  Tissue.     (Karg  and  Schmorl.j 

Illustrating  statements  made  on  several  of  the  foregoing  pages. 


CONTUSIONS  OF   THE   VISCERA  219 

CONTUSIONS  OF  THE  VISCERA. 

Contusions  of  tlu>  viscrra  niav  he  f(.ll..wc<l  l.y  nmi.y  an.l  .lisastrous  c-onscqucnros. 
They  compromise  s.icli  lesions  as  rui)tur('  of  the  liver,  kuiney,  spleen  laceration  ot  the 
bowel  bhulder  or  gall-hladder,  and  inav  occnr  hy  blows  which  do  not  break  the  snrtace; 
or  anv  of  the  viscera  niav  be  la<-erated.  pnnctnred,  or  flashed  by  i,nn.sho(,  punctured,  or 
incised  wounds.     These" will  be  more  completely  con.sidered  m  Chapter  XLV. 


CHAPTER    XXII. 

GUNSHOT  WOUNDS. 

Gunshot  wounds  are  usually  considered  with  the  special  s'ubject  of  military  surgery. 
Military  surgery  as  such,  however,  consists  in  the  application  of  general  surgical  princi- 
ples. Nevertheless  a  gunshot  wound  is  essentially  the  same  whether  it  be  received  upon 
the  battle-field  or  in  civil  life,  and  the  injury  inflicted  by  a  piece  of  flying  shell  is  in  no 
sense  different  from  that  which  may  be  received  in  a  blasting  accident. 

A  gunshot  wound  is  always  contused  and  lacerated,  and  often  ])unctured.  According 
to  its  size  and  shape,  its  location,  the  nature  and  velocity  of  the  missile,  the  distance  at 
which  the  weapon  was  discharged  will  dej)end  its  severity  and  ])rognosis. 

Shot  vary  in  size  from  those  which  weigh  but  a  fraction  of  a  grain  to  buckshot  which 
weigh  nearly  one-third  of  an  ounce.  Revolver  and  pistol  bullets  vary  in  diameter  from 
0.22"  to  0.45",  and  in  weight  from  twenty-five  grains  to  ten  times  that  amount,  and  nearly 
always  of  conical  form.  They  are  usually  made  of  compressed  lead,  sometimes  hardened 
by  the  addition  of  tin  or  antimony. 

The  old  military  weapons,  such  as  the  Springfield  rifle,  have  been  entirely  abandoned, 
and  for  them  have  been  substituted  rifles  of  smaller  bore,  projecting  bullets  of  from 
0.2.5"  to  0.31",  varying  in  weight  from  one-fourth  to  one-half  ounce  and  attaining  a  muzzle 
velocity  of  nearly  2500  feet  per  seecond.  They  have,  therefore,  a  much  increased  range 
and  may  kill  at  two  miles.  Their  trajectory  is  flatter  and  the  character  of  the  wound 
caused  by  these  modern  weapons  is  different  from  those  inflicted,  for  instance,  during 
the  Civil  War.  The  bullets  now  in  use  in  the  armies  and  navies  of  the  world  are  nearly 
all  encased  in  a  thin  covering  of  steel,  copper,  etc.,  which  is  known  as  the  jacket  or  mantle. 
They  are  from  3.5"  to  4"  in  length,  possessing  a  much  greater  range  than  a  shell  l)ullet, 
while  the  rifling  of  the  weapon  is  so  made  as  to  give  them  a  more  rapid  rotation.  In 
active  service,  moreover,  these  are  usually  fired  with  smokeless  powder.  The  so-called 
"dangerous  zone,"  i.  e.,  that  where  mounted  men  or  infantry  can  be  injured,  is  much 
wider  than  formerly. 

In  India  the  practice  has  been  introduced  of  leaving  the  point  of  the  bullet  uncovered 
by  the  mantle,  so  that  when  it  strikes  it  would  "mushroom" — especially  in  the  bone. 
These  "Dumdum  bullets,"  as  they  are  called,  from  the  place  of  manufacture,  inflict  much 
more  serious  injuries  than  do  the  relatively  smooth  perforations  made  by  the  others,  and 
have  been  considered  so  cruel  that  they  are  excluded  from  use  in  civilized  warfare. 

During  the  Russo-Japanese  war,  in  which  nearly  all  ])revious  records  were  broken, 
the  deaths  from  gunshot  wounds  constituted  but  a  small  ])r()})ortion  of  the  entire  loss  in 
camp  and  warfare,  a  larger  number  of  soldiers  dying  from  disease  and  exposure.  Statis- 
tics also  show  that  out  of  every  100  cases  of  gunshot  wounds  12  per  cent,  have  been  pro- 
duced by  bullets,  the  remaining  portion  being  caused  by  shell,  etc.  De  Nancrede  has  ei)ito- 
mized  some  interesting  figures  which  may  be  here  quoted:  In  the  United  States  army 
during  the  Spanish  war  4750  casualties  were  accurately  studied ;  of  these  wounds  of  the 
lower  extremities  constituted  nearly  33  per  cent.,  those  of  the  upper  extremities  nearly 
30  per  cent.,  those  of  the  trunk  a  little  over  22  per  cent.,  and  those  of  the  head  and  neck 
a  little  over  15  per  cent.  During  the  South  African  campaign  the  mortality  among  the 
wounded  was  5.7  per  cent.,  essentially  the  same  as  that  during  our  Cuban  and  Filipino 
campaigns,  and  in  marked  contrast  to  the  14  per  cent,  mortality  of  the  C'\x\\  War.  Con- 
sidering that  with  our  Mauser  weapons  the  trajectory  is  practically  flat  uj)  to  500  yards, 
and  they  may  kill  up  to  a  distance  of  two  miles,  it  will  be  seen  that  this  dift'erence  in 
figures  is  important.  The  British  discovered  in  their  campaign  against  the  Afghans, 
who  were  using  antiquated  weapons,  that  their  own  Lee-Metford  Ijullets  would  pass 
through  their  enemies  without  disabling  them,  while  the  British  soldiers  who  were  once 
struck  by  the  large,  soft -lead  bullets  of  their  antagonists  were  far  more  seriously  injured 
or  absolutely  disabled. 
(.220) 


auxsno'r  ikhwds 


221 


As  oiu'  I'xplaiiation  ol"  the  iiijurv  infli^ttMl  l)y  iiiodcni  projectiles  tliere  has  been 
advanced  the  theory  that  a  hiillet  witli  a  liiiih-inuzzle  velocity,  strikiii<(  an  object  while  it 
still  retains  most  of  its  orii^iiial  s|)e(>d,  compresses  and  forces  ahead  of  it  into  the  wounded 
tissues  a  small  column  of  air,  which,  exercisinjj;  an  expansive  force,  produces  more  or 
less  explosive  ett'ect,  that  may  be  seen  along  the  bullet  track  or  at  the  point  of  exit.  These 
ex|)l()sive  effects  are  proportionate  to  the  size  of  the  bull(>t,  its  bluntness,  and  its  velocity. 
This  theory  was  more  tenable  in  the  days  of  large  and  blunt  projectiles  than  today, 
for  in  time  past  exj)eriments  have  shown  that  when  a  bullet  is  dropped  into  water  from  a 
height  there  is  forced  into  the  water  along  with  it  a  certain  amount  of  air,  estimated  by 
Longmore  at  twenty  times  the  actual  volume  of  the  bullet  itself.  It  may  be  doubted, 
however,  whether  the  rifle  j)rojectiles  of  today  can  ))roduce  sufficient  air  j)ressure  to 
cause  the  destructive  effects  thus  attributed  to  it. 

Fig.  47 


«,  completely  shattered  after  perforating  a  horse's  thigh-bone  at  220  yards;  steel  mantle  stripped;  b,  ball  with 
mantle  torn  off  and  rolled  up,  core  deformed,  after  shattering  human  tibia  at  60  yards;  c,  wholly  disorganized 
ball,  which  destroyed  middle  metatarsal  bone  of  horse  at  660  yards,  steel-mantled;  d,  ball  which  shattered  a 
human  femur  at  about  750  yards,  steel-mantled;  e.  remains  of  steel  mantle  and  part  of  core  lodged  in  human 
femur,  wound  inflicted  at  about  1100  yards;  /,  q,  fragments  of  mantle  found  near  the  orifice  of  the  wound  of  exit 
at  about  1100  yards'  range,  steel-mantled;  h,  piece  of  steel  mantle  split  off  by  striking  a  dried  horse's  metatarsal 
at  over  1300  yards;  i,  steel-mantled  ball  which  perforated  the  internal  femoral  condyle  and  lodged  beneath  the 
skin  at  nearly  2200  yards.     (Recent  foreign  report.)     (De  Nancrede.) 


Another  method  of  accounting  for  shattering  eflfects  noted  in  many  of  these  wounds  is 
hydrotlynamic  ])ressure,  depending  upon  the  incompressibility  of  fluid  and  of  tissue  con- 
taining it,  and  the  narrowing  of  the  space  occupied  by  fluid  as  a  result  of  the  transfer  of 
pressure  in  all  directions.  Other  things  being  equal,  the  most  marked  eflfects  would  be 
manifest  in  organs  containing  the  most  fluid,  the  eft'ect  increasing  with  the  amount  of 
fluid,  the  speed  of  the  bullet,  its  size,  and  any  alteration  of  shape  which  it  has  undergone 
in  transit.  It  has  been  shown  that  the  hydrodynamic  pressure  of  steel-jacketed  modern 
bullets  varies  from  six  to  eight  atmospheres.  This  theory  accounts  for  the  peculiar 
destructive  eflfects  seen  in  the  brain,  the  heart,  the  stomach,  and  intestines  when  struck 
at  short  range. 

Another  method  of  accounting  for  the  results  of  a  bullet  wound  takes  account  of  the 
peculiar  effect  due  to  the  rapid  rotation  of  the  bullet,  the  movement  given  it  by  the  rifling 
of  the  barrel  from  which  it  is  fired.  It  appears  that  a  bullet  travelling  at  the  rate  of  620 
meters  per  second  will  average  about  four  rotations  per  meter.     Even  in  passing  through 


222  INJURY  AND  REPAIR 

a  human  body  this  wouhl  scarcely  give  it  hut  two  rotations  in  transit,  while  in  passinjr 
through  any  given  bone  the  force  would  be  too  slight  to  be  appreciable. 

While  the  theories  mentioned  above,  the  hydraulic  and  hijdrodipiamic,  are  attractive, 
yet  they  are  unsatisfactory;  we  can  do  little  more  than  sum  up  the  damage  done  by  a 
rifle  ball  as  due  to  arrest  and  divergence  of  its  energy,  penetration  depending  upon  its 
remaining  velocity,  its  })reservation  of  its  original  shape,  and  the  resistance  offered  Vjy 
the  part  injured.  If  the  latter  be  great,  and  its  shape  be  but  slightly  changed,  there 
are  pronounced  explosive  effects.  Moreover,  one  end  of  the  bullet  is  a  little  heavier 
than  the  other,  and  this  will  tend  to  produce  a  certain  amount  of  tilting,  by  which  a 
key-hole  wound  may  be  also  produced.  Fig.  47,  from  Ue  Nancrede,  shows  the  many 
alterations  in  shape  which  may  be  produced  under  various  circumstances.  Again, 
hard-metal  jackets  or  mantles  may  be  stripped  off  bullets  before  the  latter  reach  the 
body,  or  in  jjassing  through  it,  as  has  been  shown 

Bruns  has  shown  that  with  the  ordinary  small  arms  the  size  of  the  wounds  of  entrance 
and  exit  diminishes  with  the  decrease  in  velocity  or  increase  of  the  distance,  although 
allowance  should  be  made  for  the  manner  and  angle  at  which  the  bullet  strikes  the 
surface,  the  wound  being  circular  or  oval  according  to  these  conditions.  The  wound 
of  exit  will  depend  upon  the  direction  of  the  axis  of  the  bullet  at  the  instant  it 
leaves  it;  thus  it  may  be  oval  or  irregular.  When  the  bullet  in  transit  shatters  or 
comminutes  a  bone  the  wound  of  exit  may  be  made  much  larger  and  more  ragged 
than  otherwise.  In  a  general  way  Bruns  makes  the  statement  that,  other  things 
being  equal,  the  damage  inflicted  by  the  escape  of  a  projectile  from  the  body  varies 
according  to  distance  from  the  weapon.  Thus  up  to  fifty  meters  a  considerable  amount 
of  destruction  of  muscle,  etc.,  may  be  produced.  The  area  is  small  and  the  track  of 
the  bullet  is  smooth  and  little  larger  than  the  caliber  of  the  projectile.  Between  100 
and  300  meters  there  is  little  destruction  of  muscle,  and  the  wound  of  exit  is  smooth 
and  may  contain  some  bone  debris.  Thus  Brurs  would  make  it  appear  that  the  dis- 
tinguishable characteristics  of  near  and  distant  shots  apjiear  in  the  variations  to  be  noted 
between  the  wounds  of  entrance  and  exit. 

After  a  careful  study  of  the  alterations  in  the  shape  of  the  bullets  themselves,  Coler 
and  Schjerning  reported  at  the  Twelfth  International  Medical  Congress  that  only 
in  4.5  per  cent,  of  all  hits  does  deforming  of  the  bullet  occur;  if  hits  in  the  bones  only 
are  considered,  the  percentage  would  be  much  greater.  In  wounds  of  the  other  parts 
alone  there  is  rarely  any  deforming  effect  upon  the  projectile.  They  also  show  that 
careful  distinction  must  be  made  between  the  deformity  of  the  bullet  caused  by  the  body 
and  that  resulting  from  impact  upon  some  object  before  reaching  the  body.  Thus 
if  a  bullet  have  first  struck  a  branch  of  a  tree,  or  some  object  upon  the  ground,  it  may 
have  become  so  altered  in  shape  as  to  correspond  almost  to  a  Dumdum  bullet.  The 
harm  done  by  such  a  ricochet  shot  depends  upon  its  unexpended  energy  and  its  altered 
shape,  but  will  always  be  greater  than  if  it  had  struck  in  the  direction  of  its  long 
axis. 

The  question  of  the  heat  imparted  to  a  projectile  in  its  course  and  the  possibility  of 
its  being  sterilized  by  such  heating  are  questions  which  have  been  carefully  investigated. 
The  heat  of  a  bullet  produced  by  penetration  into  a  hard  material  will  depend  upon  the 
striking  distance  and  the  density  of  the  material.  In  the  human  tissues  the  heat  attained 
by  a  bullet,  even  when  penetrating  a  bone  at  short  range,  is  rarely  100°C.,  while  at  long 
range  it  will  scarcely  amount  to  half  of  that.  There  is  no  accurate  measure  of  the  heat 
that  may  be  engendered  in  its  passage  through  the  atmosphere,  but  the  question  is  one 
of  interest,  in  that  it  brings  up  the  possible  sterilization  of  the  bullet  and  its  capacity 
for  destroying  such  septic  material  as  it  may  carry  in  with  it.  A  series  of  experiments 
made  in  Baltimore  and  elsewhere  permit  the  following  conclusions  to  be  drawn: 

1.  The  majority  of  cartridges  in  their  original  packages  are  free  from  septic  germs, 
this  freedom  being  due  to  the  precautions  observed  dring  their  manufacture. 

2.  As  a  result  of  this  cleanliness  the  majority  of  gunshot  wounds  are  not  septic. 

3.  Such  resistant  germs  as  those  of  anthrax,  when  applied  to  the  small  bullet  of  a 
hand  weapon,  are  rarely  completely  destroyed  by  the  act  of  firing,  and  it  is  possible 
to  infect  an  experimental  animal  with  such  a  projectile. 

4.  The  ordinary  germs  of  sui)puration  are  not  always  destroyed,  and  may  also  cause 
infection. 

These  conclusions  may  be  epitomized  in  these  two  statements:  that  bullets  from 


(;vssu()T  worsDs  223 

small  liaiid  weapons  arc  not  ncf-cssarily  stcrili/x'd  Ity  tlic  act  ot"  (iriiij,',  and  that  tlicv  also 
may  infect. 

'riu'  princijial  features  (o  he  note«l  in  a  case  of  <funsliot  wound  arc  the  following: 

1.  Ilemoirliage. 

2.  Shock. 
:i.   I*ain. 

4.  Powder  hurn. 

5.  Locali/,in<^  symptoms. 
().   I\lulti|)licity  of  wounds. 

7.  Entrance    of    foreign    material. 

8.  Explosive'  effects. 

!).   Perforation  of  large  ve.s.sels  and  the  viscera. 

1.  Hemorrhage. — Hemorrhage  may  be  internal  or  external.  When  internal  it  i.s 
rarely  so  accessible  as  to  j)erinit  of  the  saving  of  Hfe,  yet  the  eflort  should  be  made  to 
a.seertaiii  the  source  of  the  hemorrhage,  as  only  in  this  way  can  life  be  saved.  For 
example:  A  j)atient  may  bleed  to  death  from  injury  to  an  intercostal  artery,  an 
epigastric,  etc.,  while  in  either  case  a  very  simple  expedient  would  tend  to  save  life. 
External  hemorrhage  is  gen(>rally  due  to  injury  of  main  vessels,  and  may  end  fatally 
unless  first  help  l)e  instantly  rendered.  Since  the  introduction  into  the  army  of 
a  trained  hospital  corps,  and  a  widespread  diffusion  of  a  kn^nvlcdge  of  "first-aid 
dressings,"  this  is  much  less  likely  to  occur  than  in  the  days  ))rcvious  to  the  use  of 
the  emergency  packet.  Recent  military  experiences  have  been  that  hemorrhages  from 
limb  ves.sels  are  much  more  likely  to  subside  spontaneously  than  those  of  the  viscera. 

2.  Shock. — Shock  is  present  in  a  large  proportion  of  gunshot  injuries,  especially 
those  of  the  viscera  and  the  region  of  the  spine.  Experienced  army  surgeons  speak 
of  the  peculiar  facial  expression  in  those  eases  of  shock  which  demand  immediate 
attention. 

3.  Pain. — The  symptom  of  pain  is  exceedingly  variable.  It  is  rarely  complained  of  at 
the  time  of  infliction,  esjx'cially  when  the  individual  is  laboring  under  stress  of  excite- 
ment. The  pain  of  a  wound  will  be  increased  by  every  movement  of  the  body.  When 
momentary  pain  is  followed  by  local  anesthesia,  and  especially  if  the  latter  be  permanent, 
it  will  indicate  the  division  of  a  nerve  trunk,  which  will  justify  an  operation  for  exposure 
of  the  site  of  the  injury  and  nerve  suture. 

4.  Powder  Bum. — Powder  burn  is  met  with  only  as  one  of  the  complications  of 
a  short  range  and  injury  of  an  exposed  part.  Its  degree  is  modified  by  the  distance  of 
the  injured  part  from  the  muzzle,  by  the  character  of  the  powder,  and  the  dimensions 
of  the  barrel.  Fish  has  shown  that  in  a  pistol  wound  at  short  range  the  burning  or 
scorching  effects,  which  he  calls  the  ''brand,"  are  always  found  on  the  hammer  side  of 
the  weapon  which  inflicted  the  w'ound,  i.  e.,  if  the  hammer  were  held  up  the  brand  would 
be  above  the  entrance  wound.  The  bullet  wound  in  such  a  case  shows  the  direction 
of  the  aim,  but  the  recoil  will  so  far  change  the  direction  of  the  barrel  as  to  divert  the 
stream  of  gases  of  combustion,  so  that  they  follow  the  new  direction  of  the  barrel,  which 
is  always  toward  the  side  of  the  hammer.  This  is  a  point  in  medical  jurisj)rudence 
which  has  been  testified  to  in  the  courts.  The  u.se  of  smokeless  ])owder  minimizes 
any  effect  of  this  kind.  It  has  been  claimed  that  a  homicide  has  been  recognized  in 
the  dark  by  the  flash  of  the  old-fashioned  gunpowder  u.sed  in  the  weapon,  but  the  use 
of  smokeless  powder  would  obviate  this  possibility.  The  most  distinctive  part  of  a 
powder  burn  is  the  appearance  of  the  tattooing  caused  by  the  lodgement  imder  the  skin 
of  grains  of  unconsumed  powder.  Such  grains,  when  accidentally  or  pur|)o.sely  con- 
taminated with  germs,  are  not  purified  by  the  act  of  firing.  This  is  less  true  of  certain 
brands  of  smokeless  powder.  Nevertheless  the  opinion  prevails  that  gunpowder  may 
serve  for  conveyance  of  infection.  The  so-called  smokeless  powders  are  of  .secret  com- 
position, although  it  is  known  that  in  a  general  way  they  are  composed  of  gun-cotton, 
dynamite  (i.  e.,  nitroglycerin),  or  picric  acid.  INIelinite  is  compcrsed  of  picric  acid  and 
collodium — /.  e.,  gun-cotton.  There  are  many  of  the  modern  ex])losives  which  depend 
for  their  final  effect  U|)on  the  combination  of  two  or  more  substances.  In  the  smokeless 
powers  there  is  usually  enough  nitroglyc-erin  to  have  a  very  noticeable  effect  should  they 
be  touched  to  the  tongue,  while  even  the  fumes  might  be  disagreeable  or  disabling. 

5.  Localizing  Symptoms  Due  to  the  Presence  of  the  Bullet. — The  greater 
the  distance  and  the  smaller  the  velocity  the  more  likely  is  a  bullet  to  lodge  within  some 


224  INJURY  AM)   REPAIR 

j)()rtif>n  of  tho  Ixxly  instead  of  passinj^  throiifjli  it.  Ii;  tlic  r'uhaii  c'am{)aign  the  pro- 
portion of  cases  of  lodgement  was  less  than  10  per  cent,  of  the  entire  nuinl)er  of  bullet 
wounds.  A  bullet  which  rests  within  the  l)ody  either  will  or  will  not  produce  disturbances 
which  may  he  more  or  less  lasting.  In  a  large  proi)ortion  of  cases  the  latter  will  prevail. 
The  number  of  pensioned  soldiers  who  are  carrying  unremoved  bullets  in  some  portions 
of  their  body  is  by  no  means  small.  A  riHe  bullet  may  remain  in  certain  portions  of 
the  cranium  without  producing  much  disturl)ance.  BuUct.H  ivhich  cause  no  trouble  are 
best  left  undisturbed.  Those  which  produce  serious  symptoms  should  he  removed.  To 
Esmarch  is  attributed  the  dictum  that  the  harm  produced  by  a  bullet  i.s  usually  done 
during  its  passage,  and  after  it  has  found  lodgement  it  ceases  to  be  a  source  of  trouble. 
While  not  invariably  true,  this  is  so  generally  the  ca.se  that  acceptance  of  this  .statement 
has  revolutionized  the  previou.sly  prevailing  view,  i.  r.,  that  a  bullet  should  be  always 
removed  if  it  l)e  possible  to  locate  and  extract  it.  In  some  instanc-es  it  may  be  located 
by  a  .study  of  the  .symptoms;  as,  for  instance,  in  certain  areas  of  the  brain,  or  when  lying 
in  close  proximity  to  joint  surfaces  it  interferes  with  their  function;  although  a  bullet 

Fk;.  48 


Multiple  shot  wounds  of  arms  and  back.      The  ulcer  o\  er  the  spine  was  produced  by  pressure,  not  by  the 
ball  (case  in  Cincinnati  Hospital,  1884;.     (Conner,  Dennis'  System  of  Surgery.) 

embedded  in  bone  often  does  not  .seriou.sly  interfere  with  the  use  of  the  affected  part. 
The  bullet  which  divides  a  nerve  trunk  rarely  lodges  in  such  position  as  to  be  considered 
when  the  repair  of  the  nerve  injury  is  undertaken;  such  wounds  will  generally  be  found 
to  be  perforating. 

6.  Multiple  Wounds. — The  same  bullet  may  sometimes  inflict  multiple  wounds,  and, 
with  modern  projectiles,  these  are  now  more  common,  as  many  as  six  wounds  having  been 
made  by  one  mi.ssile  in  its  pa.s.sage,  e.  g.,  wounds  of  the  arm  and  body.  Thus  multi- 
plicity of  wounds  may  not  indicate  that  the  patient  has  really  been  shot  more  than  once. 
In  cases  of  perforation,  for  each  wound  of  entrance  there  should  be  found  one  of  exit, 
and  at  the  first  examination  of  the  patient  the  discovery  and  consideration  of  each 
of  these  injuries  should  be  part  of  the  routine.  If  on  examination  but  one  wound  be 
discovered,  then  the  inference  is  natural  and  unavoidable  that  the  bullet  is  still  within 
the  patient's  body  (Fig.  48). 

7.  Entrance  of  Foreign  Material.  The  entrance  of  fragments  of  cloth  or  other 
extraneous  matter  is  now  less  frequent,  for  bullets  of  tremendous  velocity  rarely  carry 


GUNSHOT    WOUXDS  225 

ill  any  [K'ncpiiblc  material,  llicir  (liaiiiclcr  Ix'iiijf  .small  and  tlicir  siirtaccs  pojislu'd. 
A  ricorlu't  hullct  may  carry  tetanus  or  other  spores  i'rom  the  earth,  and  lockjaw  may 
!)('  the  result.  In  other  words,  <runshot  wounds  now  are  less  likely  to  hecome  infected 
wounds  iliaii  llicy  wvvv  years  a<;o. 

S.  Explosive  Effects.  'I'he  shattcriii<r  and  explosive  elVects  of  the  impact  of  bullets 
upon  certain  of  the  viscera  are  sometimes  disastrous,  and  yet  not  easily  seen  from  the 
outside.  This  is  e.s|K'eially  true  in  the  brain,  heart,  liver,  sj)leen,  kidneys,  and  bones. 
Almost  comi)lete  j)ul|)ificati()n  of  the  semisolid  viscera  may  occur  as  the  result  of  perfora- 
tion by  a  small  missile,  and  the  (general  condition  of  the  patient  should  be  reliecj  upon 
to  indicate  this  fact. 

9.  Perforation  of  the  Large  Cavities  of  the  Body  usually  implies  perforation  of 

at  least  a  |)()rli()ii  of  their  contained  viscera,  'riiiis  if  a  man  be  shot  tlirouji|;h  the  chest 
it  may  be  assumed  that  j)erforation  of  the  lun<f  has  occurred,  while  in  a  case  of  bullet 
wound  of  the  abdomen  it  will  rarely  be  found  that  the  viscera,  esj)ecially  the  intestines, 
have  escaj)e(l  |)erforati()n.  Still,  remarkal)le  ca.ses  are  occasionally  recorded.  "^I'lius 
1  have  seen  a  man  who  had  been  shot  through  the  abdomen  from  front  to  back,  the 
bullet  entering  just  above  the  pubi.s  and  escaping  near  the  lumbar  sj)ine,  who  never 
seemed  to  have  sufi'ercd  .seriously  from  his  injury,  although  the  bullet  was  a  large  soft 
one  from  the  old  Sj)ringfield  musket. 

Diagnosis. — More  or  less  characteristic  appearances  pertain  to  most  wounds  of 
entrance  and  of  exit,  which  render  them  reasonably  distinct  and  recognizaljlc,  even 
though  no  history  be  obtained.  Nevertheless  much  depends  U|)on  distance,  velocity, 
and  any  deformation  of  the  bullet  due  to  its  impact  upon  some  other  substance  [)revious 
to  its  entering  the  body.  An  elongated  wound  may  suggest  that  the  direction  of  the 
bullet  w^as  at  an  angle  with  the  surface  struck.  Such  wounds  are  known  as  "key-hole" 
wounds.  A  bullet  already  deformed  may  inflict  a  wound  that  will  baffle  sjjeculation. 
The  wound  of  exit  is  usually  a  little  larger  than  that  of  entrance.  When  much  larger  a 
bone  lesion  should  be  expected.  Trifling  punctures,  perhaps  made  by  particles  of  the 
bullet,  may  be  found  aroimd  the  principal  wound  or  in  the  bone  which  it  has  shattered. 

Diagnosis  may  include  a  recognition  not  merely  of  the  general  character  of  the  injury, 
but  whether  it  was  inflicted  by  one  or  more  bullets;  whether  these  bullets  have  escaped; 
and  if  not,  in  what  part  they  are  probably  lodged.  In  the  preanti.septic  days  much  of 
this  information  was  gathered  by  the  use  of  the  probe,  and  the  porcelain-tipjied  probe 
devised  by  Nelaton  was  relied  on  for  much  more  than  it  could  possibly  safely  tell.  In 
those  days  probing  was  indiscriminately  practised,  and  accomplished  more  harm  than 
good.  Now  the  probe  is  rarely  used,  at  least  at  first,  and  when  used,  it  is  connected  with 
some  electrical  device  by  w^hich  results  are  attained  with  a  minimum  of  handling.  For 
this  purpose  the  telephone  probe  of  Girdner  was  formerly  a  popular  and  ingenious 
device,  which  has  been  more  recently  supplanted  by  a  simpler  mechanism  by  which,  when 
the  end  of  the  probe  comes  in  contact  with  metal,  a  little  bell,  or  buzzer,  is  rung.  No 
probe  or  other  instrument  should  be  introduced  into  a  gunshot  wound,  for  diagnostic 
or  other  purposes,  without  observing  aseptic  precautions. 

The  mo.st  valuable  expedient  for  the  detection  and  location  of  bullets,  as  of  other 
foreign  bodies,  is  the  Rontgen  ray.  With  a  suitable  apparatus  of  this  kind  the  surgeon 
can  not  only  decide  as  to  the  location  of  the  missile,  but  whether  it  is  best  to  attempt 
an  operation  for  its  removal. 

Prognosis. — In  gunshot  wounds  not  speedily  fatal  the  prognosis  depends  upon  the 
part  injured,  the  size  and  shape  of  the  missile,  its  velocity,  the  distance  from  the  weapon, 
the  amount  of  blood  lost  before  attention  was  given,  the  character  of  the  attention 
first  received,  and  the  absence  of  such  complications  as  exposure,  rough  handling, 
etc.  The  dictum  that  the  fate  of  a  wounded  man  is  in  the  hands  of  the  surgeon  who  first 
attends  hivi  made  its  author,  Esmarch,  famous.  The  patient  having  escaped  the 
dangers  of  hemorrhage  and  shock  is  to  be  carefully  guarded  from  sepsis,  and  if  thus 
guarded  can  be  protected  against  most  of  the  other  visible  dangers  save  those  due  to 
perforations  of  large  cavities.  If,  therefore,  a  gunshot  wound  can  be  promptly  provided 
with  a  primary  a.septic  or  antiseptic  dressing,  and  in  other  respects  be  let  alone,  the 
outlook  for  the  patient  will  be  encouraging.  The  jirognosis  often  depends  upon  how 
completely  the  patient  is  let  alone  after  the  application  of  occlusive  dressing. 

Treatment. — Hemorrhage  is  the  first  consideration,  and  should  be  the  first  care 
of  the  surgeon.  Digital  pressure  may  be  resorted  to,  which  may  suffice  until  a  tem- 
15 


226 


IS.IUliY   AM)   h'h'/'A/h' 


j)<)rarv  (\\|)(Mli«"iit  li;is  hccn  supplied.  Next  in  iiii|)()rl;iiH('  is  (lisiiij'cction  of  the  area 
surroundiiig'  the  wound  and  the  apijUcutiou  of  u  sterilized  ahsorheiit  (h-essing,  with 
pressure  to  j^revent  h)ss  of  blood.  The  use  of  the  prolx",  or  any  attempt  to  at  once  ascer- 
tain the  location  of  the  bullet,  is  not  advisable.  The  (juestion  is  not,  "Where  is  the 
bullet?"  but,  ''How  much  harm  ha.s  it  alrcadij  done!'"'  And  the  first  attention  should 
be  addressed  to  atoning  for  any  harm  that  may  have  been  done.  Even  though  the 
intestines  have  been  perforated,  or  the  heart  wounded,  there  is  no  need  in  doing  any- 
thing more  than  meeting  the  immediate  emergency.  If  shock  be  extreme  it  may  be 
atoned  for  in  some  measure  by  lowering  the  head  and  bandaging  the  extremities;  while 
in  extreme  cases  hypodermoclysis  or  venous  infusion  of  saline  solution,  often  with  the 
addition  of  a  little  adrenalin,  will  be  of  service. 

Again,  physiological  rest  of  the  part  injured,  /.  r.,  iiniiiohi/izafioit,  as  well  as  absolute 
rest  of  the  j)atient's  body  and  mind,  must  not  be  neglected. 

Primary  laparotomy  has  been  done  upon  the  battle-field,  and  is  of  itself  a  testimony 
to  the  intrepidity  and  zeal  of  those  who  have  done  it;  yv{,  as  a  practice,  it  is  to  be  con- 
demned. AH  operations  uj)on  gunshot  wounds  shoidd  be  done  in  a  well-equipped 
hospital. 

P'iG.  49 


Cunshot  wound  of  forearm.      Bullet  in  situ  in  bone. 


The  i^robing  of  l)ullct  wounds  is  so  unwise  that  it  may  be  well  to  state  the  reasons  for 
its  general  condemnation : 

1.  As  it  used  to  be  practised,  neither  probe  nor  skin  nor  the  operator's  hands  were 
sterilized. 

2.  Even  when  carefully  done  it  is  often  absolutely  disappointing,  the  ])robe  failing 
to  reveal  the  presence  of  the  bullet. 

3.  By  the  time  the  j)rol)c  is  introduced  the  wound  will  be  usually  more  or  less  filled 
with  blood  clot.  To  stir  this  with  a  ])robe  is  to  invite  a  secondary  hemorrhage  or 
annoying  oozing. 

4.  Even  when  properly  used  the  probe  may  carry  in  infectious  material  from  the 
surface. 

5.  Most  wounds  made  by  modern  bullets,  even  jiistol  bullets,  are  of  such  a  character 
that  it  is  difficult  to  follow  their  track  without  using  force. 

6.  I  have  known  a  woimd  on  the  anterior  surface  of  the  body  to  be  probed  for  a  bullet 
that  had  escaped,  as  shown  by  an  examination  of  the  other  side  of  the  body,  wdiich 
the  attendants  had  failed  to  search. 


(ivxsiior  woe M)s 


227 


7.  ir  iIhtc  I)c  ^()()(|  rcjisoii  for  (■\|)|()i-.il ion  of  ;i  wound  |ci  ii  he  |)ost |)on('(|  until  the 
sur<j;('«)U  is  prepared  to  follow  a  linllci  and  extract  it.  W'hni  il  (lacs  iml  <-(ill  jor  extraction, 
it  (Iocs  not  cdl!  for  prohinij. 

S.  'I'lie  best  prohe  is  the  siirt^eou's  lin<,rer,  and  for  its  use  the  patient  <,'enerallv  re(|uires 
an  anesthetic  and   free  iueision. 

When  ninscle  is  torn  and  needs  suturini,',  or  when  tendons  or  nerves  are  divided  and 
need  the  same  resource;  when  hones  are  shattefed  and  fra<,nnents  need  to  he  removed- 
when  the  skull  has  heen  fractiifed  and  |)ortions  of  hone  driven  into  or  upon  the  ijrain; 
when  the  intestines    have  heen    perforated;    when   even   the  heart    has   heen    wounded 


Fig.  51 


Wound  iufiifted  at  loOl)  yards  by 
.steel-maiitled  ball  (fnjin  a  recent 
foreign  re]}ort).     (De  Nancrode.) 


Shattering  of  humerus  at  long  range  with  modern  projectile;  fusible 
metal  cast  showing  extent  and  character  of  laceration  of  soft  parts 
(from  a  recent  foreign  report). 


and  the  pericardium  is  filling  with  blood  so  that  the  heart's  action  is  becoming  impeded; 
in  ar.y  or  all  of  these  emergencies  the  patient  needs  surgical  relief.  But  this  should  be 
of  a  kind  that,  save  in  an  emergency,  should  be  postponed  until  suitable  preparation 
can  be  afforded. 

In  regard  to  regional  indications  in  the  treatment  of  gunshot  wounds  it  will  only  be 
possible  here  to  give  some  brief  general  hints,  the  reader  being  referred  to  the  chapters 
on  Regional  Surgery  for  more  specific  instructions.  Nearly  all  ginishot  wounds  of 
bones  are  compound  fractures,  and  are  comminuted  as  well.  The  best  treatment  is 
primary  aseptic  occlusion  and  immbolization,  without  effort  in  the  direction  of  explora- 
tion. In  an  open  wound  the  vessels  should  be  secured,  loose  pieces  of  bone  removed, 
and   jagged   bone   ends   trimmed;   while   in   some   instances  a  wire   suture  or  other 


228 


INJURY  AND  REPAIR 


mechanical  expedient  may  be  resorted  to  with  advantao;(\     Provision  should  also  be 
made  for  drainaoje. 

In  the  regions  of  tlie  large  joints  the  same  general  principles  are  applicable.  Under 
the  old  regime  a  gunshot  wound  of  the  knee  would  condenni  a  |)erson  to  am])utation 
in  the  middle  of  the  thigh.     Now,  if  such  a  limb  be  promptly  provided  with  suitable 


Fk;.  52 


Perforating  bullet  wound  of  head,  wound  of  exit  showing  braird  protrusion.     Sloughing  pressure-sore  of  scalp. 
Complete  paralysis  of  motion  and  loss  of  sjjeech.     Battle  of  Mukden.     (Major  Charles  Lynch.) 

Fig.  53 


Perforating  bullet  wound  of  head,  with  prolapse  of  brain  at  wound  of  entrance.     Oi)Pration  done  in  Russian 
Ued  Cross  Hosi)ital  at  Mukden.      Left  hemiplegia;   mind  clear.      (Major  Charles  Lynch.) 

antiseptic  dressing,  and  placed  at  rest,  the  patient  may  save  not  only  the  limb,  but  the 
u.se  of  the  jomt.  Extensive  comminution  may  call  for  excision.  Amputation  is  .seldom 
necessary,  except  when  important  bloodvessels  have  been  divided. 

About  the  head  may  be  seen  all  varieties  of  gunshot  wounds  and  their  complications. 
The  bullets  from  small  weapons  may  not  penetrate,  but  those  from  larger  ones  usually 
penetrate  and  sometimes  perforate.     Infection  is  not  an  uncommon  sequel  to  all  of 


PLATE  XITI 


Radiograph  of  Head  viewed  from  the  Left  Side,  showing  Mauser  Bullet  Lodged  in 
Brain.     (Surgeon-General's  Report  on  Use  of  Rontgen  Ray,  1900.) 


avxsiiOT  wnuxDS 


220 


[Uvsv  injuru's,  rvfii  if  inv()l\in<,'  tlic  skin  alone;  the  skull,  csiK-cially  tlu-  (lij)l(H';  tin-  iiicin- 
braiies,  or  the  brain  itself.  (See  C-hai)ter  XXXW)  Sej)tie  eonij)li"eations  are  more  likely 
to  oeeur  in  j)roj)ortion  to  (iisreij;ani  of  antiseptic  precautions  in  the  first  treatment. 
Usually  the  most  .serious  head  injuries  are  tho.se  connected  with  |)enetratinff  bullets. 
Sometimes  the  skull  underifoes  extensive  shatterini;,  and  occasionally  the  base  is  frac- 
tured. Instantaneous  death,  such  as  occurs  when  a  soldier  is  beheaded  by  a  cannon 
ball,  sometimes  causes  a  peculiar  cataleptic  ri<j;idity,  which  is  a  sjH'cies  of  inmiediate 
postmortem  rigidity,  by  wiiich  a  body  may  be  maintained  in  the  position  it  occupied 
when  struck.  Obviously,  lesions  at  the  base  are  still  more  serious  than  tho.se  of  the 
vertex,  and  wounds  of  tlu>  cerel)rum  are  nearly  always  fatal.  I  have  .seen  a  number  of 
men  who  had  been  shot  entirely  through  the  head — by  IMau.ser  or  smaller  bullet.s— who, 
nevertheless,  recovered  more  or  less  completely.  In  one  soldier,  I  recall,  the  bullet 
traversed  an  orbit  in  such  a  way  as  to  divide  the  oj)tic  nerve.  He  was  blinded,  but  recov- 
ered most  of  his  other  functions;  he  remained  well  for  some  years,  and  then  developed 
symi)t()ms  of  in.sanity.  E])ilcpsy  and  other  psychical  disturbances  are  all  more  or 
less  fre(iuent  after  head  injuries.  Plate  XTII  illustrates  how  a  bullet  may  be,  apparently, 
harmlessly  cml)ed(lc(l  in  the  interior  of  the  cranium.  Sometimes  years  after  such 
injuries  active  symptoms  make  their  first  ap])earance.  There  can  be  no  question  as  to 
the  value  of  the  information  usually  afi'orded  in  such  cases  by  the  aid  of  the  a:-rays. 


Fici.  54 


Perforating  gun>hot  wound  of  head;   two  wouiid.s  converted  into  one  by  removal  of  comminuted  bone. 
P"rom  Russian  Red  Cross  Hospital,  Mukden.      (Major  Charles  Lynch.) 

The  same  necessity  exists  here  as  elsewhere  for  primary  antiseptic  occlusion,  including 
careful  shaving  and  cleansing  of  the  scalp.  Inasmuch  as  nearly  every  gunshot  wound 
of  the  skull  calls  for  subsequent  operation — just  as  does  almost  every  compound  fracture 
— the  parts  should  be  prepared  for  it  early,  and  everything  else  should  be  left  until 
the  time  when  the  surgeon  is  ready  to  make  a  complete  operation  and  meet  all  the  indi- 
cations. In  such  a  case  hemorrhage  may  be  temporarily  checked  by  tampon.  The 
surgeon  should  not  omit  to  take  advantage  of  all  the  information  which  a  studv  of 
cerebral  localization  mayafTord  him,  since  localizing  symptoms  may  reveal  not  only  the 
course  of  a  bullet,  but  .something  regarding  its  location. 

Penetrating  iconnds  of  the  jaee  are  less  serious  than  those  of  the  cranium  proper. 
Occasionally  a  bullet  .striking  a  tooth  will  displace  it  and  drive  it  in  .some  other  portion 
of  the  face,  e.  g.,  the  tongue.  Bullets  and  loose  pieces  of  bone  should  be  removed  in 
wounds  of  the  face.  Hemorrhage  can  usually  be  controlled  by  tampons.  Interdental 
splints  may  often  be  u.sed  to  advantage,  and  in  every  case  where  the  mouth  has  been 
injured  antiseptic  mouth-washes  should  be  frequently  used;  in  the  ease  of  the  nose,  an 
antiseptic  spray  should  be  employed. 

The  7ieck  is  often  penetreated,  but  if  the  spine  and  the  important  ves.sels  and  nerve 
trunks  escape,  little  apparent  damage  may  be  done.  If  infection  occur  and  suppuration 
take  place  resulting  abscesses  should  be  opened  promptly,  as  they  might  migrate  into 


230  INJURY   AND  REPAIR 

the  thorax  or  axilla.  Even  in  tlir  neck  bullets  which  arc  pnxluciiijr  no  (hsturhaiicc 
need  not  l)e  disturbed;  but  if  positive  irritation  or  |)aral_vsis  be  caused  by  them  ilu  v 
should  be  removed.  Wounds  of  the  larynx  or  trachea,  by  involving  the  parts  in  subse- 
quent stricture,  may  call  for  trachcolomy. 

Fig.  55 


Result  of  acci(iet,tal   explosion  of  Ii.tikI  serenade,  in  a  Chinese  coolie    with    Fouitli    Division  of  .Tai)anese  Army, 

near   Mukden.      (Major  Lynch.) 


Fig 


Shrapnel     wound 
amiiutation.   .Japaiiese  soldier 


GiinfiJwt  wmiii(J.<}  of  ilir  .ypiiui/  column  below  the 
neck  are  often  complicated  by  perforations  of  the 
thorax  or  of  the  abdomen.  So  far  as  the  spine  is 
concerned  the  ]:)rincipal  question  is  regarding  the 
injury  to  the  cord  itself.  In  rare  instances  cerebro- 
spinal fluid  escapes  from  the  wound;  hemorrhage,  or 
even  the  })()ssil)ility  of  air  entering  the  canal,  is  a 
more  common  possibility.  I  have  seen  perforation 
of  the  spinal  canal,  in  connection  with  penetration 
of  the  thorax  and  lung,  so  that,  after  the  operation 
of  laminectomy,  air  escaped  thnnigh  the  bullet  wound 
in  the  spine  with  each  inspiration  and  expiration. 
Infection  in  spinal  injuries  is  always  to  be  feared 
and  caution  should  be  observed  regarding  the  main- 
tenance of  asepsis.  The  indications  for  laminectomy 
scarcely  differ  from  those  in  other  injuries  to  the  cord. 
(See  chapter  on  the  S]:)ine.) 

JVoinnls  of  the  iJiorax  are  more  likely  to  be  pene- 
trating than  formerly,  owing  to  the  conical  shape 
and  greater  velocity  of  even  small-arm  bullets. 
Emphysema  does  not  necessarily  imply  perforation 
of  the  lung,  as  air  may  enter  through  the  external 
wound  with  each  resjiiratory  effort.  When  an  imag- 
inary line  connecting  the  wounds  of  entrance  and  exit 
would  natm-ally  pass  through  the  lung,  it  may  be 
assumed  that  this  visciis  has  been  perforated.  Signs 
indicating  such  lung  injuries  are  peculiar  ])ain,  dis- 
order of  the  respiration,  more  or  Itvss  cough,  usually 
with  raising  of  l)lood;  when  the  pleural  cavity  is  more 
or  less  filled  with  blood  there  will  be  signs  of  pressure 
on  the  lung  from  presence  of  fluid.     In  other  words  a 


r.ocessitafnr  ],  j,^,^  ^^,^,„^j  ^^f  ^|^p  ]        ^^,|i]   ^s^mlly  lead  to  a  more 

r  at  battle  of  ,  ,  .  "      „  . '•      i        i 


Mukden.      (Major  Lynch.) 


or  less  com])lete  picture  of  traumatic  hydropneumo- 
thorax.  Sometimes  external  hemorrhage  is  severe, 
even  though  it  come  from  an  intercostal  or  internal  mamm-irv  vessel;  usually  the  blood 
from  these  vessels  escapes  wiihin  the  thorax.     I  have  known  an  intercostal  artery  to 


GUNSHOT   W'OCXDS 


231 


1)(^  divided  hy  a  siumII  pistol  l)ulk'l  which  scai'ccly  penetrated  tlie  tiiorax  of  a  man, 
who  died  in  eoiiset|iUMice,  when  the  insertion  of  a  small  tam|)oii  would  have  eheeked 
tiie  heinorrhat2,e  and  saved  his  life.  Liiiiij;  tissue  rarely  hleeds  seriously.  When 
henu)rrlia<i'e  is  from  the  lun<;!;  it  comes  from  a  divided  vessel  of  some  size.  A  collection 
of  l)lood  in  the  chest  is  subject  to  the  dan<rer  of  infection,  and  em])yema  is  a  frequent 
but  somewhat  delayed  consecjuence  of  gunshot  wounds  of  the  chest;  while  abscesses  in 
the  luuii'  or  mediastinum  occasionally  n^sult. 

To  the  priiiKtri/  orrluxioti,  which  should  be  the  jirsf  (ittniliot)  f/iriii  to  rrcri/  Inil/ct 
wound  ()/'  ilic  fhora.r,  tluM'c  may  be  a<id(>d  complete  inunobilization  of  the  chest.  Fluid 
already  |)rescnt,  unless  it  be  clotted  blood,  may  be  withdrawn  by  aspiration.  Traumatic, 
not  to  say  septic  j)neumoiiia,  is  a  si-rious  com|)lication.     Should  any  o|)ei-ation  be  called 


Result  of  frostbite  without  gunshot.     After   battle  of   Mukden.      (Major  Lynch.) 

Fig.  58 


Result  of  frostbite  after  two  days  and  nights  of  exposure.     .4fter  liattle  of  ]\[ukden.     (Major  Lynrh.) 


for,  like  removal  of  fragments  of  rib  or  the  checking  of  hemorrhage,  it  is  be.st  to  make 
a  free  opening  and  a  liberal  removal  of  all  particles  or  fragments,  with  amj^le 
provision  for  drainage.  Hernia  of  any  of  the  viscera  through  such  wounds  occasionally 
occurs. 

The  subject  of  in  juries  to  the  heart  will  be  dealt  with  in  the  chapter  devoted  to  the 
surgery  of  that  organ.  Not  every  perforation  of  the  heart  substance  is  fatal,  and  there 
are  enough  successful  cases  on  record  of  radical  intervention  by  resection  of  the  thoracic 
w^all,  and  of  exposure  of  the  pericardium,  even  of  the  heart  itself,  to  justify  this  method 
of  attack  in  any  case  which  will  permit  of  it.  Not  the  least  of  the  dangers  pertaining 
to  heart  injuries  is  the  impediment  to  heart  action  caused  by  a  collection  of  blood  in  the 

>  FIrs.  57,  .58  and  59,  as  well  as  the  others  preceding  credited  to  Major  Lynch,  are  due  to  the  courtesy  of  Major 
Charles  Lynch,  now  of  the  United  States  Army  General  Staff,  who  was  attached  to  the  Russian  Army  as  our 
Military  Attachf*',  aiid  who  took  them  himself. 


232 


INJURY  AND  REPAIR 


pericardial  sac.  Should  aiiythini);  further  be  called  for  it  would  he  warrantable  at  any 
time  to  explore  this  sac  and  withdraw  fluid  throuf,di  the  aspiratinjif  needle,  through  a 
trocar,  or  even  by  incision  and  drainage. 

In  the  abdomen  all  conceivable  forms  of  injury  may  be  met  with,  from  contusion.s 
produced  possibly  by  a  spent  cannon  ball,  to  lacerations  from  fragments  of  a  bursting 
shell  and  multiple  perforations  produced  by  one  or  more  bullets.  A  first  re(iuisite  in  all 
such  injuries  is  immediate  antiseptic  occlusion.  This  will  not  prevent  such  prompt 
and  further  study  of  the  case  as  may  indicate  suitable  treatment.  When  shock  is 
extreme,  indicating  the  possible  result  of  contusicms  or  laceration,  or  when  ])erforation 
of  the  stomach,  intestines,  or  bladder  is  prol^aljle,  laparotomy  should  be  performed  at 
once.  According  to  De  Nancrede  the  order  of  probable  frequency  of  these  injuries  of  the 
abdomen  is  small  intestine,  large  intestine,  liver,  stomach,  kidney,  spleen,  and  pancreas. 
Multiple  lesions  are  also  common.  The  immediate  dangers  are  those  from  shock  and 
hemorrhage,  to  be  supplemented  later  by  imminent  danger  of  .septic  peritonitis. 

Fio.   59 


Scene  in  operating  room'in  Second  Field  Hospital  of   Fifth  Division  of  Japanese  Army,  at  Mukden 
Railway  Station.     (Major  Lynch.) 

The  modern  small  bullet  cau.ses  few  surface  indications  as  to  the  amount  of  damage 
done  within,  as  in  the  thorax.  A  careful  consideration  of  the  location  of  the  wounds 
of  entrance  and  exit  will  indicate  the  probability  of  perforation,  especially  of  the  hollow- 
viscera.  The  appearance  of  blood,  either  in  the  mouth  or  from  the  rectum  or  urethra, 
the  recognition  of  a  rapidly  accumulating  amount  of  fluid,  the  presence  of  gas  in  the 
abdomen,  are  all  significant  indications  of  perforating  injury.  Several  years  ago  Senn 
advised  the  insufflation  of  hydrogen  gas  into  the  colon,  on  the  theory  that  its  escape 
from  the  intestine  into  the  abdominal  cavity  and  thence  out  of  one  of  the  abdominal 
wounds,  where  it  could  be  lighted  as  it  pas.sed  through  a  small  tube,  would  afford  a 
certain  and  unmistakable  test  as  to  perforation  of  the  bowel,  and  such  is  undoubtedly 
the  ca.se.  Nevertheless,  it  is  not  one  which  is  always  easy  or  even  po.ssible  of  application, 
a'ld  no  time  should  be  wasted  in  waiting  for  a  supply  of  hydrogen  for  this  purpf)se. 


GUNSHOT  worxDS  233 

TIk"  safest  course  and  the  iiiosl  lit'c-saviiiii;  otic  is  f.rijlorafion  when  there  is  any  douht 
as  to  the  nature  of  the  injury.  'I'liis  means  an  operator  j)ossesse(l  of  f^ood  jn<l<;nicnt, 
a  suital)le  enviroinneiu,  rij^id  antiseptic  |)recautions,  and  a  small  incision  to  l)e}^in  with, 
witli  the  finji^er  as  the  best  of  all  probes.  The  escajM'  of  bloody  fluid,  l)loody  urine,  or 
fecal  matter  will  immediately  justify  a  nuicii  more  extended  incision  through  wiiich  com- 
plete orientation  may  be  obtained.  The  first  incision  may  be  best  made  as  an  enlarge- 
ment of  the  bullet  wound,  but  any  extensive  operation  within  the  abdominal  cavity  can 
be  UKulc  through  a  sufliiiently  long  median  incision.  ( )nly  in  this  way  can  the  .source 
of  hemorrhage  be  ascertained.  Thus  the  intestines  may  be  .systematically  gone  over 
inch  by  inch.  When  perforations  are  found  they  may  be  either  dealt  with  as  they 
appear — each  opening  being  clo.sed  transversely — or  the  entire  intestinal  canal  may 
be  exposed.  Contu.sed  sj)ots  will  eventually  slough,  and  should  be  treated  as  if  they 
were  perforations.  Injuries,  therefore,  of  short  portion.s  of  the  intestines  might  ju.stify 
the  removal  of  several  inches.  Instead  of  making  multiple  resections,  it  would  be  better 
to  remove  en  masse  the  involved  portion  of  the  bowel,  and  then  make  lateral  anasto- 
mosis or  an  end-to-end  suture.  Perforations  of  the  mesentery  as  well  as  tears  in  the 
omentum  should  be  carefully  closed.  Everything  which  is  not  vitally  necessary  and 
which  has  been  injured  should  be  nMUoved.  The  ])osterior  surface  of  the  stomach, 
the  lesser  cavity  of  the  omentum,  the  region  of  the  gall-bladder  and  j)ancreas,  the  kidneys 
and  ureters,  and  the  bladder  should  be  examined,  in  order  that  injury  may  be  detected. 
After  operations  of  this  kind  the  abdominal  cavity  may  be  ffushed  with  .sterile  salt 
solution;  while  the  question  of  drainage  should  be  decided  upon  the  individual  merits 
and  indications  of  each  ca.se,  as  it  is  safer  to  drain  the  contaminated  peritoneal  cavity 
than  to  rely  upon  mere  cleansing  and  drying 

If  the  spleen  or  kidney  be  injured,  it  is  safer  to  make  a  primary  removal  of  them;  if 
they  are  not  removed,  posterior  drainage  should  be  made. 

In  uncertain  ca.ses  of  abdominal  wounds  the  back  as  well  as  the  abdomen  should  be 
scrubbed  in  order  that  if  posterior  drainage  be  necessary  it  can  be  made  without  delay. 

The  after-treatment  of  such  patients  does  not  differ  from  that  of  non-traumatic  cases. 
Abstention  from  stomach  feeding,  the  judicious  use  of  salines,  dependence  upon  hypo- 
dermoclysis  and  rectal  nourishment,  and  the  use  of  opiates  are  all  matters  of  importance. 
When  the  bladder  has  been  injured  there  is  usually  more  or  less  injury  of  some  of  the 
other  pelvic  organs.  An  empty  bladder  will  escape  more  often  than  one  which  is  full; 
while  the  latter  will  nearly  always  leak  into  the  peritoneal  cavity  or  along  the  bullet 
track,  thus  infecting  one  or  both.  The  appearance  of  blood  in  the  urine  is  one  of  the 
indications  of  bladder  injury,  and  sometimes  the  bladder  will  fill  with  blood  clot,  which 
will  produce  the  ]:)henomenon  of  retention.  Such  a  ca.se  may  rapidly  succumb  to  infec- 
tion if  relief  be  not  promptly  afforded,  and  this  may  come  through  abdominal  .section 
or  a  combination  of  it  with  exploration  through  the  perineum.  Particles  of  clothing  and 
bone  and  even  the  bullet  itself  have  been  removed  from  the  cavity  of  the  bladder.  It 
is  advisable  to  open  the  bladder  from  below  and  insert  a  .self -retaining  drainage  tube, 
by  which,  especially  when  combined  with  the  method  of  drainage  by  siphonage,  as 
described  in  the  chapter  on  Surgery  of  the  Bladder,  a  satisfactory  and  continuous 
emptying  of  the  organ  may  be  maintained. 


CHAPTER    XXIII. 
PREVENTION  AND  CONTROL  OF  HE.MORRHAGE;  SUTURES;  KNOTS. 

The  first  requisite  after  the  infiietion  of  a  wound  is  to  arrest  and  control  tlie  hemorrhage. 
In  manv  operations  upon  the  extremities  jireeautions  are  taken  to  avoid  its  occurrence, 
and  the  so-called  bloodless  method  of  operating,  which  is  effected  by  the  use  of  an 
elastic  bandage  of  pure  rubber,  is  frequently  employed  and  generally  gives  satisfactory 
results.  The  pure-gum  bandage  was  first  introduced  into  surgery  by  Martin,  of  Massa- 
chusetts, and  its  combined  use  both  as  an  elastic  bandage  and  tournitjuet  was  so  promoted 
bv  Esmarch  that  it  is  generally  known  as  Esmarch's  bandage,  and  ^Martin  has  failed 
to  receive  the  credit  due  him. 

The  elastic  bandage  used  for  this  purjX)se  should  be  about  three  inches  in  widih  and 
five  or  six  yards  in  length,  and  made  of  pure  rubber.  The  operator  begins  by  aj)j)lying 
this  to  the  tip  of  the  extremity  which  is  to  be  made  blootlless.  It  is  Avound  around  the 
limb  in  spiral  turns,  with  sufficient  force  to  press  out  the  blood  from  the  tissues  and  to 
emptv  the  vessels  into  tho.se  of  the  trunk.  It  is  continued  above  the  site  of  the  operation, 
and  then  the  limb  is  either  constricted  with  a  four)ii(jurt  of  the  old  type  or  with  one  of 
the  rubber  appliances  used  for  this  jiurpose.  A  few  turns  of  the  rubber  bandage  may 
be  jiassed  more  tightly  about  the  limb  at  this  point  and  secured  with  forceps.  The  rest 
of  the  bandage  is  then  unwrapped  from  the  limb,  which  will  be  found  pale  and  blood- 
less. Operation  may  then  be  practised  without  the  loss  of  more  than  a  few  dro])s  of 
blood.  All  divided  ves.sels  should  l)e  secured  Ijcfore  the  constriction  is  removed  and 
the  wound  closed. 

In  septic,  tuberculous,  and  malignant  conditions  no  such  pressure  should  be  made, 
as  harmful  elements  might  be  forced  into  the  circulation.  In  such  cases  the  ela.stic 
tournic|uet  is  a|)}^lied  high  up  and  no  attempt  is  made  to  force  the  Ijlood  out  of  the  limb. 
The  limb  should  be  elevated  so  that  its  veins  may  empty  before  the  bandage  is  applied, 
and  a  certain  amount  of  blood  will  thus  be  saved. 

Care  should  be  taken  in  graduating  the  tightness  of  the  constricting  band,  as  well  as 
its  narrowness,  and  in  preventing  undue  ])ressure  upon  nerve  trunks.  Ca.ses  are  on 
record  of  temporary  and  even  permanent  jjaralysis,  due  to  too  vigorous  a])plication  of 
the  tourniquet,  and  except  upon  large  and  stout  limbs  it  is  not  often  necessary  to  apply 
it  as  tightly  as  is  often  dr)ne.  Moreover  even  a  wide  rubber  bandage  when  stretched 
taut  becomes  little  better  than  a  rubber  cord  or  rubber  tube  and  sinks  into  the  ti.ssues. 
A  sterile  towel  should  be  folded  into  a  strip  and  wound  around  the  limb,  and  then  a 
tourniquet  should  be  applied  over  it  so  that  pressure  may  be  more  equably  distributed 
and  danger  of  paralysis  reduced. 

Exigencies  may  require  the  application  of  the  elastic  tourniquet  as  high  as  it  can  be 
possiblv  used,  either  u])on  the  shoulder  or  the  hi]).  This  necessity  is  usually  observed 
in  amputations  at  those  joints,  and  the  special  methods  required  will  be  more  fully  dealt 
with  when  speaking  of  these  procedures.      (See  Chapter  LVI.) 

The  elastic  liandage  should  have  been  unrolled  and  sterilized  with  the  rest  of  the 
surgical  equipment  required,  and  even  when  so  jirotected  it  woultl  be  well  to  cover  the 
limb  with  wet  sterile  towels  before  applying  the  bandage,  which  is  usually  done  at  the 
la.st  in  order  to  avoid  contamination.  When  this  is  not  done  the  final  scrubbing  should 
not  be  effected  until  the  bandage  has  been  placed,  the  tourniquet  applied,  and  the 
l)andage  again  removed. 

The  fir.<tt  mea.'iure,  then,  in  the  treatment  oj  a  icmnul  i,i  to  prevent  loss  of  Mood.  This  may 
be  done  in  various  ways,  and  the  method  should  depend  u])on  the  circumstances  of  the 
case.  In  emergencv  ca.ses  it  may  be  accomplished  either  by  direct  pressure,  by  constric- 
tion of  the  liml)  al)ove  the  injury,  or  in  some  in.stances  by  mere  position.  If  it  be  po.ssible 
to  make  direct  pressure  through  the  medium  of  some  clean — preferably  sterik — dressing 
(234) 


PREVESTIOS   AM)   COSTIiOI.   of  II I'.MoHHII ACK 


235 


iirc  now 

purpose 

ucy  (tiil- 

flrxioii, 


l'i<;.  CO 


Illustrating  forced  fiexioii  for  control  of 
hemorrhage. 


or  lii;ilci-i;il,  lliis  of  course  would   Ite  (lesii-;(l)|e.       lu  ;ill  (JNilized  ;ii-uiies  soldiers 
e(jui|>|)e(l  uilli  a  packa;,'e  ol' sterile  dressing-  hy  wliieli  au  einei'ii'euev  pad  for  tiiis 
can   !)(•  |>roui[)lly  ap|)lie(l.      Railroads  aud  steauiers  are  uow  providinji;  emerge 
fits.      Ill  iiijurv  of  the  arm  or  lej:;  advaiitaj;e  may  lie  taken  of  |)ositioii,  /.  c,  foreei 
wiiieli  is   maiiitaiiied   hy  any   measure  or  material 
which    can    he    made    availahle    for    this    jmrpose 
(y\\I,-  (•()).      Ihtjitdl  coin jircssion  over  a  main  vessel 
may  also  serve  a  i^ood  pui|)os(>.     M(mv  elevalioii  of 
the  |)art,  as,  fore.xample,  the  henil,  when  not  other- 
wise   contra-iiulieate»l,  or  a  hand  or  foot,    will  do 
much    to   cheek   venous  or   arterial    flow.      More- 
over,    in    the.se    positions     reflex     contraetion    of 
arteries  occurs,  even   in   tho.se  of  the   head  when 
the  arms  are  elevated.     For  this  reason   in  cases 
of  .serious  n()se-l)leed  it  is  often  advisable  to  ket-p 
the  arms  raised  hio-h  ahove  the  licad. 

()f  other  means  resorte(|   to  may  l)e  mentioned: 

1.  Extremes  of  Heat  and  Cold.— Water  at 

a  tem|)erature  of  \'M)°  to   ]()()°  F.    is    a   powerful 

hemostatic.        It    stimulates    contraction    of    the 

muscular  coats  of  the  ves.sels  and  ])roduces  coajj,"- 

ulation  of  the  alhuminous  ])ortions  of  the  blood 

uj)oii   the  surface  to  which  it   is  ai)plie(l,   and   in 

this  way  ])lugs  the  caj)illaries  aud  small  arteries 

and  .so  prevents  oozing.     Heat  with  jiressure  will 

be  serviceable  in  many  instances.     Cold  may  be 

employed  by  means  of  ice  or  iced  water  and  may 

be  made  serviceable  in  cavities  like  the  mouth,  the  vagina,  or  the  rectum,  after  patients 

have  recovered  from  the  anesthetic  and  at  a  time  when  hot  water  could  not  be  borne. 

Cold  has  more  of  a  constringing  efi'ect  but  less  coagulating  pro))erty. 

2.  Pressure  Directly  Applied. — This  may  be  made  with  a  tam]X)n  in  some  cavity, 
or  by  a  graduated  absorbent  dressing  whose  effect  may  be  regulated  by  pressure  of  a 
bandage  or  an  elastic  bandage.  Care  should  be  always  given  that  pressure  be  not  too 
long  nor  too  firmly  made,  and  it  should  be  released  as  soon  as  there  appears  edema  of 
the  jxirt  below  or  any  evidence  of  insufficient  circulation. 

3.  Styptics  and  Chemical  Agents. — There  are  many  substances  which  contract 
vessels  and  cause  more  or  less  coaguhition  of  blood,  and  at  one  time  there  were  many 
of  these  in  general  use,  but  they  have  been  supplemented  by  other  products,  i.  e.,  cocaine, 
antipyrine,  and  adrenalin.  The  effect  of  cocaine  is  temporary,  but  sometimes  is  suffi- 
cient in  the  urethra  or  the  nasal  cavity.  Antipyrine,  in  5  to  10  per  cent,  solution,  alone 
or  with  cocaine,  has  a  similar  effect,  but  is  more  lasting.  Some  years  ago  the  writer 
stated  that  by  mixing  f  0  per  cent,  solutions  of  antipyrine  and  tannin  there  was  precipi- 
tated a  gum-like  material  of  extraordinary  tenacity.  This  will  check  oozing  from  any 
part  to  which  it  may  be  applied,  but  it  may  adhere  so  tightly  as  to  make  it  difficult  to 
later  remove  the  tampon.  Of  the  hemostatic  drugs,  adrenalin  has  the  most  marvellous 
proj^erties.  It  can  be  procured  in  solutions  of  1  to  1000.  A  solution  of  this  strength, 
somewhat  diluted,  may  be  spread  or  applied  upon  an  oozing  surface  with  almost 
instantaneous  effect. 

The  use  of  gektfin  in  rherkiug  hemorrhage  has  given  some  satisfaction  upon  the  Con- 
tinent, but  has  not  found  much  favor  in  this  country.  It  consi.sts  of  a  .solution  of  2  ])arts 
of  pure  gelatin  to  100  parts  of  normal  salt  solution,  which  should  be  thoroughly 
sterilized.  It  is  injected  subcutaneously  to  increa.se  the  coagulability  of  the  blood,  and 
has  also  been  injected  directly  into  an  aneurysmal  sac  or  its  immediate  vicinity  to  induce 
coagulation.  It  is  likely  that  if  the  surgeon  have  a  patient  with  the  hemorrhagic  diathesis 
the  combined  u.se  of  gelatin  in  this  way  and  of  calcium  chloride  internally  would  give 
satisfactory  results. 

A  styptic  has  recently  been  introduced  by  Freund  under  the  name  ".s-///p//c/«."  It 
is  a  product  of  the  oxidation  of  narcotin,  one  of  the  opium  alkaloids,  and  is  a  yellowi.sh 
powder  of  bitter  ta.ste.     Chemically  it  is  cotarnin  hydrochloride.     It  has  been   used 


236  INJURY  AND  REPAIR 

especially  in  the  treatment  of  uterine  heniorrhfvge,  with  a  certain  degree  of  success, 
regardless  of  the  cause  of  the  hemorrhage.  It  may  also  be  given  in  cases  of  too  profuse 
menstruation.  The  average  dose  is  2  to  3  Gr.  (0.15  to  0.20)  at  intervals  of  two  or 
three  hours.  When  a  speedy  result  is  desired  twice  the  above  amount  in  10  per  cent, 
solution  may  be  given  subcutaneously. 

4.  Destructive  Methods  may  include  the  use  of  the  sharp  spoon,  chemical  caustics, 
or  the  actual  cautery.  The  curette  is  usually  employed  for  removal  of  surfaces  which 
have  attained  a  spongy  or  easily  bleeding  condition,  as  the  interior  of  the  uterus,  bleeding 
ulcers  in  other  cavities,  etc.  When  fungoid  tissue  is  scraped  to  a  base  of  healthy  tissue 
there  is  usually  a  cessation  of  further  hemorrhage.  Occasionally  there  are  cases  of 
fungating  cancer  which  bleed  upon  the  slightest  touch.  The  most  radical  way  in  which 
to  deal  with  these  for  temporary  purposes  is  to  destroy  the  spongy  tissue  which  bleeds 
so  frequently.  The  gross  part  may  be  done  with  the  sharp  spoon  and  the  cautery  may 
be  made  to  finish  the  work.  Bleeding  piles,  when  it  is  not  permissible  to  treat  them  more 
radically,  should  be  touched  with  the  actual  cautery,  with  stretching  of  the  sphincter. 
The  cautery  knife  should  not  be  made  too  hot,  as  it  may  act  similar  to  a  sharp  blade 
instead  of  merely  searing  by  its  heat. 

5.  Mechanical  Means. — When  vessels  of  considerable  size  or  masses  of  tissue  con- 
taining them  can  be  made  accessible,  the  best  means  of  control  of  hemorrhage  are  those 
which  can  be  applied  directly  to  the  vessels.  W^hen  this  is  not  possible  they  should 
be  tied  en  masse.  A  method  formerly  in  use  was  acupressure.  To  effect  this  a  needle 
was  passed  through  the  overlying  skin  beneath  the  vessel  and  out  again,  and  around 
this  a  suture  was  tied  to  make  pressure.  Since  the  introduction  of  absorbable  materials 
this  method  has  been  supplanted  by  the  use  of  catgut  sutures,  which  may  be  tied,  cut 
short,  and  left  to  absorb. 

Under  the  term  "forcipressure"  is  included  the  method  of  seizing  vessels  before,  or 
as  they  bleed,  in  small  forceps,  which  are  variously  shaped  and  constructed,  and  grouped 
under  the  name  of  hemostais.  Small  vessels  seized  between  the  blades  of  such  an  instru- 
ment will  have  their  walls  so  crushed  that  blood  clot  is  so  quickly  entangled  that  the 
forceps  can  be  removed  in  a  few  moments  with  little  or  no  danger  of  subsequent  bleeding. 
Larger  vessels  should  be  ligated. 

Torsion  is  a  substitute  for  ligature,  especially  with  the  smaller  vessels,  and  denotes  a 
twisting  of  the  vessel  end  after  its  seizure,  breaking  up  its  inner  coat,  and  effectually 
sealing  its  lumen.     Some  surgeons  rely  on  torsion  for  the  large  vessels. 

Angiotribe  is  the  name  applied  to  strong  crushing  forceps,  by  which  a  pressure  of 
several  hundred  pounds  can  be  made  through  a  lever  mechanism.  In  this  a  mass  of 
tissue,  as  the  broad  ligament,  can  be  secured  and  such  tremendous  pressure  brought  to 
bear  that  its  vessels  are  crushed  and  destroyed  beyond  possibility  of  bleeding.  Downes 
has  improved  upon  this  mechanism  by  adapting  to  it  an  electrocautery  arrangement, 
by  which  not  only  pressure  but  also  heat  is  brought  to  bear.  His  instrument  is  called 
an  electrothermic  clamp.  To  all  of  these  instruments  there  are  at  least  theoretical  objec- 
tions, in  that  they  are  more  or  less  clumsy  or  unwiekly  and  recjuire  special  equipment. 
They  devitalize  a  considerable  amount  of  tissue,  all  of  which  has  subsequently  to  be 
removed  either  by  a  process  of  sloughing  or  by  active  phagocytosis;  but  they  serve 
perhaps  a  useful  purpose  in  the  crushing  treatment  of  hemorrhoidal  tumors.  They 
have  been  used  only  by  a  few,  and  have  not  found  wide  acceptance. 

6.  Ligatures. — These  are  also  mechanical  means  of  controlling  hemorrhage,  but 
deserve  to  be  grouped  by  themselves.  Ligation  of  vessels  may  be  preliminary  or  may 
be  performed  as  needed  during  an  operation. 

By  a  preliminari/  ligature  is  meant  taking  such  precaution  as  tying  the  carotid  before 
operations  on  the  face,  the  brain,  or  the  femoral  artery  before  amputation  at  the 
hip.  There  is  also  the  method  of  temporary  ligation  of  vessels  by  the  ap))lication  of 
a  ligature  which  should  not  be  drawn  too  tightly,  but  simply  serve  the  purpose  of 
gentle  constriction  for  the  half-hour  or  so  during  which  it  may  be  needed,  after  which 
the  vessel  is  promptly  released.  If  this  ligature  have  not  been  too  tightly  applied  the 
vessel  walls  will  not  have  been  injured  and  circulation  is  restored.  Crile  has  effected 
the  same  purjjose  with  the  carotids  by  a  small  clamp  whose  pressure  may  be  regulated 
by  a  thumb-screw. 

Ligation  of  large  trunks  is  made  for  the  purpose  of  influencing  nutrition  by  diminishing 


PREVENTION   AND  CONTIiOL    OF  IIEMORRILUIE  237 

l)l()()(l  .sii|)|)Iy,  as  wlu'ii  {\\v  tVinoral  is  tied  tor  (•U'|)lijiii(iasis  of  \\\v  Ic^f,  or  (lie  carotid  is 
tiod  or  excised,  as  suggested  by  Dawhani,  to  cut  oil'  tlii'  blood  suj)j)ly  from  cancer  of 
tlie  face  or  ui'ck. 

lyigatiu'i's  are  usually  made  of  al)sorl)al)Ie  material,  such  as  catgut,  cliromicized  or  not, 
as  may  be  desired,  or  of  silk,  which  disappears  after  a  time,  but  whicii  is  not  regarded 
as  absorbable.  For  sj)ecial  purposes  other  material  has  been  used  at  times,  such  as 
stri})s  of  ox  aorta.  The  surgeon  has  his  choice  of  these,  whether  he  intends  to  ligate 
the  end  of  an  artery  or  tie  a  vessel  in  its  continuity.  For  the  latter  jjurpose  the  ligature 
is  threaded  into  an  artery  needle,  or  a  specially  devised  curved  force|)s  known  as  the 
"Cleveland"  needle.  When  tying  the  exposed  end  of  a  bleeding  vessel  it  is  desirable  to 
tie  near  the  cut  end,  so  as  not  to  leave  tissue  which  should  be  absorbed,  and  for  the  same 
reason  to  not  include  uiuiecessary  tissue.  One  of  the  forms  of  knot  similar  to  the  "reef" 
knot,  which  will  not  slip,  should  be  used.  Silk  has  the  advantage  over  catgut  in  that 
a  knot  tied  with  it  will  rarely  beconle  loose,  whereas  catgut  knots,  unless  carefully  tied, 
will  occasionally  slip.  The  ligature  knots  should  be  left  as  short  as  is  consistent  with 
protection  against  slipping. 

Fate  of  Ligatures. ^ — Silk  or  celluloid  thread  are  the  most  unabsorbable  of  ligature 
materials  ordinarily  used.  Even  these  usually  disappear  after  the  lajwe  of  time.  Ab- 
sorbable ligatures  of  catgut  disappear  after  a  few  days  or  weeks,  according  to  the  method 
of  their  preparation.  Al)sorption  is  practically  a  matter  of  phagocytosis,  the  end  of 
the  vessel  or  tissue  beyond  the  ligature  disa{)pearing  with  the  latter  by  the  process  of 
tissue  digestion. 

When  vessels  of  large  size  are  ligated  the  blood  supply  is  taken  up  by  the  collateral 
circulation.  On  the  possibility  or  practicability  of  the  latter  will  depend  the  success  of 
such  operations  as  ligation  of  large  trunks  for  the  cure  of  aneurysm.  Should  the  collat- 
eral supply  prove  insufficient,  gangrene,  l)eginning  at  the  tip  of  an  extremity,  is  an 
assured  fact. 

The  efTects  of  the  ligature  on  the  vessel  wall  will  depend  upon  the  security  with  which 
it  is  tied.  The  damage  done  to  the  inner  and  middle  coats  by  a  ligature  tied  for  per- 
manent purposes  is  usually  sufficient  to  rupture  them,  after  which  they  roll  up  inside 
the  outer  coat,  while  the  blood  contained  in  that  part  of  the  vessel  coagulates,  the  clot 
extending  to  the  first  vessels  above  and  below.  This  quickly  organizes,  becomes  infil- 
trated with  cells,  and  brings  about  the  complete  obliteration  of  that  part  of  the  vessel 
and  its  transformation  into  a  fibrous  cord.  This  can  only  occur,  however,  when  asepsis 
has  prevailed.  Should  the  ligatiu-e  prove  septic  the  patient  is  exposed  to  two  dangers: 
that  of  secondary  hemorrhage  by  ulceration  and  breaking  down  of  the  clot  instead  of 
organization,  and  the  ordinary  dangers  of  septic  infection. 

There  are  circumstances  under  which  it  may  be  well  to  modify  the  ordinary  methods 
of  ligation  and  not  to  tie  knots  too  tightly — i.  e.,  when  the  vessels  are  greatly  weakened 
by  extensive  disease,  or  so  stiffened  by  calcareous  degeneration  as  to  cause  them  to  snap 
under  rough  handling.  It  has  been  suggested  to  use  pieces  of  ox  aorta  to  prevent  these 
accidents. 

The  dangers  of  secondary  hemorrhage  pertain  mostly  to  septic  conditions.  In  an  abso- 
lutely aseptic  wound,  properly  cared  for,  secondary  hemorrhage  is  almost  impossible, 
but  as  soon  as  germ  activity  begins  lymph  barriers  are  broken  down,  tissues  softened, 
and  weakened  vascular  walls  may  give  way. 

Secondary  hemorrhage  may  call  for  ligation  of  a  main  trunk  not  previously  attacked, 
but  in  a  majority  of  cases  will  demand  reopening  of  the  wound  and  further  search  for 
bleeding  points.  Should  the  patient's  condition  be  materially  weakened  the  effects 
of  position  and  of  pressure  may  be  tried  in  suitable  cases.  But  the  pressure  which  may 
be  effective  to  check  the  hemorrhage  may  l)e  sufficient  to  completely  shut  off  circulation 
from  parts  beyond,  and  such  pressure  should,  therefore,  be  judiciously  practised  and  its 
effects  carefully  watched.  The  sigyis  of  secondary  hemorrhage  will  vary  with  the  location 
of  its  source.  Occurring  on  or  near  the  surface  it  will  usually  stain  the  dressing;  occur- 
ring deeply,  as  in  the  pelvic  or  abdominal  cavities,  it  will  produce  prompt  symptoms 
of  shock,  i.  e.,  low'ered  blood  pressure,  wdiose  degree  will  indicate  the  extent  of  the  blood 
loss.  In  these  cases,  unless  the  patient's  condition  contra -indicate  the  measure,  the 
wound  should  be  opened  under  anesthesia,  and  the  source  of  the  bleeding  sought 
out  and  mastered.     The  surgeon  should  never  overlook  the  fact  that  after  the  gradual 


238  INJURY   AND   REPAIR 

restoration  of  the  force  of  the  heart's  action,  as  the  j)atient  recovers  from  anesthesia  and 
becomes  imcontrolhibly  restless,  vessels  may  bleed  which  upon  the  ojjcrating  table 
scarcely  emitted  a  drop  of  blood.  Exjoeriences  of  this  kind  teach  the  value  of  heniostasis 
during  operation,  and  even  of  absolute  rest  induced  by  an  opiate,  innnediately  after. 

There  are  certain  conditions  in  which  the  surgeon  is  led  by  ex|)erience  to  anticipate 
liability  to  unusual  hemorrhage;  such  as  cases  of  hemophilia,  or  anything  that  savors  of 
it  or  of  scurvy.  In  j)atients  who  claim  to  be  "bleeders,"  the  surgeon  should  be  extremely 
chary  and  careful  diu-ing  his  operative  work.  There  are,  furthermore,  certain  toxemias, 
especially  that  of  choleniia,  during  which  the  blood  is  slow  in  coagulation.  When 
the  time  for  preparation  is  afforded  no  cholcmic  j)atient  :  hould  be  o])erated  without  a 
few  days'  previous  pre})aration  by  four  or  five  daily  doses  of  calcium  chloride,  20  to  30 
grains,  given  in  plenty  of  water.  This  is  known  to  greatly  increase  blood  coagulability, 
and  thereby  to  measurably  protect  the  patient  against  the  danger  of  an  oozing  of  blood 
difficult  to  control. 

The  other  measures  needful  in  the  treatment  of  secondary  hemorrhage  are  those 
described  in  Chapter  XVIII. 

TREATMENT  OF  WOUNDS. 

The  general  consideration  of  wovmds  in  the  previous  chapters  necessarily  included 
many  suggestions  concerning  their  treatment.  The  first  essential  in  the  treatment  of 
open  wounds  is  exact  heniostasis;  the  next  is  the  removal  of  dirt  and  foreign  material 
of  all  kinds,  i.  c,  visible  and  invisible.  Accidental  wounds  are  |)ractically  never  received 
U|)()n  surgically  clean  surfaces,  and  it  may  be  always  assumed  that  the  possibility  of  infec- 
tion is  present.  It  becomes  then  a  question  to  what  extent  the  surgeon  should  go  in 
removing  or  avoiding  danger.  Obviously  all  visible  foreign  material  should  be  carefully 
removed  and  all  dirt  should  be  scrupulously  washed  away.  Emergency  treatment 
of  a  bleeding  injury  in  a  well-regulated  hospital  is  one  thing,  and  the  exigency  of  a 
railroad  accident  or  casualty  away  from  civilization  is  quite  another.  The  canons  of 
antisepsis  and  asepsis  have  been  elsewhere  sufficiently  well  laid  dt)wn  to  indicate  what 
should  be  done  at  the  time  when  it  can  be  done. 

The  protective  vitality  of  the  human  tissues  permits  them  to  bear  frightful  injuries 
or  resist  infection  in  a  sur])rising  way.  But  occasional  escapes  from  severe  accidents 
by  no  means  justify  carelessness  when  caution  can  be  taken,  and  cannot  be  held  as 
.excusing  the  surgeon  for  any  neglect  in  antisepsis. 

A  bruifte  or  contusion  accompanied  by  a  slight  abrasion  may  seem  a  trifling  injury, 
and  yet  by  virtue  of  the  injury  the  resisting  powers  of  the  tissues  may  be  rendered  insuf- 
ficient to  protect  them  from  infection  through  a  break  of  the  surface.  No  relatively 
small  lesions  of  this  kind  can  be  safely  neglected,  but  should  be  cleaned  and  covered 
with  an  antiseptic  compress,  either  wet  with  some  suitalile  solution  or  smeared  with  a 
protective  ointment,  or  used  dry  with  a  suitable  antisej^tic  ])owder,  as,  for  example, 
bismuth  subiodidc.  Injuries  followed  by  considerable  swelling  should  be  treated 
according  to  the  time  which  has  elapsed  since  their  rece|)tion.  If,  for  instance,  a  bruise 
or  sprain  be  seen  early  and  before  much  swelling  has  occurred,  ice-cold  ap])lications  can 
be  made  in  the  hope  that,  by  limiting  the  flow  of  blood,  the  outpour  of  fluids  may  be 
prevented.  This  effort  should  be  seconded  by  position,  and  perhaps  by  gentle  jjressure. 
Conversely  when  a  case  is  seen  late,  after  the  tissues  have  become  waterlogged  with 
fluids,  heat  should  be  applied  in  order  that  by  stimulating  the  circulation  reabsorption 
may  more  sjiccdily  take  ])lace.     In  this  case,  also,  suitable  pressure  may  be  of  service. 

When  there  is  actual  liniiafoma,  and  the  exuded  fluid  fails  to  disapjx'ar,  an  incision 
])roperly  made  and  in  the  right  ])lac(>  may  permit  the  clot  to  be  turned  out,  and  then 
speedy  recovery  secured  by  coaptation  with  sutures  and  })ressure. 

Poultices  are  nauseous  api)lications  to  make  to  the  human  body.  By  th(Mr  indiscrimi- 
nate use  much  harm  has  been  done  and  supjuiration  encouraged  or  brought  about,  which 
but  for  them  would  not  have  occurred.  There  are  occasions  when  a  hot  fla.xseed 
poultice  may  be  of  use,  but  they  are  very  few  and  far  between.  W^ith  regard  to  such 
remedies  as  arnica,  witch-hazel,  etc.,  the  best  that  can  be  said  of  them  is  that  they 
maybe  of  some  use  by  virtue  of  the  alcohol  which  they  contain;  they  serve  the  purpose, 
then,  of  a  diluted  alcohol  and  nothing  else. 


Tia:.\rMi:\r  or  woiwds  230 

Tlicrc  is  \iriiic  in  llic  use  of  ;i  ca/d  ini  jxtch,  ov  coiiiprcss,  csiM-ciallv  in  tlic  trcatnuMit 
of  cliroiiic  aircclions  of  ilic  joints,  and  (licir  value  can  he  |)crc('|>til)ly  cnhaiiccd  hy  using 
solutions  of  sodium,  or  |)rctVial)lv  aiunioniuni  cliloridc,  aud  tlic  addition  of  a  little 
alcohol.  Ahsorlu'ut  material  wet  in  such  a  solution,  wrapped  aroimd  the  j)art,  covered 
with  oiled  silk  or  some  impervious  material,  while  the  |)art  is  kept  at  rest,  will  render 
valuable  si-rvice  in  conditions  of  this  kind. 

in  regard  to  the  relative  worth  of  heat  aud  cold  for  relief  of  pain,  the  alleviatini;  elfect 
of  heal  is  more  promptly  mauifested,  hut  that  of  cold  is  more  permanent,  and  es|)eeially 
is  this  true  of  chronic  atfeclions  of  the  joints  and  hones. 

In  the  Ircdliiiriit  of  open  iroiinds,  hieedino;  having  been  first  controlled,  all  the  sur- 
rounding |)arts,  as  well  as  the  wound  itself,  should  he  sterilized.  In  a  scalp  wound 
the  scalp  should  he  shaved  as  well  as  scrubbed.  All  jjartides  of  visible  dirt  should  Ik; 
carefully  picked  out,  and  every  particle  of  tissue  whose  vitality  is  so  e()in|)romise(l  that 
it  apparently  camiot  live  should  be  excised.  The  wound  may  then  be  irrigated  or  washed 
out  with  hydrogen  p(>ro.\ide,  and  not  until  all  this  is  done  should  the  operator  consider 
how  he  may  lK>st  close  it,  as  well  as  whether  he  needs  to  j)rovide  for  drainage.  A  ragtred 
line  of  tearing  will  leave  a  jagged  and  more  unsightly  scar,  especially  on  the  face;  there- 
fore the  margins  of  sueli  a  lacerated  wound  should  be  triniuied  before  coapting  them. 

The  method  of  closure  will  depend  on  the  degree  of  tension  necessary  for  the  purpose. 
Parts  that  come  together  easily  may  require  but  slight  suturing,  and  with  fine  catgut 
which  will  loosen  of  its(>lf  within  two  or  three  days;  the  intent  in  such  cases  always  being 
to  assist  the  sutures  by  proper  sujijiort  of  the  external  dressings. 

Buried  sutures  will  serve  a  useful  ])ur])()se  in  many  instances,  and  upon  the  face  or 
exposed  parts  of  the  body  a  subcutaneous  suture  of  fine  silk  or  horse-hair  may  be  .so 
applied  as  to  be  ea;;ily  removed  by  a  single  ])ull  and  leave  but  trifling  disfigurement. 
Female  pati(Mits  will  be  doubly  grateful  if  the  surgeon  can  leave  but  a  minimum  of 
imsightly  scar.  Fascijie  will  sometimes  retract  widely.  They  should  be  brought  together 
by  distinct  se{)arate  catgut  sutures.  Before  closure  of  a  wound  it  is  important  to  deter- 
mine that  no  such  structures  as  nerves  or  tendons  have  been  divided,  or,  if  such  injuries 
have  occurred,  to  reunite  their  ends  by  fine  silk  or  catgut  sutures.  The  writer  prefers 
silk  for  most  of  these  ])iu-poses,  although  in  a  nerve  a  fine  formalin  catgut  suture  would 
perha])s  be  the  most  ideal. 

TluM'e  are  occasions  when  it  seems  im]:)ossible  with  the  means  at  hand  to  tie  or  secure 
in  any  way  a  deep  bleeding  vessel  which  has  already  been  seized  with  a  hemostat.  In 
such  case  the  forceps  may  be  left  in  situ  for  thirty-six  to  forty-eight  hours.  This  may 
be  done,  for  instance,  in  the  groin,  in  the  axilla,  in  the  depths  of  the  neck,  and  about  the 
cranial  sinuses.  Ivife  may  be  occasionally  saved  by  this  procedure  which  would  be  lost 
from  hemorrhage  w^ithout  it.  At  other  times  a  firm  tampon  of  gauze  may  be  forced 
into  the  depths  of  a  wound  for  the  same  purpose,  and  maintained  there  by  position,  or 
by  the  pressure  of  secondary  sutures,  which  serve  the  same  purpose  and  recjuire  removal 
in  two  or  three  days.     These  measures  refer  rather  to  wounds  of  veins  than  of  arteries. 

If  one  can  be  aKsolutely  sure  of  his  a.sepsis,  he  may  close  even  an  extensive  wound 
with  little  or  no  provision  lor  dm incu/c;  but  unless  he  is  certain  regarding  it  he  should 
provide  at  least  for  escape  of  fluid  by  omitting  a  suture  occasionally,  or  by  drainage 
with  a  tube  or  a  cigarette  drain.  In  compound  fractures  not  only  must  such  provision 
be  made,  but  the  treatment  of  the  wound  may  also  include  the  introduction  of  wire  sutures 
through  bone  ends  or  the  use  of  other  mechanical  expedients. 

The  further  and  equally  important  treatment  of  wounds  consists  largely  in  maintaining 
physiological  rest  of  the  injured  ])art,  as  well  as  the  general  welfare  of  the  patient.  Paiii 
which  becomes  unendurable  causes  the  patient  to  lose  self-control  and  to  disturb  not  only 
the  dressings  but  apposition  of  wound  surfaces.  Pain,  therefore,  should  be  controlled 
by  the  mildest  expedient  that  may  suffice  to  master  it.  Elimination  must  be  maintained, 
because  the  circumstances  attending  the  injury  may  act  to  disturb  it.  A  patient  who 
shows  no  irregularity  of  pulse,  temperature,  elimination,  or  general  comfort  may  be 
assumed  to  be  doing  as  well  as  could  Ix^  expected,  and  the  dressings  need  not  perhaps  be 
changed  for  several  days.  On  the  other  hand,  with  rise  of  temperature  or  pulse,  increase 
of  restlessness,  swelling  of  the  parts,  or  disc-omfort  in  the  vicinity  of  the  wound,  the 
dressings  should  be  promptly  changed.  It  may  be  necessary  to  make  such  change  at 
the  end  of  forty-eight  hours  in  order  to  permit  the  removal  of  the  drain.     The  second 


240  INJURY  AND  REPAIR 

dressing  may  then  often  remain  a  week,  but  any  dressing  which  becomes  saturated, 
even  witli  blood,  may  dry  and  adhere  to  tlie  skin,  and  sliould  be  removed. 

It  would  be  best  to  inspect  the  wound  in  all  cases  when  the  temperature  and  pulse 
are  rising  or  when  there  is  any  disturbance  in  the  wovuid.  The  accumulation  of  blood 
in  an  aseptic  wound  may  cause  nuich  discomfort,  and  by  its  presence  interfere  with 
primary  union.  Should,  therefore,  a  wound  be  foimd  ])outing  or  its  edges  reddened  and 
swollen  it  may  be  safely  assumed  that  there  is  something  wnjng,  and  as  many  sutures 
should  be  removed  as  may  be  necessary  to  reveal  its  condition  and  permit  of  its 
treatment. 

Womids  which  arc  foul  or  scjjtic  when  they  come  under  surgical  observation  should 
be  treated  differently.  Here  the  first  attempt  sliould  be  at  antisepsis.  In  some  cases 
continuous  immersion  in  warm  water  will  give  the  btvst  results.  I  have  never  found 
anything  so  jirompt,  however,  in  cleaning  up  a  sloughing  area  as  brewers'  yeast.  When 
this  can  be  obtained  it  should  be  used  in  sufficient  abundance  to  get  the  diseased  surface 
thoroughly  wet  with  it.  In  sloughing  cases  moist  dressings  are  usually  })referable,  and 
the  best  are  the  two  above  mentioned.  This  is  true  of  those  cases  where  part  of  the 
wound  is  granulating  satisfactorily,  while  part  is  acting  badly.  Dressings  in  all  of  these 
cases  require  to  be  frequently  changed,  that  they  may  be  kept  effective. 

I  have  elsewhere  called  attention  to  the  value  of  granulated  sugar  as  an  emergency 
antiseptic  material  of  great  value. 


SUTURES  AND  KNOTS. 

Sutures. — There  are  many  varieties  of  sutures  which  have  found  favor.  Until  the 
surgeon  becomes  expert  by  long  practice  he  should  confine  himself  to  few  sutures  and 
knots.  Primary  sutures  include  continuous,  interrupted,  plate  or  modified  plate,  quill 
or  modified  quill,  chain,  and  transfixion  sutures,  and  also  certain  forms  of  suture  used 
in  intestinal  surgery.  The  above  forms  are  illustrated  in  Figs.  61  to  60.  Several  of  them 
may  be  used  in  making  what  are  known  as  buried  sutures,  i.  c.,  those  which  are  tied 
deeply,  whose  ends  are  cut  off  below  the  surface  and  left  either  permanently  or  for  later 
absorption. 

The  purpose  of  a  suture  is  to  bring  the  parts  into  accurate  ap])osition  and  so  maintain 
them.  It  is  a  mistake  to  employ  a  superficial  suture  alone,  which  may  leave  a  "dead 
space"  beneath  it.  If  but  one  suture  is  used,  as  in  closing  an  abdominal  woimd,  it  should 
pass  through  the  tissue  layers  of  the  abdomen  and  bring  each  layer  into  contact  with  the 
corresponding  layer  on  the  other  side.  Unless  this  can  be  done  a  series  of  sutures 
should  be  ussd  uniting  the  tissues  layer  by  layer.  If  these  be  made  of  formalin  or 
chromic  gut  they  will  remain  in  situ  for  a  length  of  time  sufficient  to  serve  their  purpose. 
Some  prefer  silk  for  this  purpose,  but  it  may  work  out  later;  if  sterile  and  freshly  boiled 
just  before  using  it  will  rarely  cause  this  trouble.  In  closing  a  thick  and  fat  abdominal 
wall  four  or  five  tiers  of  buried  sutures  may  be  used  and  their  effect  may  be  reinforced 
by  the  addition  of  a  modified  plate  or  quill  suture,  as  shown  in  Figs.  63  and  64. 

Fine  wire  is  preferred  by  some  operators,  and  horse-hair  by  others.  Success  pertains 
rather  to  the  perfection  of  the  method  than  to  the  material  used.  The  primary  feature 
of  all  wound  sutures  should  be  prevention  of  tension  and  protection  against  it.  Further 
support  in  the  sam(>  direction  can  be  made  by  the  use  of  adhesive  plaster  after  fastening 
the  dressing  upon  the  wound,  thus  taking  off  strain. 

Certain  expedients  have  been  resorted  to  in  sup(>rficial  wounds,  some  of  which  include 
the  afhxion  of  a  strip  of  plaster  on  either  side  of  the  wound  and  then  the  application  of 
the  suture  material  through  the  plaster  rather  than  through  the  skin.  Plasters  with 
small  hooks  have  also  been  applied,  and  then  a  shoelace  suture  applied  over  the  hooks, 
thus  lacing  the  wound  margins  .together.  Such  measures  are  convenient  for  certain 
cases,  although  they  make  the  maintenance  of  strict  asepsis  difficult  or  impossible. 
Fine-wire  clips  have  also  been  introduced,  by  which  skin  margins  may  be  held  together 
for  three  or  four  days,  or  until  they  have  had  time  to  unite  with  some  firmness,  after 
which  they  may  be  removed.  These  little  implements  can  be  sterilized  and  repeatedly 
used. 

When  an  absorbable  suture  will  serve  the  purpose  it  is  desirable  to  use  it,  since  the 


Fig.  61 


SUTURES  AND  KNOTS 

Fig.  62 


241 


Fig.  63 


Continuous  suture. 
Fig.  64 


Interrupted  suture.  Modified  plate  suture,  using  gauze  instead. 

Fig.  65  Fig.  66 


Modified  quill  suture,  using  gauze. 
Fig.  67 


Billroth's  chain-stitch. 


Transfixion  suture. 

Fig.  68 


Granny  knot. 
Fig.  71 


Clove  hitch. 


Staffordshire  knot. 


16 


242  INJURY  AND  REPAIR 

necessity  of  subsequent  removal  is  thereby  avoided.  Inasmuch  as  every  point  through 
which  a  suture  is  passed  will  show  its  own  minute  scar,  it  is  desirable  for  cosmetic 
purposes  to  use  a  subcutaneous  suture,  which  may  be  made  of  chromic  jjut,  silk,  or  fine 
wire.  If  of  catgut  it  may  be  left  to  disajipcar  spontaneously;  l)ut  a  silk  or  wire  suture 
should  be  left  with  ends  protruding  from  the  wound  so  that  after  a  few  days  it  may  be 
withdrawn  by  steady  traction  in  the  pro[)er  direction. 

Secondary  sutures  are  those  which  arc  placed  at  the  time  of  the  operation,  but  either 
not  drawn  so  as  to  unite  the  wound  edges,  or  are  tied  with  a  l)ow-knot,  so  that  they  may 
be  untied  and  utilized  later.  They  are  useful  when  either  hemorrhage  or  suppuration 
is  anticipated,  and  when  it  is  compulsory  to  pack  a  cavity  with  gauze. 

Every  suture  which  has  failed  of  its  purpose  or  ceased  to  he  effective  should  be  removed. 
Ordinarily  they  are  left  in  place  from  four  to  ten  days.  They  should  be  removed  by 
dividing  uj)on  one  side  of  the  knot,  which  should  be  seized  with  forceps  and  pulled 
upward  and  to  the  other  side.  The  suture  should  be  cut  at  a  point  where  it  is  moist,  so 
that  only  its  flexibFe  portion  may  be  drawn  through  the  parts  which  it  has  held.  More- 
over the  buried  portion  is  more  likely  to  be  sterile.  Secomlary  sutures  are  usually 
made  of  silkworm-gut,  celluloid  thread,  or  wire.  So  soon  as  they  are  found  unservice- 
able they  also  should  be  removed. 

Knots. — The  purpose  of  a  knot  is  not  achieved  if  it  slips,  and  the  "surgeon's 
knot"  is  best  for  the  purpose,  since  in  the  first  formation  one  end  is  carried  twice  around 
the  other  before  being  tied  in  the  opposite  direction.  It  requires  more  force  in  making 
it  taut,  but  it  is  safer  than  the  ordinary  reef  knot    (Fig.  67). 

Figs.  61)  and  70  illustrate  the  clove-hitch,  which  becomes  firmer  the  tighter  it  is 
pulled.  It  is  rarely  used  in  ordinary  sutures  or  ligatures,  but  may  be  made  exceedingly 
valuable.  The  Staffordshire  knot  (Fig.  71)  serves  especially  for  securing  ])edicles, 
which  are  first  transfixed  with  a  double  thread,  the  loop  thus  formed  being  slipped 
over  the  stump  and  secured  between  the  two  loose  ends  of  the  ligature,  one  end  being 
placed  over  and  the  other  under  it;  each  is  pulled  tightly  and  secured  by  an  ordinary 
knot.  When  properly  applied  it  is  effective.  When  knots  are  improperly  applied  none 
of  them  shouki  be  trusted. 

When  wire  sutures  are  used  it  is  sufficient  to  twist  the  ends,  unless  very  fine  wire  is 
used,  when  it  may  be  tied. 


CHAPTER    XXIV. 
ASKPSIS  AND  ANTISKPSIS;  TRIvVrMENT  OK  WOUXDS. 

'^riiK  inrdkal  stiulriit  of  the  present  ffcnenitioM  luis  no  conception  of  tlie  contrast 
lu'tween  the  results  of  today  and  those  of  a  i:;eneration  afjjo,  or  before  the  intnxhietion 
of  antiseptic  techni(jue  and  its  hiter  j)erfection,  asepsis.  Under  the  term  " anfi.srjjfic" 
.should  he  inchideil  tho.se  measures  intended  to  combat  sepsis,  or  surgical  infection, 
from  without.  The  term  am'p.na  is  of  later  date,  and  was  introduced  when  it  was  found 
that  the  prevention  of  infection  was  better  than  measures  calculated  to  overcome  it,  or 
atone  for  it  j)re.sence.  A  perusal  of  former  sur<rical  horrors  will  afi'ord  but  an  insufficient 
comparison  as  to  the  incalculable  benefits  for  which  we  are  ind(>bted  to  a  small  <jrouj) 
of  men,  of  whom  Lister  is  th(>  most  im])ortant;  although  the  names  of  Pasteur  aiicJ  of 
( )gst()n  should  ever  be  held  memorable  in  this  connection.  The  two  great  nineteenth 
centurv  achievements  in  surgery  were  anesthesia  and  antisej)sis,  both  oi  Anglo-Saxon 
origin,  one  American,  the  other  British. 

It  was  the  recognition  of  the  parasitic,  /.  c,  the  germ  nature  of  surgical  infections,  which 
led  to  Lister's  first  attempts  to  exclude  and  combat  the  infecting  agents.  And  while  the 
original  t(H'hni(jue  which  he  introduced  has  been  changed  in  nearly  every  particular,  the 
correctness  of  tlie  views  U])on  which  it  was  based  has  been  ever  broadened  and  strength- 
ened. We  have  learned  that  sim|)le  measures  may  be  as  effective  as  those  more  compli- 
cated, and  the  principal  changes  which  have  been  made  in  three  decades  have  tended 
toward  simplicity  and  j)revention.  Thus  heat  has  been  made  to  take  the  place  formerly 
occupied  by  carbolic  acid.  And  we  have  learned  that  parts  made  clean  need  little  anti- 
se|)tic  protecticju.  We  have  learned  that  healthy  tissues  are  endowed  with  large  powers 
of  self-j)rotection,  and  also  that  this  self-protection  is  interfered  with  by  causes  over 
which  the  surgeon  has  sometimes  but  little  control.  A  wound  in  a  body  loaded  with 
to.rir  products  is  by  no  means  protrcfrd  against  infectious  agents  by  mere  external  agencies. 
The  appearance  of  pus  in  a  wound  is  a  reflection  upon  the  surgeon.  The  ideal  aseptic 
techni(|ue  will  inckule  many  days  of  local  and  constitutional  protection,  as  has  been 
stated  in  the  sections  on  Auto-intoxication  and  on  the  Preparati(Mi  of  the  Patient. 

The  methods  of  either  antise|)tic  or  aseptic  techniciue  include  as  a  fundamental  basis 
the  necessity  for  perfect  sterilization  of  everything  which  may  come  in  contact  with  the 
woimd,  so  far  as  the  surgeon  can  control  it.  The  atmosj^here  contains  in  suspension 
bacteria,  but  their  contact  is  no  longer  dreaded,  because  of  reliance  upon  the  germicidal 
powers  of  the  fluids  and  tissues  of  the  body.  It  is  known,  however,  that  in  accumula- 
tion of  fluids  there  is  danger  as  w^ell  to  the  tissues,  either  from  rude  handling,  ajjplica- 
tion  of  large  pressure  forceps,  the  insertion  of  too  many  stitches,  or  whatever  else  may 
lacerate  or  impair  the  circulation. 

There  are  })arts  of  the  body  where  no  precautions  can  afford  complete  freedom  from 
germ  activity,  as  in  the  mouth,  the  vagina,  the  rectum.  Here  the  surgeon  must  be 
cleanly  in  his  work,  assuring  himself  that  he  introtluces  nothing  new  from  without. 
Furthermore,  after  operation  upon  these  parts  he  must  ensure  his  {)recautions  l)y  the  use 
of  mouth-washes,  douches,  etc.  On  the  other  hand,  ample  o])portunity  should  be 
afforded  for  sterilization  of  the  field  of  operation,  of  the  hands  of  the  o])erator  and  his 
assistants,  the  instruments,  ligatures,  and  dressings — everything  wdiich  may  come  in 
contact  with  the  raw  surface. 

Heat,  moist  or  dry,  is  the  simplest  of  all  sterilizing  methods.  It  is  used  in  dry 
and  in  moist  form.  The  most  resistant  spores  are  tho.se  of  anthrax,  which  is  supposed  to 
be  a  laboratory  germ,  one  not  seen  in  practice.  Most  of  the  imported  catgut  is  made  from 
the  intestines  of  sheej),  and  sheep  die  frequently  (on  the  Continent)  of  anthrax;  it  will 
thus  be  seen  that  the  danger  of  an  anthrax  infection  is  not  so  remote  as  might  first  appear, 
and  that  no  precautions  are  sufficient  which  do  not  include  a  degree  of  heat  and  length 

C  243 ) 


244  IX, JURY  AXD  REPAIR 

of  exposure  sufficient  to  kill  these  germs.  In  the  operating-room,  as  in  the  laboratory, 
has  been  introducefl  the  method  of  "fractional,"  i.  c,  repeated  sierilization.  Most  of 
the  materials  thus  exposed  may  be  left  in  superheated  steam  under  pressure  from  thirty 
to  sixty  minutes.  They  are  then  exposed  once  or  twice  more  to  the  same  heat  at  inter- 
vals of  twenty-four  hours.  In  order  to  make  heat  thoroughly  useful  its  effects  should 
permeate  everything  which  it  is  expected  to  so  sterilize;  hence  the  addition  of  steam 
under  pre.'isure,  especially  when  dressings,  towels,  etc.,  are  folded.  It  is  well  to  have 
a  form  of  sterilizer  that  permits  .steam  to  be  turned  off  and  drying  to  be  accom})lished 
slowly  by  the  aid  of  dry  heat. 

Next  to  steam  thus  utilized  is  boiling  water,  in  which  nearly  ever\'thing  can  be  sterilized. 
Silk  sutures  and  silkworm-gut  may  also  be  sterilized  in  this  way;  animal  suture  does  not 
permit  of  it  unless  previoush'  hardened.  The  effectiveness  of  boiling  water  is  increa.sed 
by  adding  to  it  1  per  cent,  of  sodium  bicarbonate,  by  which  its  boiling  point  is  raised. 

Dry  heat  is  employed  in  an  oven,  or  its  equivalent,  preferably  in  some  apparatus  by 
which  temperature  can  not  only  be  measured  but  maintained.  In  such  a  mechanism 
it  is  well  to  have  the  temperature  raised  to  300°  F.  for  at  least  half  an  hour,  and  then  let 
its  contents  cool  slowly. 

Another  method  of  sterilization  is  by  using  volatile  or  easily  volatilized  ehemicals, 
such  as  formalin  in  its  fluid  form,  or  its  equivalent  called  paraform,  which  comes  in 
crystals  or  may  be  had  in  tablets  ready  for  use.  Formalin  is  a  powerful  bactericidal 
agent,  and  if  used  in  such  form  as  to  be  sure  of  its  penetration,  good  results  may  be  expected. 
Some  materials  and  instruments  which  are  injured  by  steam  or  dry  heat  may  be  kept  in 
an  atmosphere  of  paraform,  or  sterilized  by  exposure  to  formalin  vapor,  being  then 
subsequently  protected  against  exposure  in  a  sealed  package.  Catheters  which  have 
been  boiled  or  cleansed  can  be  thus  exposed,  as  Hutchings  has  shown,  and  can  be  re- 
garded as  safe  for  use.  They  can,  moreover,  be  resterilized  in  the  same  way.  Naphtha- 
lene has  similar  properties,  but  is  not  quite  so  strong.  The  writer  is  accustomed  to  use 
one  or  the  other  of  these  in  jars  or  receptacles  containing  dry  dressings,  catheters,  and 
rubber  gloves. 

If  aseptic  methods  are  practised  there  will  be  l)ut  little  use  for  the  employment  of 
any  antiseptic,  either  in  solution  or  in  any  other  form. 

Boiled  water  and  sterile  salt  solution  should  be  available  for  all  purposes.  It  is  cus- 
tomary, however,  to  ha\'e  a  solution  of  mercuric  chloride  on  hand,  which  is  colored  in 
order  that  it  may  not  be  mistaken  for  any  other,  in  which  to  rinse  the  hands,  especially 
after  they  have  been  in  alkaline  solution. 

The  first  thing  to  be  sterilized  should  be  that  part  of  the  body  upon  which  operation 
is  to  be  made.  In  some  cases,  as  about  the  feet,  the  mouth,  etc.,  this  preparation  should 
be  begun  two  or  three  days  beforehand ;  in  other  cases  twelve  to  twenty-four  hours  will 
suffice.  Preparation  should  be  begun  with  soap,  nail-brush,  and  razor,  the  parts  being 
thoroughly  cleansed  and  shaved.  It  is  then  customary  with  most  operators  to  keep 
a  moist  and  antiseptic  dressing  applied  upon  surfaces  thus  cleansed,  which  should  be 
protected  from  drying  by  a  covering  of  oiled  silk  or  rubber  tissue.  Green  soap  is  usually 
employed,  which  may  have  added  to  it  a  small  percentage  of  carbolic  acid  or  lysol. 
The  mercurial  preparations  are  too  irritating  to  the  skin.  Carbolic  acid  has  the 
reputation  of  being  absorbed  rapidly.  On  tender  skins  and  in  certain  parts  of  the 
body  it  is  impossible  to  make  such  applications,  especially  of  soap  poultices.  Under 
these  circumstances  repeated  washings  and  some  protection  should  be  practised.  Feet 
upon  which  operations  are  to  be  made  should  be  soaked  repeatedly  and  scrubbed. 
Twenty-four  hours  previously  to  operating  on  the  head  the  scalp  should  be  shaved— 
preferably  forty-eight  hours — and  prepared  as  above.  For  operations  in  the  mouth 
the  tooth-brush  and  antiseptic  mouth-washes  should  be  frequently  used.  For  those  in 
the  vagina,  douches,  etc.,  should  be  frequently  administered. 

The  preparation  of  the  field  of  operation  includes  a  final  scrubbing,  with  a  washing 
of  alcohol  or  alcohol  and  ether.  The  hands  and  external  clothing  of  the  surgeon  and 
his  assistants  should  be  sterilized,  also  the  towels,  suture  materials,  instruments,  and 
dressings. 

Lawson  Tait  was  the  first  to  teach  the  great  value  of  absolute  and  mere  c-leanliness. 
This  applies  in  large  degree  to  the  hands  of  the  chief  operator  and  of  the  assistants. 
"With  a  large  amount  of  scrubbing  and  cleansing  of  the  hands  it  is  not  possible  to  put 


ASEPSIS  AND  ANTISEPSIS  245 

llicm  into  a  (•(tiidilioii  of  ideal  sterilization.  'I'liis  is  perliaps  inoi-e  true  of  tlie  hands  of 
•sonu'  than  those  of  others.  A  realization  of  this  fact  has  led  to  the  introduction  of 
(;!(,rr.s\  either  thin  rul)l)er  or  cheap  cotton.  The  former  may  he  used  re|)eatedly.  The 
latter  are  sterilized  hy  repeated  hoiliut;  and  may  then  be  u.sed  again.  Rubber  gloves 
may  be  sterilized  by  steam  or  boiling  water,  and  may  be  cleansed  with  soa[)  and  water 
oroneof  the  stronger  antiseptic  solutions.  The  introduction  of  rubber  gloves  has  brought 
great  imj)r()vement  in  results.  Tlu'  gloves,  however,  constitute  an  impedinieiit  to  some 
of  the  finer  work  and  the  easy  recognition  of  ti.ssue.  Not  the  least  im|)ortant  of  the 
advantages  of  rubber  gloves  is  the  protection  they  afford  to  the  surgeon's  hands  and  to 
oth(>r  patients.  Many  accidental  infections  may  be  saved  the  ojjcrator  if  his  Jiands 
can  be  kej)t  out  of  j)us,  while  the  us(>  of  gloves  permits  the  operator  to  j)ass  from  a 
pus  case  to  a  clean  one  without  exciting  fear.  A  snugly  fitting  glove  is  best  drawn  upon 
the  dry  hand  by  the  aid  of  sterilized  talcum.  But  the  hand  which  it  encloses  should  have 
been  previously  thoroughly  sterilized  so  that  it  will  not  l)e  a  source  of  danger  .sliould 
the  glove  be  pricked  or  torn.  Tiie  operator  can  keep  his  hand.s  in  more  favorable 
condition  by  using  gloves  dry  in  this  way  than  by  macerating  his  hands  inside  of  wet  ones. 

The  quest it)}i  of  hand  .stcrilizafion  is  an  imjiortant  one,  whether  the  gloves  are  to  be  worn 
by  some  or  all  of  the  operating  staft".  There  are  occasions  when  it  is  im|)ortant  to  make 
the  hands  absolutely  clean  because  no  gloves  can  be  procured.  Even  the  hands  encased 
in  gloves  should  be  thoroughly  prepared,  as  there  is  no  knowing  when  the  glove  may 
tear  and  the  surgeon's  bare  hand  come  into  contact  with  the  patient's  ti.ssues.  Running 
water  is  preferable  to  a  basin  filled  with  it,  for  while  it  runs  it  carries  away  such  material 
as  may  be  detached  by  soap  or  nail-brush.  If  it  be  not  possible  thus  to  wash  the  liands, 
then  repeated  basins  of  sterilized  water  should  be  used,  and  all  the  crockery  or  metal 
ware  used  in  the  process  should  be  sterilized,  so  that  the  hands  will  not  be  contaminated 
by  handling  unsterilized  material.  Nail  cleaners  are  essential  agents,  to  be  vigorously 
u.sed,  and  nail-brushes  should  be  sterilized  after  each  using,  and  there  should  be  a  sepa- 
rate brush  for  each  oj^erator.  The  common  soaps  and  even  the  officinal  green  soap  are 
not  sterile.  The  former  should  be  relied  on  only  for  the  first  cleaning,  and  the  latter 
should  be  sterilized  before  use.  A  dirty  hand  should  not  be  thrust  into  a  receptacle 
containing  freshly  sterilized  green  soap.  The  outside  coating  of  dirt  should  first  be 
removed  by  an  ordinary  soap.  Vegetable  fiber  has  been  recommended  by  many,  but  it 
is  not  as  good  as  ordinary  corn-meal,  which  should  be  sterilized  before  using.  It  is  not  as 
gritty  nor  as  keen  as  sand,  and  yet  it  is  sufficiently  rough  to  serve  admirably  the  purposes 
of  a  curry-comb.  A  first  scrubbing  with  common  soap  and  a  nail-brush,  followed  by 
green  soap  with  corn-meal,  and  this  by  a  thorough  use  of  the  nail  cleaner  and  a  clean 
nail-brush,  will  ordinarily  serve  to  put  the  hands  in  a  reliable  condition.  It  is  the 
practice  of  some  to  add  antiseptics  to  the  soap,  e.  g.,  lysol  and  thymol.  A  number 
of  years  ago  I  introduced  ordinary  musiard  flour  for  this  purpose,  basing  its  use  upon  the 
fact  that  the  essential  oil  of  mustard  is  one  of  the  most  potent  of  the  vegetable  antiseptics, 
in  addition  to  its  power  as  a  deodorizer.  (Parenthetically  it  may  be  said  that  when 
unj)leasant  odor  attaches  to  the  unprotected  hands  after  making  a  postmortem  examina- 
tion, or  opening  an  offensive  collection  of  pus,  the  use  of  mustard  will  quickly  remove 
the  taint.)  Even  mustard  is  not  absolutely  reliable,  nor  is  anything  else  which  can  be 
tolerated  by  the  human  skin.  A  method  much  in  vogue  a  few  years  ago  was  to  wash 
the  hands  in  a  solution  of  potassium  permanganate,  and  then  to  decolorize  the  skin  in 
another  strong  solution  of  oxalic  solution.  This  method  was  at  one  time  regarded  as 
an  effective  one,  but  it  is  severe  upon  the  skin.  Another  method  in  use  at  present  com- 
bines commercial  chloride  of  lime  with  saleratus;  here  free  chlorine  is  supposed  to  be 
the  active  agent. 

The  bacteriological  side  of  this  subject  has  been  investigated  by  numerous  observers, 
particularly  Dr.  E.  R.  McGuire,  attached  to  the  Buffalo  Surgical  Clinic,  who  reached 
the  following  conclusions:  Absolute  sterility  of  the  hands  is  unattainable,  but  as  toward 
this  result  nothing  takes  the  place  of  long  and  vigorous  mechanical  scrubbing  under 
aseptic  precautions ;  the  use  of  antiseptics  on  the  skin  is  of  questionable  value  and  often 
distinctly  harmful ;  the  operator  whose  hands  perspire  freely  should  wear  gloves  in  every 
case;  the  use  of  rubber  gloves  is  not  ideal,  but  gives  the  nearest  approach  to  it. 

No  material  should  be  used  which  is  so  harsh  that  it  \\'\\\  injure  or  destroy  the  epi- 
thelial cells  either  upon  the  operator's  hands  or  upon  the  patient's  skin. 


246  IXJURY  A.\D  REPAIR 

Solutions  of  gutta-percha  in  its  different  solvents,  or  of  collodion  in  acetone,  have 
been  suggested  as  forming  a  covering  for  the  hands  hy  quickly  drying  ujmju  tlie  skin. 
The  merit  of  these  preparations  is  questionable,  and  the  length  of  time  required  to 
dissolve  the  coating  makes  them  impracticable.  They  have  found  little  favor  among 
surgeons. 

Xext  to  the  sterilization  of  the  parts  to  be  operated,  and  the  hands,  may  be  considered 
treafmrnt  of  septic  tissues  or  fluids  and  protection  against  further  infection.  Clean  and 
uninfected  tissues  need  no  other  precautions  than  those  already  descril>ed,  plus  extra 
care  in  hemostasis,  in  order  that  there  Ix'  no  clot  left  in  .which  germs  may  find  a  nidus, 
and  the  careful  closure  of  the  wound  in  such  a  way  that  no  cavities  or  "flratl  sjxices" 
may  be  left  in  which  blfM)d  may  later  collect.  Surgeons  generally  agree  that  the  less 
clean  tissues  are  handled  and  the  less  contact  they  undergo  with  foreign  materials  the 
more  readily  they  heal.  The  ideal  fluids  with  which  to  cleanse  parts  or  to  wash  away 
blood  clot  are  sterile  salt  solution  and  boiled  water.  Antiseptic  solutions  should  not  be 
used  upon  healthy  tissue;  but  when  abscess  ca\'ities  have  l)een  opened  and  when  pus  or 
other  infectious  material  have  come  in  contact  with  fresh  raw  surfaces,  every  effort  should 
lie  made  to  overcome  its  effects.  It  is  customary  in  abdominal  ojx-rations  to  "wall  off" 
the  site  of  a  pus  focus  so  that  contamination  of  adjoining  surfaces  may  Ije  avoided, 
by  placing  gauze  packing  around  it.  Other  ex{x-dients,  e.  g.,  the  use  of  a  rublx'r  dam 
in  any  of  its  modifications,  which  will  aid  in  this  pnrjX)so,  should  Ix-  adopted.  Upon 
brain  surfaces,  as  upon  the  ruptured  jxrineum,  and  in  vaginal,  rt^ctal,  and  numerous 
other  operations,  a  continuous  fine  stream  of  salt  solution  may  Ik-  directed  with  great 
benefit. 

An  abscess  of  any  kind,  no  matter  where  located,  should  be  thoroughly  cleansed, 
its  ca\'ity  disinfected,  and  easy  access  made  to  the  outer  wound.  The  interior  of 
such  cavities  should  be  scraped  with  a  sharp  spoon.  After  curetting,  a  thorough 
washing  or  swabbing,  often  with  the  use  of  hydrogen  dioxide,  will  often  prove  service- 
able. Even  a  treatment  of  this  kind  does  not  afford  as  complete  disinfection  as 
may  \w  secured  by  free  application  of  pure  carbolic  acid  or  of  a  strong  solution  of  zinc 
chloride  (.50  per  cent.).  The  effect  of  this  is  not  only  to  more  completely  sterilize,  but 
to  so  sear  the  cauterized  surfaces  as  to  make  them  incapable  of  absorption.  Excess  of 
the  caustic  should  be  wiped  away,  or  antidoted,  in  the  case  of  carbolic  acid  by  further 
swabbing  with  alcohol,  or  in  the  case  of  zinc  chloride  by  merely  washing  out.  Such 
a  surface  should  heal  naturally  after  sloughing,  yet  it  is  rarely  safe  to  completely  do.se 
such  a  cavity.  A  light  packing  of  clean  gauze,  or,  as  the  writer  Is  fond  of  using  it,  of 
gauze  sopped  in  balsam  of  Peru,  will  permit  such  a  ca^^ty  to  quickly  close  by  the  granu- 
lation process  without  further  disturbance.  Bone  cavities,  esjX'cially,  are  well  treated 
with  zinc  chloride,  it  Ix-ing  difficult  to  so  thoroughly  disinfect  such  a  focus  that  it  may 
Ix"  safely  closed  without  drainage;  or  they  may  Ik'  filled  with  bone  chips  or  paraffin. 

Visible  tissue  which  is  sure  to  slough  should  l>e  removerl  with  scissors  or  the  sharp 
spoon,  in  orfler  to  save  valuable  time.  .Sometimes  the  actual  cautery  may  Ix*  used  to 
great  advantage,  as  in  chancroidal  buboes,  where  every  particle  of  raw  surface  will 
Ije  infected  by  the  pus  which  flows  over  it,  and  where  it  is  ad\-isable  to  cauterize  not 
merely  the  suppurative  focus,  but  everything  which  may  come  in  contact  with  its 
pus. 

InstniTnents. — In.struments  are  now  all  made  of  metal,  usually  nickel-plated, 
which  will  stand  at  lea.st  a  certain  amount  of  exprjsure  to  heat.  It  is  not  sufficient, 
however,  to  sterilize  in.struments  alone,  but  basins,  irrigator  nozzles,  and  ever\lhing  else 
which  may  h)e  wanterl  during  the  course  of  an  operation  should  l>e  equally  prepared  for 
it.  Inasmuch  as  hard  rubl>er  does  not  well  stand  even  boiling  water,  instruments  should 
be  made,  .so  far  as  po.ssible,  of  metal  or  of  glass.  Boiling  water,  or  "live"  .steam,  are 
universally  employed  for  this  purpose;  while  to  the  water  is  often  adderl  1  per  cent, 
of  ordinary-  washing  .soda,  which  enhanc-es  its  .serviceability.  Fifteen  to  twenty  minutes' 
actual  boiling,  or  its  equivalent,  will  be  sufficient  for  ordinary-  purpo.ses.  All  instruments, 
such  as  knives  and  scLssors,  deteriorate  after  repeated  use  in  this  way  and  need  to  be 
frequently  sharpened.  Catheters  also  may  be  sterilized  by  boiling  and  .should  be  con.stantly 
kept  expo-sed  to  some  volatile  antiseptic,  such  as  formalin  f.<ee  alx)ve).  .Sterile  material 
should  be  used  upon  the  inhalers,  and  the  metal  parts  of  these,  as  well  as  mouth-gags, 
hypodermic  .syringes,  and  the  like,  should  all  Ix-  fx)iled. 


ASEPSIS    AM)    ANTISEPSIS  247 

Dressings,  etc.— Not  only  the  (lr('.ssin<;s  wliicli  arc  to  he  (•in|)l()yed  after  an  operation, 
l)Ut  tile  <,MU/c,  the  cotton,  or  tlie  sca-sponffcs  wliicli  may  \)r  used  (lnrin<;  tlu-  sanir  slionld 
have  been  twice  sterilized  cither  hy  dry  heat  or  steam,  in  order  to  ensure  security.  No 
ahsorhent  material  sliould  he  packed  tijjhtly  if  it  is  to  be  subjected  to  steam,  as  it  is  not 
easily  penetrated,  even  under  pressure.  Moreover,  not  only  these  materials  but  the 
sheets,  (jowns,  aprons,  towels,  splints,  and  everything);  which  may  come  into  near  aj)i)roach 
or  actual  contact  with  the  wound  should  be  jm-pared  in  the  same  way.  After  steriliza- 
tion all  these  materials  should  be  enclosed  in  ^erm-proof,  sterile  wra|)pers  of  some  kind 
or  in  sterile  jars  or  boxes. 

As  a  postoperative  precaution,  all  materials  which  can  be  destroyed  after  use  in  a 
septic  case  should  be  hiininl.  If  this  be  not  practicable,  they  should  be  soaked  for 
twenty-four  hours  in  a  strono;  solution  of  corrosive  sublimate,  say  1  to  500.  At  the  con- 
elusion  of  operation  there  should  be  no  opjiort unity  left  for  dissemination  of  infec- 
tion. 

Sponges, — In  place  of  sponges,  gauze  or  absorbent  cotton  wrapped  in  gauze  are  now 
generally  in  use,  prepared  as  above.  There  are  some  purj)oses  for  which  sea-sponges 
are  very  convenient  if  they  can  be  made  reliable.  Those  which  are  received  fresh  from 
the  dealer  should  be  freed  from  sand  by  beating  in  a  mortar,  placed  in  a  solution  of 
1  to  oOO  of  potassium  permanganate,  and  then  transferred  to  a  solution  of  sodium  sul- 
phite containing  o  per  cent,  by  volume  of  pure  hydrochloric  acid;  in  this  they  remain 
until  they  are  bleached  out,  which  will  take  but  a  few  mimites.  They  are  tlien  thor- 
oughly washed  in  sterile  water  and  stored  in  5  per  cent,  carbolic  solution! 

Suture  Materials,  etc.— Wire,-  silkworm-gut,  horse-hair,  and  silk  or  linen  thread 
may  be  sterilized,  if  not  rolled  too  tightly,  by  twice  boiling  for  a  half-hour,  and  then 
being  allowed  to  dry,  or  preserved  in  5  per  cent,  carbolic  solution  or  in  sterile  alcohol. 
Disappointment  often  comes  from  rolling  these  materials  so  tightly  upon  sjx>ols  that 
sterilization  of  the  deeper  layers  is  not  complete.  This  is  true  of  catgut  as  well  as  of 
the  other  animal  sutures. 

Catgut. — Cafr/id,  so  called,  is  usually  made  from  the  intestine  of  the  sheep,  and  must 
be  freed  from  anthrax  germs  or  spores.  It  should  be  rolled  loosely  on  spools  or  rods, 
each  layer  separatetl  from  that  beneath  by  a  piece  of  gauze.  The  writer  prefers  to  free 
it  from  animal  fat  by  a  preliminary  soaking  in  ether  or  benzene.  After  this  it  mav  be 
sterilized  by  boiling  in  alcohol,  preferably  absolute,  which  must  be  in  a  container  not 
tightly  closed.  This  is  placed  in  water,  raised  gradually  to  boiling,  and  should  boil  for 
two  hours.  This  process  should  be  repeated  at  least  once  after  the  expiration  of  twentv- 
four  hours.  This  is  the  simplest  of  all  procedures  and  generally  proves  reliable.  Other 
methods  are  those  of  exposure,  for  instance,  to  cumol,  a  volatile  paraffin  oil,  in  which  it 
is  boiled  under  ])ressure  in  a  special  apparatus,  the  temperature  being  raised  considerably 
above  the  boiling  point  of  water  (300°  F.).  When  the  receptacle  is  opened  the  cumol 
is  drawn  off  or  evajx)rates  and  the  catgut  is  left  dry  and  sterile.  It  should  be  either  kept 
dry  in  a  sterile  jar  or  in  alcohol.  Some  prefer  to  add  to  the  latter  a  small  amount  of  oil 
of  juniper,  which  has  a  little  hardening  effect  upon  the  animal  material. 

Catgut  should  be  tested  repeatedly  to  be  assured  of  its  sterility.  Special  methods 
of  preparing  catgut  are  as  follows: 

Formalin  Gut  is  prepared  by  placing  the  gut,  wound  as  mentioned,  in  a  3  per  cent,  for- 
malin solution  for  three  hours.  If  the  sterility  of  that  which  is  used  be  not  assurefl, 
then  this  preparation  should  be  boiled  in  water  for  fifteen  minutes.  Catgut  of  large  size 
should  be  immersed  in  a  solution  stronger  than  the  above.  It  will  probably  be  sufficient 
to  give  this  a  final  boiling  at  the  time  of  operation.  This  is  almost  as  lasting  as  chro- 
micized  gut. 

Chromicized  Gut. — Gut  to  be  thus  prepared  should  be  wound  in  single  lavers  on 
spools  and  immersed  in  a  solution  of  potassium  bichromate  1.5  to  2.5,  carbolic  acid  and 
glycerin  each  10,  and  water  1000  parts.  It  is  allowed  to  remain  in  this  solution  for 
twenty-four  hours,  then  dried  and  boiled  in  water,  or  in  alcohol  under  pressure,  in  Avhich 
it  is  subsequently  stored.  According  to  the  length  of  exposure  and  the  strength  of  the 
solution,  this  gut  will  resist  absorption  from  ten  to  thirty  days. 

Iodine  Gut  is  growing  in  favor  with  some  surgeons.  It  is  prepared  by  immersing 
catgut  in  a  10  per  cent,  solution  of  iodine,  in  which  it  is  kept  for  a  week.  After  removal 
it  is  allowed  to  dry  and  is  stored  dry,  but  should  be  kept  protected  from  exposure. 


248  INJURY  AXD  REPAIR 

Silkworm-gut  may  be  boiled  in  a  2  per  cent,  lysol  solution  for  tjne  hour,  which  makes 
it  pliable.  Sometimes  it  is  convenient  to  have  it  .stained  black  in  order  that  the  sutures 
may  be  better  distinguished  when  removed.  In  this  ca.se  it  is  allowed  to  stand  in  a  1 
per  cent,  silver  nitrate  solution  for  from  twelve  to  twenty-four  hours.  This  gives  it  an 
almost  black  stain,  but  tends  to  make  it  more  brittle.  It  may  be  kept  in  alcohol,  or  dry 
in  a  sterile  receptacle. 

Silk. — Silk  should  be  spooled  loosely,  boiled  in  a  similar  s<jlution  for  one-half  hour,  and 
again  in  plain  water  just  before  using.  It  may  be  stored  dry  or  in  alcohol.  It  may  be 
also  stained  l)]ack. 

Celluloid  Thread. — This  .should  be  washed  and  scrubbed  in  green  soap  and  hot  water, 
after  which  it  is  spooled,  and  then  boiled  for  thirty  miimtes.  It  may  be  .stored  dry 
or  in  alcohol.     This  is  a  linen  thread  covered  with  a  film  of  celluloid. 

Kangaroo  and  Reindeer  Tendons  are  ])reparcd  es.sentially  as  is  catgut,  but  if  boiled 
in  alcdlidl  they  inu>t  be  kept  ccncrcd  with  the  fluid,  as  they  tend  to  disintegrate. 

Drainage  Tubes  of  rubljer  should  be  boiled  in  soda  solution  for  fifteen  minutes,  and 
may  tlien  be  >ti)red  either  in  1  {xt  cent,  formalin  solution,  or  dry  in  a  suitable  tulx". 

Oiled  Silk  and  Rubber  Tissues  are  first  prepared  by  washing  in  1  to  500  .sublimate 
soluti(Hi,  then  dried,  and  exposed  in  an  air-tight  jar  to  the  vapor  of  formalin  or  paraform. 

The  above  are  the  methods  usually  in  vogue  in  the  writer's  clinic,  and  may  be  relied 
upon.  These  materials  should  l)e  frequently  tested  by  dropping  fragments  into  culture 
tubes  and  watching  the  result,  but  only  after  taking  the  precaution  to  precipitate  or 
neutralize  the  antiseptic  ])revi()U<ly  u-ed  in  their  preparation. 

Antiseptic  Solutions,  Applications,  etc.— In  well-regulated  clinics  sterile  .salt 

solution  is  always  at  hand.  As  has  been  stated  the  old  six  per  mille  solution  may  l)e 
improved  by  adding  1  part  of  potassium  chloride  and  2  parts  calcium  chloride.  For 
emergency  purpo.ses  tablets  are  now  prepared  which  will  jjermit  the  rapid  preparation 
of  these,  of  any  desired  strength.  To  this  a  little  corrosive  sublimate  may  be  added  with- 
out producing  decomposition.  When  sublimate  is  u.sed  alone,  or  in  other  combinations, 
a  little  vegetal)le  or  mineral  acid,  such  as  tartaric  or  hydrochloric,  should  l>e  added,  as 
most  of  the  water  u.sed  contains  lime. 

When  a  maximum  of  bactericidal  effect  is  desired  with  a  minimum  of  irritation,  the 
silver  salts,  either  the  lactate  or  the  citrate,  will  probably  afford  the  best  results.  The 
former  may  be  userl  as  strong  as  1  to  300,  the  latter  1  to  .500.  The  writer  has  frequently 
used  the.se  solutions  for  washing  out  the  peritoneal  cavity,  in  cases  of  tuberculous  peri- 
tonitis, where  they  serve  their  purpose  admirably.  For  washing  out  tuberculous  joints 
and  many  other  abscess  cavities,  solutions  of  silver  nitrate  of  1  to  1000  to  1  to  2000  are 
most  serviceable;  or,  for  the  same  purposes,  boiled  water,  to  which  has  been  added 
sufficient  tincture  of  iodine  to  give  it  a  mahogany  color.  In  caring  for  such  cases  it 
is  good  practice  to  alternate  the  solutions,  using  them  on  alternate  days. 

Antiseptic  poirders  or  applications  in  dry  form  are  useful  for  many  purposes.  At  one 
time  iodoform  was  very  popular;  it  was  supjx).sed  to  act  by  virtue  of  the  iodine  set 
free  in  the  presence  of  decomposing  organic  material.  It  is  now  .seldom  used,  partly 
becau.se  of  its  tell-tale  odor,  and  partly  because  of  the  disappointment  which  its  use  often 
brings.  It  is,  moreover,  an  active  toxic  agent  of  itself,  and  has  many  times  given  rise  to 
symptoms  of  intoxication,  such  as  mental  depression,  delirium,  nausea,  and  anorexia. 
Under  all  these  circumstances  free  iodine  can  be  detected  in  the  urine. 

There  are  numerous  substitutes  for  iodoform,  many  of  which  are  superior  to  it  in 
antiseptic  properties,  while  most  of  them  are  free  from  odor  and  toxic  qualities.  Two 
substances,  however,  are  u.sed  extensively — naphthalene  and  bismuth  snhiodide  or  red 
iodide.  The  former  has  a  markefl  odor  and  is  more  or  less  volatile,  which  makes  it 
particularly  valuable.  The  latter  is  odorless,  non-toxic,  and  of  much  greater  value  as 
an  antiseptic  than  most  of  the  others,  because  it  will  give  off  free  iodine  under  favorable 
circumstances.  A  good  plan  is  to  use  it  in  the  preparation  of  gauze  and  dressings,  as 
well  as  for  a  du.sting  powder  upon  the  .skin. 

The  absolute  value  of  these  local  applications  is  questionable,  becau.se  a  wound  will 
sometimes  heal  under  the  protection  of  a  piece  of  foil  or  gutta-j>ercha  tissue  as  well  as 
when  dressed  in  any  other  way.     This  is  true  only  of  wounds  in  part  surgically  clean. 

Drainage. — Drainage  has  been  resorted  to,  more  or  less  intermittently,  since  earlie.st 
historical   times.     It  is  pro^"ided  for  the  removal  of  deleterious  fluids  or  of  superfluous 


ASEPSIS  AXD  ANTISEPSIS  240 

exudates  or  iransiidaies.  It  /\  a  rerof/nilion  soinrtlmrs  of  a  veeesmiji,  af  oilier  times  a 
eoiije.ssion  of  fear  which  may  or  may  not  Ik'  justified.  It  is  had  practice  to  cover  a 
focus  of  previous  <;aii<:;reiie  or  sup|)uratioM  in  such  a  way  that  tiu*  infected  cavity  is  closed 
to  the  escape  of  accuniuhitiii<^  Huid.  This  may  be  prevented  by  the  use  of  a  suitable 
drain.  At  times  a  clean  operation  may  be  made,  and  yet  in  such  loose  tissue,  or  to  such 
an  extent,  that  it  is  preferable  to  jirovide  for  the  escape  of  blood  rather  than  let  it  occur 
and  force  a])art  surfaces  which  should  be  in  close  contact.  A  drainage  tube  may  serve 
as  a  vent  throuj^h  which  blood  may  escape  that  has  oozed  after  closure  of  the  wound. 
After  j)elvic  operations  |)rovision  should  be  made  for  the  withdrawal  of  accumulating 
fluid  which  mitjht  serve  as  a  culture  medium  for  ij;erms.  Drainajije  is  therefore  necessary 
in  many  instances. 

It  will  sufiice  sometimes  to  suture  loosely  a  part  or  the  whole  of  a  wound,  so  that  should 
tension  occur  from  retention  there  may  be  s])ontaneous  escape.  This  may  be  termed 
indireet  drainacje ,  and  sometimes  has  to  be  made  still  more  complete  by  leaving  out  some 
sutures,  or  by  placing  seeondary  sutures,  which  are  only  utilized  some  days  later,  when 
previously  infected  surfaces  have  become  healthy  and  are  granulating,  so  that  they  can 
be  brought  together. 

By  direct  drainage  secretions  and  fluids  are  guided  toward  the  dressings,  which  should 
be  absorbent  or  so  arranged  as  to  provide  for  their  accommodation;  thus  in  drainage  of 
the  gall-bladder  or  of  the  urinary  l)ladder  the  tube  may  be  connected  with  a  suitable 
receptacle  by  siphonage.  Capillary  drains  may  he  made  of  a  few  strands  of  silkworm- 
gut,  which  is  non-absorbable,  or  of  catgut,  which  is  absorbable,  and  to  which,  perhaps, 
no  further  attention  need  be  paid.  This  will  answer  for  conducting  away  small 
amounts  of  fluid  which  exude.  Gauze,  or  its  equivalent  in  the  shape  of  some  form  of 
wicking,  affords  an  excellent  material  for  removing  fluid  by  osmosis.  The  thinner 
the  fluid  the  more  perfectly  it  serves  this  purpose.  The  gauze  must  be  changed  fre- 
quently, as  these  lesions  may  become  filled  with  coagulated  material,  in  which  case  it 
woukl  act  merely  as  a  phig-  The  so-called  cigarette  drain  consists  of  folds  of  gauze, 
or  a  small  roll  of  it,  surrounded  by  sterilized  oiled  silk  or  gutta-percha  tissue,  in  which 
are  cut  numerous  holes.  The  same  purpose  may  be  achieved,  but  often  not  so  well, 
by  a  piece  of  rubber  tubing  split  down  one  side.  The  gauze  drains  by  osmosis,  and  the 
rubber  prevents  any  adhesion  to  the  wound  margins  and  any  pain  in  the  removal  of  the 
drain;  w^hile  a  certain  amount  of  fluid  may  escape  around  and  outside  the  smoother 
surface. 

When  the  fluids  to  be  removed  are  more  dense — e.  g.,  pus — tubular  drains  should  be 
provided.  These  vary  in  size  from  that  of  a  lead-pencil  to  that  of  the  finger.  A  tube 
which  is  too  small  becomes  easily  plugged.  They  are  perforated  with  numerous  ojien- 
ings  for  the  ready  entrance  of  fluid  save  in  those  cases,  like  the  gall-bladder  or  the  pelvis, 
where  it  is  desirable  to  drain  only  the  depths  of  a  cavity.  These  tubes  are  usually  made 
of  rubber,  the  purer  forms  of  gum  being  preferable.  For  some  purposes,  especially  in 
the  pelvis,  tubes  of  glass  or  aluminum  are  used;  these  are  non-collapsible.  They  may 
be  emptied  by  a  capillary  drain,  or  by  the  frequent  use  of  a  small  syringe  with  a  long 
nozzle,  by  which  they  are  pumped  out  at  regular  intervals.  Metal  and  glass  tubes  can 
be  resterilized  and  used  again.  All  other  drainage  material  should  be  burned  as  soon 
as  removed.  There  are  occasions  when  it  is  well  to  use  a  dressed  drain — ?.  e.,  a  tube 
surrounded  by  absorbent  gauze,  and  this  again  by  rubber  tissue  or  oiled  silk.  In  many 
instances  it  is  w^ell  to  prevent  the  loss  of  a  drainage  tube  by  passing  through  its  outer  end 
a  safety  pin,  or  by  stitching  it  to  the  margin  of  the  skin  wound.  Tubes  have  been 
lost,  especially  within  the  thoracic  cavity  after  operating  for  empyema,  more  often  than 
is  perhaps  generally  known,  and  for  a  lack  of  precaution  in  this  respect. 

Tubes  of  decalcified  chicken  hone  have  been  used  and  are  occasionally  serviceable. 
They  are  made  by  cleaning  the  cooked  bones  of  the  fowl,  soaking  them  in  20  per  cent, 
hydrochloric  acid  solution  until  decalcified,  trimming  the  ends,  cleaning  the  interior, 
and  are  then  sterilized  by  boiling  in  a  saturated  solution  of  ammonium  sulphate.  They 
are  then  washed  in  sterile  water  and  preserved  in  alcohol.  They  correspond  to  catgut, 
and  will  ordinarily  last  in  the  tissues  for  about  eight  days.  They  may  be  chromicized, 
as  is  catgut,  in  which  case  they  endure  considerably  longer. 


CHAPTER     XXV. 

PREPARATION  OF   PATIENTS  FOR  OPERATION  AND  THEIR 
A  FTER-TR  E  ATM  ENT. 

At  the  risk  of  some  repetiticjii  it  is  proposed  to  epitomize  here  a  few  directions  on  a 
subject  of  great  importance,  to  which,  as  well  in  theory  as  in  practice,  tocj  little  attention 
is  often  paid.  For  present  purposes  patients  may  be  divided  into  two  classes:  those  who 
have  sustained  accidents  or  sudden  surgical  diseases,  where  no  time  is  afforded  for  prepa- 
ration; and' those  who,  having  chronic  conditions,  are  subjected  to  surgical  measures 
which  are,  however,  sometimes  made  abrupt  by  sudden  decision.  In  the  former  case 
the  surgeon  is  compelled  to  work  hastily;  for  the  latter,  time  for  preparation  should  be 
always  afforded.  Experience  teaches  that  a  few  days,  sometimes  even  a  few  weeks, 
may  be  well  spent  in  preparing  a  jjatient  for  a  surcrical  op-ration. 

In  emergency  cases,  aside  from  the  asual  scrubbing  and  shaving,  there  may  be  several 
matters  to  which  it  is  well  to  give  attention.  The  stomach  should  be  washed  out  just 
before  the  administration  of  the  anesthetic,  or  soon  afterward.  If  there  be  time  the  rectum 
should  be  emptied,  and  the  bladder  always;  too  much  care  cannot  be  given  to  the.se 
performances.  The  degree  of  shock  should  be  estimated  and  appropriate  treatment 
given,  according  to  principles  stated  in  the  chapter  on  Shock. 

Foresight  will  often  dictate  the  prpparation  of  some  part  oj  the  body  not  directly  itt- 
volved  in  the  field  of  injury;  for  example,  in  any  gtmshot  or  stab  wound  of  the  abdomen 
or  in  a  case  of  acute  pancreatitis  the  back  shoulil  \»-  -fri:lil)e'(l  and  cleansed  and  the 
patient  laid  upon  sterilized  material,  so  that  >lii)uM  po-itrior  drainage  be  required  it 
may  be  promptly  made  without  waste  of  time  required  for  preparation.  In  head  injuries, 
if  the  scalp  or  cortex  of  the  skull  be  involved,  the  entire  head  should  be  shaved.  In 
preparation  of  patients  for  operation  upon  the  mouth,  tonsils,  or  stomach  an  anti.septic 
mouth-wash  should  be  used  in  order  to  avoid,  so  far  as  po.ssible,  contamination  from  these 
germ-laden  regions.  It  is  especially  in  cases  undertaken  for  the  chronic  pathological 
crjnditions  that  time  can  be  afforded  for  careful  [jreparation.  It  may  I>e  assumed  that 
every  patient  suffering  from  a  chronic  surgical  malady  has  been  so  disabled,  in  at  least 
some  function,  that  elimination  has  l)een  interfered  with.  The  emunctories  of  the  body 
comprise  essentially  the  skin,  the  lungs,  the  intestines,  and  the  kidneys.  Every  one 
of  the.se  should  be  made  to  pjerform  its  work  more  fully. 

The  skin  should  be  stimulated  by  hot-air  fxttJis-,  for  wliich  purpose  patients  may  be  .sent 
daily  to  the  Turkish  baths,  while  others  should  take  their  sweats  in  cabinets  or  in  bed. 
If  it  be  po.ssible  after  the  skin  has  been  made  to  perspire  profusely  the  patient  should 
be  put  into  a  hot  bath  and  the  skin  thoroughly  scrubbed. 

The  lungs  may  be  stimulated  partly  by  improving  the  heart's  action,  partly  by  certain 
e.xerci-ses,  and  by  getting  the  patient  out  into  the  open.  The  intestines  should  l)e  made 
to  perform  their  work,  preferably  by  the  miklest  measures  that  may  prove  effective. 
Mercurials  are  agents  of  great  value,  as  they  not  only  stimulate  secretions  but  are  anti- 
septic in  their  effects.  Sodium  phosphate  is  useful  when  something  stronger  Ls  not 
required. 

^Iany  patients  who  are  found  in  this  class  will  have  impaired  digestion,  for  which  a 
regulated  diet  should  be  supplied;  and  such  ca.ses  may  call  for  lavage,  as  well  as  for  a 
careful  examination  of  stomach  contents,  in  order  that  appropriate  aids  to  digestion  may 
be  given.  Most  patients  suffer  from  intestinal  torp<^>r,  especially  of  the  large  intestine, 
and  the  daily  administration  of  a  high-up  colon  icash,  with  the  patient  in  the  knee-chest 
position,  will  give  gratifying  results. 

It  has  been  suggested  that  in  all  operations  upon  tlu-  u]j|Hr  alimentary  canal  it  would 
be  of  great  advantage  to  feed  the  patient  during  the  previous  forty-eight  hours  upon 
.sterilized  food. 


PREP  A  RATIOS  OF   PATIKXTS  FOR  OPFRATIOX  A  XI)  AFTER-TREATMENT     251 

A  ainjul  stiidji  of  flic  iirinr  should  !)<•  iiijidc,  hotli  (|iiiiiitit;itiv('  and  (lualitalivc.  The 
gross  iiicasiirciMciit  of  thr  aliioiiiit  ('.\(  r('ti'<l  in  tvvciity-rour  hours  is  of  iiuportaiicc  It 
is  ni'ccssarv  to  know  wliat  anioutit  of  sohds  is  hciujj  daily  excreted,  as  well  as  the  amount 
of  Huid.  liciial  iit.siifficicnrif  w  one  of  the  difficult ira  with  which  the  surjijeon  has  often 
to  deal,  ami  caution  should  he  used  when  opcratinjij  uj)on  a  patient  sufi'ering  from  this 
condition.  Extra  work  is  thereby  imj)os(>d  upon  other  enumetories.  A  depraved 
Mood  circulation  throui^h  the  hrain  will  often  impair  its  function  and  lead  to  delirium 
in  mild  or  serious  form.  The  heart's  action  will  he  impaired  and  sc|)tic  infection  is 
mad(>  more  possihle,  in  spite  of  every  j)recaution  included  in  antiseptic  tcchni(jue.  In 
the  chapter  on  Inflection  it  was  stated  that  certain  cases  of  snrijical  se|)sis  commence 
as  infections  from  within,  dwi'  to  failure  in  unloadinif  the  hody  of  its  content  of  disease 
germs. 

II ijprrariditi/  should  be  also  corrected.  In  order  that  this  may  be  properly  done,  the 
urine  should  be  tested  by  a  more  accurate  method  than  by  litmus  jwper.  The  restle.ss- 
ness  and  con.secjuent  wound  disturbances  which  may  ensue  after  operation  may  be  due 
to  failure  in  the  r/iniination  of  urie  arid  and  the  oxalates;  alkaline  diuretics,  therefore, 
are  an  important  feature  in  the  j)re|jaration  of  many  surgical  patients. 

The  hlood  and  circulation  should  not  be  neglected  in  these  cases.  These  patients 
are  freipu-ntly  aneniic.  A  high  degree  of  anemia  is  recognized  by  methods  described 
in  the  chapter  on  the  Blood.  Much  may  be  done,  even  in  a  short  time,  to  improve  the 
quantity  and  the  quality  of  the  blood,  by  attention  to  nutrition  and  elimination.  By 
these  same  measures  the  heart's  action  will  be  also  greatlj'  strengthened,  but  much  can 
be  accomplished  in  this  direction  by  the  u.se  of  digitalis,  cactus,  or  other  of  the  heart 
stimulants,  and  by  the  administration,  preferably  subcutaneously,  of  strychnine.  This 
is  usually  given  in  too  small  doses.  Two  hypodermic  injections  of  ^V;  ^^i'*  (0.002) 
a  day  will  have  a  pronounced  effect.  While  the  heart  is  thus  fortified  as  against  shock 
before  the  ordeal,  adrenalin  will  prove  the  most  effective  agent  during  it  and  after  it  is 
pas.sed. 

Intestinal  fermentation  or  decomposition  is  a  prominent  feature  of  many  of  these  cases. 
If  it  be  possible  to  select  a  drug  which  has  antiseptic  properties  that  may  be  effective  in 
the  intestine  and  in  the  kidneys,  it  will  come  near  to  being  the  ideal  in  this  respect. 
The  attendant  has  here  to  choose  from  many  remedies,  and  his  choice  will  depend 
largely  on  his  personal  experience.  It  is  better  to  u.se  a  few  remedies  and  use  them 
well  than  to  be  indiscriminate. 

Salol,  benzosol,  betanaphthol,  sodium  sulphocarbolate,  and  the  salts  of  mercury 
and  arsenic  will  furnish  sufficient  compounds  from  which  to  .select.  AYhen  the  urine 
is  alkaline,  as  it  often  is  in  certain  kidney  and  bhulder  disea.ses,  urotropin  may  be  advan- 
tageously combined  with  one  of  the  others. 

In  the  way  of  general  preparation  of  tho.se  patients  who  have  to  undergo  operations 
upon  the  mouth,  the  nasopharynx,  the  esophagus,  trachea  or  larynx,  and  upper  alimentary 
canal,  they  should  be  sent  to  the  dentist  in  order  that  their  teeth  may  be  put  in  good 
condition  and  accumulations  of  tartar  removed,  and  then  u.se  an  anti.septic  mouth- 
wash, or,  when  necessary,  a  nasal  spray,  in  order  that  there  may  be  avoidance  of 
infection  from  the  bacteria  which  abound  in  these  jiarts.  Patients  often  have  diseased 
and  carious  teeth,  and,  in  hospital  patients  especially,  the  mouth  is  often  in  a  dirty  con- 
dition. So  long  as  any  wound  surface  is  so  situated  as  to  be  in  danger  of  contamination 
from  these  sources,  this  should  be  minimized  as  far  as  possible. 

Prevention  of  Peritonitis.— Experiments  have  been  made  by  jSIikulicz  with 
regard  to  the  value  of  nuclein  in  producing  an  artificial  and  protectiir  leukocytosis  before 
abdominal  operations,  hoping  thereby  to  accomplish  more  or  less  in  the  way  of  pre- 
vention of  peritonitis.  The  procedure  is  based  upon  the  well-known  property  of  nucleinic 
acid,  or  nuclein,  to  produce  a  prompt  but  transitory  increase  in  the  number  of  leukocytes. 
To  take  advantage  of  this,  3  to  5  Cc.  of  nuclein  solution  is  administered  beneath  the 
skin,  say  twelve  hours  and  again  six  hours  previous  to  the  operation.  Should  any 
septic  agent  be  introduced  or  liberated  during  its  performance,  the  leukoc^'tes  will 
be  present  in  additional  numbers  to  act  as  phagocytes  and  exert  their  active  protective 
powers. 


252  INJURY  AND  REPAIR 


AFTER-TREATMENT. 


The  care  of  patients  after  operation  is  a  factor  in  a  surgeon's  success  and  calls  for 
discrimination  and  judgment.  The  fact  that  the  odor  of  chloroform  or  ether  persists 
about  the  patient  and  in  his  breath  for  hours  after  their  administration  shows  to  what 
extent  they  have  been  dissolved  and  are  circulating  in  the  blood.  If  elimination  have 
already  been  attended  to,  and  so  far  improved  as  to  permit  the  emunctories  of  the  body 
to  tlo  work  up  to  their  capacity,  these  anesthetics  may  be  promptly  eliminated.  The 
longer  they  circulate  in  the  blood  the  greater  the  disturbance  to  other  functions  and 
the  more  difficult  it  is  to  get  normal  function  equalized. 

The  things  especially  to  be  guarded  against,  so  far  as  one  may  prevent  them,  are 
tiausea,  vomiting,  extreme  restlessness,  pain,  inactivity  of  the  bowels,  insufficiency  of 
the  kidneys,  and  the  toxic  action  of  any  antiseptics  or  drugs  which  may  have  been  used, 
e.  g.,  iodoform. 

Nausea  and  vomiting  after  operations  are  due  not  so  much  to  mere  reflex  activity  as 
to  the  elimination  of  the  anesthetic  by  the  stomach  and  its  irritant  action.  No  matter 
how  produced,  such  vomiting  is  of  itself  most  depressing,  mentally  and  j^hysiologically, 
and  is  injurious  in  a  large  proportion  of  cases,  and  efforts  should  be  made  to  prevent  it. 
So  long  as  it  was  regarded  simply  as  a  reflex  act  drugs  were  theoretically  sufficient  for 
its  treatment,  but  with  the  ajipreciation  of  its  actual  causation  it  will  be  seen  that  the 
irritating  material  should  be  removed.  This  may  be  done  with  the  minimum  of  dis- 
comfort and  the  maximum  of  advantage  by  means  of  the  stomach  tube.  Lavage, 
therefore,  constitutes  the  most  rational  and  effective  treatment  in  cases  of  postoperative 
vomiting. 

That  the  anesthetic  reaches  the  stomach  by  way  of  the  circulation  and  is  excreted  by 
the  gastric  mucosa  has  been  proved  by  the  studies  of  Ttirck.  He  showed  that  the  same 
is  also  true  of  morphine.  He  showed,  moreover,  that  the  stronger  anesthetics  disturb 
the  metabolism  of  the  cells  and  that  toxic  products  are  thereby  produced  which,  being 
reabsorbed,  cause  an  auto-intoxication  reducing  vital  resistance  of  the  blood  serum  and 
the  tissues.  Thus  during  anesthesia  there  occurs  an  atony  of  the  stomach  walls  with 
the  escape  of  the  anesthetic  into  the  stomach,  which,  acting  as  an  irritant,  leads  to  an 
increased  amount  of  toxin  production.  The  discoloration  of  the  gastric  mucosa  and 
the  capillary  hemorrhage  which  take  place,  as  shown  postmortem  in  cases  where  persist- 
ent vomiting  is  a  feature,  illustrate  the  disturbing  effect  of  the  stronger  anesthetics  upon 
the  stomach  itself.  This  furnishes,  then,  the  reason  for  icashing  out  the  stomach  imme- 
diately after  stopping  the  anesthetic  and  before  the  patient  leaves  the  operating  table.  It 
cannot  be  said  that  by  this  measure  postoperative  vomiting  will  be  abolished,  but 
its  frequency  will  be  materially  lessened. 

Lavage  may  also  be  practised  to  great  advantage  not  merely  immediately  after  the 
operation,  but  during  the  ensuing  twenty -four  hours,  or  later  should  vomiting  recur  or 
come  on  late.  On  the  other  hand,  where  time  has  not  been  afforded  in  which  to  suitably 
prepare  a  patient  for  operation,  it  is  advantageous  to  wash  out  the  stomach  before 
administering  the  anesthetic  as  well  as  after.  This  is  recommended  as  a  general  measure, 
and  without  special  reference  to  those  cases  where  operation  is  directed  to  the  stomach 
itself  or  to  the  intestinal  tract,  where  it  has  become  an  established  part  of  the 
preparation  to  carefully  cleanse  these  viscera. 

Several  points  in  the  performance  of  lavage  will  be  of  great  service  to  patient  and 
operator.  It  should  be  performed  quickly  in  order  to  reduce  the  length  of  the  discom- 
fort, and  the  water  used  should  be  warm,  at  least  1 10°  F.  If  the  throat  be  previously 
sprayed  with  weak  cocaine  solution  (2  per  cent.),  or  if  a  cocaine  lozenge  be  dissolved 
in  the  mouth,  the  tube  can  be  introduced  with  less  gagging  and  difficulty.  The  lubricant 
should  be  flavored  with  wintergreen  or  some  other  aromatic. 

Where  vomiting  continues  in  spite  of  lavage  it  is  advantageous  to  give  a  full  dose  of 
chloral  with  a  little  starch-water  in  the  rectum;  2  or  3  Gm.  of  chloral,  with  as  much 
sodium  bromide,  to  which,  in  case  of  severe  pain,  a  little  opiate  may  be  added,  may  be 
profitably  used  in  cases  where  the  patient  is  restless  and  where  sleep  is  fitful  or  perhaps 
impossible.  This  will  be  more  beneficial  than  drugs  administered  by  the  mouth.  It 
is  seldom  rejected,  and  is  very  soothing. 


AFTER-TREATMENT  253 

Exircmr  restlessness  is  un(lesiral)lo  from  ovory  point  of  view.  In  sonic  cases  when  it 
c-oines  on  early  it  is  an  evidence  of  insnflicient  oxyifcnation  and  may  be  combated  by 
the  administration  of  o.\y«i;cn  gas.  It  frequently  accompanies  shock  and  constitutes 
one  of  its  most  (Usturbinf^  features.  It  may  be  combated  by  a  subcutaneous  dose  of 
morphine  or  heroine,  or  chloral  in  doses  of  2  (jm.,  with  as  much  sodium  bromide,  thrown 
into  the  rectum  with  salt  solution.  The  effect  may  not  be  as  prompt,  but  it  is  often 
nuich  better.  Restlessness  is  not  always  a  .sym{)tom  of  pain,  but  is  occasionally  an 
uncontrollable  rcfle.x  nervous  phenomenon. 

Ajtrr  operations  plnjsioloyiral  rest  of  the  operated  part  is  necessarii  for  the  |)roccss  of 
j)ronipt  repair.  After  abdominal  operations,  especially  when  restlessness  and  vomitinjj 
are  combined,  much  harm  may  be  done  if  the  patient  cannot  keep  the  parts  (juiet. 

Pain  will  often  accompany  restlessness,  and  frequently  accentuate  it,  especially  when 
j)atients  have  not  yet  fully  returned  to  consciousness.  It  may  be  relieved  by  warm  or 
cold  ajiplications.  In  some  cases  an  ice-bag  may  be  used  as  soon  as  the  patient  is  })laced 
in  bed — for  example,  after  breaking  up  an  ankylosis.  In  mild  cases  the  use  of  chloral 
in  the  rectum,  as  above,  with  an  opiate  added,  may  be  sufficient.  When  pain  is  severe 
liyi)odcrmics  of  morphine  or  heroine  should  be  given.  Secretion  should  not  be  disturbed 
by  such  drugs  as , these,  yet  as  between  them  or  permitting  patients  to  suffer  intensely, 
my  opinion  is  that  opium  should  be  given  judiciously,  providing  it  prove  sufficient. 
In  extreme  cases  morphine  seems  to  be  the  only  medicament  upon  which  complete 
reliance  can  be  placed.  When  the  opiates  seem  to  produce  nausea  the  difficulties  are 
heightened.  It  may  be  decided  in  some  cases  to  push  the  opiate  to  the  point  of  narco- 
tism, prefering  to  keep  the  patient  in  this  semistupefied  condition  for  two  or  three 
days  and  until  the  series  of  early  dangers  have  been  passed.  Opiates  should  be 
given  with  great  discretion  lest  the  opium  habit  be  encouraged  if  not  formed. 

Lately  there  has  come  into  use  a  remedy  which  has  little  or  no  unpleasant  after-effects, 
and  upon  w^hich  a  good  deal  of  reliance  can  be  placed,  namely,  aspirin,  which  may  be 
given  in  1  Gm.  doses,  repeated  as  necessary.  If  it  be  combined  with  phenacetin,  in 
doses  of  half  that  amount,  the  combination  will  be  more  effective  than  either  alone. 
This  will  often  prove  a  serviceable  substitute  for  opiates  in  any  form. 

After  operation  upon  the  lower  bowel,  or  in  any  part  of  the  pelvis,  patients  may  com- 
plain of  pain,  sometimes  severe,  referred  to  the  reetiim.  Relief  may  be  obtained  by 
throwing  into  the  rectum,  through  a  flexible  tube,  one-half  to  one  pint  of  warm  linseed 
oil.     This  will  often  take  the  place  of  an  anodyne  or  a  suppository. 

The  next  question  is  one  of  eartharsls.  If  the  alimentary  canal  have  been  properly 
emptied,  as  it  should  have  been  before  the  operation,  the  bowels  may  be  allowed  to  rest 
for  the  ensuing  forty-eight  hours.  At  the  expiration  of  that  time  the  lower  bowel 
should  be  emptied.  Whether  this  be  done  with  laxatives  administered  by  the  mouth 
or  by  enema  will  depend  on  the  character  of  the  case  and  the  reliability  of  the 
stomach.  When  vomiting  is  distressing  little  can  be  accomplished  from  above.  In 
most  cases  the  first  effort  is  to  be  made  by  the  administration  of  a  thorough  colon  wash, 
or  by  the  use  of  an  enema,  which  may  perhaps  best  consist  of  tfx-gall,  glycerin,  and  a 
saturated  solution  of  Epsom  salt.  If  this  be  thrown  up  high,"  and  retained  a  while, 
it  will  in  all  probability  be  effective.  Should  the  operation  have  been  one  upon  the 
rectum  extra  care  will  be'j^eeded  for  the  patient's  comfort,  and  just  jjreceding  the 
stool  a  small  amoyimt  of  olive  bil  should  be  administered  through  a  tube.  Many  patients 
wuU  complain  of  gaseous  distention  or  other  discomfort,  due  apparently  to  fermentation, 
and  partly  perhaps  to  the  air  which  they  have  swallowed  during  the  act  of  vomiting, 
or  because  of  nausea.  No  matter  how  produced  it  will  afford  relief  to  get  rid  of  this 
gas,  and  while  this  may  be  partly  accomplished  by  an  enema,  it  will  be  more  thoroughly 
effected  by  a  mercurial,  given  by  the  mouth,  to  be  followed  by  a  saline  laxative.  In 
order  that  flatus  may  escape  without  effort,  a  rectal  tube  may  be  inserted,  w-hich  later 
may  be  utilized  for  the  administration  of  an  enema.  Save  in  rare  instances  it  is  a  mistake 
to  allow  accumulation  of  fecal  matter,  as  the  stercoremia  thus  favored  may  easily  lead 
into  a  more  profound  form  of  poisoning  by  its  interference  with  elimination  and  vital 
resistance. 

Attention  should  be  also  given  to  the  bladder  and  to  the  urine.  Renal  insufficieney 
is  one  of  the  great  dangers  pertaining  to  the  use  of  anesthetics.  This  may  be  combated 
by  2  Gr.  doses  of  sparteine  sulphate  every  three  hours  (McGuire). 


254  INJURY   AND  REPAIR 

Many  patients  arc  unable  to  void  urine  after  operations,  particularly  after  those  upon 
the  female  jjenitalia,  and  ihe  use  of  a  catheter  is  often  necessary.  This  should  Ix*  used 
with  antiscj)tic  prcc-autions,  both  as  to  the  patient,  the  instrument,  and  the  operator's 
hands.  Mucli  of  this  difficulty  can  be  avoided  by  injectini];  20  Cc.  of  a  2  per  cent, 
sterilized  bororfiyccriii  solution  through  a  catheter  in  the  evening  after  the  o|xjra- 
tion.  Its  action  is  usually  prompt,  and  in  five  to  ten  minutes  the  patient  spontaneously 
empties  the  bladder  without  unj)leasant  after-effects. 

After  abdominal  and  ])elvic  o|)erations  the  patient  should  not  be  allowed  to  urinate, 
but  should  be  systematically  catheterized.  The  bladder  should  never  be  allowed  to 
become  distended.  The  amount  and  character  of  urine  passed  should  be  carefully  noted. 
In  serious  ca-ses  the  amount  of  solids  eliminated  should  be  estimated,  in  order  that  it 
may  be  kept  up  to  the  necessary  standard.  In  fact,  efficient  and  sufficient  elimination 
is  more  necessary  after  the  prolonged  administration  of  an  anesthetic  than  after  almost 
any  other  event.  When  sufficient  fiuid  to  keep  up  the  standard  cannot  be  administered 
by  the  stomach,  it  should  be  introduced  into  the  rectum  or  given  beneath  the  skin.  Two 
or  three  enemas  of  salt  solution  should  be  administered  each  day,  and  in  urgent  cases 
the  normal  solution  should  be  thrown  beneath  the  skin,  and  this  should  be  rei:>eated  as 
often  and  as  long  as  may  be  necessary.  When  the  patient  begins  to  show  evidence  of 
what  is  vaguely  described  as  uremia,  i.  e.,  the  toxemia  of  renal  in.sufpciencij,  not  only 
should  warm  water  be  used  in  these  ways,  but  hot-air  bed  baths  should  be  given  twice  a 
day  if  necessary,  in  order  that  some  of  the  work  of  the  kidneys  may  be  assumed  by  the 
skin.  Hot-air  baths  stimulate  the  kidneys  as  well,  and  these  measures  will  prove  more 
effective  than  most  of  the  diuretics,  although  digitalis  and  pilocarpine  by  the  skin  may 
be  of  assistance. 

Patients  frequently  complain  of  excessive  dryness  in  the  mouth.  This  may  be  relieved 
by  occasionally  dropping  beneath  the  tongue  one-half  of  an  ordinary  hypodermic  tablet 
of  j\t  Gr.  pilocarpine;  also  by  mouth-washes  which  contain  a  little  glycerin,  and  by 
keeping  the  lips  moistened  with  glycerin.  Excessive  sweating  can  sometimes  be  relieved 
by  giving  a  hot-air  bed  bath  or  a  hot  mustard  foot  bath,  as  the  extra  action  of  the  skin 
thus  induced  checks  the  spontaneous  drain. 

Delirium  and  acute  mania  occasionally  supervene  after  operations.  It  should  first 
be  made  clear  that  the.se  are  not  due  to  any  antiseptic  or  drug.  Iodoform  is  less 
frequently  used  than  formerly.  Children  and  aged  people  become  delirious  with  less 
provocation  than  do  those  in  middle  life.  Such  delirium  is  generally  an  expression  of  a 
toxemia,  and,  in  addition  to  such  other  measures  as  may  be  necessary,  calls  for  control 
and  restraint  and  more  active  elimination,  as  in  so-called  uremia.  In  proportion  to 
the  degree  of  mania  must  l)e  the  restraint  prescribed.  A  restraining  sheet  or  a  strait- 
jacket  may  be  sometimes  needed.  When  these  conditions  arise  in  surgical  patients 
more  harm  will  come  from  the  violation  of  the  principle  of  physiological  rest  than  from 
the  drugs  which  may  be  needed  to  secure  it.  The  milder  measures  should  be  first  used, 
abstaining  as  far  as  possible  from  opiates,  which  are  probably  the  least  desirable  of 
all,  but  which  may  be  occasionally  demanded.  Chloral,  the  bromides,  cannabis 
indica,  alone  or  in  combination,  may  be  made  to  render  more  valuable  service.  Hyos- 
cine,  in  doses  of  ihn  to  in  Gr.  beneath  the  skin,  will  often  control  when  other  remedies 
fail ;  it  may  prove  invaluable.  When  delirium  tremens  C()m])licates  a  case  it  may  be 
treated  as  suggested  in  the  chapter  on  Various  Intoxications. 


PART   V. 

SURGICAL  AFFECTIONS  OF  THE  TISSUES  AND 
TISSUE  SYSTEMS. 


CHAPTER  XXVI. 

CYSTS  AND  TUISIORS. 
GENERAL    CONSIDERATIONS. 

A  TUMOR  /.<?  a  new  formation,  not  of  infiammatory  orKjin,  characterized  by  more  or  less 
histolorjical  conformity  to  tlie  tissue  in  wliich  it  has  orirjinated,  and  haviny  no  physio- 
logical function. 

By  the  above  definition  it  is  intended  to  separate  the  new-growths  from  a  distinctive 
class  of  neoplasms  which  are  of  inflammatory  (i.  e.,  of  infectious)  origin,  to  which  the 
generic  term  of  infectious  granulomas  has  been  given.     (See  Part  II.) 

Exceedingly  vague  notions  have  prevailed  concerning  the  nature  and  origin  of  tumors, 
and,  while  the  clinical  observations  of  writers  in  the  past  will  never  lose  their  value,  the 
ideas  which  have  prevailed  concerning  their  pathology  constitute  interesting  reading  in 
a  historical  sense,  but  are  now  of  small  value.  Accurate  notions  scarcely  prevailed 
until  Virchow  demonstrated  that  tumor  cells  nowise  differ  from  cell  types  which  are 
met  either  in  embryonic  or  in  adult  tissues.  Tumors,  like  all  other  parts  of  the 
body,  are  built  up  of  cells,  and  the  points  concerning  which  we  need  most  lighi: 
regard  the  influences  which  determine  cell  overproduction  in  these  charactejiatic 
forms.  Concerning  the  views  that  have  prevailed,  this  is  scarcely  the  place  iti  which 
to  offer  an  epitome.  I  shall  therefore  take  up  but  few  of  the  explanations  which  have 
been  offered  to  account  for  tumor  growth,  and  will  emphasize  that,  according  to  our 
present  light,  there  is  no  explanation  sufficient  to  cover  all  cases,  but  that  it  is  now  one 
cause  and  now  another  which  may  determine  this  peculiar  form  of  cell  activity. 

Irritation  and  Trauma. — The  effort  is  often  made  to  explain  the  presence  of 
tumors  upon  the  hypothesis  or  the  known  fact  of  some  previous  injury.  Frequently 
tumors  appear  in  sites  where  there  have  been  previous  traumatisms,  but  this  sequence 
of  events  by  no  means  proves  a  definite  relation  of  cause  and  effect.  On  the  other 
hand,  there  are  forms  of  irritation  which  are  often  followed  by  tumor  formations. 
Probably  no  woman  escapes  without  one  or  more  bumps  or  bruises  upon  the  breast, 
yet  they  do  not  produce  tumors  in  more  than  a  trifling  proportion  of  cases.  Per  contra, 
upon  the  lower  lip  of  inveterate  clay-pipe  smokers  and  the  scrotum  of  chimney-sweepers 
there  develop  certain  forms  of  malignant  ulcer  (epithelioma)  which  so  often  and  so 
significantly  follow  upon  the  irritation  thus  produced  that  it  is  impossible  to  avoid 
conviction  that  one  is  the  cause  of  the  other.  Should  events  prove  the  parasitic  nature 
of  any  of  these  growths  they  will  also  prove  that  the  irritation  causes  surface  lesions 
through  which  infection  easily  occurs.  In  regard  to  the  relative  frequency  with  which 
cancer  in  some  form  follows  trauma  we  should  not  forget  the  well-known  fact  that 
traumatism  usually  diminishes  tissue  resistance.  If  cancer  be  an  expression  of  infection, 
as  many  (including  the  writer)  believe,  the  possible  relation  between  trauma  and  malig- 
nant disease  may  be  better  appreciated, 

(255) 


256  SURGICAL  AFFECTIONS  OF  THE  TISSUES 

Inflammation. — This  refers  to  inflammation  in  the  sense  in  which  it  has  been 
used  in  the  past,  implying  a  varial)le  condition,  sometimes  including  and  sometimes 
excluding  infection,  the  term  covering  a  confused  mixture  of  irritation,  hy})eremia, 
and  infection.  In  so  far  as  it  concerns  inflammation  as  considered  in  the  present  work 
it  should  not  be  here  included,  since  inflammation  (/.  c,  infection)  produces  neoplasms 
of  a  class  considered  in  Part  II  and  is  distinctly  ruled  out  from  present  consideration 
(i.  e.,  the  infectious  granulomas). 

If  inflammation  in  the  former  sense  be  more  than  hyperemia  it  may  be  regarded  as 
predis})()sing  to  cell  activity,  but  not  necessarily  to  tumor  formation  as  distinguished 
from  hypertrophy  of  a  given  part  or  tissue.  If  it  refer  to  irritation,  this  has  been 
acknowledged  as  a  factor  in  the  etiology  of  tumors,  but  as  an  uncertain  one.  Cancer 
of  the  gall-bladder  or  liver,  which  occasionally  results  from  the  irritation  of  a  gallstone, 
or  the  cancer  of  the  breast  that  follows  eczema  of  the  nipple,  may  be  regarded  in  this 
light  as  additional  illustrations  if  it  is  preferred  to  interpret  them  in  this  way.  If  by 
inflammation  be  meant  the  infectious  granulomas,  they  have  already  been  considered. 
As  the  term  "inflammation"  can  scarcely  mean  anything  except  hyperemia,  irritation, 
or  infection,  we  seem  to  have  completely  ruled  it  out  from  consideration  as  by  itself  an 
active  cause  leading  to  tumor  formation. 

The  Embryonal  Hypothesis  of  Cohnheim.— This  in  hs  ingenuity  and  in  its 

ap])lical)ility  is  a  fascinating  explanation,  which  is  undoubtedly  sufficient  for  at  least 
a  certain  number  of  instances.  According  to  Cohnheim,  only  one  causal  factor  for 
tumors  exists — i.  e.,  anomalous  embryonic  arrangement.  He  regards  them  as  entirely 
of  embryonal  origin,  no  matter  how  late  in  life  they  may  develop  and  apjiear.  Briefly 
summarizing  his  views,  they  are  to  the  effect  that  in  the  early  stages  of  embryonal 
development  there  are  produced  more  cells  than  are  necessary  for  the  construction  of  a 
certain  part,  so  that  a  number  of  them  remain  superfluous.  ^Yhile  these  may  remain 
very  small,  they  possess,  on  account  of  their  embryonal  nature,  a  potent  proliferating 
power.  This  superfluous  cell  material  may  be  distributed  uniformly,  in  which  case 
it  will  develop  whole  system  arrangements,  like  supernumerary  fingers,  etc.,  or  it  may 
remain  by  itself  in  one  place,  and  will  then  develop  a  tumor.  In  the  latter  case  the 
tumor  may  appear  early  or  not  until  late  in  life,  according  to  the  time  at  which  the 
cell  collection  receives  the  necessary  stimulus,  or  because  of  its  suppression  by  resistance 
of  surrounding  structures.  It  may  be  an  irritation  or  an  injury,  such  as  above  alluded 
to,  which  shall  give  it  this  stimulus;  as,  for  example,  it  is  reasonable  to  think  that  certain 
nevi  and  other  congenital  conditions  which  develop  later  into  cancers  do  so  in  accordance 
with  this  view.  Surgeons  generally  find  little  fault  with  Cohnheim's  hypothesis,  except 
that  as  yet  they  decline  to  see  in  it  an  explanation  for  all  cases.  Nevertheless  for  dermoid 
and  teratomatous,  and  for  all  heteroblastic  tumors,  it  seems  to  afford  the  only  tenable 
explanation.  Thus  chondromas  of  the  parotid  and  of  the  testicle  are  most  easily 
explained  in  this  way,  and  that  cartilaginous  islands  occur  in  the  shafts  of  adult  bones  is 
well  known. 

Heredity. — In  regard  to  heredity  being  a  factor  in  the  etiology  of  neoplasms  there 
is  reason  to  believe  that  a  favorable  tissue  disposition  may  be  inherited,  but  there  is 
nothing  to  show  that  it  permits  the  actual  transmission  of  the  disea.se. 

Parasitic  Theory. — The  parasitic  theory  of  tumor  formation  has  only  within  a  few 
years  taken  definite  form  and  shape,  as  a  result  of  evolution  from  vague  suggestions  and 
scattered  observations.  It  im])lies  that  tumors,  and  they  are  mainly  of  the  malignant 
type,  are  due  to  irritation  produced  by  extrinsic  agencies,  parasites  of  some  kind,  which, 
introduced  from  without,  act  as  do  bacteria  in  the  now  well-known  infectious  granulomas. 
While  this  theory,  perhaps,  does  not  afford  an  absolutely  satisfactory  explanation  of  all 
the  phenomena  of  malignancy,  it  nevertheless  comes  nearer  to  it  than  does  any  other 
hypothesis  now  before  the  profession,  the  arguments  in  favor  of  it  being  scientific  and 
jjositive,  and  those  against  consisting  mainly  of  mere  negations.  Summed  up  these 
arguments  may  be  stated  as  follows: 

1.  Comparative  Pathology. — The  argument  from  comparative  pathology  begins  with 
the  lower  forms  of  life.  Tumors  in  trees  and  plants  are  well  known  to  vegetable 
pathologists  and  botanists  as  of  frequent  occurrence.  They  vary  in  size  from  the  most 
trifling  galls  to  those  large  woody  masses  known  as  xylomas,  which  are  essentially  tree 
cancers,  since  they  tend  to  the  destruction  of  the  tree.     These  are  known  to  be  invariably 


PLATb  XIV 


i»' 


A      »- 


♦  V. 


V  _ 


Adenocarcinoma  with  Young  Parasites.      (Parasites  blue.      Plimmer's  method.) 

(This  plate  is  introduced  to  illustrate  the  preseiioc  of  para.sites,  whose  minute  and  actual  character  is 

not  yet  positively  determined,  but  whose  existence  is  undeniable.) 

(From  Gaylord's  paper  in  the  Third  .\nnual  Report  of  the  New  York  State  Pathological 

r.uliiiialory  of  the  University. of   Buffalo. 


PLATE  XV 


t 


Rapidly  Growing  Carcinoma  ot   breas 


(,  riie  i.aiasitcs  herein  demunst rated  are  still  subjects  of  careful  and  minute  study,      li  would  tlierclon 

seem  premature  to  make  detailed  statements  concerning  their  exaet  nature.) 

(.From  Caylord's  paper  in  the  Third  .Annual  Repoit  of  the  New  York  f^tate  PatholoKical 

Laboratory  oi  the  University  of  BulTalo.) 


PLATE  XVI 


<^--f 


■~».-j»f> 


Fig.   1.     Parasites,  at  one  time  called  Russell's  Bodies,  at  Periphery  of  Epithelioma  of  Tonsil 

(Oil  immersion.) 


Fig.  2.     Sams  in  Lymph  Node  before  Epithelial  Invasion.     (From  N.  Y.  State  Path.  Lab.  Rep.) 


Fig.  3.     Papillary  Adenocarcinoma  of  Ovary,  shov/ing  Intracellular  Ameboid  Forms  of  Parasites. 

(From  N.  Y.  State  Path.  Lab.  Rep.; 


CYSTS  AND  TUMORS  257 

(liK-  to  extrinsic  a<;('iicir.s,  siicli  jis  insects,  fungi,  etc.  As  water  freezin<j  in  tlie  hark  of 
a  tree  may  crack  it  open  and  tluis  leaA'c  ()|)])ort unity  for  sul)se(juent  infection,  so  may 
injuries  upon  the  hody  surface  make  trifhnti;  lesions  which  predispose  to  suhse(juent 
infection  and  cancer  in  man  and  animals.  Exclude  j)arasites  from  such  traumatic 
lesions  on  jilants  and  there  will  he  no  xylomas. 

2.  The  Analogy  Afforded  by  the  Infectious  Granulomas. — These  arc  universally  conceded 
to  he  of  parasitic  ori>fin,  while  their  clinical  course  and  hehavior  in  every  respect  make 
many  of  them  almost  as  malif^nant  as  the  true  cancers  become. 

3.  Metastasis.  This  is  in  every  otherdisea.se  considered  to  be  one  of  the  most  si<i;nifi- 
cant  expressions  of  infection,  yet  until  recently  few  of  tho.se  who  have  willingly  accorded 
to  metastasis  its  now  common  interpretation  in  tuberculosis  have  been  willing  to  give 
it  the  .sanu"  dignity  as  a  factor  in  the  spread  of  canci-r  and  an  im])ortant  explanation  of 
its  nature.  Why  should  (>very  other  disease  characterized  by  metastasis  be  everywhere 
viewed  as  jiarasitic,  and  cancer,  in  which  occur  some  of  its  most  positive  expressions, 
be  denied?  MeiaMasis  has  the  force  and  significance  of  an  inoculation  experiment 
prrfornird  under  farordblr  ri rrumstanccs . 

4.  Evidence  of  Local  Infectivity. — The  involvement  of  a  part  which  has  lain  in  contact 
with  a  cancerous  lesion,  as  about  the  mouth  or  the  vulva,  and  in  many  other  ways  and 
places  of  which  medical  literature  is  now  full,  and  the  instances  of  cancer  following 
the  knife  woimd,  especially  following  the  track  of  the  trocar  used  for  tapping  a  case  of 
cancerous  ascites,  stamp  the  disease  as  having  an  infectivity  which  cannot  be  explained 
on  any  inherent  ])r()perty  of  its  own. 

5.  Microscopic  Appearances. — While  it  is  true  that  but  few  observers  have  been  able 
to  agree  upon  a  definite  cancer  parasite,  it  is  also  true  that  many  of  the  best  observers 
have  seen,  described,  and  figured  bodies  that  do  not  belong  in  the  cells  of  a  cancerous 
growth  excejit  they  are  there  in  the  roll  of  active  agents,  and  the  appearances  which 
have  been  described  by  Pfeiffer,  Plimmer,  Gaylord,  Calkins,  and  others  are  not  to  be 
explained  aw^ay  as  mere  artefacts,  but  must  be  given  a  place  in  our  estimation  which 
they  would  attain  of  themselves,  as  exciting  suspicion,  were  there  no  other  facts  cor- 
roborating the  views  that  they  are  in  some  way  actively  connected  with  the  production 
of  the  di.sease.     (Sec  Plates  XIV,  XV,  XVI.) 

G.  Inoculation  Experiments. — No  feasible  plan  has  been  devised  for  practising  inocu- 
lation experiments  upon  human  beings.  It  is  known,  however,  that  the  disease  may  be 
transmitted  in  some  cases  among  animals  of  the  same  species,  and  the  transfer  has 
been  made  in  a  few  instances  from  man  to  the  lower  animals.  In  the  Gratwick  Laliora- 
tory  (Buffalo)  the  disease  has  been  thus  transmitted  through  hundreds  of  mice,  and  has 
thus  afforded  the  best  means  of  studying  it  in  its  varied  phases,  albeit  in  small  animals, 
ever  yet  enjoyed.  But  cancer  does  occur  in  animals  and  has  proved  to  be  capable  of 
inoculation,  and,  therefore,  has  responded  to  one  of  the  severest  tests  of  the  value  of 
the  theory.  Moreover  the  facts  cited  above  (under  4)  are  essentially  successful  auto- 
inoculation. 

7.  Clinical  Observations. — Add  to  the  features  already  mentioned  above  those  im- 
|)ressions  which  come  from  accurate  observation  and  correlation  of  the  phenomena 
attending  many  cases  of  cancer,  and  a  plausibility  is  thus  lent  to  the  parasitic  theory 
wdiich  it  can  never  gain  from  study  in  the  dead-house  or  through  the  microscope.  The 
resemblance  between  it  and  other  known  infections,  the  local  and  general  alterations  of 
tissues  and  fluids,  the  chemical  changes  by  which  the  cachexia  of  the  disease  is  brought 
about — these  with  other  features  all  conspire  to  give  the  keen  observer  of  cases  of  cancer 
an  impression  of  parasitism  or  infectiousness  which  nothing  can  efface.  Add  to  these 
its  endemic,  sometimes  almost  epidemic  occurrence,  its  apparent  transmission  by  con- 
tact, and  the  fact  that  it  is  but  little  influenced  either  by  nutrition  or  drugs,  and  the 
argument  is  still  strengthened.  As  against  these  arguments  little  has  been  advanced 
save   denials   or  negations. 

In  thus  upholding  the  parasitic  theory,  the  writer  w^ould  not  wish  to  be  understood 
as  claiming  either  that  the  parasite  has  yet  been  discovered  or  its  nature  positively  made 
out,  nor  that  it  is  a  question  of  one  organism  alone;  rather,  on  the  contrary,  he  feels 
that  it  is  probably  a  question  of  several  agents,  probably  of  protozoan  character,  perhaps 
too  small  to  be  recognized  with  the  lenses  of  today,  perhaps  belonging  to  some  as 
yet  unstudied  class  of  organisms,  making  themselves  known,  however,  as  do  the  hypo- 
17 


258  SURdlCAL  AFFECTIONS  OF   TIIF   TISSUES 

thctical  parasites  of  sy|)liilis  and  scarlatina,  hy  their  cflects.  'Vo  accept  the  parasitic 
view  is  to  reconcile  many  (hscrepancies  of  earlier  times  and  to  give  an  entity  to  the  dis- 
ease by  which,  and  until  something  better  be  found,  we  may  be  more  safely  guided  in 
its  management. 

The  parasitic  theory  lends  plausil)ility  to  the  statement  which  the  writ(>r  wishes  to 
emphasize,  that  cancer,  like  many  of  the  other  infectious  diseases,  is  at  first  a  local 
condition,  that  it  is  not  transmitted  by  inheritance,  and  that  there  is  a  time  in  the 
history  of  every  cancer  when,  //  it  could  be  recognized  sufficiently  early,  and  ?'/  it  were 
also  accessible  and  thoroughly  removed,  it  could  he  cured. 

Nomenclature. — The  nomenclature  of  tumors  has  been  much  confused,  and  if 
some  new  terms  are  introduced  it  is  [oerhaps  better  than  to  cling  to  some  which  have 
prevailed  in  the  past.  Various  systems  have  been  followed  of  naming  them  according 
to  their  supposed  nature  or  their  evident  tendency,  or  according  to  some  purely  arl)itrary 
classification;  thus  there  is  the  distinction  into  Jwmolor/ous  and  heterologous  or  hetero- 
plastic, according  as  they  are  similar  to  or  variant  from  that  tissue  in  which  they  seem 
to  originate;  or  they  have  been  referred  to  as  henujn  and  malicpumt  according  to  the 
disposition  which  they  evince;  and  these  terms  are  in  sufhciently  frequent  use  to  demand 
acceptance.  The  distinction  between  benign  and  malignant  is  convenient  and  in  some 
respects  accurate,  implying  little  in  regard  to  histological  structure,  but  much  in  regard 
to  their  effect  upon  the  individual. 

So  far  as  method  of  classification  goes,  the  anatomical  (i.  e.,  the  histological)  has  proved 
far  the  most  satisfactory,  and  is  that  which  is  now  generally  adopted.  It  is  the  basis 
for  the  classification  followed  in  the  ensuing  pages.  But  even  here  it  is  impossible  to 
maintain  abrupt  or  always  accurate  distinctions,  because  tumors  are  frequently  of 
mixed  type,  and  it  is  required,  if  desired  to  express  their  composition  by  their  names, 
to  sometimes  combine  words  in  an  awkward  fashion. 

By  common  consent  that  tissue  which  predominates  furnishes  the  concluding  portion 
of  the  compound  term,  while  l)y  prefixing  other  terms  we  endeavor  to  imply  the  composite 
character  of  the  neo|)lasm. 

Thus  we  have  osteochondroma,  fibromi/oma,  viyofibroma,  etc.,  and  it  is  necessary  often 
to  reduplicate  terms  in  order  to  be  accurate  in  descri|)tion.  While  this  complicates 
phraseology,  it  nevertheless  furnishes  to  the  reader  a  reliable  clue  as  to  the  general 
character  of  such  a  growth;  and  if  one  reads,  for  instance,  of  a  myxochondrosarcoma, 
he  prom]:)tly  infers  therefrom  that  thereby  is  meant  a  tumor  essentially  a  sarcoma, 
in  which  both  myxomatous  degeneration  and  cartilaginous  formation  have  taken 
place. 

In  the  same  way  the  jirefix  cgsto  is  frequently  used  to  imply  a  combination  of  originally 
solid  tumor  which  had  undergone  cystic  changes  in  whole  or  in  part. 

The  old  term  cele  is  frequently  used  as  a  suffix,  implying  neoplastic  changes  in  an 
organ,  or  at  least  the  formation  there  of  a  tumor.  Thus  we  have  hronchocele,  hydrocele, 
and  cystocele.  Again,  certain  terms  are  used  in  a  different  sense  from  that  originally 
intended.  Thus  the  term  sarcoma  has  a  definite  significance,  whereas  originally  it  had 
little  meaning  and  was  applied  inadequately  and  indiscriminately.  Old  terms  also, 
like  fungus  hematodcs,  are  now  used  rather  in  a  descriptive  sense,  because  for  any  such 
tumor  we  can  find,  on  accurate  examination,  a  jiroper  term  taken  from  descriptive  path- 
ology. Therefore  the  student  of  today  should  read  the  works  of  the  older  writers, 
especially  concerning  neoplasms,  with  a  certain  amount  of  intelligence,  as  well  as  of 
apology  for  the  inaccuracy  and  misnomers  of  the  past. 


TREATMENT  OF  TUMORS. 

The  results  of  treatment  of  tumors  leave  much  still  to  be  desired,  particularly  when 
dealing  with  those  of  malignant  nature.  So  far  as  purely  internal  treatment  is  concerned, 
we  have  not  yet  discovered  drugs  which  with  any  certainty  influence  cell  growth  to  the 
extent  of  making  them  reliable  or  effective.  In  the  past,  and  even  at  present,  numerous 
remedies  have  been  advocated  as  having  more  or  less  power  in  this  direction.  Of 
them  all  it  is  probable  that  arsenic  in  some  form  is  more  efficacious  than  any  other. 
This  is  true  in  the  case  of  the  disease  elsewhere  spoken  of  as  malignant  lymphoma,  or 


r/..iN,s7 /•'/(■. r/7o.v  OF  rrMoRs  259 

I lodt/hin'.s  (li.srasr,  which  partakes  iiuich  of  the  characttT  of  some  of  tlie  other  neophisnis. 
Hut  to  say  that  arseiiie  alone  or  any  other  known  remedy  can  be  rehed  upon  at  all  times 
is  luakiiii;  a  hold  assertion. 

Operable  Tumors.  The  tnatinnit  of  opcmhlr  tumors  is  essentially  surgical  (i.  c, 
It  pc  rati  re),  althouijh  to  a  lar<]je  extent  results  are  based  ujjou  the  essential  character  of 
individual  cases.  But  it  can  be  stated  that  to  be  successful  in  the  removal  of  «/??/ 
luuior  its  complete  extirpation  is  imperative.  Even  the  most  bcnifijn  fjjrowths  will  return 
if  only  partially  removed.  This  is  true  even  of  innocent  cysts,  which  will  be  often 
reformed  if  a  |)orti()n  of  the  cyst  wall  be  allowed  to  remain.  Comj)lete  extirpation  is 
ordinarily  a  simple  measure  when  tumors  are  encapsulated,  as  arc  often  many  of  the 
iimocent  tumors.  On  the  other  hand,  the  performance  of  some  of  these  operations 
is  made  diflicult  and  hazardous  by  the  location  of  the  tumor,  as  in  many  large  uterine 
fibroids,  tumors  of  the  thyroid,  etc.  But  when  (lcalin<;  with  malij^nant  tumors  the  secret 
of  success  is  to  extirpate  them,  sacrificing  everything  which  may  apj)car  to  l)e  involved 
unless,  like  a  large  bloodvessel  or  iinportant  organ,  it  be  essential  to  the  life  of  the  part 
or  of  the  individual.  These  statements  are  made  when  sj)eaking  of  tumors  in  a 
general  way.  More  specific  directions  will  be  given  when  dealing  with  particular 
forms  or  in  the  chapters  on  Special  and  Regional  Surgery. 


CLASSIFICATION  OF  TUMORS. 

Following  custom  in  large  degree,  yet  being  guided  by  undeniable  facts  concerning 
histological  structure,  tumors  will  be  classified  and  considered  as  follows: 

1.  Cysts. 

2.  Dermoids. 

3.  Teratomas. 

4.  Tumors  of  connective-tissue  type. 

5.  Tumors  of  nerve  elements. 

G.  Tumors  derived  from  epithelium. 

1.  Cysts. 

A  cyst  may  be  defined  as  a  tumor  containing  one  or  more  cavities  filled  ivith  fluid  or 
semifluid  contents.  This  specifies  nothing  with  regard  to  the  location  nor  the  character 
of  the  cyst  wall  nor  the  nature  of  the  fluid  contents.  Following  Sutton,  I  divide  cysts 
into  four  groups: 

Retention  cysts. 

Tubulo  cysts. 

Hydroceles,  or  distention  cysts. 

Gland  cysts. 

Retention  Cysts. — These  imply  a  previously  existing  cavity  whose  outlet  is  obstructed 
and  whose  contents  consequently  accumulate,  often  to  such  a  degree  that  the  original 
character  of  both  containing  wall  and  contained  fluid  is  entirely  altered.  When  this 
occurs  in  glands  or  gland  ducts  there  is  usually  complete  atrophy  of  gland  tissue,  pro- 
viding sufficient  time  have  elapsed.  Such  cysts  are  due  either  to  permanent  or  tem- 
porary arrest  of  flow.  In  hydronephrosis,  for  example,  there  is  obstruction  of  the  renal 
outlet  and  dilatation  of  its  pelvis,  with  partial  or  complete  atrophy  of  the  kidney  structure, 
imtil  a  cyst  of  enormous  size  may  be  present.  When  a  similar  condition  obtains  in  the 
ut.TUs,  as  by  obstruction  of  the  cervix,  perhaps  due  to  injury  done  during  labor,  we  have 
a  condition  known  as  hydrometra,  seen  occasionally  in  women,  often  in  the  lower  animals, 
and  particularly  in  those  having  a  bicornate  uterus,  causing  a  condition  often  mistaken 
for  an  enormously  dilated  Fallopian  tube.  Similarly,  w^hen  the  common  bile-duct 
is  obstructed,  which  may  be  due  to  impacted  gallstones,  to  inflammatory  lesions  or 
tumors,  there  may  be  such  backing  up  of  bile  in  the  gall-bladder  as  to  produce  the 
condition  known  as  hydrocholecyst. 

Under  any  of  these  circumstances  pyogenic  bacteria  may  produce  infection  which 
will  be  more  or  less  promptly  followed  by  suppuration;  and  then,  instead  of  hydro- 


260  SURGICAL   AFFECTIOXS  OF   THE   TISSUES 

nephro.s'i.s,  hijdrometra,  hydrosalpinx,  etc.,  we  have  pyoncplirosis,  pyometra,  and  pyosal- 
pinx. 

Tubulo  Cysts. — These  are  cystic  dilatations  of  certain  functionless  ducts  and  obso- 
lete canals  which  no  longer  serve  a  useful  purpose.     They  comprise: 

1.  Cysts  of  the  ViteUo-intestinal  Duct. — Cysts  (originating  from  this  functionless  duct 
occupy  the  uinhilif  al  rcLnmi,  sometimes  projecting  externally,  sometimes  internally. 
They  are  usually  lined  with  mucous  memhrane  furnished  with  villi  and  columnar  epithe- 
lium. Such  a  cyst  may  be  confounded  with  an  uml)ilical  hernia.  These  cysts  occa- 
sionally ojx-n  at  the  umbilicus  and  discharge  irritating  material,  sometimes  fecal  matter. 
Cystic  dilatation  of  the  portion  of  the  duct  originally  connected  whh  the  ileum  is  also 
sometimes  seen. 

2.  Allantoic  Cysts. — These  are  connected  with  the  urachus,  which  should  ordinarily 
be  found  as  a  fibrous  cord,  but  which  occasionally  persists  in  a  pervious  condition,  in 
whole  or  in  |)art.  At  birth  it  Ls  often  traversed  by  a  narrow  canal  lined  with  epithelium 
continuous  with  that  of  the  bladder.  The  urachus  lies  outside  the  peritoneum,  and 
may  be  dilated  at  any  point  between  its  two  extremities.  ^Vl](■Il  the  cntiiv  urachus  is 
pervious  urine  is  disr-harged  from  the  navel. 

3.  Cysts  Connected  with  Remains  of  the  Wolff  an  Ecdy. — The  Wolffian  body,  or  the 
mesonc])hr()-~,  i>  iiitiinarily  n-lalcd  with  the  development  of  the  kidney,  the  ovary,  and 
the  testis.  In  the  two  latter  locations  glandular  elements  may  be  met,  persisting  in 
adult  life. 

In  the  male  the  tubules  persist  as  excretory  ducts  from  the  testis,  but  in  the  female 
they  persist,  in  a  vestigial  condition,  as  the  parovarium  and  Gartner's  ducts.  The 
ovary  proper  consists  of  the  oophoron  and  the  parocphoron,  the  former  being  the  egg- 
bearing  ponion,  the  latter  receiWng  the  tubules  from  the  adjoining  structure  known  as 
the  parovarium.  The  paroophoron  gives  rise  to  cysts  ^\hich  btirrow  deeply  between 
the  layers  of  the  broad  ligament,  make  their  way  alongside  the  uterus,  and  raise  the 
peritoneum.  It  is  a  peculiarity  of  these  cysts  that  their  inner  walls  often  become  papillo- 
matous, and  may  even  <li  \i  lop  such  a  crop  of  warty  outgrowths  that  these  make  their 
way  through  the  cyst  wall  and  protrude  into  the  abdominal  cavity,  where  they  sometimes 
become  detached  and  are  dropped  as  loose  bodies  into  the  peritoneal  sac.  The  con- 
dition is  also  often  accompanied  by  warty  growths  u|X)n  the  peritoneal  surfaces.  The.se 
need  give  rise  to  no  alarin,  Ijecause  they  usually  disap]x*ar  sjjontanetmsly  with  removal 
of  the  tumor.  Paroophoritic  cysts  are  to  be  distinguished  from  parovarian  cysts,  which 
develop  from  the  parovarium,  this  latter  consisting  of  a  number  of  tubules  situated 
between  the  layers  of  the  mesosalpinx,  composed  of  an  outer  series  known  as 
Kobelfs,  an  inner  set,  about  a  dozen  in  number,  known  as  the  veiiical  tubules,  with  a 
straight  tube,  running  at  right  angles  to  these  through  the  broad  ligament  to  the  vagina, 
known  as  (iartners  duct,  which  is  homologous  with  the  vas  deferens  in  the  male.  Cystic 
dilatation  of  Kobelt's  tubes  is  often  seen,  these  cysts  being  very  small  and  having 
no  clinical  importance.  Cysts  arising  from  the  vertical  tubules  are  usually  transparent 
until  they  attain  considerable  size,  when  their  walls  thicken.  Their  contained  fluid 
is  not  harmful,  and  after  rupture  of  such  cysts  internally  the  fluid  is  ab.sorbed.  Such 
cysts  may  rupture  and  refill  several  times.  As  betireen  the  paroophorons  and  parovarian 
cysts  the  latter  are  easily  enucleated,  carry  the  ovary  u])on  one  side,  and  have  the  Fal- 
lopian tube  stretched  over  them  ^nthout  communication. 

The  internal  sections  of  Gcidners  duct  are  more  often  involved  in  animals  than  \t 
women,  but  excellent  illastrations  of  cystic  dilatation  of  its  various  jxjrtions  have  been 
observed,  usually  in  the  walls  of  the  vagina. 

Corresponding  to  the  above-mentioned  conditions  in  the  female  th?re  are  in  the  male, 
as  the  result  of  changes  in  the  Wolffian  body,  two  condition.s — encysted  hydrocele  of  the 
testicle,  and  general  cystic  degeneration  of  the  same.  Like  the  ovary,  the  testicle  is  a 
complex  organ  ^^•ith  remnants  of  the  me.sonephros  persisting  among  its  ducts,  while 
only  a  few  of  the  Wolffian  tubules  remain.  True  encysted  hydroceles  arise  sometimes 
in  the  efferent  tubes  of  the  testis  and  sometimes  in  Kobelt's  tubes  (the  same  structures 
which  in  the  female  give  rise  to  parovarian  cv.sts),  the  two  conditions,  therefore,  being 
analogous  and  homologous.  These  cysts,  though  closely  associated  with  the  testis, 
lie  outside  its  tunica  vaginalis.  Their  contained  fluid  is  usually  clear  or  of  a  milky 
whiteness,  due  to  fat  globules.     Sometimes  it  contains  sjxrmatozoa.     Another  variety 


CLASSIFICATIO.W  OF   TUMORS  261 

is  cystic  dilatation  of  one  or  more  of  Kohr/t'.^  Iiihti/c.s-,  which  is  often  described  as  involving 
the  hi/daiid  oj  Morf/ar/ni. 

(icnrral  ri/stic  (li,sra.sr  of  flic  testis,  iviiown  also  as  adenomatous  deij[eneration,  was 
formerly  referred  to  as  hydatid  disi-ase  of  the  same  or<jan.  The  multiple  cysts  a|)|)car 
to  ori<i;inatc  in  tln'  renmant  of  the  mcsonej)hro.s  still  pcrsistinj^,  known  as  the  paradidi/mis. 
The  cavities  arc  lined  with  cj)ithclium,  and  papi/lomatou.s  intrarij.stir  formation  is  not 
unconunoM.  These  tumors  have  been  called  by  a  number  of  imj)roper  names,  such 
as  "cystic  sarcoma,"  etc. 

Hydroceles.  The  term  hydrocele  has  covered  numerous  conditions.  At  present, 
when  no  otiier  locality  is  desiu;iiated,  hydrocele  of  the  tunica  vaf];inalis  is  understo(xl. 
(The  term  implies  a  rollcction  of  ivatrry  fluid  in  a  previou.sly  cxistbuj  .serous  rurifij.) 
This  is  the  most  common  form. 

Possil)ility  of  its  formation  dc|)ends  upon  the  jjrolonjfation  of  the  peritoneal  cavity 
which  takes  place  in  advance  of  or  along  with  the  descending  testicle,  and  which  in 
many  of  the  lower  animals  remains  connected  with  the  general  cavity  throughout  life. 
In  men  only  is  it  expected  to  close,  even  before  birth.  When  the  portion  which  extends 
along  the  spermatic  cord  is  not  completely  obliterated  there  is  encysted  liydrorek  of  the 
cord,  or  funicular  hydrocele,  which  is  not  common.  The  common  form  of  hydrocele 
is  constituted  by  serous  effusion  into  the  tunica  vaginalis,  and  occurs  usually  without 
recognizable  exciting  cause.     It  will  be  treated  more  fully  in  its  appropriate  place. 

The  corresponding  process  of  peritoneum  in  the  female  is  known  as  the  canal  of  Nude; 
and,  when  persistent,  this  also  becomes  distended  with  fluid  and  f(jrms  a  cyst  known  as 
hydrocele  of  the  canal  of  Nuck,  occupying  the  inguinal  canal. 

In  many  of  the  lower  animals  the  ovaries  are  contained  within  a  serous  sac  derived 
from  the  peritoneum,  which  is  so  connected  with  the  opening  of  the  Fallopian  tubes  that 
when  the  ova  escape  from  the  ovary  they  enter  these  tubes  and  pass  to  the  uterus  A\ithout 
entering  the  general  peritoneal  cavity.  This  ovarian  sac  is  subject  to  serous  distention, 
and  constitutes  a  condition  called  by  Sutton  an  ovarian  hydrocele.  x\n  homologous 
condition  occurs  sometimes  in  the  human  female,  by  pathological  adhesion,  and  such 
cysts  may  attain  large  size.  They  project  from,  and  are  intimately  connected  with,  the 
posterior  layer  of  the  broad  ligament. 

Hydroceles  of  the  Neck. — Hydroceles  of  the  neck,  so  called,  are  cystic  collections  of 
congenital  origin  found  in  the  cervical  region,  due  to  dilatation  of  ducts  or  clefts  which 
should  have  disappeared  at  or  before  birth.  The  forms  of  cyst  to  which  the  name 
"hydrocele  of  the  neck"  are  usually  limited  are  recognizable  at  or  soon  after  birth,  and 
constitute  fluctuating  tumors,  often  extending  beneath  the  clavicle  into  the  axilla  or  down 
upon  the  thorax.  They  may  occupy  the  entire  lateral  region  of  the  neck,  and  may  be 
unilateral  or  bilateral — may  be  single  or  multilocular,  and  may  even  intercommunicate. 

They  originate  always  beneath  the  deep  fascia.  Some  of  these  cysts  are  undoubtedly 
due  to  dilatation  of  lymph  spaces.  This  is  particularly  true  of  the  multilocular  forms. 
There  is  noted  in  many  of  them  a  tendency  toward  spontaneous  recovery,  but  many 
again  require  operative  measures  for  their  eradication.  Occasionally  their  w^alls  are 
extremely  vascular,  even  to  the  degree  meriting  the  term  nevoid. 

Some  of  these  cysts  are  considered  by  Sutton  to  be  essentially  examples  of  the  laryngeal 
saccules  which  are  met  with  as  diverticula  from  the  laryngeal  mucous  membrane,  which 
undermine  the  deep  cervical  fasciae  of  certain  monkeys.  These  air  chambers,  which 
are  normal  in  the  monkey,  communicate  with  the  larynx  through  the  thyrohyoid  mem- 
brane, and  occasionally  run  down  beneath  the  upper  border  of  the  thorax.  Many  of 
the  cysts  having  this  resemblance  are  closely  related  to  the  hyoid  bone  and  to  the  larynx, 
and  there  is  much  to  substantiate  the  view  thus  quoted. 

Glandular  Cysts. — Ramila  is  an  altogether  too  comprehensive  term  which  has 
long  been  used  in  surgery,  alluding  to  cysts  in  the  floor  of  the  mouth,  and  not  indicating 
minutely  their  character  nor  their  exact  location.  At  present  this  term  should  either  be 
restricted  in  signification  or  be  eliminated.  If  used,  it  should  be  confined  to  retention 
cyst.<i  due  to  obstruction  of  the  .submaxillary  or  sublingual  ducts.  Such  obstruction  is 
often  caused  by  salivary  calculi  impacted  in  the  duct  orifices.  In  other  instances  it  is 
due  to  cohesion  of  the  margins  of  the  outlet.  A  similar  condition  in  the  parotid  duct 
is  known,  but  is  less  common.  Aside  from  this,  certain  other  cysts  originate  from 
minute  beginnings  in  and  about  the  floor  of  the  mouth,  being  due  to  dilatation  of  the 


262  SURGICAL  AFFECTIOXS  OF   THE   TISSUES 

raucous  glands,  particularly  one  near  the  tip  of  the  tongue,  sometimes  known  as  Nuhn's 
gland.  Dermoid  cysts  in  this  locality  are  not  uiuonimon.  Formerly  cysts  of  the  floor 
of  the  mouth  were  described  as  ranida. 

Panrreafir  cysts  correspond  in  large  degree  to  salivary  cysts,  the  pancreatic  duct  be- 
coming dilated  by  retention  when  its  orifice  is  obscured;  and,  indeed,  the  condition  has 
been  referred  to  as  panrreaiie  ranula.  Sometimes  the  canal  is  dilated  in  distinct  por- 
tions, so  that  the  condition  resembles  a  string  of  cysts;  at  other  times  it  is  the  terminal 
portion  which  is  most  enlarged.  Such  cysts  attain  large  size  and  contain  mainly 
mucoid  material.  Examples  have  been  reported  showing  that  they  have  attained  a 
capacity  of  two  gallons. 

In  the  mesentery  there  sometimes  develop  cysts  which  are  known  as  chyle  cysis,  whose 
sacs  appear  to  be  formed  of  separate  mesenteric  layers,  their  cavity  being  occupied  by 
fluid  identical  with  chyle.     Such  tumors  also  sometimes  attain  great  size. 

In  the  eyelids  one  occasionally  meets  with  cystic  dilatations  of  the  lacrymal  ducts. 
These  are  known  as  dacryopic  cysts  or  dacryops.  Fistulas  result  when  they  are  opened 
through  the  skin,  and  if  meddled  with  at  all  they  should  be  radically  extirpated.^ 

Pseudocysts. — In  his  elaborate  work  on  tumors  Sutton  has  made  a  distinct 
classification  of  pseudocysts,  which  lack  some  of  the  characteristics  of  genuine  cysts, 
yet,  nevertheless,  are  entitled  to  consideration  in  this  place.  Among  these  are  included 
i7itesti)ial  diverticula  and  vesical  diverticula,  in  either  of  which  instances  hernial  pro- 
trusions of  the  mucous  membrane  through  the  outer  coating  of  the  bowel  or  of  the  bladder 
occur,  thus  forming  pouches.  These  are  common  in  the  bowel,  rare  in  the  bladder; 
especially  in  the  former  locality  they  are  often  multiple.  This  condition  is  often  referred 
to  as  sacculation,  and  sacculation  of  the  bladder  may  even  be  confounded  with  true 
urachus  cyst.  They  are  of  little  consequence  so  long  as  foreign  materials,  such  as 
feces,  urinary  calculi,  etc.,  do  not  lodge  in  them.  But  they  occasionally  cause  .serious 
trouble.  Diverticula  have  been  mistaken  for  appendices,  while  diverticula  from  the 
bladder  have  been  encountered  in  hernia  operations. 

Pharyngeal  diverticula  give  rise  to  rare  but  most  interesting  tumors.  It  is  well  known 
that  the  Ijranchial  clefts,  which  in  early  fetal  life  connect  with  the  ])harynx,  are  sometimes 
not  completely  closed,  and  that  a  portion  of  one  may  persist  abnormally,  giving  rise  to 
a  condition  known  as  the  pouch  of  Rathke.  There  may  also  occur  sacculation  of  the 
})haryngeal  wall  where  it  joins  the  esophagus,  or  hernial  protrusions,  esf>ecially  in  Rosen- 
miiller's  fossa. 

Cystic  dilatation  of  Rathke's  pouch  occurs  near  the  upper  part  of  the  pharynx,  and 
may  attain  the  size  of  a  marble.  Hernial  pouches  are  .seldom  mistaken  for  cysts,  and 
are  of  importance  mainly  because  of  the  fact  that  food  or  other  foreign  material  gathers 
and  lodges  in  them.  Most  of  the  other  cystic  abnormalities  of  the  pharynx  pertain  to 
dermoids,  and  will  be  considered  shortly.  In  a  general  way,  these  pharyngeal  tumors 
have  been  grouped  as  pharyngoceles. 

Similarly  in  the  esophagus  and  trachea  hernial  protrusions  occur,  and  lesions  clo.sely 
resembling  retention  cysts  may  be  seen. 

Synovial  cysts  (i.  e.,  those  containing  synovial  fluid)  may  arise  (1)  by  protrusion  of 
synovial  sheaths,  (2)  by  distention  of  bursae  in  the  vicinity  of  joints,  or  (3)  by  hernial 
protrusions  of  joint  membranes.  They  are  often  met  with  in  connection  with  the 
larger  joints,  more  particularly  about  the  knee.  In  this  way  tumors  as  large  as  goo.se- 
eggs  may  be  formed,  while  their  location  may  be  so  shifted  that  they  present  them.selves 
in  perplexing  ways.  To  that  form  produced  by  hernial  protrusion  of  the  lining  of  a 
tendon  sheath  has  been  given  the  name  ganglion. 

The  simple  ganglion  is  frequently  seen  on  the  back  of  the  wrist,  and,  while  it  is  always 
connected  with  the  tendon  sheath,  it  undoubtedly  often  connects  with  the  sMiovial  mem- 
brane of  the  carpal  joints.  The  compound  ganglion,  so  called,  is  a  much  more  serious 
and  extensive  affair,  being  one  which  has  prolongations  in  two  or  more  directions,  and 
containing  peculiar  bodies,  known  as  melon-s-eed  bodies,  which  appear  to  be  fibrinous 
concretions  worn  round  and  smooth  by  attrition.  These  are  present  sometimes  in 
enormous  numbers.     (See  Tuberculosis  of  Synovial  Structures,  Chapter  IX.) 

'  In  the  treatment  of  cysts,  as  of  many  abscesses  (e.  p.,  those  of  the  gland  of  Bartholin),  it  will  be  of  advan- 
tage to  empty  the  cavity  through  a  small  trocar  or  needle  and  then  to  fill  it  with  melted  paraffin,  as  suggested 
by  Pozzi.  When  it  has  thus  been  distended  it  can  be  dissected  out  with  much  more  deliberation  and  more 
easily  than  would  be  otherwise  possible. 


CLASSIFICATIOX  OF  TUMORS  263 

liiir.s(r  are  iionnal  in  many  well-known  .situations  in  the  l)o(l\ ,  hut  may  undergo  cystic 
dilatation  and  lu-comc  amioyino  tumors.  In  many  other  places,  under  the  influence 
of  friction  or  mechanical  irritation,  there  develoj)  hursa'  which  are  known  as  advnttiiious. 
'I'hese  are  sometimes  suhtcndinous,  and  may  communicate  alike  with  joint  sheaths  and 
tendon  sheatiis.  These  are  true  cysts  of  new  formation  not  develojH'd  from  a  j)re-existing 
cavity. 

They  are  largely  the  effect  of  peculiar  occuj)ation,  as  in  housemaids  and  carjx't-layers 
there  are  formed  frecpiently  prepatellar  bur.sa',  while  miners  get  them  upon  the  elbow, 
porters  uj)on  the  shoulder,  plasterers  upon  the  forearm,  etc.  In  the  same  way,  by  the 
pressure  of  ill-fitting  boots,  an  adventitious  bursa  is  developed  over  the  expanded  head 
of  the  first  metacarpal  bone,  thus  forming  a  condition  known  as  bunion. 

Neural  Cysts.  'I'hi.s  term  has  l)een  applied  by  Sutton  to  pseudoeystie  dilata- 
tion of  certain  cavities  found  in  the  brain  and  central  nervous  system.  IlydrocepJialits 
is  in  one  sense  a  |)seu(locyst  of  this  variety.  Corres])onding  to  it  in  fetal  life  is  liijdmni- 
nios.  Hydrocele  or  cystic  dilatation  of  the  fourth  ventricle  is  well  known.  Cra7iial 
meningoceles,  whicli  are  hernial  protrusions  of  brain  membranes,  are  also  pseudocysts, 
to  l)e  included  in  this  category.  They  will  be  considered  in  Cha])ter  XXXVI.  Ceplial- 
heniatoina  may  be  also  included  in  the  same  w^ay.  Spina  bifida,  a  condition  whicli  will 
be  describtnl  in  Chapter  XXXVIII,  is,  nevertheless,  practically  a  cyst  of  congenital 
origin  involving  the  spinal  meninges.  One  form  of  spina  bifida  is  (onstituted  by  cystic 
dilatation  of  the  central  canal  of  the  spinal  cord,  and  produces  .syrinyoinijelorcle.  These 
conditions  will  be  treated  more  fully  in  their  approj)riate  j)laces. 

Sutton  has  rendered  a  great  service  by  showing  that  the  brain  and  spinal  cord  are 
evolved  from  a  segment  of  the  primary  intestines,  and  that  the  intestinal  canal  and 
the  neural  canal  coniniunicate  in  fetal  life  at  their  lower  terminations;  while  it  has 
been  shown  by  several  that  in  the  earlier  forms  of  mammalian  life  they  were  also  con- 
nected by  their  anterior  terminations.  It  is  in  this  way  that  certain  complex  tumors  of 
the  sacral  and  coccygeal  region  are  to  be  explained.  So  also  is  the  collection  of  lymjihoid 
tissue  in  the  vault  of  the  pharynx,  known  as  Luschka's  tonsil,  aiul  in  the  coccygeal  region, 
known  as  Luschka's  gland,  it  being  a  curious  and  instructi\e  fact  that  lymj)hoid  tissue 
of  this  character  is  always  met  with  in  the  neighborhood  of  obsolete  canals. 

Hydatid  Cysts. — These  cysts  are  the  indirect  product  of  the  eggs  of  the  Taenia 
echinococcus,  a  form  of  tape-worm  which  infests  the  alimentary  canal  of  dogs.  The 
eggs  reach  in  some  direct  or  indirect  way  the  food  or  water  taken  into  the  human  stomach 
and  are  there  hatched;  the  young  animals  migrate  through  vessel  walls  and  are  deposited 
in  some  tissue  or  organ  where  the  cyst  later  develops.  These  cysts  have  a  thick,  elastic 
wall,  with  a  lining  containing  cells,  involuntary  muscle  fibers,  and  a  water-vascular 
system.  After  such  a  cyst  has  attained  the  size  of  an  inch  or  more,  small  vesicles,  or 
"brood  capsules,"  begin  to  develop,  which  present  at  one  point  a  retractable  head,  with 
scolices  so  arranged  in  crown  form  as  to  produce  sucking  disks.  According  to  the 
date  at  which  the  cyst  is  opened  appearances  will  differ.  Sometimes  a  large  cavity 
will  be  filled  with  multiple  "daughter  cysts,"  and  sometimes  these  will  have  disapjieared, 
so  that  the  cyst  fluid  contains  nothing  distinctive.  After  having  ceased  to  develop, 
hydatids  frequently  undergo  atrophy  and  even  become  calcified;  the  characteristic 
booklets  are  the  last  of  the  distinctive  features  to  disappear. 

These  growths  may  be  rapid,  even  to  the  point  of  producing  necrosis  and  rupture, 
or  may  be  very  slow  and  persist  almost  unchanged  for  years.  The  disease  is  uncommon 
among  the  native-born  population  of  the  United  States,  and  most  of  its  examples  are 
seen  in  emigrants.  It  is  exceedingly  prevalent  in  Iceland  and  in  New  Zealand.  It 
occurs  most  often  in  the  liver,  but  is  frequently  met  with  in  these  countries  in  the  lungs, 
the  brain  and  spinal  canal,  and  the  bones,  but  may  be  encountered  in  any  part  of 
the  body.  When  located  near  the  intestinal  tract  or  the  air  tract  the  cysts  are  more 
liable  to  penetration  by  ordinary  germs  of  sepsis,  and  then  may  suppurate.  It  is  not 
infrequent  to  have  conversion  of  an  hydatid  cyst  into  an  abscess.  Before  or  after  such 
change  it  may  undergo  rupture,  spontaneous  or  traumatic,  and  this,  according  to  the 
nature  and  amount  of  its  contents,  and  the  location  of  the  opening,  will  promptly  produce 
more  or  less  grave  symptoms.  While  spontaneous  recovery  has,  in  rare  instances, 
followed  rupture,  it  has  perhaps  more  often  led  to  fatal  result.  At  all  events,  it  will 
produce  serious  and  perhaps  distressing  symptoms. 

The  only  radical  treatment  for  hydatid  cysts  is  extirpation.     When  this  is  not  possible 


204  SURGICAL  AFFECTIONS  OF   THE   TISSUES 

the  cyst  may  be  opened  and  the  margins  of  the  openino;  attached  to  those  of  the  skin 
wound.  After  being  evacuated  it  shoukl  be  packed  and  drained,  and  then  may  be 
expected  to  slowly  contract,  perhaps  even  to  the  point  of  obliteration.  The  contents  of 
such  a  cyst  should  not  be  allowed  to  escape  into  any  of  the  body  cavities,  since  their 
sterility  can  not  be  always  relied  u])on. 

Cystic  Degeneration. — Ilnnatocrlr  is  an  expression  meaning  a  tumor  composed 
originally  of  effused  ])l()()d  which  has  undergone  chemical  and  other  changes,  which 
consist  of  lamination  and  thickening  of  its  exterior  jiortion  and  fluidification  of  the 
interior,  until  in  course  of  time  such  an  internal  blood  clot  niay  be  converted  into  a 
distinct  and  plainly  walled  cyst.  This  condition  may  be  seen  in  two  locations — namely, 
in  the  pelvis  and  heiiccen  the  eranium  and  the  brain,  or  in  the  brain.  The  hemoglobin 
gradually  disajipears,  and  the  contents  of  these  cysts  are  translucent  or  even  watery  in 
appearance.  Hematoceles  may  form  where  there  has  been  internal  hemorrhage  in  cer- 
tain locations  which  has  failed  to  absorb,  and  where  no  pyogenic  infection  has  occurred. 

Pseudocystic  changes  occur  in  other  tumors  and  in  other  j^arts  of  the  body  as  the  result 
oi  miieoid  and  eolloid  liquejaotionfi.  In  the  midst  even  of  apparently  dense  and  entirely 
defined  tiunor  masses  changes  of  thi,s  kind  occur,  and  lead  to  formation  of  cavities 
containing  fluid  of  variable  consistence,  causing  the  tumor  when  divided  to  present 
the  appearance  of  the  geodes  or  quartz  rocks,  containing  cavities  lined  with  quartz 
crystals.  The  occurrence  of  such  cystic  changes  is  indicated,  in  naming  such  a  tumor, 
by  prefixing  the  term  cysto-,  as  cystosarcoma,  cystofibroma,  etc. 

2.  Dermoids. 

Dermoids  are  cysis  or  inmors  eoniaining  iissues  and  appendages  ichieh  are  developed 
from  the  epihlast,  and  which  occur  when  skin  and  mucous  membrane  are  not  normally 
found.  The  simplest  form  of  dermoid  is  a  cyst  whose  interior  is  lined  with  modified 
skin,  containing  sebaceous  glands  antl  hair  follicles,  from  which  often  numerous  long 
hairs  are  produced.  Even  sweat  glands  may  be  present.  Its  cavity  is  occupied  by 
mixed  material,  pultaceous  in  character,  made  up  of  sebum,  cholesterine,  and  growing 
hairs  which  are  often  rolled  into  balls.  The  sebum  is  the  product  of  the  glands  contained 
in  the  cyst  wall. 

A  complex  form  of  so-called  dermoid  cyst  is  met  with  in  which  there  are  unstriped 
muscle  fiber,  teeth,  mammary  glands,  etc.  These  belong  rather  to  the  class  of  teratomas, 
as  they  contain  more  or  less  tissue  not  of  epiblastic  origin. 

A  dermoid  tumor  is  one  lacking  cystic  characteristics,  made  up  of  tissue  largely  devel- 
oped from  the  epiblast,  with  more  or  less  tissue  of  mesoblastic  origin.  Such  a  tumor 
may  contain  much  connective  tissue,  fat,  fetal  hyaline  cartilage,  and  nerve  tissue,  while 
from  its  exterior  long  hair  may  grow,  and  teeth  project  from  its  surface  or  be  embedded 
within  its  substance.  Such  tumors  are  generally  found  in  the  pharynx  and  about  the 
rectum. 

The  explanation  of  dermoids  and  teratomas  may  be  gleaned  from  embryology,  and 
rests  upon  the  arrangement  of  the  different  blastodermic  layers  of  the  develo})ing  ovum, 
and  u})on  the  facts  already  alluded  to  in  explaining  Cohnheim's  hypothesis  of  the  origin 
of  tumors.  Strictly  speaking,  a  dermoid  should  contain  only  that  which  may  be  developed 
from  the  epiblastic  layer.  It  is  well  known  that  teeth  and  hair,  as  well  as  sebaceous 
material,  are  epiblastic  products.  Consequently  such  material  may  be  found  within 
a  dermoid  and  needs  no  further  explanation  than  an  epiblastic  inclusion,  according  to 
Cohnheim's  views.  But  so  soon  as  such  a  tumor  contains  bone,  muscle,  etc.  {i.  e., 
tissues  of  mesoblastic  origin),  we  should  drop  the  term  dermoid  and  consider  it  a  teratoma. 
Such  is  the  distinction  between  these  two  terms.  According  to  Wilm's  researches,  any 
tumor  of  this  sort  which  contains  epithelial  jiroducts  as  teeth  or  hair  is  sure  to  contain 
also  mesoblastic  elements,  and  thus  to  belong  to  the  latter.  The  term  epidermoids 
has  been  applied  to  the  former. 

The  most  prominent  characteristics  of  dermoid  cysts  are:  (1)  Skin,  which  may  be 
thick  or  thin,  lined  with  papillae,  containing  more  or  less  pigment,  its  deeper  layers 
possessing  a  quantity  of  fat.  (2)  Hair,  which  next  to  skin  is  the  most  constant  structure 
found  in  dermoids;  this  may  be  present  in  trifling  amount  or  in  long  coils  or  balls.  It 
is  of  interest  that  in  dermoids  found  in  animals  covered  with  wool  we  find  the  same 


CLASSIFIVATIOX  OF   TUMORS  265 

character  of  liairv  .stnicdirc,  wliilc  in  hinls  dermoids  contain  leathers  ratlier  than  hairs. 
(3)  Schacrous  (jhuids  and  (heir  pecnhar  secretion  are  invariably  found.  These  may  be 
of  Iarii;(>  si/e,  and  sebaceous  retention  cysts  may  be  .seen  in  the  walls  of  dermoids.  Some- 
times lionii/  matter  or  tissue  is  found  in  these,  in(licatin<j  the  same  relation  between 
horn  and  sel)aceous  structures,  as  we  .see  u|)on  the  external  skin  in  other  instances.  So, 
too,  material  resemblinij;  the  texture  of  Hn<i;er-nails  is  occasionally  found  projcclinir  into 
the  cavity. 

The  fluid  or  semifluid  contents  of  the.sc  cysts  consist  usually  of  .sebaceous  material, 
cholesterin,  epithelial  debris,  etc.  Sometimes  it  is  thick,  sometimes  thin — and  occa- 
sionally consi.sts  almost  entirely  of  mucus. 

It  is  not  unconunou  to  find  structures  in  orarian  dermoids  clo.sely  analofijous  to,  or 
actually  resemblinij;,  inainniart/  glands.  'I'hese  may  be  mere  ni])j)le-like  |)roces.ses  of 
skin,  or  comjiletely  (ieveloj)ed  mamma',  well  formed,  l)Ut  without  ducts  or  o;lan(l  tissue, 
may  occupy  such  a  cyst.  These  really  are  jm-iKlomamma',  becaii.se  they  have  no  ducts. 
Nevertheless,  irlandular  tissue  is  not  always  absent,  "^riiis  re.sembhuice  ])roceeds  even 
farther,  in  that  in  some  of  these  ovarian  mamnue  changes  occur  analogous  to  tho.se  which 
take  i^lace  in  normal  breasts. 

The  ej)ibla.st  .seems  to  have  the  powcM-  of  developing  mammary  glands  or  supernumerary 
mamma'  in  many  locations — in  fact,  upon  any  part  of  the  body  surface.  About  the 
thorax  they  are  common;  upon  the  abdomen  they  are  rarely  observed;  and  they  have 
been  found  even  upon  the  labia. 

Sweat  glauds'  are  infrequent  in  dermoids.  Teeth  are  quite  common.  These  may 
vary  in  number  from  two  or  three  up  to  several  hundred — niay  be  embedded  in  definite 
sockets  or  simj)ly  sprout  from  the  cy.st  wall.  Occasionally  bone  material,  lodging  such 
teeth  and  crudely  resembling  a  ja^v,  will  be  found. 

Dermoids  containing  mucous  membrane  are  found,  especially  in  connection  with  the 
ovary  and  with  the  jiostanal  gut  (i  e.,  the  original  communication  between  the  spinal 
and  alimentary  canals). 

It  is  curious  that  imder  these  circumstances  mucous  membrane  is  sometimes  furnished 
with  hair,  as  it  normally  is  in  the  stomach  or  other  cavities  of  some  of  the  lower  animals. 
Mucous  glands  and  retention  cysts  of  these  glands  are  also  found  in  ovarian  dermoids. 
This  will  be  more  readily  understood  if  the  mutability  of  skin  and  mucous  membrane 
be  not  forgotten.  The  transition  from  one  to  the  other  is  not  difficult,  and  we  find 
all  intermediate  stages  between  the  two  extremes — if  not  in  man,  at  least  in  animals. 
This  will  account  for  the  fact  that  skin -covered  dermoid  tumors  are  found  in  certain 
parts  of  the  alimentary  canal,  and  particularly  in  the  pharynx.  These  tumors  grow- 
also  from  the  mucous  membrane  of  the  bowel,  of  the  rectum,  or  even  of  the  small 
intestine. 

Sutton  has  made  a  division  of  dermoids  into  three  classes : 

1.  Sequestration; 

2.  Tubulodermokls; 

3.  Ovarian. 

1.  Sequestration  Dermoids. — Sequestration  dermoids  occur  chiefly  in  situations 
where  during  embryonic  life  coalescence  takes  place  between  two  surfaces  possessing 
an  epiblastic  covering,  although  sometimes  this  coalescence  practically  occurs  late  in 
life    and    by    implantation. 

Dermoids  of  the  trunk  occur  particularly  where  opposite  halves  of  the  body  wall 
coalesce — that  is,  in  the  midline  of  the  trunk  and  head.  Dermoid  cysts  are  rarely 
found  in  connection  wi"th  spina  bifida,  and  certain  tumors  spoken  of  as  spina  bifida 
undoubtedly  are  dermoids.  Anteriorly  dermoids  occur  frequently  in  the  scrotum, 
and  occasionally  in  the  testicle.  At  the  umbilicus  they  are  rarely  found — usually  as 
pedunculated  tumors  projecting  externally.  In  the  midline  of  the  thorax  and  neck 
they  are  most  common  opposite  the  manubrium,  dropping  down  behind  it  to  invade 
the  anterior  mediastinum.  Near  the  hyoid  bone  they  occur  relatively  frequently;  about 
the  head  they  are  met  with  most  commonly  at  the  angles  of  the  orbits — more  so  at  the 
outer  than  at  the  inner  angle.  Dermoid  cysts  are  know^n  to  oculists  as  growing  upon  the 
iris  or  springing  from  the  conjunctiva.  x\bout  the  ear  they  are  not  infrequent;  in  the 
roof  of  the  mouth,  especially  if  this  be  incomplete,  w^e  frequently  find  cysts  of  epiblastic 
origin. 

Sequestration  dermoid  cysts  are  also  undoubtedly  found  in  connection  with  the 


266 


SURGICAL  AFFECTIONS  OF  THE  TISSUES 


dura  mafrr,  in  the  scal|),  most  cominonlv  at  tlie  anterior  fontanclle,  at  the  root  of  the  nose, 
and  at  the  external  occipital  protuherance,  where  they  niay  he  confounded  witli  sel)a- 
eeous  cysts  or  with  nienin<,^)celes.  In  order  that  a  dermoi(l  of  the  (hira  may  communi- 
cate with  the  skin  there  must  of  coiu'se  be  osseous  defect. 

Sequestration  dermoids  upon  the  hmbs  have  been  mostly  n^ported  as  sebaceous  cysts. 
They  are  rare,  and  usually  associated  with  antecedent  injury,  by  which  epiblastie  struc- 
tures are  driven  in  and  implanted  in  such  a  way  that  as  they  develop  they  give  rise  to 
these  peculiar  tumors.  These  are  what  Sutton  calls  implantation  dermoids.  They 
are  found  upon  th(>  fingers  and  elsewhere. 

Tubulo dermoids. — These  are  largely  connected  with  obsolete  canals  and  ducts.  It 
is  a  great  service  which  Sutton  has  rendered  in  proving,  a])parently  beyond  the  possi- 
bility of  doubt,  that  the  central  canal  of  the  nervous  system  is  really  of  intestinal  origin, 
and  may  be  regarded  as  a  disused  segment  of  the  primary  alimentary  canal.  He  has 
also  shown  how  it  behaves  occasionally  as  do  otiier  functionless  ducts,  and  that  cysts 


Fig.  72 


Fig.  73 


Solid  dermoid  escaping  from  pelvis.    (Original.) 


Congenital  dermoid  cyst  of  pelvis.    (Ahlfeld.) 


anfl  dermoids  in  connection  with  it  are  to  be  thus  exj^lained.  He  and  others  have 
also  shown  the  anterior  as  well  as  the  posterior  communication  of  the.se  canals,  antl  the 
pituitary  body  are  to  be  regartled  in  this  light  as  the  same  formation  of  lymphoid  tissue 
around  an  obsolete  canal  which  we  see  in  Luschka's  tonsil  close  by,  and  in  Luschka's 
gland  at  the  other  extreme  of  the  canal. 

The  primary  alimentary  canal  was  a  continuous  tube  lined  with  a  continuous  layer 
of  columnar  epithelium.  That  portion  connected  with  the  yolk  sac  develops  into  the 
intestine,  the  balance  into  the  central  nervous  canal.  Portions  of  this  canal  are  in  post- 
natal life  absolutely  obsolete;  others  persist  in  a  rudimentary  condition.  Dermoid 
cysts  and  dermoid  tumors  develoj:)  in  coimection  with  eac-h  of  these.  In  some  there 
is  a  large  central  cavity;  others  are  almo.st  absolutely  solid.  Thus  we  find  dermoids  in 
the  coccygeal  region,  which  have  been  variously  regarded  as  sarcomas,  adenomas,  etc., 
which  are  really  of  origin  as  stated  above  and  should  be  considered  sim])ly  as  dermoid 
tumors.  Most  of  these  project  outwardly;  some  of  them  ari.se  and  develop  within  the 
pelvis.     Dermoid  cysts  and  tumors  are  also  met  with  in  connection  with  the  rectum — 


CLASSIFICATION  OF  TUMORS  207 

sonictiincs  lu'twcon  the  rccluiii  and  llu>  hladdcr,  and  iK'twccii  the  rectum  and  tlie 
spiiic.  Dermoid  tumors  are  also  found  in  eonneetion  with  the  pituitary  body.  These 
soinelimes  deveiop  within  tlie  cranium,  or,  ajxiii'i,  protrude  |)erha|)s  into  the  orbit, 
jH'rhaps  into  the  ])haryiix. 

Tlii/roid  dcntioids  are  tumors  of  <;reat  interest.  'I'liey  deveh)p  sometimes  about  tlie 
eranio|)liarvni:;eal  canal,  which  may  be  detected  as  u  small  canal  in  the  macerated 
sphenoid  bone  of  a  fetus,  and  which  before  birth  is  filled  with  fibrous  tissue.  It  connects 
with  a  HH-ess  in  the  middle  line  and  at  the  base  of  the  skull,  |)resentinj);  in  the  j)l)aryn.\, 
which  is  often  referred  to  as  the  buna  pliari/iu/ra.  It  is  around  tliis  recess  that  the 
lymphoid  tissue  known  as  the  "pharyngeal  tonsil"  develops.  It  may  be  thus  e.\j)ected 
that  the  roof  of  the  pharynx  should  be  the  oeeasional  site  of  dermoids.  It  is  from  the 
})harynx  or  the  floor  of  the  mouth  that  in  vertebrates  the  thyroid  body  arises.  In  higher 
forms  it  becomes  dissociated  from  the  pharynx  and  shifts  its  position.  The  thyroid 
body  is  develojx'd  around  the  thyroid  duct,  which  first  ai)pears  as  the  thyrohyoid  duct, 
which  later  becomes  divided,  that  ])ortion  in  relation  with  the  tongue  Iji-coming  the  tliyro- 
lingual  duct,  the  remaining  portion  persisting  as  the  thyroid  duct.  These  are  j)resent 
about  once  in  every  ten  subjects,  according  to  Sutton,  the  canal  when  persistent  being 
lined  with  epithelium.  When  the  extremities  of  these  ducts  become  (Kcluded  reten- 
tion cysts  may  form.  In  the  same  way  dermoids  of  the  tongue  are  formed,  similar  to 
those  occurring  on  the  scalp.  These  are  frequently  mistaken  for  sebaceous  cysts. 
They  may  be  unilateral,  central,  or  even  bilateral.  The  lingval  duct  is  also  of  interest, 
because  it  would  ap{)ear  that  certain  cases  of  epithelioma  of  the  tongue  arise  along  this 
duct,  and  perforating  malignant  ulcer  of  the  tongue  is  thus  produced.  Dermoid  tumors 
of  the  lingual  or  thyroid  ducts  resemble  in  structure  the  thyroid  body.  The  thyroid 
duct  may  also  be  detected  in  many  adults  running  from  the  isthmus  of  the  thyroid  body 
to  the  posterior  aspect  of  the  hyoid  bone,  and  surrounded  by  muscle  tissue.  Sometimes 
the  space  usually  occupied  by  this  duct  is  represented  by  a  series  of  detached  bodies 
known  as  accessory  thyroids.  These  are  not  infrequently  the  seat  of  cysts,  sometimes 
of  considerable  size.  (The  accessory  thyroids  often  enlarge  when  the  main  thyroid 
has  been  extirpated  for  disease.)  Thus  cysts  in  close  relation  to  the  hyoid  bone  are 
common.  Some  of  them  grow  slowly,  while  others  grow  rapidly  and  contain  much 
fluid.  Many  of  them  are  unilateral,  and  are  often  mistaken  for  enlargements  of  one 
lobe  of  the  thyroid.  Cysts  growing  from  accessory  thyroids  are  often  filled  with  ])apil- 
lomatous  masses,  and  are  occasionally  the  seat  of  malignant  degeneration. 

In  the  omphalomesenteric  duct  or  its  remains,  especially  in  relation  with  the  umbilicus, 
we  often  meet  with  small  cysts  or  tumors  in  infants  and  young  children.  When  the 
duct  is  persistent  it  presents  normal  intestinal  structure,  and,  like  the  appendix,  possesses 
much  adenoid  or  lymphoid  tissue. 

Another  and  very  important  form  of  tuhnJodermoids  develops  in  connection  with  the 
branchial  clefts  of  the  neck.  Congenital  fistulas  of  the  neck  have  been  long  known, 
but  only  comparatively  recently  understood.  Of  the  branchial  clefts  it  is  well  known 
that  the  first  alone  should  persist,  as  the  Eustachian  tube.  Occasionally,  however, 
they  fail  to  become  obliterated,  and  then  we  have  congenital  tumors  or  cysts,  which  may, 
perhaps,  not  develop  to  appreciable  size  until  somewhat  late  in  life;  or  there  may  l)e 
fistulous  passages  opening  either  into  the  pharynx  or  externally,  forming  canals  varying 
in  length  from  half  an  inch  to  two  inches,  secreting  a  little  fluid  because  lined  with  epi- 
thelium. When  these  become  inflamed  an  abscess  results.  W'hen  they  open  externally 
the  opening  is  often  marked  by  a  little  tag  of  skin  containing  a  fragment  of  yellow 
cartilage.  These  are  often  referred  to  as  cervical  auricles.  They  open  along  the  line 
of  the  sternomastoid  muscle.  The  internal  openings  of  these  fistulas  frequently  form 
diverticula  from  the  pharynx  or  esophagus.  Thus  it  will  be  seen  that  dermoid  cysts 
about  the  neck  are  principally  relics  of  openings  or  ducts,  \\hich  are  normal  in 
embryonic  life,  but  which  should  have  been  obliterated  at  or  long  before  birth.  Con- 
genital fistulas,  however,  may  be  met  with  in  the  middle  line  of  the  neck,  which  are  not 
to  be  confounded  with  branchial  fistulas,  but  rather  with  the  ducts  previously  described. 

Ovarian  Dermoids  and  Teratomas. — These  may  be  unilocular  or  multilocular 
cysts,  usually  the  latter.  They  are  lined  with  epithelium,  and  contain  mostly  mucoid 
fluid,  the  inner  coat  being  practically  identical  with  mucous  membrane.  Occa- 
sionally, however,  the  skin  is  furnished  with  hair,  sebaceous  glands,  teeth,  and  even 
nipples.     The  multilocular  cysts  are  practically  an  aggregation  of  those  just  described. 


268  SURGICAL  AFFECTIOXS  OF  Till':  TISSUES 

Thev  are  surrounded  hy  dense  capsules,  often  attain  (jreat  diineiisioiis,  and  are  made  up 
of  primary  cysts  resenihlintij  lar^e  cavities  in  a  lioneycoinh-like  mass,  which  itself  is 
occupied  by  secondary  cysts,  and  he]on<i|;  rather  to  the  class  of  nmcous  retention  cysts, 
these  beinp;  occupied  l)y  still  smaller  ones,  which  are  histoloffically  indistinguishable 
from  distended  ovarian  follicles.  In  these  large  tumors  we  find  in  some  cases  hair,  in 
others  teeth,  and  in  others  sebaceous  glands,  etc.,  the  dermoid  constituents  being  scattered 
throughout.  As  Wilms  has  shown,  in  almost  every  tumor  of  this  character  a  projection 
may  be  found  whose  summit  is  covered  with  epiblastic  elements,  which  when  cut  in 
serial  transverse  sections  will  show  in  its  deeper  j)ortion  other  epithelial  collections  repre- 
senting a  feebU"  attempt  to  develop  a  nervous  system,  or  lung  tissue,  while  mesoblastic 
elements,  like  connective  tissue,  cartilage,  and  bone,  a])pcar  scattered  throughout,  as 
though  a  very  crude  effort  had  been  made  to  reproduce  an  atypical  embryo. 

3.  Teratomas. 

So  far  the  endeavor  has  been  to  limit  the  term  dermoid  to  tumors  which  are  essentially 
of  rpihlastic  formation,  their  location  being  explained  on  the  inclusion  theory  of  Cohn- 
heim.  There  is  also  a  still  more  complicated  tyjje  of  tumor,  composed  of  tissues  of  both 
cpihlafiiic  and  mrsohlaMic  origin,  pei'haps  even  hi/poh/a.s-fir.  Their  consideration  l)clongs 
to  that  department  of  pathology  known  as  ferafo/of/t/,  which  is  su])posed  to  deal  especially 
with  monsters.  Strictly  s])eaking  a  irrafoma  refers  to  an  irregular  tumor  or  mass  con- 
taining tissues  and  fragments  of  viscera  of  a  suj>pressed  fetus  which  is  attached  to  an 
otherwise  normal  individual.  Nevertheless  the  term  is  often  apj)lied  to  growths  which 
are  the  result  of  luxuriant  mesoblastic  development  in  which  neither  form  nor  member 
of  a  suppres.sed  fetus  is  present. 

The  presence  of  supernumerary  members  is  largely  connected  with  what  is  called 
dichotomi/,  alluding  thereby  to  cleavage  either  at  the  anterior  or  posterior  end  of  the 
developing  embryo.  When  the  whole  embryonic  axis  divides  firin.s  inaij  he  produced, 
but  should  cleavage  be  jiartial  we  may  have  a  monster  with  two  heads  if  it  be  anterior, 
or  one  with  three  or  more  limbs  if  it  be  posterior.  Children  born  with  these  deformities 
are  usually  called  monsters,  and  the  study  of  such  cases  belongs  entirely  to  tera- 
tology. But  in  certain  tumors  small  portions  of  a  suppressed  fetus  may  develop,  as,  for 
instance,  from  the  posterior  jiortion  of  the  sacrum,  or  within  the  abdomen  or  thorax, 
or  u])on  the  neck  or  face,  which  on  dissection  may  contain  a  few  vertebra;  or  processes 
resembling  fingers  associated  perhaps  with  a  structure  resembling  intestine  or  liver. 
This  should  be  called  a  teratoma.  Such  tumors  possess  for  the  pathologist  the  greatest 
value.  In  surgery,  however,  they  are  rare,  and  there  are  scarcely  two  cases  alike.  The 
(piestion  of  operation  will  often  arise,  as  it  does  with  superiumieiary  limbs,  and 
each  case  should  be  studied  upon  its  own  merits.  Sometimes  they  are  amenable  to 
extirpation. 

Embryonal  Adenosarcoma.  Embryonal  adenosarcoma  is  a  term  given  to  certain 
teralomatous  tumors  peculiar  to  renal  and  adrenal  structure,  which  present  peculiar 
characteristics  in  the  mi.xture  of  elements  which  enter  into  their  composition.  At 
various  times  these  tumors  have  been  called  adenoma,  sarcoma,  rhabdomyoma,  con- 
genital cystic  kidney,  etc.  They  have  been  also  likened  to  the  thyroid.  They  comprise 
a  group  of  neoplasms,  always  congenital  in  origin,  which  usually  appear  early  in  life, 
but  occasionally  occur  in  advanced  adult  life.  One  of  the  most  marked  s[)ecimens 
of  this  kind  the  writer  removed  from  a  man  over  fifty  years  of  age.  Most  of  the  speci- 
mens, however,  described  in  literature  ))ertain  to  the  young.  On  minute  examination 
they  oft(>n  present  a  strange,  mixed  picture  of  voluntary  muscle  elements  intermingled 
with  ejMthelium  arranged  to  imitate  acinous  glands,  with  cystic  dilatations  of  the  true 
kidney  tissue.  They  often  attain  enormous  size,  and  undergo  such  proliferation  of  meso- 
blastic elements  as  to  resemljle  sarcoma.  Their  occurrence  is  to  be  explained  only  on 
the  principles  of  Cohnheim's  hypothesis.  When  the  original  Wolffian  body  is  being 
differentiated  from  the  elements  about  it  a  confusion  of  the  same  with  the  excretory 
tubular  beginnings,  which  are  to  empty  into  the  Wolffian  duet,  occurs.  Thus  we  have 
the  commencement  of  a  mixed  mass  which  presents  itself  as  a  more  or  less  rapidly 
growing  tumor,  in  which  even  cartilage  or  other  mesoblastic  structures  may  be  met 
with.     It  is  scarcely  possible  that  any  two  specimens  should  yield  exactly  the  same 


CLASSII'ICATIOS  OF   TlMOli,^  269 

niicrosc()|)ic  pictiirt',  iniuli  (k'|)fiuliiii;  on  wlictlKT  oiu'  cli'incnt  or  the  other  prevail. 
In  ji  few  of  them  there  may  oeeur  also  a  mixture  of  adrenal  elements.  Sometimes  the 
renal  strueture  itself  is  more  or  less  distinct,  and  rides,  as  it  were,  upon  the  surface  of 
the  tumor;  at  other  times  it  is  entirely  mixed  uj)  with  it.  While  the  condition  is  usually 
limited  to  one  side  it  may  he  a  douhle  affection,  so  that  the  second  kidney  hecomes  u.sele.ss 
and  the  patient  succumbs.     The  only  treatment  is  extirpation. 

'reratoniatous  tumors  are  sometimes  found  hani^int^  in  the  pharynx,  attached  hv  a 
small  |K'dicle,  where  they  may  he  confounded  with  dermoids  unless  carefullv  examined 
after  removal.  Many  instances  of  this  tyjK'  of  tumor  are  found  in  animals.  Here  no 
false  sentiment  will  prevent  complete  examination  and  preservation  of  the  specimen. 
They  are  also  encountered  in  the  sacral  and  coccygeal  regions. 

4.  Tumors  of  Connective-tissue  Type. 

Lipoma. — Lij)omas,  or  tumors  composed  of  fat,  are  the  most  common  of  the 
neo])lasms.  Their  normal  type  is  the  ordinarij  adipose  tissue  of  the  body,  and  mav  be 
divided  into  the  encapsulated  and  the  diffuse,  the  former  of  which  are  surrounded  by 
fibrous  tissue.  The  difiuse  lipomas  are  those  which  have  no  capsule,  and  where  the 
pathological  collection  of  fat  merges  into  that  normally  present — in  other  words,  they 
are  not  circumscribed. 

Subcutaneous  Lipomas. — Subcutaneous  lipomas  are  j^erhaps  the  mo.st  common  of  all, 
and  are  usually  irregularly  lobulated  and  encapsulated,  adherent  rather  to  the  skin  than 
to  the  deej)er  tissues.  Usually  but  one  is  found  in  an  individual,  though  instances  of 
multi])le  lipomas  are  not  rare.  They  develop  sometimes  to  enormous  size,  cases  being 
on  recortl  where  the  tumor  has  even  weighed  one  hundred  pounds.  They  may  be 
met  with  at  any  point  on  the  surface  of  the  body.  The  lobules  often  burrow  between 
the  muscles,  and  those  found  in  the  palm  of  the  hand  penetrate  even  beneath  the  palmar 
fascife.  They  are  sometimes  markedly  pedunculated,  and  often  hang  by  a  small  stem. 
The  diffuse  subcutaneous  lipoma  is  most  common  about  the  neck,  in  the  groin,  and 
in  the  axilla. 

Subserous  Lipomas. — Subserous  lipomas  are  mostly  retroperitoneal,  and  large  tumors 
of  this  chara<tcr,  mistaken  for  ovarian,  have  been  successfully  removed  by  opera- 
tion. They  also  occur  in  the  hernial  canals  and  spaces.  They  develop  beneath 
the  peritoneum  covering  the  intestines,  and  in  this  location  give  rise  occasionally  to 
intussusception.  Here  in  their  pathological  development  they  have  the  general  form 
and  significance  of  appendices  epiploic^. 

Subsynovial  Lipomas. — Subsynovial  lipomas  occur  about  various  joints  and  tendon 
sheaths;  within  the  knee  they  assume  a  distinctive  t^-pe  which  has  been  called  lipoma 
arljorescens,  where  they  take  on  a  dendritic  appearance  and  arrangement.  Submucous 
lipomas  are  rare.  Intermuseular  fatty  tumors  are  occasionally  met  with,  an  interesting 
•  variety  being  that  which  develops  between  the  masseter  and  buccinator  muscles.  Intra- 
muscular forms  rarely  occur,  as  well  as  a  variety  known  as  parosteal,  which  arises  in 
connection  with  the  jx'riosteum.  Fatty  tumors  also  occur  within  the  spinal  dura,  as 
well  as  outside  of  it  within  the  spinal  canal,  and  more  or  less  lipomatous  alterations  are 
common  in  connection  with  spina  bifida. 

Lipomas  are  ordinarily  easy  of  recognition,  save  when  deeply  located.  The  sub- 
cutaneous forms  are  intimately  related  with  the  overlying  skin,  and  have  a  dough-like 
consistence  which  is  usually  ])athognomonic.  Tumors,  suspected  to  be  fatty,  in  the 
middle  line  of  the  l)ack  or  cranium  are  always  to  be  viewed  with  suspicion,  as  they  are 
often  connected  with  congenital  meningeal  protrusions. 

An  encapsulated  lipoma  when  thoroughly  removed  will  not  return. 

^Nlixed  forms  of  fibrous  and  fatty  neoplasm  are  occasionally  .seen,  and  are  referred  to 
as  lipoma  fihromatosujn  or  fibroma  lipomatosum,  according  as  one  or  the  other  tissue 
predominates.  These  growths  are  innocent  in  their  character,  but  call  for  thorough 
extirpation.  They  frequently  give  rise  to  considerable  discomfort  or  pain,  and  are 
called  lipoma  dolorosa. 

Fibroma. — Fibromas  are  tumors  compo.sed  of  fibrous  tissue,  which,  when  of 
pure  type,  are  found  to  be  not  so  common  as  was  formerly  supposed,  the  majority  of 
tumors  hitherto  roughly  groui^ed  as  fibromas  containing  either  muscle  tissue  or  sarco- 


270 


SURGICAL  AFFECTIONS  OF   THE   TISSUES 


inatoiis  I'IciiK'iits,  which  takes  them  out  of  the  category  of  pure  fibroma.  A  typical 
fil)roiiia  is  ordinarily  dense,  and  is  composed  of  wavy  bundles  of  fibrous  tissue  whose 
cells  are  long  and  slender  and  closely  j«icked  together,  the  mass  being  permeated  by 
distinct  bloodvessels. 

Fibroma  occurs  most  commonly  in  the  ovary,  the  uirnis,  the  iniestinr,  the  fjmn  (epulis), 
in  nerve  .sheaths,  and  in  the  skin  in  the  lorm  of  so-called  painful  subcutaneous  tubercles 
and  inolluscum  jitn'osum.  There  is  also  a  fibrous  tumor  of  the  skin,  known  as  keloid, 
sustaining  to  fibroma  the  same  relation  that  exists  between  exostosis  and  osteoma. 

Painjul  subcutaneous  tubercle  is  a  sample  of  pure  fibroma  in  the  shape  of  a  small, 
flattened,  pea-like  tumor  which  never  attains  great  size.  It  is  situated  loosely  in  the 
subcutaneous  structure  and  may  form  a  visible  prominence.  Insignificant  as  it  would 
thus  a{)pear,  it  becomes  the  seat  of  exasperating  pain,  particularly  when  touched  or 
handled,  which  may  radiate  to  considerable  distances.  The  etiology  of  these  growths 
is  unknown. 

In  the  ovary,  the  uterus,  the  intestine,  and  the  larynx  true  fibrous  tumors  are  patho- 
logical curiosities  rather  than  common  lesions. 

Fig.  74 


■J  _v«-.. 


. -Jir  ^r;'  ^  --  -  -  ?,"^— ~  "^^"^S-^^^'Q 


^^^fc^^^^-r^^^^'^*^ 


Keloid  of  external  ear:  a,  dense  tissue  of  skin;  6,  fibrous  connective  tissue;  f,  epidermis.     (Klebs.) 

Epulis. — Epulis  means  any  tumor  growing  upon  the  gum.  The  term  was  formerly 
ap])lied  in  an  indistinct  and  too  comprehensive  way,  although  it  is  still  retained  in 
literature.  But  pure  fibromas  do  spring  from  the  fibroosseous  structure  of  the  gmn 
and  alveolar  process.  They  are  covered  with  the  gingival  mucous  meml)rane  and 
seem  to  spring  from  the  periodontal  membrane.  They  seldom  attain  large  size,  and 
then  only  l)y  neglect.  By  the  pressiu-e  of  such  tumors  teeth  may  be  separated  and  dis- 
tortion of  the  mouth  ])roduced.     They  should  be  promptly  extir])ated. 

Keloid. — Keloid  is  a  fibrous  neoplasm  arising  mainly  in  cicatric-ial  tissue,  which  is 
essentially  fibroid  in  structure.  It  is  a  neoplams  which  often  follows  the  general 
outline  of  the  scar  in  which  it  grows,  consists  in  elevation  of  the  surface,  ordinarily 
quite  smooth,  sometimes  of  a  delicate  pink  from  the  dilated  vessels  which  it  contains. 
Keloid  is  the  bete  noir  of  surgeons,  as  it  fretiuently  complicates  and  disfigures  scars 
which  have  at  first  been  satisfactory,  and  since  it  indicates  a  condition  which  it  is 
discouraging  to  deal  with,  because  when  it  is  removed  there  is  usually  recurrence  of 
growth  within  a  few  months  after  cicatrization.  It  often  occurs  in  stitch-hole  scars 
and  upon  the  site  of  extensive  burns,  and  may  be  observed  after  puncture  of  the 
ears  for  ear-rings,  and  has  also  been  observed  in  scars  left  by  smallpox,  acne,  etc. 
It  is  more  prevalent  in  the  colored  race  than  in  the  white.  In  negroes  multiple 
keloid  tumors  are  often  seen,   occasionally  in   large  numbers.     Their  explanation  is 


i'l.ASSIhlCATlOS   Oh'    Tl'MOh'S 


271 


uiikiiowii,  and  il  may  In-  tliat  sonic  (rillin«>;  injury  lias  iircccdc-d  cadi  individual 
tiinior  (Fifj;.  71). 

The  tirafiiinit  of  keloid  will  he  considered  in  (lie  cliaptcr  on  tlic  Snr<ri(al  Diseases  of 
the  Skin. 

Desmoids.  'I'll is  term  has  been  a|)i)lied  to  tumors  of  a  certain  clinical  type  which 
arise  from  the  lihrous  struclures,  usually  of  the  ahdoininal  wall,  and  produce 'neoplasms 
like  the  fihromas  of  other  parts  of  th(>  I'lody.  Thv  use  of  the  term  should  be  restricted 
to  those  tumors  which  jirocced  |)riniarily  only  from  muschvs,  tendons,  and  ai)()neuroses, 
or  i)erliai)s  from  lifiamentous  and  periosteal' tissues.  These  tumors  are  usually  single, 
attain  sonu^times  considerable  she,  gnm  slowly,  rarely  involve  other  structures,  and 
not  infrequently  develop  to  such  an  extent  as  to  encroach  upon  either  pelvis  or  the  abdo- 
men, or  both.  'J'hey  have  been  known  to  attain  to  tiie  weifrht  even  of  ten  pounds  or 
more.  They  are  usually  more  or  less  encapsulated,  and  are  firm  and  dense  in  structure. 
Under  the   microscoj)e   they  have 

the  <:;eneral  appearance  of  c(>llular  Fig.  75 

fibroma.  Sarcomatous  elements 
may  be  met,  while  they  occasion- 
ally undergo  cystie  degeneration. 
Their  occurreiiee  niay  be  ex- 
plained, at  least  in  some  in- 
stances, on  the  embryological 
theory  of  Cohnheim. 

The  ircalment  of  desmoids  con- 
sists in  their  complete  extirj)ation. 
T'hey  should  not  be  allowed  to 
attain  large  size  beeause  their 
removal  may  entail  a  serious 
weakening  of  the  abdominal  wall. 
There  should  be  such  plastie  re- 
arrangement of  abdominal  pro- 
teeting  membranes  as  to  retluce 
the  resulting  weakening  to  a 
minimum. 

Psammoma. — Psammoma  is  a 
term  applictl  to  a  form  of  hard 
fibroma  met  with  in  the  dura 
mater,  in  which  there  has  oc- 
curred a  petrefaction  of  some  of 
the  cells — i.  e.,  a  deposition  of 
calcareous  salts,  which  gives  it  a 
gritty  or  sandy  apearance. 

CilOndroma.—The  true  chon- 
droma is  a  tumor  composed  of 
hyaline  cartilage.  It  occurs  in 
the  long  l)ones,  usually  in  relation 
with  epiphyseal  cartilages,  and  is 
often  noted  during  the  earlier 
years  of  life.  While  it  is  usually 
a  solitary  tumor,  multiple  chon- 
dromas are  often  seen,  especially 
upon  the  hands.  These  tumors 
are  often  encapsulated  and  form 

deep  hollows,  in  which  they  rest.  Unless  pressing  upon  nerve  trunks  they  are  pain- 
less and  slow  of  growth.  They  are  exceedingly  dense  and  hard,  and  ordinarily 
immovable.  Mucoid  softening  (i.  e.,  cystic  degeneration)  is  common,  and  the  softened 
areas  may  give  rise  to  fluctuation.  There  may  be  coincident  calcification  or  ossification 
in  any  of  these  groAvths.  It  is  noted  as  a  curious  circumstance  by  Sutton  that  their  tissue 
reseiiibles  histologically  the  bluish,  translucent,  e]:)iphyseal  cartilage  seen  in  progressive 
rickets. 

To  the  small  local  hypertrophies  of  cartilage  which  are  seen  especially  about  joints, 


Multiple  enchondromas. 


272  SURGICAL  AFFECTIONS  OF   THE   TISSUES 

about  the  larynj^eal  fartilages,  and  the  triangular  cartilage  of  the  nose,  are  giver^.  the 
term  ecchondrosca.  They  are  most  common  in  the  knee  in  connection  with  rheumatoid 
arthritis,  and  occur  as  prominences  along  the  margins  of  the  joint  cartilage.  They  may 
project  to  such  an  extent  as  to  be  detached  by  accident,  after  which  tliey  become  movable 
and  floating  bodies  in  the  joints.  Many  of  the  floating  cai-tilages  or  Ixxlies  found  in 
joints  are  detached  ecchondroses,  which  may  be  smoothed  off  by  attrition,  and  may  be 
found  singly  or  multiple,  even  several  hundred  existing  in  one  joint. 

C hofidromatous  changes  as  occurring  in  sarcomatous  tumors  have  been  alluded  to.  It 
seems  to  be  easy  for  connective  tissue  to  form  hyaline  cartilage,  and  mixed  tumors  may 
thus  be  seen  in  connection  either  with  sarcoma,  fibroma,  or  other  forms. 

Treatment. — The  treatment  of  chondroma  is  solely  oj)erative.  Unless  the  integrity 
of  a  member  or  a  limb  be  compromised,  such  a  tumor  can  usually  be  shelled  out  from 
its  location,  but  requires  that  the  matrix  be  completely  extirpated;  all  of  which  may  call 
for  the  use  of  powerful  bone  instruments.  At  other  times  amputation  is  the  only  measure 
which  may  relieve  from  deformity,  pain,  and  disability.  The  ecchondroses  occurring 
within  joints  necessitate  incision  and  evacuation,  with  the  most  rigid  aseptic  precau- 
tions, with  or  without  drainage.  When  practised  according  to  modern  technique  this  is 
almost  invariably  successful.  In  former  times  many  lives  were  lost  because  of  septic 
infection. 

Osteoma. — Under  the  head  of  nomenclature  I  have  already  endeavored  to  dis- 
tinguish as  between  exostosis,  or  irregular  bone  outgrowth,  and  osteoma,  as  a  distinct 
tumor  which  is  composed  of  bone  tissue,  with  the  subvariety  odontoma,  or  tumors  of 
dental  origin  and  structure.     Osteoma  is  regarded  by  some  as  ossifying  chondroma, 

Fig.   76 


h 


a 

Double  osteoma  of  the  skull.     (Mus^e  Dupuytren.) 


for  it  is  nearly  always  found  near  epiphyseal  lines,  and  is  always  covered  by  hyaline 
cartilage  when  thus  found.  Nevertheless  it  is  not  invariably  such.  We  speak  of  com- 
pact or  itJory  osteoma  and  of  a  cancellous  form.  The  former  is  identical  with  the  com- 
pact tissue  of  the  shafts  of  long  bones,  and  may  occur  anywhere,  but  is  most  common 
about  the  cranium,  at  the  frontal  sinus,  the  external  meatus,  and  the  mastoid  process. 
Osteomas  growing  into  the  frontal  sinus  of  oxen  form  large,  lobulated,  bony  masses,  some- 
times weighing  several  pounds,  and  as  dense  as  ivory.  Some  of  these  tumors  growing 
into  the  cranial  cavity  have  been  regarded  as  ossified  brains.  Osteomas  in  connection 
with  the  external  auditory  meatus  may  partially  obscure  this  channel  and  cause  deafness. 
They  constitute  ivory-like  growths,  which  sometimes  defy  the  finest  steel  instruments 
with  which  the  surgeon  can  supply  himself. 

Cancellous  osteomas  grow  in  the  cranium  as  well  as  in  the  long  bones,  and,  like  the 
compact  forms,  only  occasion  pain  by  pressure  upon  nerve  trunks. 

Exostoses. — Exostoses  are  classed  by  Sutton  as — 

1.  Those  formed  by  ossification  of  tendons  and  their  attachments.  There  should  l)e 
excluded  from  this  group  such  natural  or  evolutionary  processes  as  the  supracondyloid 
process,  the  third  trochanter  of  the  femur,  etc.  Over  or  around  such  exosto.ses  bursjE 
will  form  to  mitigate  as  much  as  possible  the  effect  of  friction.  Such  an  outgrowth  is 
known  as  an  exostosis  bursa;  it  is  most  frequently  seen  on  the  inside  of  the  femur  imme- 
diately above  the  knee. 

2.  Subungual  exostoses,  occurring  usually  beneath  the  nail  of  the  big  toe. 

3.  Exostoses  due  to  calcification  of  inflammatory  exudations,  including  the  rare  con- 
dition known  as  myositis  ossificans. 


PLATE  XVII 


FIG.    1 


Round-cell  Sarcoma.      (  Low  power. ) 


Spindle-cell  Sarcoma.      (Low  power.) 


CLASSIFICATIO.X   OF    TV  MORS 


273 


WluMi  a  (nic  oslroina  is  oiuc  (lioroiijjlily  rciuovcMl  there  is  no  tendeiiey  to  reeurreiico. 
'riioroiii'li  removal,  however,  calls  soiiietiiiies  for  serious  and  often  niutilatintj  operations, 
which  nuiv  become  danjijerous  when  the  f^rowth  involves  the  curve  of  a  rih  or  a  larjjje 
portion  of  the  skull.  At  other  times  amputation  is  rendered  necessary.  Special  forms 
rciiuire  special  treatment. 

Sarcoma.  Komierly  this  name  implied  a  fleshy  tumor,  and  was  made  to  cover 
inaiiN  dill'erent  conditions.  Now  sarcoma  means  a  tumor  composed  of  immature  meso- 
hlastic  or  emhrijouic  tissue  in  ivhicli  cells  predomiuate  orer  iutercellular  material.  Sarcomas 
are  sometimes  encapsulat(>d;  they  merfije  into  and  infiltrate  the  surroundinj:;  tissue  and 
disseminate  widely,  and  have  usually  these  j)ropensities  and  characteristics  to  such  a 
dei,n-ee  as  to  constitute  malignancy.  For  the  laity  sarcomas  and  carcinomas  are 
toijether  included  in  the  comprehensive  term  of  cancer;  for  the  surgeon  they  constitute 
hut  one  form  of  cancer.  Sarcomas  are  classified,  according  to  the  shape  of  their  cells 
and  their  disj)()sition,  into— 

A.  Hound-cell; 

B.  Spindle-cell; 

C.  Mi/eloid. 

To  these  are  added  other  varieties  mentioned  below. 


Fig.  77 


Fig.  78 


Osteoma  of  frontal  sinus.     (Neisser.) 


Recurring  sarcoma  of  parotid.     (Original.) 


A.  Round-cell  Sarcoma. — This  is  simple  in  construction,  and  consists  of  round  cells 
containing  very  little  intercellular  substance.  The  nuclei  of  the  tumor  cells  stain  easily, 
the  cells  themselves  varying  in  size  in  different  cases.  Bloodvessels  lead  up  to  the  tumor, 
but  in  the  interior  appear  rather  as  channels.  These  tumors  have  no  lymphatics :  they 
grow  rapidly,  infiltrate  easily,  recur  quickly,  and  give  rise  to  numerous  metastatic  or 
secondary  dejxjsits.  They  may  affect  any  part  of  the  human  body.  The  size  of  the 
cells  is  supposed  to  be  in  some  measure  an  index  of  their  malignancy — the  smaller  the 
cell  the  more  malignant  the  tumor.  They  appear  at  all  periods  of  life.  They  are  per- 
haps the  most  commonly  seen  of  malignant  tumors  in  animals.     (See  Plate  XVII.) 

Lymphosarcoma. — This  tumor  is  composed  of  cells  similar  to  the  previous  form,  but 
enclosed  in  a  delicate  meshwork  resembling  that  of  lymph  nodes,  hence  the  term  li/mpho- 
sarcoma.     Lymphosarcomas  are  not  to  be  confounded  with  enlargements  nor  with  the 
specific  granulomas  involving  these  lymphatic  structures. 
18 


274  SURGICAL  AFFECTIONS  OF   THE   TISSUES 

B.  Spindle-cell  Sarcoma. — In  this  form  tlic  cdls  luivc  a  spindle  shape  and  run  in  all 
directions,  so  that  sections  will  show  them  in  various  shapes  and  sizes.  In  some  ca.ses 
the  cells  are  small  and  slender,  in  others  large.  The  size  of  the  cell  is  a  measure  of 
the  malignancy  of  the  tumor.     (See  Plate  XVII.) 

The  largest  of  these  spindle  cells  are  frequently  striated  transversely  like  voluntary 
muscle  fiber,  and  tumors  composed  of  this  form  have  been  considered  as  tumors  of 
striped  muscle  tissue,  and  are  generally  called  rhabdomyoma.  There  is  no  tumor 
of  striped  muscle  fiber,  and  the  rhabdomyomas  of  writers  generally  shuold  be  considered 
as  spindle-cell  sarcoma,  or  may  be  dignified  by  the  name  mijo.sarcoma.  (See  Rhabdo- 
myoma, under  Myoma.) 

Alveolar  Sarcoma. — This  is  a  rare  form,  in  which  the  cells,  contary  to  the  general  rule 
of  sarcomas,  assume  an  alveolar  arrangement  strongly  imitating  that  of  epithelial  cells 
in  carcinoma.  Almost  invariably,  however,  on  close  examination  it  will  be  possible 
to  distinguish  a  delicate  reticulum  between  individual  cells,  Avhich  is  never  met  with  in 
cancer. 

C.  Myeloid,  or  Giant-cell  Sarcoma. — In  this  form  the  tissue  resembles  histologically 
the  red  marrow  of  young  and  growing  bone,  containing  large  numbers  of  multinuclear 
cells  embedded  in  a  matrix  of  spindle  or  round  cells.     These  tumors  usually  occur  in 

Fig.  79 


t 


Sarcoma  of  femur  following  fracture — i.  e.,  developing  in  callus.     (Original.) 

the  long  bones,  and  when  freshly  cut  look  like  a  piece  of  liver.  They  constitute  most 
of  the  epuhdes  or  cases  of  epulis — /.  e.,  spongv  tumors  springing  from  the  gums.  (See 
Plate  XVIII.,  Fig.  2.) 

Giant  or  multinuclear  cells  should  be  present  in  considerable  numbers  to  entitle  a 
tumor  to  classification  in  this  group.  When  round  cells,  spindle  cells,  or  giant  cells 
mingle  in  nearly  equal  projiortion  the  tumor  should  be  called  a  mixed-cell  sarcoma. 

D.  Osteosarcoma. — Osteosarcoma  is  something  more  than  sarcoma  of  bone,  which 
latter  may  spring  from  the  fibrous  or  medullary  elements.  It  is  sarcoma  of  the  specific 
bone-forming  connective  tissue,  including  the  osteoblasts  and  osteoclasts;  in  other 
words,  of  the  stroma  of  the  bone.  Under  these  circumstances  real  bone  develops  through- 
out the  tumor,  and  it  is  essentially  a  bony  neoplasm.  In  like  manner  there  may  be 
true  osteofibroma.  These  tumors  are  to  be  distinguished,  even  clinically,  from  the  medul- 
lary sarcomas,  which  develop  within  the  bone  and  expand  it,  even  to  enormous  propor- 
tions, the  bony  covering  then  being  a  mere  shell. 

E.  Chondrosarcoma. — Chondrosarcoma  resembles  osteosarcoma  in  that  it  is  sarcoma 
of  the  stroma  of  cartilage,  or  of  the  specific  tissue  which  produces  cartilage.  In  it  true 
cartilage  (white  fibrous)  also  is  found  throughout  the  tumor.  Chondrofibroma  is  also 
possible.     (See  Plate  XIX.) 

F.  Endothelioma. — Endothelioma  has  been  called  various  names,  and  its  true  character 
has  been  only  lately  determined.     It  is  composed  particularly  of  the  endothelial  cells 


PLATE  XVIII 

FIG.   1 


Angiosarcoma.      (Low  power.) 


FIG.  2 


Giant-cell  Sarcoma.      (High  power.) 


PLATE   XIX 


FIG.    I 


Chondrosarcoma.      (Low  power.) 

FIG.  2 


Osteosarcoma.      (Low  power.) 


PLATE  XX 


^MBM^^'^^^^W&^ 


'  *§»  w.^^ 


Melanosarcoma  of  Skin.      (  Dry  high  power. ) 


CLASS/FlCA'noX   OF    T(.\f()h'S 


275 


wliicli  line  lln-  Ivinpli  .spacrs,  ;iii(l  wliicli  li;i\c  iio  pcciiliai-  .secretion.  It  is  met  willi  most 
(ifleii  in  the  skin  (espeeially  (»!' llic  face),  in  the  paiolid  re«,n()ii,  in  llie  i;-enilal  ^'lands,  (lie 
hones,  tlie  lymph  nodes,  and  dnra. 

The  niieroseopie  |)icliire  of  tiiese  tninors  varii's  greatly,  the  endothelial  cells  orteti 
shapint;  and  ijroupinjj  themselves  so  as  to  imitate  epitlielionia.  In  donhtfnl  eases  the 
primary  location  or  ori<;in  of  the  (growth  should  be  ascertained. 

Kndotheliomas  ar(>  mainly  of  rapid  fj:rowth,  and  often  show  a  hi<fh  dejrree  of  inalijf- 
naney.  If  thoroujfhly  e.\tirj)ate<l  hefou'  metastasis  has  occurred,  profjuosis  is  fair; 
hut  metastases  hap|)cn  early  hecau.se  of  the  direct  connection  of  the  tumor  with  the 
lymph  current. 

(;.  Angiosarcoma.  Anjiiosarcoma  is  a  sarcoma  arisincr  from  the  adveutitia  of  the 
hloodvessi'Is.  It  is  characterized  by  its  e.xtraordiuary  vascularity,  (he  eas(>  with  which 
hemorrhages  into  tiie  structm-e  of  the  tumor  take  place,  and  the  f"re(juency  of  pigmenta- 
tion. PrrithcJiomas  constitute  a  subvariety,  uiet  with  especially  in  the  kidneys,  the  bones, 
and  the  skin,  and  originate  in  the  j)erithelial  cells  between  the  ca|)illaries  and  the 
perivascular  lymph  spaces.  They  are  more  vascular  than  the  angiosarcomas.  The 
latter  are  common   in    {\\v  liver.     In  many 

ea.ses  the  c-ells  of  these  tumors  siunilate  the  ''"••  ''^"  ' 

coluumar   epithelium    of   aclenocarcinonia.  a 

(See  Plate  XVH I,  Fig.  I.) 

II.  Cylindroma. — This  is  a  term  applied 
to  tumors  of  the  angiosarcomatous  type  in 
which  hyaline  changes  have  occurred,  so 
that  along  the  vessels  a|)pear  cylindrical 
ma.sses  of  altered  cells.  Similar  a])j)ear- 
ances  are  noted  in  certain  endotheliomas 
and  are  due  to  tiie  same  hyaline  degener- 
ation. 

I.  Melanosarcoma  (hrftcr  known  o.?  Mela- 
noma).— This  refers  to  the  deposition  of 
pigment,  rather  than  to  type  or  shape  of 
cell,  the  distinguishing  feature  of  these 
growths  being  the  presence  both  in  the 
cells  and  in  the  intercellular  substance  of 
a  variable  quantity  of  blackish  pigment. 
Of  all  the  forms  the  melanotic  growths  are 
considered  the  most  malignant.  They  in- 
variably recur  after  removal,  lead  to  second- 
ary deposits  at  long  distances,  and  present 
the  most  intractable  and  incin-able  forms  of 
cancer.  Deposition  of  pigment  in  carcino- 
mas is  most  rare,  if  ever  met  with,  and  the 
growths  of  melanotic  type  should  be  rele- 
gated entirely  to  the  class  uncJer  consid- 
eration. The  tumors  most  often  develop 
from  pigmented  nevi  of  the  skin,  though 
primary  melanoma  of  the  deejX'r  parts  of 
the  bodv  is  known.  These  will  be  treated  more  fullv  in  the  chapter  on  the  Skin.  (See 
Plate  XX.) 

This  name  has  been  variously  ap])lied  by  different  writers  to  different  growths.  In 
order  to  avoid  confusion  it  would  be  well,  in  using  it,  to  be  definite. 

General  Characteristics  of  Sarcomas  and  Endotheliomas. — I'he  vascular  suj)]jly  of  sarcomas 
varies  within  wide  limits.  In  nearly  all  instances  it  is  of  capillary  character,  the  blood 
circulating  rather  through  vessels  without  well-marked  walls.  While  large  ves.sels 
may  be  found  about  and  in  the  periphery  of  these  timiors,  distinct  vascular  structure 
is  usually  absent  from  the  more  internal  portions,  which  will  explain  the  frequency  of 
hemorrhage,  its  persistency  after  operation,  and  the  ease  with  which  large  extravasa- 
tions occur.  True  hematocele  may  thus  take  place  within  sarcomatous  tumors,  with 
the  usual  later  cystic  alterations,  and  thus  in  one  way  we  have  the  condition  known  as 
cijstosarcoma. 


Endothelioma  of  the  soft  palate:  o,  dilated  lymph 
space;  h,  endothelial  cells  with  beginning  cystic  for- 
mation; c,  completely  formed  cyst.      (,\'olkmann.) 


276  SURGICAL   AFFECT  loss  Of    TUB   TISSUES 

In  attacking  these  growths  the  vascular  and  bloody  area  may  he  met  just  ahoiit  their 
margins,  the  bloodvessels  expanding  as  they  arrive  at  the  tumor,  and  sometimes  bleeding 
extensively.  L  nder  most  circumstances,  however,  this  hemorrhage  can  l)e  controlled 
l)y  packing  or  by  operating  at  a  greater  distanc-e  from  the  circumference  of  the  growth. 

Mfta.<it(m.9  in  .mrcoma  j.«  common,  dissemination  occurring  mainly  along  the  veins, 
as  these  growths  connect  with  the  venous  channels  and  jx-rmit  of  easy  detachment 
of  fragments,  which  are  then  carried  along  as  emboli.  These  emboli  pass  naturallv 
to  the  right  side  of  the  heart,  and  thence  to  the  lungs,  where  it  is  most  common  to  find 
secondary  gro^^hs,  except  in  areas  emptying  into  the  portal  veins,  in  which  case  the 
/j'lrr  will  be  the  most  common  site.  Sarcomas  are  destitute  of  l^niphatics,  and  dis- 
semination does  not  occur  through  these  channels. 

Infiltration  is  also  a  common  phenomenon  with  these  growths.  This  is  generally 
seen  in  muscular  tissue,  particularly  with  growths  proceeding  from  the  j^eriosteum  and 
projecting  into  it. 

Sarcomas,  like  other  tumors,  tend  to  grow  along  the  lines  of  least  resistance.  Hence 
processes  of  these  tumors  will  insinuate  themselves  into  fissures  and  interspaces,  and 
penetrate  {perhaps  even  into  the  cavities,  from  which  it  is  hazardous  or  impossible  to 
remove  them.  Thus,  sarcomas  springing  from  the  head  of  a  rib  have  been  known  to 
extend  through  an  intervertebral  foramen  and  give  rise  to  an  intraspinal  tumor,  causing 
fatal  pressure. 

Secondary  changes  are  usually  seen  in  sarcomas,  the  most  frequent  being  hemorrhage. 
Myxomatous  degeneration  is  also  frequent,  and  gives  rise  to  cystic  conditions.  Calci- 
fication is  common,  particularly  in  the  slowly  growing  tumors  which  arise  from  bone. 
Upon  the  other  hand,  necrosis  (i.  e.,  ulceration)  is  common  in  growths  which  project 
upon  the  surface  or  into  any  of  the  open  cavities  of  the  body.  Ulceration  here  is  growth 
at  a  rate  faster  than  nutrition  will  justify,  and  gangrene  is  to  be  regarded  as  a  failure 
to  supply  sufficient  blood.  It  may  also  mean  infection,  of  which  it  is  a  usual  exj^res- 
sion. 

Timiors  of  this  character,  which  luxuriate  upon  reaching  the  surface,  and  bleed  easily 
upon  the  slightest  touch,  were  formerly  known  as  fungus  hematodes.  The  name  may 
be  preserved  for  the  sake  of  convenience,  but  should  be  held  to  mean,  in  almost  every 
instance,  a  rapidly  growing  round-cell  sarcoma. 

Sarcoma  is  common  in  the  lower  animals,  particularly  so  in  horses — most  common 
in  those  of  gray  color.  It  is  met  with  also  in  cows  and  various  other  domestic  and 
undomesticated  animals. 

Myxoma. — The  myxomas  are  composed  of  mucous  tissue ,  whose  best-known  normal 
representative  is  the  Whartonian  jelly  of  the  umbilical  cord.  True  m^-xoma  should 
be  distinguished  from  myxomatous  degeneration,  which  occurs  frequently  in  cartilage, 
fibrous  tissue,  and  sarcoma,  and  which  brings  about  a  similar  condition  of  affairs, 
though  of  essentially  different  origin.     M\-xomas  appear  under  the  following  forms: 

1.  Polypi. — These  include  many  of  those  which  grow  in  the  nose.  The  pure  form  of 
nasal  m}-xoma  proceeds  from  the  mucous  membrane  of  the  nasal  passages  or  sometimes 
from  the  accessory  sinuses.  But  most  of  the  so-called  nasal  polypi  are  due  to  edematous 
hyi^ertrophies  of  the  submucosa.  The  jX)lypi  usually  hang  as  gelatinous  tumors  of 
grayish-yellow  tint,  being  present  sometimes  singly,  sometimes  in  clusters  or  in  large 
numl>ers.  Their  principal  effect  is  to  produce  nasal  obstruction,  with,  perhaps,  subse- 
quent serious  disorder,  due  to  decom|>osition  or  to  extension  into  the  pharynx  or  other  ■ 
ca\ities.  Similar  growths  also  occur  from  the  mucous  membrane  of  the  t^-mpanum,  and 
constitute  the  common  variety  of  aural  poh-pi. 

2.  Cutaneous  Myxoma. — Cutaneous  m^-xoma  is  not  common.  It  presents  usually 
as  a  sessile  tumor,  although  about  the  perineum  and  labia  the  tumors  may  become 
pedunculated.  It  is  often  difficult  to  distinguish  l^etween  a  m\-xoma  of  the  skin  and 
a  sarcoma  of  the  same  which  has  undergone  myxomatous  degeneration,  and  which 
then  should  lie  called  sarcoma  m}-xomatodes.  The  latter  tend  to  recur  after  removal ; 
hence  tlie  impcrtanc-e  of  exact  diagnosis. 

3.  Neuromyxoma.  Xeuromyxoma  is  a  similar  condition  involving  the  nerve  trunks, 
and  is  dealt  with  tmder  Neuroma. 

]\I\-xomas  require  complete  removal,  and,  in  the  nose  especially,  cauterization  or 
destruction  of  the  surface  from  which  they  spring.  When  this  is  thoroughly  done  they 
do  not  recur;  otherwise,  they  are  likely  to  require  subsequent  operation. 


CLASSIFICAT/OX  OF   TUMORS  277 

Myoma.  -Th(>  tmo  myoniii  is  ;i  tumor  coniposcd  of  nnsiriprd  or  hivoliminry  musrle 
lilxr.  I  iitil  recently  it  lias  heeii  eustoinary  to  divide  the  inyomas  into  the  Icioriiij- 
0///0.V  in  eontradistinction  lo  the  rli(ih(loinj/om(u\  the  latter  heiiif^  supposed  to  he  tumors 
ol"  voluntary  nuisele  fiber.  M ijoina.s  are  met  with  only  where  involuntary  mn.srlr  fihfr  i.s 
found — namely,  in  the  uterus  and  adnexa,  the  vagina,  the  esophagus,  alimentary  canal, 
the  prostate,  the  t)Iadder,  and  the  skin.  They  form  rnrap-sulatrd  tumors  composed 
of  fusiform  nniscle  cells  with  a  rod-like  nucleus,  the  size  of  the  cells  varying  greatly  in 
delfcrent  specimens.  The  bundles  of  muscle  fibers  are  nnich  contorted,  and  it  is  often 
difiicult  in  a  single  section  to  decide  to  just  what  class  of  cells  tliev  belong. 

'riicse  tumors  arc  most  common  in  and  about  the  uterus,  and  are  referred  to  as  infra- 
niiintl  when  developing  in  the  true  uterine  tissue,  and  sulnnucou.s  and  .suh.srron.s  when 
situated  just  beneath  one  or  the  other  of  the  adjoining  membranes.  '^I'hey  differ  in 
their  rate  of  growth,  are  firm  in  composition,  and  are  moderately  vascular,  sometimes 
containing  areas  of  .softening  and  becoming  even  cy.stic.  In  rare  in.stances  they  become 
enormously  vascular,  and  are  then  known  as  caverncms  myomas.  Aside  from  mucoid 
or  colloid  changes  they  occasionally  underg(i  fatty  metamor[)hosis  or  calcareous 
infiltration,  "^riie  latter  is  {)ossible  to  such  an  extent  as  to  lead  to  a  condition  of  uterine 
(■(t/ciih. 

Uterine  myoma  is  liable  to  septic  infection,  which  frequently  follows  exploration 
of  the  uterus  or  the  changes  incident  to  pregnancy  or  j)arturition.  It  then  becomes  a 
case  for  immediate  operation.  Uterine  myomas  do  not  occur  before  pul)erty,  rarely 
before  the  age  of  thirty-five,  and  are  most  common  between  the  thirty-fifth  and  forty- 
fifth  years  of  life.  They  produce  disaster  not  alone  by  their  size,  but  by  hemorrhage, 
by  j)ressure  on  adjoining  viscera  (rectum,  kidneys,  etc.),  and  occasionally  by  torsion  of 
a  long  pedicle. 

Myomas  are  found  in  the  esophagvs,  in  the  walls  of  the  stomach,  where  they  are  fre- 
C[uently  confounded  with  malignant  tumors,  in  the  prostate  and  wall  of  the  bladder, 
and  in  connection  with  the  skin.  As  soon  as  they  give  rise  to  inconvenience  or  to  dan- 
gerous symptoms  they  are  to  be  dealt  with  surgically,  as  no  other  treatment  has  proved 
of  lasting  benefit. 

The  rhahdomyomas  deserve  but  brief  description.  The  striated  muscle  fibers  of  which 
these  tumors  are  composed  have  been  often  confused  with  spindle-shaped  sarcoma 
cells.  They  are  met  with  almost  exclusively  in  the  mixed  tumors  of  the  kidney  under 
Teratomas. 

]\Iyoma  or  myofibroma  is  exceedingly  likely  to  undergo  sudden  conversion  into  a 
form  of  growth  entitling  it  to  be  called  maligyiant  myoma. 

Angioma. — Angiomas  are  tumors  composed  of  bloodvessels,  and  group  themselves 
under  three  headings,  in  accordance  with  the  structure  of  the  vascular  system: 

1.  Capillary  Angioma,  or  Nevus. — Capillary  angioma,  or  nevus,  is  the  mo.st  common 
form  of  all,  and  is  frecjuently  seen  in  the  skin  and  subcutaneous  tissue.  When  the  con- 
dition is  spread  over  a  relatively  large  area  it  gives  rise  to  a  discoloration  known  as 
port-wine  mark,  and  called  telangiectasis  by  the  pathologists.  The  condition  is  often 
congenital  or  l^egins  soon  after  birth.  The  color  of  the  aft'ected  area  determines  whether 
the  vessels  belong  to  the  venous  or  to  the  arterial  system.  These  tumors  may  be  found 
in  all  parts  of  the  body,  on  the  surface,  on  the  submucous  surfaces  of  the  tongue,  the 
inside  of  the  mouth,  the  conjunctiva,  and  the  vulva.  The  tendency  is  tow^ard  gradual 
increase  in  size;  rarely,  spontaneous  contraction  and  obliteration  occur. 

2.  Cavernous  Tumors. — These  are  similar  in  structure  to  the  corpus  cavernosum, 
and  are  called  erectile  tumors.  They  are  common  in  connection  with  the  skin,  and  are 
exaggerated  forms  of  the  variety  first  described,  the  vessels  becoming  not  merely  dilated 
but  cavernous  in  arrangement.  They  occur  occasionally  in  the  tongue,  in  the  voluntary 
muscles,  and  in  the  liver,  and  are  noted  very  rarely  in  the  mammse,  in  the  larynx,  and 
subperitoneally. 

A  similar  condition  is  met  with  in  the  so-called  cavernous  tumors  which  involve  various 
organs,  especially  the  thyroid  and  the  liver.  In  these  instances  a  part  or  the  whole  of 
the  organ  may  be  involved,  and  presents  great  increase  in  size  and  evidences  of  vascu- 
larity. 

In  cavernous  growths  of  the  thyroid  are  ves.sels,  veins  especially,  the  size  of  the 
thumb,  while  with  the  ear  not  touching  the  body  of  the  patient  a  distinct  venous  murmur 
may  be  heard. 


278 


SURGICAL  AFFECTIONS  OF   THE   TISSUES 


3.  Arterial  or  Plexiform  Angiomas. — Artrrial  or  plcxitorm  angiomas,  when  of  any 
particular  siz(>,  are  called  cirsoid  aiirarij.siii  or  ancurijsin  hi/  anastomosis.  This  form 
consists  of  arteries  al)normal  both  in  numher,  length,  and  diameter,  tortuous  in  arrange- 
ment, occurring  often  in  the  scalp,  but  rarely  in  the  |)erineum  or  genitalia,  and  seldom  in 
other  parts  of  the  body.  (See  Aneurysm,  Chapter  XXVIII.)  These  tumors  are  liable 
to  rupture  from  external  injury,  and  necessitate  ligation  of  the  main  arterial  trunks, 
with  ]X'rhaps  extirpation  of  the  tumor  mass. 

Recognition  of  angiomas  is  not  difficult  unless  they  are  deeply  concealed.  The 
effect  of  intermitting  pressure,  the  emptying  and  refilling,  and  the  distinction  between 
arterial  and  venous  growths  by  the  result  of  alternating  ])rcssure  and  relaxation,  either 
above  or  below  the  growth,  with  discoloration  of  the  skin,  and,  in  the  larger  growths, 
audible  murmur,  leave  little  doubt  of  the  character  of  the  growth. 

When  such  growths  are  small  they  may  be  dealt  with  by  electrolysis,  the  needles  from 
both  poles  being  introduced,  or  that  from  the  negative,  the  j)ositive  being  applied  upon 
some  neighboring  portion  of  the  body.  The  effect  of  the  electric  current  is  to  determine 
coagulation  of  the  blood  in  the  tissues  acted  upon,  and  this  is  followed  by  organiza- 
tion of  thrombus,  conversion  of  vascular  into  cicatricial  tissue,  shrinkage,  and  possible 
eventual  disappearance  of  the  mass.  Radical  excision  under  an  anesthetic  should  be 
made,  dissecting  out  the  mass,  securing  bleeding  vessels,  and  reuniting  the  parts  by 
sutures,  with  the  expectation  of  securing  ];)rimary  iniion.  This  is  the  quickest  and  in 
many  cases  the  least  disfiguring  method.  Old  methods  of  ligation  of  surrounding 
vessels  or  the  subcutaneous  ligature  are  now  practically  discarded.  The  injection 
methods  as  formerly  practised,  especially  the  use  of  iron  salts  in  solution,  are  severely 
condemned,  as  death  is  liable  to  occur.  With  electrolysis  and  excision  the  surgeon  has 
nearly  all  the  measures  which  he  will  need  to  practise  for  the  medical  treatment  of 
angiomas. 

Lymphangioma. — Lymphangiomas  are  tumors  composed  of  lymph  vessels  and 
bear  resemblance  to  the  tumors  above  considered.  They  may'  be  divided  into  three 
varieties: 

1.  The  Lymphatic  Nevus. — The  lymphatic  nevus  is  composed  mostly  of  lymphatics 
nearly  normal  in  size,  and  occasionally  colored  red  by  the  presence  of  bloodvessels. 

When  ])ricked,  pure  lymph  or  blood-stained 
lym])h.  will  fiow.  They  are  usually  small,  and 
are  noticed  during  chiklhood.  They  may 
occu'-  anywhere  upon  the  surface  of  the  body 
or  in  the  mouth,  generally  in  connection  with 
the  tongue,  where  they  may  appear  as  large 
pa])ill;t^  involving  a  portion  or  all  of  the  dor- 
sum. When  the  lymphatic  structures  of  the 
tongue  are  thus  enlarged  and  involved  the 
condition  is  known  as  marrof/lossia,  and  con- 
sists of  enlargement  of  the  organ,  sometimes 
to  a  degree  not  permitting  its  retention  in 
the  mouth,  but  leading  to  its  constant  j)rotru- 

^,j^  "ii^^^^^^F  ''^^*'"  ^^'^^-  <^^)- 

^^r^  Jal^^Kffr  -•  Cavernous    Lymphangioma.  —  Cavernous 

\  4j^0^    aW\/-^  lymjihangioma  corresponds  to  cavernous  angi- 

oma, and  is  a  condition  in  which  the  lymph 
vessels  become  positively  cavernous  and  sac- 
culated. 

3.  Lymph  Cysts. — Lymph  cysts  are  the  still 
more  aggravated  form  which   lymphatic  dila- 
tation   may  attain,  and  are  usually  encajjsu- 
(Neisser.)      Uitcd,    comjilicatcd    with  more    or    less   tense 
tissue,  and  j)roduce  a  condition  of  the  parts, 
especially  about   the  scrotum   and  labia,   to    which    the    term    elevhantiasis    is  often 
a])plied  (Fig.  S3). 

The  question  of  congenital  occlusion  or  dilataiion  of  h/mph  channels  is  one  w^hich  has 
been  made  the  subject  of  large  separate  monographs  (especially  by  Busey).  Numerous 
tumors,  essentially  of  lymph-vascular  origin,  are  found  upon  the  lips,  in  the  neck,  and 


Fig.  81 


Lymphangioma  oi    Up;  macrocheilia. 


CLASSIFICATION  OF   TUMORS 


279 


elsewluTO,  wliicli  ^roW  slowly,  uiv  nioiv  or  less  clastic  iiiul  sj)onf:fy  nj)on  j)rcssurf-, 
arc  frc(iucntly  covered  with  skin,  from  which  hair  j^rows  most  luxuriantly,  and  in  which 
|)i<,Mncnt  or  papillomatous  structures  are  disj)ersed.  "^I'hesc  tumors  are  called  ntrn-voua 
liniiors,  are  ot"  slow  ifrowtli,  and  undcrj^o  spontaneous  involution,  hut  usually  re()uire 
surffical  rcliei".  They  arc  often  confounded  with  l)ran(lii()<j;cnic  and  other  coufrcnital 
cysts  of  the  neck. 

Treatment. The  treatment  for  the  smaller  lymphatic  tumors  is  sim])le,  hut  here  elec- 
tricity is  less  to  he  relied  upon  and  excision  is  more  urirently  demanded.  Electrolysis 
will  cause  coa<i;ulation  of  hlood,  hut  not  of  lym))h — at  least  not  to  nearly  the  same  extent; 
consequently  its  usefulness  is  restricted  to  hlood-vascular  tumors.  Excision,  then,  is 
the  hest  remedy.  When  this  is  impracticable  much  can  he  done  by  galvanoj)uncture 
or  iifiii puncture,   the    cicatricial  contraction   followino;    multiple    |)uncturcs    leading   to 

li<;.  S2  Fig.  83 


•J(F 


Congenital  lymphanKionia.      (Original.) 


Lymphangioma  of  lower  extremity.      (Original.) 


reduction  in  size  of  the  affected  part.  The  enlargement  of  the  tongue  spoken  of  above 
as  macroglossia  may  be  treated  by  ignipuncture  or  by  electrolysis,  if  necessary  under 
an  anesthetic,  the  effect  of  the  electric  current  here  being  not  to  produce  coagulation, 
but  apparently  absorption  of  fibrous  tissue  and  changes  which  come  slowly  rather 
than  by  obliterative  processes. 


5.  Tumors  of  Nerve  Elements. 

Glioma. — Glioma  is  a  malignant  tumor  developing  directly  from  actual  nerve  structure 
or  that  of  the  original  nerve  elements,  and  is  clinically  allied  to  the  sarcomas.  It  arises 
from  the  neuroglia,  and  hence  is  confined  to  the  central  and  peripheral  nervous  system, 
mainly  the  former.  It  is  most  common  in  the  brain,  the  cord,  and  in  connection  with 
the  optic  nerve  and  fundus  of  the  eye.  It  is  often  extremely  vascular,  the  vessels  being 
sacculated,  and  is  usually  met  with  "in  solitary  form.  When  near  the  surface  of  the  cor- 
tex such  a  tumor  may  appear  like  a  great  convolution  (Virchow).  In  the  basal  portions 
of  the  brain  it  may  attain  considerable  size.  In  the  cord  it  is  rare,  usually  limited  to 
the  cervical  region.  In  the  orbit  and  eye  it  may  produce  marked  exophthalmos.  It  is 
more  frequent  in  the  yoimg  than  in  the  aged. 


280  SURGICAL  AFFECTIONS  OF  THE  TISSUES 

Glioma  is  an  exceedingly  malignant  form  of  tumor,  ant!  operation  is  rarely  performed 
sufficiently  early  to  more  than  prolong  life.  Dissemination  hy  continuity  is  the  rule 
rather  than  metastasis.     It  kills  usually  hy  its  pressure  effect  on  the  nerve  centres. 

Neuroma. — True  neuromas  spring  from  the  structures  of  nerve  trunks,  which 
trunks  may  also  be  the  site  of  other  tumors,  mainly  fibromas  and  sarcomas,  with  which 
neuromas  may  be  easily  confounded.  The  most  common  nerve  tumor  is  the  neuro- 
fibroma, which  grows  from  the  structure  of  a  nerve  sheath,  its  long  axis  usually  coinci- 
ding with  that  of  the  nerve  trunk.  Tumors  of  this  class  vary  greatly  in  size,  are  often 
multiple,  and  in  other  instances  affect  nearly  all  the  nerves  in  the  body.  They  are  ex- 
tremely liable  to  mi/.voinafou.i  degeneration,  which  will  account  for  many  of  the  instances 
reported  as  myxoneuroma,  etc.  They  attack  cranial  and  spinal  nerves  alike,  and  no 
nerve  or  nerve  root  in  the  body  is  exemj^t.  The  sensory  nerves  apjiear  more  liable  to 
attack  than  the  motor.  The  nerve  least  often  attacked  is  the  optic.  They  are  not  rare 
upon  the  roots  of  the  spinal  nerves,  in  which  location  they  may  attain  to  such  size 
as  to  press  upon  the  cord  and  induce  paraplegia.  ^Multiple  neuromas  are  often  asso- 
ciated with  molluscum  fibrosum  {q.  v.).  There  is  an  instance  on  record  in  which  IGOO 
of  these  tumors  were  found  after  careful  dissection  of  the  neuroskeleton,  and  another 
in  which  at  least  2000  were  found,  60  of  them  involving  the  pneumogastric  trunks  and 
their  branches. 

Fig.  84  Fig.  S.'S 


Plexiform  neuroma  of  chest  wall  in  a  young 
Plexiform  neuroma,  dissected  free  from  all  child.     Illustrating   its  gross  external   resem- 

adherent  tissues.     (Le.xer.)  blance  to  lymphangioma.     (Lexer.) 

Plexiform  Neuroma. — Plexiform  neuroma  is  relatively  rare.  This  is  a  ty{)e  of  nerve 
tumor  in  which  all  the  branches  of  a  given  nerve  which  are  distributed  to  a  particular 
area  become  enlarged  and  elongated,  the  overlying  skin  being  stretchetl  and  thin.  Such 
a  tumor  seems  like  a  loo.se  bag  containing  a  number  of  vermiform  l)odies,  resembling  the 
sensation  given  when  palpating  a  varicocele.  On  .section  each  of  the  affected  nerves 
reveals  a  quantity  of  myxomatous  tissue  replacing  the  nerve  sheath.  They  are  in  large 
measure  congenital.  The  skin  overlying  a  ])lexiform  neuroma  will  frecjuently  be  found 
to  be  pigmented,  variously  altered  in  thickness,  and  covered  with  fine  hair.  The.se 
growths  have  been  frequently  mistaken  jar  lymphangioma   (Figs.  84  and  So). 

Malignant  Netiroma. — Alalignant  neuroma  (so  called)  will  generally  be  found  to  be  a 
true  sarcoma  of  nerve  .structures,  usually  of  the  spindle-cell  variety.  Traumatic  neuroma 
is  often  .seen  in  amputation  stumps,  where  the  terminations  of  the  divided  nerves  become 
bulbous,  attaining  the  size  of  cherry  stones,  the  tumors  being  composed  of  a  mixture  of 
connective  tissues  and  nerve  fiber,  from  which  in  time  the  true  nerve  structure  usually 
recedes  or  vanishes.  They  form  when  suppuration  has  been  profu.se  or  healing  long 
delayed,  and  when  sufficient  care  has  not  been  exercised  to  prevent  entangling  of  the 
nerve  ends  in  the  scar  of  the  wound.  They  give  ri.se  to  much  pain,  and  often  necessitate 
re-amputation.  The  bulbous  enlargement  is  the  result  of  j^rolongcd  irritation  in  a  nerve, 
and  has  been  noted  aroimd  various  foreign  bodies. 


CLASSIFICATIOX  OF  TUMORS  2S1 

True  neuroma  is  innocent  i>i  tendency,  though  often  painful.  It  is  the  sarcoma  of 
nerve  tissue  which  |)ro(hices  si<ijns  of  niali<jnancy.  A  true  neuroma  wliicli  causes  unen- 
(iural)Ie  pain  sliouhl,  when  accessihie,  he  removed.  It  is  sometimes  j)ossihle  to  separate 
the  tumor  nuiss  from  the  balance  of  the  nerve  trujik,  and  thus  to  remove  it  without  ex- 
cision of  the  nerve.  At  other  times  it  is  impossihie  to  avoid  division  and  ensuin<j  |)aralvsis. 
Divided  nerve  ends  should  he  Ijrouglit  together  by  catgut  sutunv,  l)y  whicli  means  it 
may  l)e  possible  to  avoid  |)ermanent  loss  of  function.  Nerve  grafting  is  also  resorted 
to  for  repairing  .such  defects.  Removal  of  })ainful  neuromas  due  to  injuries  to  the  head 
has  more  than  once  been  the  means  of  curing  traumatic  epilep.sy. 


C.  Tumors  Derived  from  Epithelium. 

These  tumors  consist  of  specific  epithelial  elements  supported  and  more  or  less  bound 
together  by  a  vascular  connective-tissue  stroma.  The  only  apjiarent  exception  to  this 
statement  is  tumor  of  dental  tissue.  The  teeth  are  positively  modified  and  petrified  or 
calcified  epithelial  products. 

Odontoma. — The  odontomas  are  tumors  com])osed  of  one  or  more  of  the  dental 
tissues,  arising  either  from  tooth  changes  or  teeth  in  process  of  develo])ment.  They 
may  be  divided,  according  to  Sutton,  as  follows: 

1.  Epithelial  Odontomas. — These  are  provided  with  a  ca|)sule,  and  present  usually 
as  a  series  of  cysts  separated  by  thin  septa,  containing  mucoid  fluid,  while  the  growing 
portions  have  a  redtlish  tint  not  unlike  sarcoma.  They  are  most  frequent  about  the 
twentieth  year  of  life,  but  may  occur  at  any  age.  They  probably  arise  from  persistent 
remains  of  the  epitheliimi  of  the  original  ejiamel  organs. 

2.  Follicular  Odontomas. — These  are  often  called  "dentigerous  cysts."  They  arise  in 
connection  with  ])cnnaiient  teeth,  and  especially  with  the  molars,  sometimes  attaining 
great  size  and  producing  conspicuous  deformity.  The  tumor  consists  of  a  wall  represent- 
ing the  expanded  tooth  follicle,  and  a  cavity  containing  viscid  fluid,  with  some  part  of 
an  imperfectly  developed  tooth,  occasionally  loose  and  more  or  less  displaced  in  location. 
The  cyst  wall  always  contains  calcareous  material.  These  tumors  rarely  suppurate. 
They  occur  also  in  animals. 

3.  Fibrous  Odontomas. — These  consist  of  condensed  connective  tissue  in  a  developing 
tooth,  presenting  as  a  tumor  with  a  firm  outer  wall  and  a  loose  inner  texture,  blending 
at  the  root  of  the  tooth  with  the  dental  papilla  and  indistinguishable  from  it.  The 
developing  tooth  thus  becomes  enclosed  within  the  capsule  before  it  protrudes  from  the 
gum.     These  tumors  are  most  common  in  ruminants,  being  often  multiple. 

4.  Cementoma. — A  tumor  of  fibrous  character  whose  capsule  has  ossified  or  calcified, 
the  developing  tooth  thus  becoming  embedded  in  a  mass  of  dental  cementum.  These 
tumors  occur  most  fref(uently  in  horses. 

5.  Compound  Follicular  Odontomas. — These  are  tumors  containing  a  number  of  masses 
of  cementum  resembling  small  teeth,  or  even  amounting  to  well-formed  but  ill-shaped 
teeth  composed  of  all  three  dental  elements.  In  such  a  tumor  teeth  may  be  found  in 
great  numbers.     They  occur  in  the  human  subject  as  well  as  in  animals. 

6.  Radicular  Odontomas. — These  are  tumors  which  arise  after  the  crown  of  the  tooth 
has  been  completetl  and  while  its  roots  are  yet  in  process  of  formation.  The  crown, 
being  unalterable  enamel,  does  not  enter  into  the  composition  of  these  growths,  which 
then  consists  of  dentine  and  cementum  in  varying  proportions.  They  are  rare  in  man, 
but  frequent  in  other  animals,  and  often  multiple. 

7.  Composite  Odontomas. — These  are  hard  tumors,  bearing  little  or  no  resemblance 
in  shape  to  normal  teeth,  occurring  in  the  jaws,  consisting  of  a  conglomeration  of  enamel, 
dentine,  and  cementum,  presenting  abnormal  growth  of  all  the  elements  of  the  tooth 
germ.     So  far  this  tumor  has  only  been  found  in  man. 

Little  is  said  about  the  odontomas  in  general  surgical  literature.  These  tumors,  as 
they  grow,  are  often  regarded  as  due  to  necrosed  bone  or  to  unerupted  teeth,  while  fibrous 
odontomas  have  been  often  regarded  as  myeloid  sarcomas.  No  tumor  of  the  jaw, 
especially  in  young  people,  should  lead  to  excision  of  the  jaw  until  it  has  been  demon- 
strated that  the  tumor  is  not  one  of  the  above  forms.  When  diagnosticated  as  true 
odontoma  its  complete  removal  is  all  that  is  necessary. 


282 


SURGICAL  AFFECTIONS  OF  THE  TISSUES 


Papilloma,  or  Fibro-epithelioma. — The  type  of  papilloma  is  this  common  wart, 
consisting  of  a  central  stem  of  fibrous  tissue  and  bloodvessels  covered  by  ef)ithelial 
projections   and    proliferations.      Pa])illomas   are   usually   sca.nle  and   villous. 

1.  Warts. '-^These  are  .sessile  j)apillomas,  most  common  on  the  skin,  often  .seen  on 
iinicous  surfaces,  and  occurring  sometimes  singly,  often  in  crops,  "^riiey  are  exceedingly 
connnon  about  the  prnnruiii,  where  skin  and  nuicous  membrane  meet,  and  are  regarded 
as  due  to  the  irritation  of  specific  discharges.  The  papillomas  occurring  about  the 
genitalia  are  known  as  condijlomas.  The  growths  in  the.se  instances  are  frecjuently  so 
luxuriant  and  proliferative  that  they  assume  fungf)id  shape,  and  are  called  mulhcrry 
groirt/i.i.  Warts  grow  .slowly  or  rapidly  according  to  circumstances.  Warty  growths 
may  attain  enormous  size  and  become  vascular.  Late  in  life  they  are  frequently  the 
starting  points  of  epithelial  ingrowths,  and  then  become  true  epithelioma.s — t.  e.,  cancer. 
Warty  growths  sometimes  line  the  buccal  cavity  and  cornj)licate  cases  of  marrof/lo.s-sa. 
They  occur  also  in  the  lari/ii.v,  and  when  situated  near  the  glottis  may  cause  dyspnea 
and  fatal  obstruction  to  respiration.  It  is  claimed  by  some  that  cutaneous  warts  will 
disappear  with  continued  small  internal  dosage  of  Fowler's  .solution.     (See  Plate  XXI.) 


Fig.  86 


PaiWllcni.-i  .,f  tl,r.  liladder. 

2.  Villous  Papillomas. — These  are  met  with  most  commonly  in  the  hladdrr,  occasionally 
in  the  pelvis  of  the  kidney.  They  are  identical  with  chorionic  villi,  and  occur  most 
often  singly.  It  frequently  happens  that  long,  fine  tufts  are  detached  and  carried  away 
with  the  escaping  urine.  Another  form  of  villous  growth  ari.ses  from  the  choroid  [)lexu.ses 
of  the  lateral  ventricles  in  the  brain.  These  may  grow  and  attain  a  size  sufficient  to 
produce  disturbance    (Fig.  NO). 

.3.  Intracystic  Villous  Growths. — These  are  seen,  for  example,  in  mammary  cysts. 
These,  of  course,  are  lined  with  epithelium,  which  acts  here  as  it  does  in  other  localities, 
and  proliferates  more  or  less  rapidly  under  unknown  circumstances.  In  dealing  with 
jmroophoritic  cysts  the  presence  of  these  growths  has  also  been  alluded  to. 

4.  Ovarian  Papilloma. — There  is  a  form  of  ovarian  papilloma  which  partakes  of 
the  nature  of  a  malignant  tumor,  in  that  separated  particles  seem  to  attach  themselves 
to  peritoneal  surfaces,  where  they  grow  luxuriantly.     Either  this  is  an  expression  of 

'  Warts  are  by  many  pathologists  considered  as  mere  evidences  of  hypertrophy  from  persistent  irritation. 
They  are  here  retained  among  the  tumors  lest  too  much  violence  be  done  to  formerly  received  notions. 


PLATE  XXI 


it;" 

;nx^^ 

■^ 

■v 

'•i<- 

.  ■  >:s^Vrr 

.  % .,.-/ 


o 


•«si 


Photographic  Reproduction  of  Papi 


^ov/ power.      (Gavlurd.^ 


CLASSIFICATIOS  OF   TUMORS 


283 


piirjisitisin  or  iiifcctivity,  or  else  of  tlic  iinphiiitatioii  of"  tumors,  whicli,  to  the  writer's 
iniud,  coustitutt's  u  stroiijf  arifiimciit  for  the  |)ara.siti.sin  of  cancer.  After  alxloniiuul 
section,  with  removal  of  the  orii^iiial  focus,  these  j^rowths  often  (hsappear.  This  afi'ords 
a  |)arallel  to  the  instances  of  cure  of  tuberculous  j)eritonitis  after  the  same  procedure. 

.").  Cutaneous  Horns.  -These  are  also  epithelial  outjijrowths,  and  are  met  with  in  four 
varieties  (Sutton): 

(a)  Scl)(ur()u.'<  horn.s-,  quite  common,  arising  i)y  protrusion  of  contents  of  a  sebaceous 
cvst  throu<];h  a  rupture  in  its  wall  or  tlirou<,'li  its  duct,  with  consc(|ucnt  dcsiccati(Mi  by 
exposure  to  the  air,  while  fresh  material  is  consecjuently  added  at  the  basis  so  lon^  as 
sebaceous  secretion  continues.  'I'hese  (jjrowths  soften  when  soaked  in  weak  li(juor 
potassiP. 

(h)  Wariji  Itortis,  structurally  identical  with  the  above,  but  <!;rowin^  from  warts  instead 
of  from  sebaceous  cysts.  Both  these  forms  are  often  found  about  the  head.  Cutaneous 
horns  are  also  met  with  in  ovarian  dermoids.  They  are  common  in  the  lower  animals 
and  may  attain  large  size. 

(c)  Hants  ffroiritu/  from  cirafrirrs,  especially  of  bones,  are  rare,  but  a  cornificd  con- 
dition of  the  cicatrix  itself,  with  formation  of  scales  resemblinj;^  those  from  horns,  is  not 
uncommon. 

((I)  Nail  liorti.s-  are  simply  overgrown  nails,  occurring  on  the  digits  and  toes  of 
bedridden  patients  who  never  walk  (Fig.  87). 

Fig.  87 


Nail  horns.     (Original.) 

Treatment. — All  these  forms  of  epithelial  outgiowth  call  for  radical  removal,  which 
im})lies  complete  extirpation  of  the  membrane  or  tissue  from  which  the  growth  occurs, 
after  which,  if  effected,  there  is  no  recurrence.  If  .some  be  left  there  is  tendency  to 
recedive. 

Mucous  Polyp. — Similar  papillary  and  often  pedunculated  epithelial  tumors  frequently 
hang  or  project  from  the  mucous  membrane — e.  g.,  the  rectum.  The  pedicle  really 
projects  from  the  submucosa.  Between  the  layers  of  the  overgrown  mucosa  are  found 
altered  glands.  So  long  as  the  growth  of  these  polyps  is  toward  the  exposed  surface 
they  are  innocent  and  wellnigh  harmless,  unless  they  attain  fair  size;  but  so  soon  as  they 
grow  inward  and  the  boundary  of  the  submucosa  is  transgressed  they  assume  malig- 
nant aspects  at  once.  Such  transformation  is  by  no  means  rare,  and  constitutes  a 
strong  argument  for  their  prompt  removal. 

Goitre;  Struma. — Pathologically  the  various  enlargements  of  the  thyroid  known  as 
goitre  or  struma  constitute  essential  neoplasms.  (See  chapter  on  Regional  Surgery 
of  the  Neck.)  In  this  condition  either  the  epithelial  or  the  connective  ti.ssue  may  be 
primarily  at  fault. 


284  HVRCICAL   AFFKCTIOXS  OF   THE   TISSUES 

1.  Struma  Parenchymatcsa  Nodosa. — Tliis  in(lu(l(>s  also  t\\v  colloid  and  the  cystic 
varieties,  and  refers  to  an  enorinons  overproduction  of  the  epithelial  elements  (paren- 
chyma) in  distended  alveoli,  where  they  often  underf^o  colloid  softenini;;.  So  marked 
are  these  chanp;es  in  numerous  instances  that  multiple  cysts  (minute  or  large)  result. 
The  collective  volume  of  such  altered  tissue  may  be  very  large. 

2.  Struma  Fibrosa. — Tliis  prestMits  itself  in  the  way  of  dense  enlargement  of  the  thyroid, 
the  stroma  being  the  tissue  now  involved,  even  to  the  extent  of  causing  much  of  the 
alveolar  structure  to  disappear  or  become  obliterated.  In  this  condition  calcification  is 
common,  and  calcareous  concretions  or  patches  are  often  found. 

Even  benign  tumors  of  the  thyroid  show  occasionally  a  tendency  to  metasta.ses.  Ca.ses 
are  on  record  (jf  benign  goitre  causing  general  metastases,  and  even  of  metastasis  without 
noticeable  thyroid  enlargement.  These  occur  most  often  in  the  bones,  less  frequently 
in  the  lungs  and  other  organs.  They  are  more  common  when  the  goitre  has  undergone 
colloid  changes.     The  reasons  for  these  changes  are  unknown. 

In  either  form  hemorrhages  are  common,  with  their  resulting  blood  cysts  or  their 
solid  residue,  in  which  case  i:»igment  is  usually  found.  Both  forms  are  often  accompanied 
by  enlargement  of  the  vessels,  and  sometimes  these  become  enormously  dilated  and 
constitute  an  almost  insuperable  obstacle  to  successful  removal.     (See  Thyroidectomy.) 

Ovarian  Cystoma. — The  cystomas  of  the  ovarian  region  assume  two  types:  (1) 
Glandular  cystoma,  and   (2)   papillary  cystoma. 

1.  Glandular  Cystoma. — The  glandular  type  produces  the  multilocular  forms,  with 
numerous  small  and  large  cavities,  filled  with  fluid  which  varies  in  color  and  appearance 
within  wide  limits,  having  usually  the  consistency  of  mucus  or  thin  pus,  and  containing 
a  small  number  of  cylindrical  epithelial  cells.  The  cyst  wall  may  contain  tubular  gland- 
like structures  reaching  into  the  surrounding  connective  tissue. 

2.  Papillary  Cystoma. — The  papillary  type  presents  projections  into  cavities  of  papil- 
lomatou.s  outgrowths  from  their  walls,  which  are  covered  by  cylindrical  epithelium, 
which  latter  also  lines  the  cavities.     It  is  most  common  in  the  parovarium. 

It  is  rare  to  find  a  pure  type  of  either  variety;  both  forms  are  usually  blended.  Malig- 
nant transformation,  of  the  latter  type  especially,  occurs  easily  and  insidiously,  and 
explains  many  disap]:)ointments  in  result. 

Adenoma  and  Fihro-adenoma.— Adenoma  is  a  tumor  whose  type  is  the  jwrmal 
secretin^  (/laud,  from  which  it  differs  in  being  an  abnormal  outgrowth  or  product,  but 
particularly  in  that  it  has  no  power  of  producing  the  secretion  peculiar  to  the  gland  tissue 
or  type  from  which  it  grows.  The  adenomas  occur  for  the  most  part  as  circum- 
scrilied  tumors  in  the  mammae,  parotid,  thyroid,  liver,  and  in  the  mucous  membranes 
of  the  bowels  and  the  uterus.  They  may  be  single  or  multiple;  in  the  intestine  they  are 
usually  multiple.  In  certain  locations  (e.  g.,  the  mamnue)  they  attain  enormous  dimen- 
sions, and  in  the  ovary  tumors  of  this  character  may  be  met  with  weighing  forty  or  fifty 
]K)unds.  The  true  adenoma  shows  no  tendency  to  infection  of  neighboring  lymphatics, 
and  gives  rise  to  no  .secondary  deposit,  and  when  it  cau.ses  death  it  is  usually  because 
of  size  or  pressure  upon  important  organs.  It  displays  a  marked  tendency  to  cystic 
alteration,  while  the  relative  proportion  of  epithelium  and  connective  tissue  or  stroma 
^■aries  within  wide  limits.  In  some  cases,  in  which  the  former  is  small  in  amount,  the 
prei)onderance  of  the  latter  has  caused  the  use  of  the  term  adenosarcoma.  which  is  really 
a  misleading  name. 

The  distinction  between  adenoma  and  true  carcinoma  is  in  some  respects  but  slight, 
and  this  fact  will  account  for  the  conversion  which  many  innocent  gland  tumors  seem 
to  undergo  from  one  into  the  other.  As  soon  as  the  epithelial  cells  lose  their 
regularity  of  disposition  and  collect  in  groups,  or  make  their  way  outside  of  the  acini 
into  the  tissues,  then  the  change  from  the  benign  to  the  malignant  tumor  has  begun,  and 
the  entire  clinical  aspect  of  the  case  has  altered.  This  change  may  be  the  result  of 
external  irritation,  of  such  tissue  changes  as  pregnancy  and  lactation,  or  of  the  undefined 
changes  which  advancing  years  .seem  to  produce.     (See  Plate  XXII,  Fig.  2.) 

Adenoma  occurs  in  the  breast  as  cystic  adenoma  or  fibro-adenoma.  The  former  often 
attains  large  size,  is  encapsulated,  the  acini  are  much  dilated,  while  from  the  walls  of  the 
epithelium-lined  cavities  frequently  project  papillomatous  processes,  forming  what  are 
called  intracystic  growths.  Cystic  adenomas  grow  slowly,  produce  atrophy  of  mammary 
tissue  by  pressure,  occur  after  puberty  until  the  menopau.se,  and  rarely  give  rise  to  pain 
until  they  become  large.     As  they  grow  they  distort  the  breast  until  it  may  become 


PLATE  XXII 


Fibromyoma  of  Uterus.      (Low  power.) 


FIG    2 


Fibro-adenoma  of  Breast.      (Low  power.) 


PLATE  XXIII 

FIG.   1 


/  <'r5 


L:ri' 


Epithelial  Pearl  Formation  in  Squamous  Epithelioma.      (Middle  power.) 


FIG.  2 


Malignant  Adenoma  of  Rectum.      (Middle  power.) 


('L.\SSIFlC.\y/(>.\   OF    TI'MOJ^S 


285 


Fig. 


immkIuIoms.  WluMi  {\\v  <jr()\v(li  of  coiiiicctivc  tissue,  pcciiliar  to  the  tumor  in  that  it 
is  rich  in  miclci,  tonus  wcll-niarivcd  partitions  hctwccii  ulvooli,  the  growth  is  called 
prriraiKtIiriilar  adciio/ihroind,  \\\uc\)  may  assume  a  tubular  or  an  acinose  type.  When 
the  alveoli  and  ducts  are  tiiemselves  invaded  by  ingrowth  of  this  tissue,  then  we  iiave 
the  intrantnn/i'riilnr  (ulnio/ihroiiia,  which  constitiites  a  fijrowth  sometimes  horderinir 
on  llu-  nialij,niant.  When  the  arrano;ement  of  ej)ithelial  cells  in  the  acini  and  ducts 
hecomes  irret^ular  and  aty|)ical,  then  malignant  transformation  has  hei^un. 

Fihnt-adruomn  occurs  also  in  the  breast  as  a  small  tumor,  enca|)sulated,  usuall\' 
superhciallv  placed,  movable  in  its  site,  often  multi|)le;  most  conunon  between  the  tw'en- 
tieth  and  thirtieth  y<'ars  of  life;  often  painful,  especially  durin<jj  menstruation;  tender 
upon  pressure.  Both  forms  may  occur  in  yomif/  men.  A  form  of  fibro-adenoma  in 
which  fibrous  tissue  is  greatly  in  excess,  which  never  attains  great  size,  is  common  in 
the  breasts  of  unmarried  women.  It  gives  rise  to  nmch  pain  and  distress,  but  is 
clinically  not  malignant.     (See  Plate  XXII,  Fig.  2.) 

Adenoma  occurs  frequently  in  sebaceous  glands  as: 

1 .  Sebaceous  Cysts. — Sebaceous  cysts  are  generally  known  as  '}(rns.  These  tumors  com- 
monly begin  as  n^tention  c-ysts,  the  ducts  of  the  sebaceous  glands  becoming  occluded.  But 
in  many  cases  there  is  no  occlusion  of  the 
ducts,  and  their  secretion  may  be  easily  ex- 
j)ressed.  I'l^'y  occur  wherever  sebaceons 
glands  abound,  but  es|)ecially  ni)on  the 
scalp.  They  are  usually  multij^le,  vary 
greatly  in  size,  are  easily  movable  over  the 
bone,  and  are  intimately  related  to  the 
skin,  while  the  duct  orifice  is  frecpiently 
recognized  by  a  black  spot,  after  removing 
which  sebum  can  be  expressed.  These 
cyst-adenomas  are  encapsulated,  and  can 
be  easily  shelled  out  of  their  matrices,  save 
when  inflamed,  in  which  case  they  are  often 
astonishingly  adherent.  Their  contents  con- 
sist of  pultaceous  debris  resembling  old 
epithelial  scales,  fat,  cholesterin,  etc.  The 
contents  of  these  cysts  are  very  prone  to 
decompose,  and  they  become  as  offensive 
as  anything  with  which  the  surgeon  has  to 
deal.  Putrefaction  may  be  independent  of 
inflammation  or  coincident  with  it.  When 
irritated  these  gland  cysts  become  inflamed 
and  may  suppurate,  suppuration  being  tantamount  to  cure  by  spontaneous  processes. 
They  may  also  ulcerate,  without  suppurating,  and  form  foul-smelling  ulcers,  or  give  rise 
to  cutaneous  horns. 

2.  Sebaceous  Adenomas. — These  arise  from  the  sebaceous  glands,  which  are  lobulated, 
like  those  about  the  nose  and  ear.  Adenomas  from  this  source  are  extremely  liable  to 
ulceration,  may  undergo  calcification,  and  are  often  mistaken  for  epithelioma  because 
of  the  fungous  ulcerations  to  which  they  give  rise. 

3.  Adenocarcinoma. — Sutton  has  also  described  an  adenocarcinoma  of  the  peculiar 
sebaceous  glands  named  after  Tyson.  These  are  found  particularly  at  the  base  of  the 
prepuce,  this  form  of  tumor  being  rare.  Adenomas  arising  from  the  mucous  glands, 
which  are  usually  transformed  into  cysts,  are  also  known,  as  well  as  other  gland  tumors 
springing  from  the  glands  of  Bartholin,  Cowper,  etc.  (See  Plate  XXIII,  Fig.  2,  and 
Plate  XXIV.) 

Pituitary  adenovias  are  either  analogous  to  struma  or  belong  to  the  mixed  tumors  of 
dermoid  or  teratomatous  type. 

Prostatic  adenoma  is  in  large  degree  fibromyoma  of  that  body,  with  more  or  less  hyper- 
trophy of  its  glandular  structures.  Minute  cystic  alterations  may  occur  also,  as  well 
as  growth  resembling  intracanalicular  fibro-adenoma. 

Adenoma  is  occasionally  observed  in  the  salivary  glands,  where  it  is  usually  encapsu- 
lated, and  may  undergo  cystic  changes.  It  has  been  observed  in  the  liver  and  pancreas. 
In  the  former  its  pseudo-ducts  often  contain  inspissated  material  of  bile-green  tint. 


Multiple  atheromatous  cysts  (wens).     (Lexer.) 


286  SURGICAL  AFFECTIONS  OF   THE   TISSUES 

The  lesions  of  the  kidney  referred  to  as  eystadenoma  are  now  grouped  anioiig  the 
teratomas,  and  are  described  under  that  heading.  They  present  interesting  examples 
of  mixed  tumors. 

In  the  testis,  as  in  the  ovary,  epithehal  tumors  frequently  present  themselves,  but  they 
j)artake  less  often  of  the  type  of  pure  adenoma,  and  incline  rather  to  that  already 
described  under  Ovarian  Cystoma.  Even  in  the  j)aradidyniis  tumors  of  this  same  char- 
acter are  found,  with  cystic  or  even  paj)i!lary  alterations. 

In  the  mucous  vicmhrane  of  the  stomach  and  bowels  adenoma  visually  presents  as 
an  ovoid  tumor,  attaining  such  size  as  to  give  ris?  to  me(  hanical  obstruction  either  by 
pressure  or  by  traction.  Adenoma  of  the  pyloric  region  is  a  repetition  in  structure  of 
the  pyloric  glands.  In  the  rectum  it  presents  usually  as  a  poly]X)id  outgrowth,  often  seen 
in  young  children.  Such  tumors  are  generally  small,  and  when  solitary  they  often  hang 
by  a  distinct  stalk. 

Similar  polypoid  tumors  present  in  the  cervical  canal  of  the  uterus,  where  are  also 
found  sessile  and  racemose  tumors,  all  of  which  are  structural  repetitions  of  the  glands 
met  with  in  the  cervix  uteri.  Adenoma  of  the  uterine  cavity  is  seldom  seen;  it  is  also 
rare  in  the  Fallopian  tube,  but  occasionally  presents  as  a  dendritic  outgrowth  from  the 
mucous  membrane   distending  the  tube. 

Epithelioma. — Epithelioma  is  common,  especially  where  there  is  transition  from 
one  kind  of  epithelium  to  another,  and,  of  all  other  localities,  ])articularly  where  skin 
and  mucous  membrane  meet — e.  g.,  the  lips,  the  vulva,  and  the  anus.  Epithelioma  dif- 
fers from  papilloma  in  that  the  former  is  no  longer  limited  by  basement  membrane,  but 
passes  beyond  it  into  the  underlying  connective  tissue  and  presents  dotcn — rather  than 
up — growth.  Characteristic  of  epithelioma  are  the  so-called  cell  nests  or  pearly  bodies, 
Avhere  there  seems  to  be  a  tendency  to  globular  arrangement  of  cells  with  such  conden- 
sation or  alteration  that  they  lose  their  ability  to  take  stains,  and  appear  as  a  more  or 
less  lustrous  mass,  showing  off  by  contrast  among  the  standard  surrounding  tissue. 
On  this  account  they  are  often  called  pearly  bodies.  Recognition  of  these  is  tantamount 
to  diagnosis  of  epithelium.      (See    Plate    XXIII.) 

This  form  of  neoplasm  is  essentially  the  same,  no  matter  what  its  clinical  varieties. 
These  comprise  a  wart-like  growth  or  nodule,  which  quickly  becomes  an  ulcer  with 
elevated  edges,  ulceration  being  due  to  necrosis  of  cells  farthest  from  the  periphery;  or, 
again,  the  disease  may  start  as  an  ulcerated  fissure,  ulceration  and  infiltration  keeping 
pace,  in  which  case  there  is  a  sharply  defined  ulcer  with  undermined  edges.  A  third 
variety,  often  seen  upon  the  lips,  comprises  a  projecting  mass,  with  more  or  less  horny 
surface.  In  nearly  all  of  these,  however,  the  characteristic  cell  nests  with  their  onion-like 
arrangements  of  cells  will  be  found. 

Epithelioma,  especially  when  exposed  to  the  air  or  to  surface  irritation,  quickly  ulcer- 
ates and  tends  to  involve  all  the  surronding  tissues,  while  occasionally  the  distinctive 
cells  proliferate  so  rapidly  as  to  give  the  ulcer  more  or  less  of  a  bursal  or  a  caulifiower- 
like  arrangement.  From  such  a  surface  there  is  a  constant  discharge  of  foul-smelling 
detritus  or  of  sloughs.  Even  bone  cannot  resist  its  progressive  invasion  and  slowly 
disintegrates  before  the  advancing  mass.  Cartilage  is  resistant,  and  usually  preserves 
its  integrity.  In  other  words,  the  tendency  of  epithelioma  is  toward  constant  encroach- 
ment and  infiltration,  and  toward  a  fatal  termination  from  hemorrhage  by  ulceration, 
from  sej)tic  infection,  exhaustion,  or  other  accidents.  The  wart-like  forms  run  the 
slowest  course  of  all,  but  even  here  the  malignant  tendency  is  most  evident. 

Lymph-node  Infection. — A  striking  characteristic  of  epitheliomas  is  the  invasion  of 
the  adjoining  lymph  nodes,  which  attain  a  size  disproportionate  and  bearing  no  necessary 
relation  to  that  of  the  primary  growth.  This  constitutes  one  of  the  most  serious 
complications  of  the  condition.  This  lymphatic  invasion  partakes  of  the  malignant 
character  of  the  disease,  and  from  every  focus  of  this  character  infiltration  and  de- 
struction proceed.  Infected  nodes  also  show  an  early  tendency  to  central  degeneration 
and  to  spurious  cyst  formation  When  the  overlying  skin  becomes  involved  we  have 
extensive  sloughing  and  the  conversion  into  large  malignant  ulcers.  Dissemination 
to  a  distance  (i.  e.,  metastasis)  is  rare  in  epithelioma — much  more  so  than  in  carcinoma. 
(See  Plate  XXV,  Fig.  2.) 

About  the  mouth  epithelioma  is  not  common  before  the  thirty-fifth  year,  though  I 
have  seen  it  on  the  lip  of  a  twenty-year-old  woman.  It  is  vastly  more  common  in  men 
than  in  women,  and  more  frequent  on  the  lower  than  the  upper  lip.     In  the  tongue 


PLATE   XXIV 


Primary  Papillary  Adenocarcinoma  of  the  Kidney.      (One-half  original  size.) 

(Gaylord.) 


FIG.  2 


Section  of  the  Primary  Growth.      (Gaylord. 


PLATE   XXV 


X^. 


K/i- 


?o^ 


'■;  *•. 


-^  A< 


-rVJ 


h-r^ 


**3 


^i'v:^ 


',%.-. 


Carcinoma  developing  in  a  Thrombus  in  the  Portal  Vein.       (Middle  power.) 

(Gaylord.) 


FIG.  2 


X^>-r-* 


Metastasis  of  Squamous  Epithelioma  in  a  Lymph  Node.      Pearl  Formation. 

(Middle   Power.) 


PLATE  XXVI 


FIG.  1 


Epithelioma  of  Tongue.      Enlarged  three  diameters. 


FIG.  2 


Paget's  Disease  of  the  Nipple.      Enlarged  two  diameters 

Photographs  from  hardened  unstained  specimens. 


Cl.ASSIFNWriOX    OF    TI.MOh'S 


2S7 


it  scltltim  (icciii's  hrl'orc-  llic  Idiliclli  vcar.  I(  scciiis  to  Ih'  iiiorc  comiiioii  liolli  on  the 
lip  and  tonj^iic  in  nii-n  with  l)a(l  teeth  and  in  confirnicd  smokers,  thns  ji'iviiifj  rise  to  (ho 
view  often  held  tliat  it  is  |)urely  a  matter  of  irritation.  It  may,  however,  Im-  (hie  to 
contact  infi'ction  siionhl  it  l)e  ri^^arded  as  of  parasitic  orifjin.  In  one-fiftli  of  the  cases 
of  iM)itheHoma  of  the  tonfi;ue  there  are  pnu'cdinj;  lesions,  nsnally  (lescril)ed  as  huko- 
phikiaov  irlithi/().s'i,s-  o^  the  t()ii<;iu> — conditions  characterized  by  e])ithelial  rednplication 
and  the  formation  of  dense  phupies  or  scales.  Tiiesc  lesions  are  usually  regarded  us 
precancerous  conditions.      (See  Plate  XXVI.) 

The  di.sease  often  starts  near  the  stumj)  of  a  ran'nii.s  foofli,  in  which  case  infiltration 
and  erosion  l)c<;in  promptly  and  projrress  rapidly.  Hpithelioma  of  the  (oiif/iic  has  lieen 
known  to  follow  alonj:;  the  obliterated  track  of  the  thyrolinii;ual  duct,  and  in  this  way 
to  hriuii  :d)out  a  perioratin<;  ulcer. 

Kpitlu'lionia  of  the  vNoylnKjus  is  a  common  cause  of  stricture  of  this  j)assa<!;e-way. 
It  leads  to  ulc(M-ation,  and  usually  to  j)erforatioti  into  the  trachea  or  some  other  cavity 
or  passaije  (/.  r.,  a  bloodvessel).  In  the  larynx  the  di.sease  is  well  known,  and  fjives  rise; 
to  inten.se  and  finally  fatal  .sym{)toms,  but  has  been  dealt  with  suec-e.ssfully  by  radical 
ojierations  for  extirpation  of  the  entire  organ.     (See  Chapter  XLI.) 


Viv..  89 


J-  iG.  90 


Epithelioma  of  forehead  and  eyelid.      (Neisser.) 


Epithelioma  of  lip.      (Neisser.) 


Occurring  upon  the  .scrotum,  epithelioma  has  been  called  chimufii-swerpers  cancer, 
or  souf-irarh-,  and  has  been  ascribed  to  the  irritation  of  foreign  material.  Ulcera- 
tion and  infection  of  the  inguinal  nodes  usually  proceed  rapidly  and  disastrously.  It 
is  believed  also  that  tar  and  paraffin  may  ])roduce  similar  irritation,  and  paraffin  cancer 
has  been  described  by  various  writers.     It  usually  occurs  upon  the  scrotum. 

The  skin  lesions  which  precede  the  formation  of  paraffin  cancer  resemble  those  seen 
in  chinmey-sweeper's  cancer.  The  skin  becomes  dry,  thickened,  parchment-like, 
while  the  openings  of  the  sebaceous  glands  become  obstructed  by  the  tar  or  other  material, 
producing  acne-like  lesions.  Warty  outgrowths  then  occur,  and  these  become  the  seat 
of  malignant  ulceration.  In  chimney-sweeper's  cancer  the  scrotum  is  usually  first 
affected  in  a  chronic  dermatitis,  to  which  warty  outgrowtlis  succeed,  these  enlarging 
and  growing  downward  as  ulceration  takes  place. 

About  the  external  genitalia  epithelioma  is  not  uncommon,  particularly  in  and  about 
the  prepuce.  Such  a  degree  of  phimosis  as  leads  to  retention  of  smegma  is  certainly 
a  predisposing  cause,  not  only  in  man  but  in  the  lower  animals.  Epithelioma  of  the 
viilva  has  been  described  under  the  name  esthiomene,  and  requires  to  be  recognized  and 
dealt  w^ith  promptly  if  the  surgeon  .should  attempt  a  radical  cure.     In  the  vagina  and 


288 


SURGICAL   AFFECTIOXS  OF   THE   TISSUES 


about  the  cervix  uteri  it  is  comnioii,  a  larjie  pntportion  of  cases  of  cancer  of  the  uterus 
beinff  cssentiaHy  e])itheh(jinas  of  the  cervix. 

In  and  about  .srar.s-  and  upon  grauulatinrj  ulcers  e])itheHonia  is  (luite  common.  One 
danger  to  which  a  chronic  uk-er  is  always  e.x()osed  is  that  (jf  epitheh<Hnatous  transforma- 
tion. These  growths  also  attack  lupu.s  scars,  or  even  any  tissues  actively  involved  in  the 
lupoid  process.     This  is  particularly  true  lietween  the  fortieth  and  sixtieth  years  of  life. 

Among  the  viscera  the  gall-bladder  is  probably  more  often  involved  in  distinct  epithe- 
liomatous  changes  than  any  other.  It  presents  as  a  uniform  thickening,  and  cau.ses 
augmentation  in  size,  so  that  a  distinct  tumor  projects  from  beneath  the  liver.  In  this 
location   dessemination    is   rare. 

Epithelioma  is  to  be  regarded  as  having  an  essential  malignant  tendency.  Its  treat- 
ment demands  early  removal  oi  diseased  parts  and  complete  extirpation  of  involved 
lym[)h  nodes.  It  is  only  the  small  and  incipient  growths  which  should  be  attacked 
by  stich  destructive  agencies  as  cancer  pastes  or  the  electrolNlic  current. 

Rodent  Ulcers. — Under  the  name  of  rexlent  ulcers,  lupus  exedens,  nenl-jne-tangerr, 
etc.,  writers,  mostly  English,  have  described  a  variety  of  epithelioma,  met  especially 
upon  the  face,  to  which  a  separate  cla.ssification  has  usually  been  a.ssigned.  L  ntil 
recently  it  has  been  generally  regarded  as  a  local  ulceration,  distinct  from  cancer. 


Fig.  91 


Yv:.  92 


*^^ 


Rodent  ulcer.     (Original.) 


In  some  text -books  it  is  described  as  lupus  exedens.  It  is  preceded  usually  by  a  nodular 
condition  of  the  skin,  vascular,  breaking  down  into  a  regular  ulceration,  but  little  ele- 
vated, the  base  of  the  ulcer  deeply  excavated,  with  a  striking  disproportion  between 
ulceration  and  new-growth.  In  this  particular  variety  infiltration  seems  to  be  continu- 
ouslv  in  advance  of  the  rodent  process,  the  former  being  excessive,  the  latter  but  slight. 
This  variety  of  epithelioma  rarely  j^roduces  lymphatic  involvement;  the  discharge  is 
.slight,  the  pain  complained  of  inconsiderable.  Occasionally  it  entirely  alters  its  aspect, 
and  mav  present  features  of  the  conventional  epitheliomatous  type. 

The  development  of  cancer  in  lupus  areas  is  now  of  sufficiently  frequent  occurrence  to 
demand  attention.  Whether  the  epithelium  which  gives  rise  to  it  is  to  be  accounted  for 
bv  Cohnheim's  hypothesis,  as  having  been  cut  off  in  the  course  of  healing  and  become  a 
cell  rest  to  subsequently  undergo  malignant  degeneration,  is  not  yet  settled.  It  has 
been  suggested  that  curettage  might  cause  fragments  of  epidermis  to  be  loosened  and 
then  entangled  in  the  cicatrix,  and  thus  be  responsible  for  subsequent  malignant  changes. 
When  luy)us  thus  degenerates  it  assumes  usually  the  pa|)illomatous  form,  which  rarely 
involves  lymph  nodes,  while  the  change  which  follows  .r-ray  treatment  often  succeeds  a 
hyperkeratosis  and  rapidly  involves  gland  structure. 

Rodent  ulcer  allies  itself  with  the  t}-pe  of  tubular  epithelioma  springing  from  the 
outer  sheath  of  the  hair  follicle,  sending  out  cylindrical  processes  which  freely  blend 
with  one  another.  It  is  to  be  regarded  as  an  equally  malignant  type  of  ulceration  with 
other  cancerous  ulcers,  and  demands  the  same  thorough  and  radical  measures  for  its 
relief  as  do  other  forms  of  epithelioma.      It  is  perhaps  the   most  favorable  one  with 


CLASSIFICATIOX   OF    TlMOh'S  289 

which  to  (k'iil,  hcH-Juiso  of  tlio  usual  firc'(h)ni  from  involvcnitMit  of  (Iccp  lymphatics.  No 
distiiutive  measures  are  necessary  for  its  relief — only  those  which  are  thorouj^di. 

Carcinoma. Carcinoma  is  a  tumor  fipriiif/ing  from  prri'.ri.sfiuf/  (/land  li.ss'iir, 
whicli  it  more  or  less  closely  resemhli's  in  tyjx',  save  that  the  nl ructural  flintilariti/  is 
iiicoinnh'tr,  the  e])ithelial  cells  now  collectinj^  in  irre<i;nlar  clusters,  or  fillinjr  the  acini 
anil  obstructing  the  (hu-ts,  or  hurstini;-  beyond  the  basement  membrane  and  invadinj]^ 
the  surroundinji;  tissues.  They  frcciucntly  so  fill  the  ducts  as  to  appear  in  colunuuir 
arrantjenient  when  seen  under  the  microscope,  and  this  has  given  rise  to  the  use  of  a 
term  so  \aguc  as  to  have  no  place  in  pathology^ — i.  c,  rij/indroma.  Carcinomas  may 
arise  from  any  of  the  secreting  glands,  but  more  conmionly  from  some  than  from  others. 
Thev  have  no  ca/j.v///r,v.  They  infiltrate  the  surrounding  tissues,  usually  involve  the  lym- 
phatics earlv,  are  liable  to  spread  to  the  snperficial  tissues  and  to  vleerate,  and  to  undergo 
rarioiis  degenerative  changes.  Nearly  all  cancerous  tumors  abound  in  lym|)hatics, 
which  will  explain  the  ra])idity  with  which  the  lym})h  nodes  become  infected,  as  well 
as  the  tiMidency  to  dissemination,  which  is  characteristic  of  these  growths.  Dissemina- 
tion leads  to  so-called  secondary  or  metastatic  growths,  which  may  make  their  apj)ear- 
ance  in  any  organ  or  tissue,  even  in  the  bones,  where  they  give  rise  to  changes  of  texture 
that  make  spontaneous  fractin-e  easy.  It  is  characteristic  of  carcinoma  that  the  metas- 
tatic tumors  which  it  may  j)roduce  will  reproduce  almost  perfectly  the  type  of  the  primary 
tumor  whence  the  embolic  fragments  which  have  })roduced  them  spring.  The  amoimt 
of  dissemination  varies  exceedingly:  it  may  even  become  so  marked  and  widespread  as 
to  produce  a  condition  analogous  to  that  met  with  in  miliary  tuberculosis — niiliarij 
carcinosis.  A  similar  condition,  much  more  rare,  is  seen  in  dissemination  of  sarcoma, 
and  is  known  as  milianj  sarcomatosis.  A  constantly  spreading  cancerous  infiltration 
of  the  superficial  tissues,  which  is  noted  most  often  after  mammary  cancer,  is  described 
under  the  form  of  cancer  en  cuirassc,  or  jacket  or  corset  cancer.  Instances  will  be  seen 
in  which  this  infiltration  of  the  surrounding  structures  has  extended  nearly  or  even  com- 
pletely around  the  thorax.  It  gives  rise  to  a  brawny  induration  which  is  unyielding, 
and  is  studded  here  and  there  by  nodules  that  tend  to  ulcerate,  to  fungate,  and  to  bleed 
easily.     It  is  perhaps  the  most  hopeless  form  of  cancerous  disease. 

The  older  writers  have  constituted  two  or  three  clinically  distinct  forms  of  carcinoma, 
based  mainly  upon  the  relative  hardness  or  softness  of  the  tumor  and  the  invaded  tissues. 
The  term  scirrhus  is  thus  applied  to  a  tumor  in  which  connective  tissue  preponderates 
and  epithelial  cells  are  relatively  deficient.  On  the  other  hand,  the  term  encephaloid 
has  been  applied  to  a  tumor  in  which  the  connective  tissue  seems  barely  sufficient  to 
hold  the  mass  together,  while  the  epithelial  cells  are  in  vast  preponderance.  These 
are  all  tumors  of  the  round  epithelial-cell  type,  and  these  distinctions  are  of  clinical 
interest,  yet  have  no  great  pathological  import,  save  that  in  a  general  way  the  greater 
the  proportion  of  epithelial  elements  the  sooner  will  life  be  terminated  by  destructive 
processes.  In  other  words,  the  more  the  tumor  may  partake  of  the  encephaloid  type  the 
worse  the  pror/nosis  or  the  shorter  the  probable  duration  of  life.  Again,  these  tumors 
pursue  a  varying  clinical  course.  In  those  tinnors,  particularly  of  the  scirrhus  type, 
where  the  connective  tissue  largely  preponderates,  there  is  often  an  eventual  reduction 
in  the  size  of  the  part  involved,  and  such  reduction  of  vascularity  and  of  nutritive  activity 
that  the  rate  of  growth  is  thereby  perceptibly  checked.  The  so-called  atrophying  can- 
cers of  the  breast  are  the  best  examples  of  this  type  of  cancerous  disease.  Here  the 
volume  of  the  gland  is  diminished  rather  than  augmented,  and  the  disease  may  last  for 
a  number  of  years.     It  is  questionable  whether  it  is  well  to  operate. 

The  so-called  colloid  forms  of  cancer  are  simjily  the  expression  of  pathological  changes 
occurring  in  growths  of  more  distinct  type.  Thus  colloid  softening  may  occur  in  any 
tumor  in  which  cancer  cells  predominate,  and  the  so-called  colloid  cancers  of  the  peri- 
toneum, the  ovary,  etc.,  are  either  examj)les  of  such  alterations  or  arc  possibly  endo- 
theliomas arising  in  these  locations.  The  term  villous  cancer,  with  other  terms  like  it, 
should  be  expunged  from  all  scientific  literature,  unless  these  terms  are  used  in  purely 
adjective  anci  clinical  sense,  for  they  imply  nothing  accurate  as  to  histological  struc- 
ture, and  are  often  misleading  and  inaccurate. 

Carcinoma  is  most  common  in  the  following  regions: 

In  the  breast  it  appears  particularly  in  two  forms: 

1.  Acinous  Cancer;  and 

2.  Duct  Cancer. 
19 


290 


SVRdlCAL   AFFECTIOSS  OF   THE   TISSUES 


Fig.  93 


1.  Acinous  Carcinoma. — Ac-inou.s  carcinoma  is  u.sually  of  the  scirrhu.s  type.  It  may 
ari.se  at  any  jxiitioii  of  the  breast,  and  if  anywhere  near  the  nipjile  it  will  eau.se  retraction 
of  that  prominence,  which  is  always  pathognomonic;  elsewhere  it  leads  to  puckering 
and  adhesion  of  the  overlying  skin.  The.se  tumors  infiltrate  widely,  especially  along 
the  connective-ti.ssue  stroma  and  the  fibrous  ti.ssue  which  intersperses  the  fat  of  the  breast. 
They  are  usually  firm  and  sometimes  exceedingly  dense.  A  form  of  scirrhus  known 
as  atrophying  scirrhus  consists  largely  of  strands  of  fibrous  tissue,  injected  here  and 
there  with  epithelial  cells.  It  Ls  the  slowest  in  growing  of  all  the  forms  of  cancer,  andt 
by  its  contraction  tends  to  reduce  rather  than  augment  the  size  of  the  mamma. 

Acinous  cancer  Ls  rare  before  the  age  of  thirty,  most  common  between  forty  anrl; 
fifty.  It  occurs  in  women  in  all  conditions  of  life,  married  and  single,  but  is  rarely 
noted  in  the  male  breast.  The  most  dangerous  form  is  that  which  appears  during 
lactation.  Ordinarily  its  progress  is  .slow.  As  it  augments  in  volume  it  infiltrates  the 
surrounding  tissues,  becomes  adherent  to  the  pectoral  fascia,  infiltrates  the  muscle 
fi!)ers,  and  finally  attaches  itself  to  the  perio.steum  of  the  ribs.     The  infiltrated  tissues 

tend  to  shrink  rather  than  to  increa.se  in  volume. 
Lymphatic  infection  occurs  early  in  this  form, 
and  is  a  pathognomonic  sign.  It  occurs  mostly 
in  the  axillary  lymphatic  nodes,  but  may  often 
be  detected  in  the  neck  above  the  clavicle. 
When  the  skin  is  involved  there  is  a  tendency 
toward  ulceration  and  fungoid  condition.  This 
is  preceded  by  the  purplish  appearance  of  the 
tense  skin.     (See  Plate  XXVII.) 

Pain  is  an  uncertain  and  variable  feature.  It 
is  irnjwrtant  to  emphasize  this  fac-t,  as  many  of 
these  conditions  have  been  lightly  regarderl 
becaiLse  of  freedom  from  pain.  Pain  is  not  a 
con.stant  phenomenon  in  cancer.  On  the  other 
hand,  it  is  sometimes  inten.se,  either  localized  or 
radiating  and  referred  to  distant  points.  Pain  is 
particularly  noticed  in  cases  which  assume  the 
form  of  cancer  en  cnirasse.  Secondary  deposits 
in  viscera  frequently  occur,  particularly  in  the 
abdominal  organs  and  the  lungs;  but  any  organ  may  be  the  seat  of  .secondary  infection, 
and  this  is  found  occasionally  in  the  bone-marrow,  not  alone  of  the  sternum  or  ribs, 
but  of  distant  bones,  and  is  called  marrow  injection.  As  the  result  of  cancerous  affec- 
tion of  .serous  membranes  effusions  of  fluid  frequently  take  plac-e,  as  in  the  pleura, 
peritoneum,  and  pericardium,  and  this  fluid  is  often  Ijlood-stained. 

In  con.sequenc-e  of  pressure  upon  the  venous  trunks  in  the  axilla  there  is  often  a  swelling 
of  the  arm  upon  the  affected  side,  dropsical  in  character,  known  as  lymphatic  edema. 
The  arm  grows  heavy,  the  patient  lo.ses  control  of  it,  and  the  skin  may  become  so  dis- 
tended by  effusion  as  to  cause  the  limb  to  resemble  a  cast.  This  is  due  not  alone  to 
pressure  u|X)n  the  veins  but  to  involvement  of  the  lymphatics,  and  upon  careful  examina- 
tion p>ositive  dilatation  of  the  l^Tnphatic  ves.sels  may  be  noted.  Pain  is  a  usual  accom- 
paniment of  thi-;  form  of  edema. 

2.  Duct  Carcinoma. — This  appears  especially  about  the  time  of  the  menopause,  when 
glandular  structure  has  disappeared  and  only  ducts  remain.  It  is  common,  without 
reference  to  cancer  in  these  instances,  to  find  cy.stic  dilatation  of  numerous  ducts,  which 
vary  in  size  from  a  mustard  .seed  to  that  of  a  cherry.  These  arc  referred  to  by  Sutton 
and  others  as  involution  cy.fts.  They  are  filled  with  mucf)id  material  and  have  a  bluish 
tint.  They  occur  usually  upon  the  under  surface  of  the  gland.  Such  cystic  breasts 
are  common,  and  when  apjx-aring  in  diffu.sed  form  may  be  easily  mistaken  for  cancer. 
Pain  is  not  frequent.  This  condition  is  certainly  a  precancerous  stage,  since  the  dilated 
ducts  are  often  the  .starting  points  of  cancer,  and  occasionally  of  papillomatous  or  villous 
outgrowths  from  their  walls. 

Duct  cancer  implies  the  form  which  arises  in  these  dilated  ducts,  most  commonly 
in  the  terminal  branches,  appearing  ordinarily  as  a  single  tumor,  but  sometimes  as  a 
mass  of  .separate  nodules.  Intracystic  and  intracanalicular  growths  of  this  character 
are  often   found.     When  assuming  the  truly  cancerous   phases  they  may  be  spoken 


■■Pig-skin' 


.aiice  of  cancerous  breast. 


PLATE   XXVII 


FIG.   1 


Scirrhus  Carcinoma  of  Breast.      (Middle  power.) 

FIG.  2 


Soft  Infiltration  Carcinoma  of  Breast,  showing  Stroma.      (Mallory's  connective- 
tissue  stain.) 


CLASSIFICATIOX   OF   TIMORS 


201 


of  as  duci  cnturrs,  otlicrwiso  jus  dud  pupilloina.s.  'I'licy  liavo  gi-nerally  been  referred 
to  as  intracanaliriilar  fibroma.s.  Duct  cancers  are  less  tense  than  tlie  preceding  variety, 
antl  when  situated  near  the  surface  often  discolor  the  skin.  It  is  from  tliese  cases  that 
there  is  seen  a  more  or  less  abundant  discharge  of  fluid  resemhling  h/oodi/  mi/k.  These 
tumors  grow  slowly,  lymphatic  involvement  is  late,  and  in  gciicial  tlic\  present  the  least 
malignant  forms  of  l)reast  cancer. 

Carrinonia  of  .srhacroii.s  (jlnuds  is  by  all  means  most  conunon  in  those  specialized 
glands  named  after  Tyson,  occurring  about  the  prepuce.  They  give  rise  to  the  usual 
forms  of  cancer  in  this  locality. 

Carcinoma  in  the  pro.siatc  is  not  common,  and  is  usually  confined  to  old  men.     In-' 
filtration  proceeds  around  the  base  of  the  bladder  at  the  same  time  and  binds  the 
pelvic  vi.seera  together.     The  pelvic  lym- 
phatics   become    early  infected  and   dis-  ^i<^-  9* 
semination    is    frequent.      (See    Prostatic 
Hypi-rtrophy.) 

Carcinoma  in  the  .ml irarij  r/laud.f  is  not 
common;  it  is  more  frecjuciit  in  the  paro- 
tid region,  occiu'ring  at  middle  life,  grow- 
ing rapidly,  infiltrating  surrounding  parts, 
and  tending  to  ulceration. 

Carcinoma  of  the  liver  varies  in  its 
arrangement  and  appearance.  Some- 
times it  appears  iu  the  form  of  nodules; 
at  other  times,  as  a  more  diffuse  malig- 
nant infiltration  by  cells  relatively  al)un- 
dant  in  number,  so  that  the  clinical 
aspects  of  the  case  conform  rather  to  the 
encephaloid  or  medullary  type. 

Carcinoma  of  the  kidney  was  formerly 
described  as  encephaloid,  meaning  there- 
by simply  a  malignant  tumor  of  soft 
structure.  It  is  probable  that  a  large 
proportion  of  these  tumors  were  sar- 
comas. Nevertheless,  true  carcinoma  of 
the  kidney  is  possible. 

Carcinoma  of  the  ovary  may  originate 
as  such,  or  be  the  result  of  a  transforma- 
tion from  an  ovarian  cystoma  (see  above). 

No  better  illustration  can  be  offered  of  the  infectivity  of  cancer  cells  (be  the  secret 
of  this  infectivity  what  it  may)  than  the  rapid  dissemination  of  cancer  throughout 
the  peritoneal  cavity,  which  sometimes  follows  the  removal  of  an  apparently  non- 
malignant  tumor  which  is  undergoing  this  change. 

On  the  other  hand,  in  the  testicle  such  tumors  are  common — more  so  than  sarcomas. 
It  is  likely  that  many  of  them  arise  from  the  paradidymis. 

Carcinoma  of  the  stomach  is  a  frequent  disease.  It  involves  the  tubular  glands,  espe- 
cially in  the  pyloric  region,  and  conforms  to  them  in  type.  After  involving  the  mucosa 
it  spreads  to  the  entire  coats  of  the  stomach  and  infiltrates  adjacent  structures,  while  the 
mesenteric  lymphatics  are  usually  early  and  notably  involved.  Were  it  possible  to 
recognize  this  involvement  early  in  the  course  of  the  disease  diagnosis  of  pyloric  cancer 
and  operative  interference  would  be  much  more  common  and  hopeful.  Secondary 
involvement  is  generally  in  the  adjoining  viscera,  but  may  be  seen  at  a  distance. 
}»Iiliary  carcinosis  has  been  noted  after  pyloric  cancer.  This  form  usually  occurs  between 
the  fortieth  and  sixtieth  years  of  life,  the  duration  of  the  disease  not  being  long. 

In  the  intestine,  and  particularly  in  the  rectum,  carcinoma  proceeds  also  from  the 
mucous  glands,  and  tends  constantly  to  extend  at  its  periphery  and  involve  the  entire 
lumen  of  the  bowel.  It  seems  to  be  inseparable  from  a  tendency  to  contraction  of  the 
gut  and  consequent  annular  stricture.  Ulceration,  favored  by  surface  irritation  and 
infection,  occurs  almost  always  early.  Above  the  rectum  it  usually  occurs  in  the 
neighborhood  of  the  sigmoid  flexure.  Cripps  has  observed  that  when  cancer  of  the 
rectum  spreads  downward  and  involves  the  anus,  it  loses  its  typical  glandular  character 


Recurring  carcinoma  of  male  breast.      vUriginal.) 


292  SURGICAL  AFFECTIONS  OF  THE  TISSUES 

and  assumes  the  type  of  epithelioma,  or  squamous-cell  cancer.  In  these  cases  the  pelvic 
and  mesenteric  lymphatics  are  infiltrated  and  metastatic  affections  are  common. 

Carcinoma  may  appear  in  any  portion  of  the  uieru-s-,  but  is  more  common  in  the  lower 
than  in  the  upper  half.  It  assumes  the  ty{>e  of  the  cervical  glands,  spreads  rapidly, 
infiltrates  widely,  ulcerates  early,  and  disseminates  frequently.  By  extension  of  ulcera- 
tion the  formation  of  urinary  and  of  fecal  fistulfe  is  common.  Pyosalpinx  and  hydro- 
salpinx are  also  favored,  while  the  spread  of  the  disease  is,  in  fact,  more  common  when 
it  involves  the  cervix  than  when  it  involves  the  uterine  fundus. 

Malignant  Chorion  Epithelioma. — This  has  also  been  called  decidnoma  maligmim, 
a  malignant  growth  of  chorionic  epithelium.  Inasmuch  as  this  tumor  also  includes  a 
syncytial  layer  it  has  been  known  as  sijncijtioma.  Such  tumors  usually  contain  elements 
derived  from  both  layers  of  the  chorion.  They  follow  pregnancy,  generally  within  a  few 
months,  and  are  often  preceded  or  accompanied  by  a  hydatidifonn  viole.  This  growth 
constitutes  a  malignant  neoplasm.  It  pertains  to  ulcerating  uterine  growths  character- 
ized by  early  extensive  metastasis,  which  prove  fatal.  It  has  been  shown  that  similar 
gro^vths  occur  not  only  in  the  uterus  but  also  in  the  testicle,  and  thus  the  scope  of  the 
term  has  been  much  enlarged.  In  its  biology  it  resembles  the  sarcoma ;  in  its  histology,  the 
carcinoma.     It  is  more  malignant  than  any  other  known  growth.     (See  Plate  XXVIII.) 

Occurring  within  the  uterus  its  most  important  clinical  feature  is  a  tendency  to 
frequent  and  alarming  hemorrhage.  When  occurring  about  the  testicle  this  trouble 
rapidly  becomes  fungoid,  bleeding  easily  and  excessively,  the  limgs  being  among  the 
first  organs  to  show  metastasis,  which  takes  place  through  the  blood  as  well  as  the  lymph- 
atic vessels,  for  the  cells  of  these  growths  seem  to  penetrate  the  capillaries.  By  the 
time  a  diagnosis  is  made  a  case  is  likely  to  be  too  far  advanced  to  admit  of  radical  treat- 
ment. If  scrapings  could  be  examined  early,  shreds  of  syncytioma  would  be  found, 
and  it  might  be  possible  that  a  complete  hysterectomy  would  be  of  use. 

iNIetastatic  nodules  consist  mostly  of  round,  dark  masses  presenting  a  more  or  less 
pronounced  fibrous  structure.  These  are  generally  found  in  the  limgs  and  cerebnun, 
where  the  vessels  are  large  and  the  tissues  soft.  There  is  usually  a  sharp  contrast  between 
such  a  tumor  and  the  surrounding  tissues.  The  time  which  elapses  between  delivery  and 
the  appearance  of  the  growth  is  from  three  to  ten  weeks.  The  tumor  rapidly  spreads  to 
the  upper  portion  of  the  vagina.     The  trouble  probably  begins  some  time  before  delivery. 

The  latest  tendency  among  pathologists  is  to  refer  a  growth  of  this  kind  to  the  tera- 
tomas. In  women  this  tumor  is  particularly  a  teratoid  growth,  some  cells  of  the  fecun- 
dated ovum  giving  rise  to  neoplasms,  while  the  ovum  itself  thus  derived  may  misdevelop 
into  a  hydatidiform  mole.  The  tumor  may  be  properly  regarded  as  consisting  in  effect 
of  fetal  cells;  it  is  built  up  of  these  cells,  without  bloodvessels  and  connective  tissue, 
and  so  belongs  to  a  class  by  itself.  Occurring  in  women  it  is  almost  always  a  consequence 
of  pregnancy;  occurring  in  the  testicle  or  in  the  ovary  it  .should  be  regarded  as  proceeding 
from  ectodermal  cells.  For  their  treatment  the  earliest  and  most  radical  measures  only 
will  suffice. 

Suprarenal  Epithelioma;  Hjrpemephroma. — Grawitz  has  distinctly  established 
the  right  of  these  tumors  to  separate  consideration,  for  he  first  determined  their  origin 
and  identity.  Hypernephroma  is  a  tumor,  found  mainly  in  the  kidney,  composed  of 
adrenal  rests,  or  bits  of  accessory  suprarenal  tissue  imprisoned  within  the  renal  cap- 
sule. Their  minute  structure  is  often  that  of  the  adrenals,  with  a  tendency  toward  the 
type  of  perithelioma.  They  have  hitherto  been  considered  examples  of  sarcoma  of  the 
kidney,  but  are  to  be  abruptly  distinguished  from  it  in  most  instances.  Tumors  of 
this  character  have  also  been  found  within  the  capsule  of  the  liver  and  along  the  sj^er- 
matic  artery.  In  the  kidney  the  tumor  portion  is  usually  distinct  from  the  renal  tissue; 
it  is  often  enclosed  within  a  sort  of  capsule,  and  rarely  connects  with  the  pelvis.  Hence, 
though  exceedingly  liable  to  hemorrhages,  blood  rarely  escapes  by  the  ureter.  Hyper- 
nephroma is  delicate  in  structure,  and  its  vessels  give  way  readily.  After  this  has 
happened  a  true  hematoma  may  result.     (See  Plate  XXVIII.) 

Similar  neoplasms  form  in  the  adrenals  themselves.  These  tumors  vary  in  degree  of 
malignancy,  some  of  them  scarcely  deserving  the  designation  malignant.  They  may  be 
met  at  any  age,  but  are  more  common  in  adult  life.  Before  removal  they  are  not  to  be 
differentiated  from  other  tumors  of  the  kidney.  Their  cells  manifest  this  peculiarity  in 
that  they  contain  a  notable  percentage  of  glycogen.  It  should  also  be  added  that  even 
in  true  sarcoma  of  the  kidney  proliferating  adrenal  elements  may  be  found. 


PLATE  xxvirr 


FIC. 


.^' 


Hypernephroma  Renalis.      (Medium  magnification.) 

FIG.  2 


♦tI.  w    :      \*  .     ^^     *  **.  X  *  *^  ^  ^7^. '-If -'ilk,. 


Chorion  Epithelioma. 


CESEHAL  DIAUSUSTIV  FEATURES  UE  MALlGXAXT  dUOWTlIS 


293 


GENERAL  DIAGNOSTIC  FEATURES  OF  MALIGNANT  GROWTHS. 

'i'lic  follow  iiij;  tahirs  arc  licrt-  inserted,  trusting  that  they  may  aid  the  yoiiii<j  |)ra(ti- 
tioiier  in  distiiii,Miishiiii;  in  a  t;eneral  way  between  heniffii  and  nialiijnant  tumors,  and 
even  in  makinj^^  a  dia<fnosis  between  sarc-oma  and  carcinoma.  I  have  also  inserted  a 
table  dilferentiatinj;  the  clinicah  appearances  of  e|)itheiioma  and  of  lupus.  In  tliese 
tables  comprehensiveness  has  not  been  aimed  at,  rather  simplicity,  while  it  is  not  denied 
that  ca-ses  are  met  with  in  which  diafjnosis  may  be  exceedinfrly  difficult,  and  in  which 
the  common  sij^ns  herein  mentioned  may  be  found  either  absent  or  misleading: 


IaMLK   I.  —  DlFKEKKNTIATION    BETWEEN   BeNIGN   AND  MaLIGNANT  GkOVVTHS. 


Benign  Growths. 

Common  at  all  ages. 
I  sually  slow  in  jirowth. 

No  evidences  of  infiltration  or  dissemination. 
.\re  often  encapsulated,  nearly  always  circum- 
scribed. 
Rarely  adherent  unless  inflamed. 
Harely  ulcerate. 

Overlying  tissue  not  retracted. 

No  lymphatic  invoh  ement  when  not  inflamed. 

No  leukocytosis. 

Elimination  of  urea  unaffected. 


Malignant  Growths. 

Rare  in  early  life 

T'sually  rapid  in  growth. 

Infiltration  in  all  cases,  dissemination  in  many. 

Ne\er  encapsulated,  seldom  circumscribed. 

Always  adlierent. 

Often  ulcerate — nearly  always  when  surface 

is  involved. 
Overlying  tissue  nearly  always  retracted. 
Lymphatic  invohement  an  almo.st  constant 

feature. 
Leukocytosis  often  marked. 
Deficient  elimination  of  urea  (?). 


Table   II. — Di.\gnosis   between   Sarcoma   .\nd   Carcinoma. 
Sarcoma.  Carcinoma. 


Occurs  at  any  age. 

Dis.seminates  by  the  bloodvessels  (veins). 

Arises  from  mesoblastic  structures. 

Distant  metastases  are  more  common. 

Contains  l)lood  channels  rather  than  complete 
bloodvessels. 

Less  prone  to  ulceration. 

In\-olvement  of  adjacent  lymphatics  not  com- 
mon. 

Secondary  changes  and  degenerations  are  more 
common. 

(Sugar  present  in  the  blood?) 


Rare  before  thirtieth  year  of  life. 
Disseminations  by  the  lympiiatics. 
Arises  from  glandular  (epithelial)  tissues. 
Less  so. 
Contains  vessels  of  normal  type. 

More    so. 

Almost    invariably   adjacent    lymphatics   are 

involved. 
Degenerations  not  common ;  other  secondary 

changes  rare. 
(Peptone   present   in   the   blood?) 


Differential  diagnosis  between  epithelioma  and  ulcerating  gumma  will  be  found  in 
Chapter  IX. 

Table  III. — Diagnosis  between  Epithelioma  and  Tuberculosis  (Lupus). 


Epithelioma. 

Preceded   usually   by   continued 

warty  growths. 
Diathesis  plays  no  known  part. 


irritation   or 


Rarely  multiple. 

Area  of  thickening  ahead  of  ulceration. 

Ilceration  advancing  from  a  central  focus. 
Border  usually  raised  and  exerted,  regular  in 

outline. 
Often  assumes  fungoid  type. 
Base  may  be  deeply  excavated 
Usually  painful. 
Bleeds  easily. 
Never  tends  to  cicatrize. 

Most  rare  in  tiie  young. 
Discharge  is  \erv  offensi\e. 
Lymphatic  invohement  nearly  always. 


Tuberculosis  (Lupus). 

Irritation  plays  no  figure.     Preceded  usually 

by  nodules. 
Diathesis    evident.     Coincident  evidences  of 

tuberculous  disease  elsewhere. 
Often  multiple. 
Extension    of    ulceration    not    preceded    by 

thickening. 
Various  foci,  which  may  coale.'^ce. 
Border   abrupt,    eaten,    irregular,    thickened, 

firm,  often  inverted,  irregular  in  outline. 
Never   fungoid. 

Base  nearly  level  with  surface. 
Seldom  painful. 
Seldom  bleeds. 
As    marginal    ulceration    proceeds    there    is 

often  cicatri7ation  at  centre. 
Common    in    the    young. 
Discharge  rarely  ofTensive. 
Rarely. 


294 


SURGICAL  AFFECTIONS  OF   THE   TISSUES 


GENERAL  CONSIDERATIONS  CONCERNING  CANCER. 

Cancer  is  one  of  the  most  fatal  of  diseases,  yet  has  no  sympioinalohgy  of  its  own. 
Tt  produces  no  sym'ptovift  which  may  not  be  produced  by  other  affections,  and  this  lack 
of  j)athognomonic  features  constitutes  one  of  the  great  difficuhies  in  diagnosis.  It 
may  disturb  every  function  of  tlie  j)art  involved.  Experimenters  have  sought  in  vain 
for  a  distinctive  feature  by  which  the  disease  can  be  recognized;  neither  in  the  blood 
nor  in  the  various  organic  tissues  have  such  changes  been  found  that  can  be  explained 
only  on  the  hypothesis  of  cancer.  The  pain  which  it  is  supposed  to  cause  is  often 
lacking,  and  is  extremely  variable  and  uncertain.  The  cachexia  of  its  terminal  stages 
is  not  characteristic,  no  matter  how  pronounced,  and  may  be  explained  by  a  variety  of 
conditions,  all  of  which  may  accompany  the  disease.  The  search  for  the  suspected 
parasites  cannot  be  made  with  such  certainty  as  to  lead  to  any  definite  conclusions.  It 
is  known  by  a  complex  of  clinical  conditions  or  by  microscopic  sections  of  tissues  already 
removed. 

When  the  disease  is  superficial  it  is  easily  recognized,  but  when  deep-seated,  recogni- 
tion comes  later.' 

•  Since  the  discovery  of  Spirochaita  pallida  in  syphilis,  Mulzer  and  Loewenthal  have  found  spiral  organisms  on 
the  surface  of  ulcerating  tumors.  Borrel  also  found  spirochaetce  in  conjunction  with  lielminthia  in  two  enclosed 
mouse  tumors,  and  also  in  a  large  tumor  sent  from  Ehrlich's  laboratory.  None  of  these  authors  attributed 
any  significance  to  the  presence  of  these  organisms,  but  recently,  through  the  publication  of  Gaylord,  in  the 
Journal   of   hifectious  Discn/<rs,  who  has  found  a  characteristic  small   spiral  organism  in  nine  out  of   ten  primary 


]{at  with   primary  cystosarcoina  of  tliyrcjid;    cage  infectio;i  in  ))reviiiusl.\-  healthy  animal  ke|)t   in  cage  formerly 
occupied  by  rat  with  same  condition.     (Gaylord  and  Clowes,  Jour.  Amer.  Med.  Assoc,  .January  5,  1907.) 


Fir..   96 


Rat  with  tumor  produced  by  transplantation  from  that  represented  in  J'ig.  95. 
(Gaylord  and  Clowes,  loo.  eit.) 


GENERAL   Rh'MAh'KS  ().\    Tff/-:   TUI'.ATMKST  OF  CAXCER  295 

The  iiiicroscopic  |ii(tiin'  may  explain  coii^idcral)!!'  in  rc<faiil  to  ilic  rmurc  as  well  as 
the  past.  For  iiistaiict',  in  a  case  of  sarcoma  tlic  presence  of  small,  roimd  cells,  ami 
especially  of  pii;meiit,  besjx-aks  a  degree  of  maligiiaiicy  which  probably  iiothini^  vet 
known  can  baffle.  A  chemical  examination  of  the  tumor  after  removal  may  make 
the  surgeon  alert  regarding  the  future  of  the  ca.se,  according  to  the  amount  of  glycogen 
contained  within  the  ma.ss,  since  the  glycogen  content  is  in  direct  proportion  to  its 
malignancy.  For  a  while  some  reliance  was  placed  upon  the  })ercentage  of  urea  elimi- 
nation, but  this  is  influenced  by  so  many  factors  as  to  have  proved  unreliable. 

The  rflaiions  which  cancer  hrar.s-  to  other  diseasr.s-  are  of  consiflerable  interest.  Those 
between  cancer  and  trauma  have  been  discussed;  tuberculosis  |)crhai)s  Ls  the  condition 
which,  next  to  pure  local  irritation,  j)redisposes  to  cancerous  invasitjii.  '^I'he  trans- 
formation of  tuberculous  into  caiu-erous  lesions  can  be  best  appreciated  where  it  can 
be  most  readily  inspected,  i.  e.,  on  the  skin,  and  it  is  well  known  that  lupus  lesions 
frequently  imdergo  this  change.  This  is  also  true  of  large  ulcers,  which  may  undergo 
a  direct  transformation  into  epithelioma,  or  pass  through  the  intermediate  stage  of 
tuberculous  infection.  Cancer  in  tuberculoius  lymph  nodes  is  also  a  matter  of  interest. 
Again,  cancers  and  tuberculous  lesions  may  exist  side  by  side  in  the  same  organ,  as  in 
the  lung  or  the  brain.  Distinct  sarcomatous  nodules  have  been  found  in  infiltrated 
lungs  and  alongside  of  tuberculous  cavities,  while  cancer  of  the  face  will  not  infrec|uentlv 
be  found  associated  with  tuberculosis  of  the  cervical  lymjjhatics.  Lubarsch  has  claimed 
that  4  to  o  per  cent,  of  tuberculous  patients  sufi'er  also  from  cancer,  and  that  about 
20  per  cent,  of  cancer  patients  suffer  from  tuberculo.sis. 

The  method  of  death  in  cancerous  patient.s  is  as  free  from  distinctive  characteristics 
as  the  course  of  the  disease.  It  is  usually  associated  with  two  prominent  features, 
malnutrition  and  some  terminal  infection.  At  the  last  there  is  usually  some  toxemia, 
which  renders  the  closing  hours  free  from  actual  ])ain,  while  if  the  toxemia  be  profound 
patients  may  linger  unconscious  for  several  days. 


GENERAL  REMARKS  ON  THE  TREATMENT  OF  CANCER. 

Accepting  the  views  exjiressed  when  discussing  the  nature  of  the  cancerous  process, 
the  following  may  be  assumed  to  be  true:  Cancer  begins  as  a  local  disease.  There  is 
therefore  a  period  in  its  history  when  //  it  be  recognized  in  time,  if  it  be  or  can  be  made 
accessible,  and  if  it  be  thoroughly  removed,  it  can  be  frequently  cured.  The  "ifs"  in 
the  foregoing  statement  afford  such  insuperable  ob.stacles  in  so  many  cases  that  the 
difficulties  in  the  way  of  treatment  are  very  great.  It  has  been  said  that,  "The  resources 
of  surgery  are  rarely  successful  when  practised  upon  the  dying."  It  happens  too  often 
that  these  cases  are  not  submitted  to  the  surgeon  until  long  after  the  favorable  period 
above  indicated  is  past.  This  is  explained  by  the  difficulties  of  diagnosis,  by  the  inac- 
cessibility of  many  primary  cancers,  and  by  the  unwillingness  of  patients  to  submit  to 
the  knife.  Nevertheless  the  best  time  to  treat  a  cancer  is  when  its  existence  is  first 
suspected,  and  the  best  way  is  the  most  radical,  i.  e.,  by  thorough  extirpation. 

While  such  extirpation  should  include  a  wide  area  of  apparently  healthy  tissue  and  of 
the  entire  organ  which  seems  to  be  involved,  for  instance,  in  the  ca.se  of  the  liver,  this 
last  may  be  impossible;  and  yet  by  removal  of  a  considerable  area  of  healthy  liver 
around  a  cancerous  gall-bladder  the  writer  has  seen  complete  and  apparent  final  recovery 
follow.     The  principal  direction  Is  to  be  thorough. 

moase  tumors,  and  in  all  of  the  transplanted  mouse  tumors  of  three  distinct  strains  in  the  New  York  State 
Cancer   Laboratory,  the   subject   has   attracted   new  interest. 

Gaylord's  organism  is  best  demonstrated  by  the  Levaditi  silver  method,  but  can  be  seen  by  experienced 
observers  in  the  li^^ng  fresh  state.  It  measures  from  2. .5  to  7.8  microns  in  length,  and  the  individuals  have 
from  four  to  thirteen  closely  packed  abrupt  turns.  The  organism  measures  0.6  micron  in  diameter.  Thus 
far  it  has  been  impossible  to  stain  it  with  any  of  the  aniline  stains,  which  characteristic  appears  to  distinguish 
it  from  the  organism  described  by  Borrel  and  Loewenthal.  Calkins  has  also  found  this  organi.sm  in  a 
spontaneous  mouse  tumor  in  New  York.  The  distributicjn  of  the  organism  in  the  growing  periphery  of  the 
tumors,  whe.i  considered  in  the  light  of  Fischer's  work  with  Scarlet-R.  would  make  it  appear  not  impossible 
that  the  organism  bears  an  etiological  relation  to  the  tumors  in  which  it  occurs. 

In  the  light  of  the  well-authenticated  cases  of  cage  infection  and  the  evidence  of  immunity  now  definitely 
determined,  the  way  should  be  prepared  for  the  discovery  of  the  organism  or  organisms  of  cancer.  At  present 
this  organism  would  appear  strongly  in  evidence  as  its  cause. 


296  SURGICAL  AFFECTIONS  OF   THE   TISSUES 

That  cancer  so  often  returns  after  op(;rative  attack  is  largely  due  to  the  fact  that  the 
general  practitioner,  under  whose  observation  most  of  these  cases  first  come,  is  slow 
to  recognize  the  malady,  and  timid  to  advise  radical  methods. 

It  has  been  recognized  that  in  cancer  the  internal  administration  of  arsenic  has  been 
beneficial.  In  order  to  obtain  the  best  results  from  its  use,  it  nuist  be  pushed  to  the 
physiological   limit  and   in   preparations  of  the  most  active  and   reliable   kind.' 

Treatment  by  Toxins  of  Erysipelas. — A  number  of  years  ago  Fehlciscn,  calling  atten- 
tion to  the  fact  that  cancers  had  seemed  to  im])rove  or  possibly  even  disa{)pear  after  an 
attack  of  erysipelas,  suggested  deliberate  infection  of  the  surface  of  such  a  growth  from 
a  case  of  erysij)elas.  In  this  procedure  he  met  with  some  success,  but  there  were  numer- 
ous objections  to  it,  one  being  the  impossibility  of  controlling  the  spread  of  the  infection 
thus  produced.  Coley,  of  New  York,  then  undertook  a  much  more  systematic  study 
of  the  relation  between  the  two  diseases,  and  devised  a  method  of  injecting  the  toxins 
|)roduced  l)y  the  streptococci  of  erysipelas  and  of  reinforcing  them,  if  necessary,  by  those 
of  the  bacillus  prodigiosus.  The  intent  of  this  treatment  is  to  produce  reasonable 
reaction  in  the  hope  of  mitigating  the  rapidity  of  the  growth,  checking  its  progress,  or 
even  causing  its  tlisappearance.  It  has  been  on  trial  now  i'ov  several  years,  and  while 
in  a  few  cases  of  sarcoma,  especially  in  the  hands  of  its  originator,  the  treatment  has 
apparently  been  of  service,  it  has  proved  disappointing  in  the  majority  of  instances. 

Liquid  Air. — The  application  of  liquid  air  to  superficial  malignant  growths  has  proved 
successful  in  a  number  of  instances,  but  inasmuch  as  this  is  practicable  in  only  one  or 
two  of  the  largest  cities  of  the  country,  it  is  not  a  measure  which  need  be  discussed 
here  at  length.  The  liquid  seems  to  act  as  an  almost  painless  escharotic,  and  its  use 
produces  sloughing,  or  a  drying  up  under  a  scab,  which  after  a  day  or  two  will  loosen 
and  be  easily  detached. 

Radium. — This  remarkable  element  has  aroused  within  the  past  few  years  an  amount 
of  scientific  interest  and  experimentation  with  which  there  is  little  else  to  compare. 
The  enormous  expense  of  a  j^reparation  of  any  great  activity,  and  the  rather  bewildering 
contradictory  statements  wdiich  have  been  made  by  those  who  use  the  weaker  prepara- 
tions, have  caused  it  to  occupy  a  doubtful  position  in  any  list  of  reliable  therapeutic 
agencies.  It  is  undeniable  that  certam  rodent  ulcers,  tuberculous  lesions  of  the  skin, 
and  a  few  carcinomatous  lesions  have  been  much  improved  or  apparently  cured  by  its 
use.  It  is  ordinarily  used  in  glass  or  aluminum  tubes  or  capsules,  which  are  applied 
upon  the  surface  of  the  growth  to  be  treated.  It  has  also  been  used  sprinkled  upon 
a  plaster  whose  surface  has  been  prepared  with  Canada  balsam,  and  thus  directly  ap- 
plied. Again,  it  has  been  enclosed  in  a  capsule  to  which  a  strong  silk  thread  has  been 
fastened  so  that  the  former  may  be  swallowed,  retainetl  in  the  stomach  for  a  few  hours, 
and  then  withdrawn.  These  last  means  of  using  it  are  of  questionable  value.  Of  still 
less  value  are  the  suggestions  to  dissolve  it  in  water  or  to  administer  water  in  which  a 
receptacle  containing  radium  has  been  allowed  to  stand.  There  is  much  of  interest 
and  perhaps  something  of  value  in  radiotherapy,  but  nothing  as  yet  of  positive  value  in 
the  hands  of  the  profession  generally. 

Ultraviolet  Light,  or,  as  it  is  often  named  after  its  promoter,  Finsen  light,  has  proved 
of  value  in  many  cases  of  lupus,  and  in  some  cases  of  superficial  epithelioma.  Its  effects, 
however,  can  scarcely  be  made  to  penetrate  into  the  deeper  tissues,  and  in  its  use  it  is 
even  necessary  to  make  pressure  upon  the  part  treated  with  quartz  compressors,  because 
ordinary  glass  shuts  out  a  great  proportion  of  these  rays  from  whatever  source  may 
produce  them,  and  because  it  is  necessary  to  create  a  temporary  anemia  of  the  lesions, 

'  The  preparations  of  arsenic  which  have  proved  most  satisfactory  are  the  imported  cacodylate  of  sodium,  which 
comes  in  capsules  ready  sterih'zed  for  use,  and  the  following  solution,  which  is  original  and  needs  to  be  made  up 
in  accordance  with  the  formula  herewith  furnished: 

(1)  Dissolve  7  grains  mercuric  biniodide  with  10  grains  potassium  iodide  in  a  little  water.  (2)  Dissolve  48 
grains  arsenic  bromide  in  a  little  water  with  the  aid  of  gentle  heat.  (3)  Dissolve  24  grains  gold  chloride 
in  a  small  amount  of  water.  (4)  Mix  the  mercuric  and  the  ar.senic  solutif>ns  and  then  add  the  gold  solution, 
which  will  cause  a  whiti.sh  precipitate,  becoming  browni.sh  in  color.  (5)  Heat  this  mixture  and  decant  the  clear 
portions,  setting  it  aside.  (6)  Add  2  drachms  nitromuriatic  acid  to  the  above  precipitate  and  heat  gently 
until  a  clear  red  solution  results.  (7)  Add  to  this  the  decanted  portion  of  5,  which  will  cause  a  reddish  pre- 
cipitate. Heat  the  whole  mixture  up  to  the  boiling  point  and  until  all  residue  is  dissolved.  (8)  Add  sufficient 
distilled  water  to  make  1.5  fluidounces.     The  product  should  be  bright,  clear,  and  wine  colored. 

Of  this  solution  10  drops  are  supposed  to  represent  1/100  grain  mercuric  chloride,  l/.SO  grain  gold  chloride,  1/1.5 
grain  arsenic  bromide.  The  commencing  do.se  is  10  minims,  which  may  be  increased  to  25  or  more,  taken  in 
abundance  of  water. 


GENERAL  REMARKS  OS   THE   TRh'ATMhWT  OF  CANCER  297 

as  tlic  fluids  of  tlic  Ixxly  have  (he  same  cllVct  as  docs  i^lass.      l^'or  (licsc  reasons  the  method, 
wliicli  is  of  l)iil  limited  value,  can  he  made  serviceable  in  hut  a  small  |)ro|)ortion  of  cases. 

X-ray  Therapy.— The  U()ntii:en  or  cathode  rays  have  |)laycd  a  lar<;e  |)art  during  the 
last  few  years  in  the  therapy  of  cancer.  wSueh  varyin<f  statements  liave  been  made 
eoneerninf;  their  value  as  to  keep  them  still  on  trial  ami  nothing  very  j)ositive  can  be 
said  reijardini;  their  efHcaey.  It  may  be  said,  iiowever,  that  the  nearer  the  malif:;nant 
tjrowth  is  to  the  surface  of  the  body  the  more  promptly  can  their  effects  be  produced 
The  superficial  j^rowths,  especially  of  the  e|)ithcliomatous  variety,  often  yield  readilv 
to  their  use;  the  deeper  the  hvsion  the  more  vaj^uc  the  efi'ect,  both  in  character  and  |)er- 
manence.  It  has  been  the  writer's  (>xperience  that  they  furnish  the  best  method  of 
relieving:;  |)ain,  in  a  larije  number  of  tiiese  tjrowths,  short  of  the  anodyne  efi"ecfs  produced 
by  j)owerful  drui>;s,  which  are  in  every  other  respect  undesirable.  lie  holds  that  no 
one  ean  predicate  with  certainty  what  may  be  their  efVect  in  any  (jiven  instance,  but 
that  they  are  worthy  a  trial  in  every  inoperable,  |)ainful,  or  otherwise  hopeless  case. 
Oeeasionally  improvement  follows  their  use,  while  in  the  next,  apparently  a  similar  case, 
one  may  be  doomeil  to  great  disajipointmcnt.  There  are  as  yet  no  indications  by  which 
the  cases  which  are  most  amenable  ean  be  easily  recognized.  Even  in  cases  of  extensive 
and  disseminated  alnlominal  cancer  marvellous  imj)rovement  may  follow,  but  never 
a  cure.  It  is  indeed  questionable  whether  deej)  cancer  can  ever  be  really  cured  by  these 
means.  As  against  their  undoubted  and  unchallenged  value  in  some  instances,  certain 
tlisadvantages  are  met  in  tiie  difficulty  of  selecting  a  j^roper  vaciuim  tube,  the  frequency 
and  tluration  of  exposure,  the  distance,  etc.  Dermatifis,  sometimes  mild,  sometimes 
severe,  has  too  often  followed  the  injudicious  use  especially  of  a  "high"  tube,  and  more 
painful,  irritable,  or  intractable  ulcers  are  seldom  seen  than  some  following  so-called 
".T-ray  burns"  of  the  skin.  Moreover  this  is  not  the  worst  of  these  ca.ses,  for  efforts 
intended  for  the  best  have  been  in  repeated  instances  turned  into  a  travesty  by  the 
development  on  surfaces  thus  burnedof  epithelioma,  necessitating  later  mutilating  opera- 
tion. A  well-known  American  surgeon  suffered  amputation  of  one  hand  and  nearly 
all  of  the  other  as  a  penalty  for  inattention  to  the  destructive  effects  of  too  prolonged 
exposure  of  his  hands.  It  has,  therefore,  impressed  itself  upon  the  writer  that  the  .r-rays 
should  not  be  indiscriminately  employed.  Nevertheless  in  skilled  hands  and  used 
with  great  discretion  they  can  be  made  a  pow^erful  instrument  for  good  in  many  cases, 
especially  for  the  relief  of  pain.  They  should  never  be  regarded  as  a  substitute  for 
operation  if  operation  be  feasible,  but  they  may  often  be  employed  to  advantage  after 
operating,  in  serious  cases,  where  there  is  reason  to  fear  recurrence. 

The  efficiency  of  the  a'-rays  is  apparently  enhanced  by  the  simu/fancou.t  adrninisira- 
tion  of  thyroid  extract;  although  the  explanation  for  this  improvement  is  not  known,  it 
is,  however,  of  enough  importance  to  be  borne  in  mind.  The  extract  should  be  given 
in  5-grain  doses  three  or  four  times  a  day.  All  the  remarks  above  made  may  pertain 
as  well  to  the  employment  of  cathode  rays  in  non-malignant  affections,  i.  e.,  tuberculous 
lesions,  neuralgia,  etc. 

Miscellaneous  Measures. — A  large  number  of  suggestions  concerning  the  treatment 
of  cancer  have  emanated  from  various  sources  and  from  men  of  w'idely  different  views. 
Beaston,  of  Glasgow,  being  impressed  by  the  physiological  relationships  and  sympathies 
between  the  ovaries  and  the  mammary  glands,  has  suggested  the  benefit  of  the  removal 
of  the  ovaries  in  hopeless  cases  of  mammarij  cancer,  holding  that  the  nutrition  of  the 
mamma  being  thus  influenced  there  would  be  more  or  less  subsidence  of  pathological 
activity.  He  has  reported  instances  in  which,  apparently,  this  measure  had  the  desired 
effect;  nevertheless  it  has  not  found  general  favor. 

Based  upon  views  concerning  the  hyperacidity  of  the  blood  and  tissues  in  the  can- 
cerous condition,  it  is  believed  that  there  is  a  pronounced  indication  for  the  internal  use 
of  alkalies;  and  the  hypodermic  injection  of  5  minims  of  a  1  per  cent,  solution  of  a 
chemically  pure  soap  has  been  recommended  by  Webb,  on  the  theory  that  it  promotes 
the  separation  of  cholesterin  from  the  living  cell.  He  would  increase  the  dose  until 
00  minims  are  given  at  one  time,  every  other  day.  A  20  per  cent,  solution  of  Chian 
turpentine,  dissolved  in  sterile  oil,  has  also  been  recommended  to  be  used  in  the  same 
way.     These  are  recent  suggestions  of  unknow^n  value. 

In  the  general  management  of  cancer  jmtients,  two  things  should  be  kept  in  mind: 
(1)  That  they  are  entitled  to  i-elief  from  suffering  in  the  least  harmful  way  in  which  it 
may  be  offered,  and  (2)  there  comes  a  time  in  the  history  of  many  of  these  cases  when 


298  SURGICAL  AFFECTIONS  OF   THE   TISSUES 

all  other  considerations  may  he  set  aside  in  favor  of  comfort  and  tran(jnillity.  Opium 
and  other  "dru^s  that  enshive"  have  their  disadvantages,  i)ut  these  cannot  outweigh 
the  benefit  which  they  may  confer  in  the  last  stages  of  cancer.  The  icnninal  'pains 
of  maligtiant  disease  should  be  assuaged  at  any   necrssarij  eosf   of  other  considerations. 

But  while  all  this  is  going  on  elimination  must  not  be  neglected.  Opiates  are  pecu- 
liarly liable  to  diminish  secretions  and  peristaltic  activity.  The  skin,  the  kidneys, 
and  the  bowels  should  be  kept  active  by  measures  which  serve  this  purpose,  and  if  it 
be  desirable  to  prolong  life,  nutrition  should  be  regulated  and  frequently  administered, 
but  it  is  absolutely  necessari/  to  maintain  elimination. 

The  latest  suggestion,  viz.,  to  ti'cat  cancer  by  injections  of  pancreatic  ferments 
(trypsin  and  amylopsin),  seems  to  the  writer  to  be  based  upon  erroneous  notions  con- 
cerning the  nature  and  causation  of  the  disease,  and  to  hold  out  only  specious  hope  of 
self-justification. 


CHAPTER     XXVII. 

THE    SKIN. 

It  is  proposcMl  hero  to  treat  only  of  those  diseases  of  the  skin  which  may  complicate 
sur<i;ical  cases  or  call  for  sur<;ic-al  treatment. 

Dermatitis  may  be  produced  by  chemicals,  caustics,  antl  various  irritants;  the  former, 
for  instance,  by  the  use  of  strong  antiseptics  upon  sensitive  skins,  and  the  latter  as  when 
fecal  matter  or  urine  is  poured  over  unprotected  skin  or  allowed  to  remain  in  contact 
with  it.  Ammoniacal  urine  will  prove  irritating,  as  will  also  that  of  diabetes.  When 
carbolic  acid  was  in  general  use  it  gave  rise  to  great  trouble  uj)on  the  hands  of  man\ 
surgeons,  while  iodine,  iodoform,  and  other  such  remedies,  as  well  as  the  stronger  mer- 
curial preparations,  will  cause  local  symptoms  similar  to  those  j)ro(luced  by  ])(>ison  ivy. 

This  may  be  j)revented,when  the  condition  has  occurred,  by  aj)j)lying  soothing  lotions 
or  mild  astringents,  with  anodynes,  in  dry  dusting  |)owtler  or  in  ointment  form.  Cocaine 
in  small  amounts,  or  preferably  orthoform  with  menthol,  may  be  employed  in  either  of 
these  ways.  When  an  acid  discharge  is  exjx'cted  the  skin  should  be  protected  with  an 
ointment  or  with  collodion  or  rubber  cement;  the  latter  by  drying  will  leave  a  thin  film 
upon  the  surface.  Thus  around  a  fecal  fistula  the  skin  will  be  irritated  and  more  or 
less  macerated,  and  should  always  be  thus  protected  when  ])ossible. 

Between  sixty  and  seventy  drugs  are  known  to  produce  distinct  forms  of  dermatitis, 
such  as  cojjaiba,  cubebs,  the  various  preparations  of  iodine,  l)romine,  and  arsenic,  some 
of  the  aniline  preparations,  quinine,  etc.;  while  the  various  antitoxic  serums,  especially 
that  of  diphtheria,  will  sometimes  produce  a  skin  disturbance.  In  these  cases  it  is 
only  necessary  to  recognize  the  source  of  the  trouble  and  remove  the  cause  by  stopping 
the  drug.  Should  dermatitis  produce  such  restlessness  as  to  interfere  with  the  })hysio- 
logical  rest  necessary  for  a  wound  or  fracture  an  opiate  should  be  administered. 

DERMATITIS  CALORICA. 

Dermatitis  ealoriea  means  the  varying  degrees  of  irritation  which  may  be  set  up  by 
extremes  of  heat  and  cold,  continuous  or  alternate,  as  in  .so-called  cliilblanis.  These 
are  often  seen  upon  the  feet,  but  occur  upon  the  hantls  and  even  the  face,  /.  e.,  in  places 
most  exposed  and  least  supplied  with  blood.  The  lesion  occurs  in  patches,  often  with 
livid  discoloration,  and  causes  sensations  varying  from  discomfort  to  acute  pain,  almost 
always  aggravated  by  warmth;  while  the  skin  appears  inflamed,  though  to  the  touch  it 
usually  seems  cool. 

Treatment. — Chilblains  occur  mo.st  frequently  in  the  anemic  and  those  with  uric-acid 
diathesis,  but  may  be  met  at  any  time.  The  constitutional  treatment  should  not  be 
overlooked.  Much  pertains  to  good  care  of  the  feet,  especially  after  exposure.  After 
wetting  or  chilling  they  should  be  dried  and  then  rubbeil  with  boric-acid  talcum  powder, 
containing  1  or  2  per  cent,  of  menthol;  this  may  be  dusted  uj)on  the  feet,  before  going 
outdoors,  upon  return,  and  when  there  is  discomfort. 

It  will  often  give  relief  to  immerse  the  feet  in  warm  water  containing  sufficient  tincture 
of  iodine  to  give  it  a  mahogany  color;  or  the  feet  may  be  simply  dipped  in  this  and  then 
allowed  to  dry  without  using  a  towel.  The  use  of  hydrogen  dioxide  diluted  two  or  three 
times  has  been  highly  commended.  If  this  proportion  of  dioxide  be  added  to  four  or 
five  parts  of  hot  saturated  solution  of  sodium  bicarbonate  the  efficacy  of  the  measure 
will  be  much  enhanced.  In  extreme  cases  frequent  use  of  the  following  formula  will 
probably  give  more  relief  than  anything  else:  Carbolic  acid  1  part,  ichthyol  and  tinc- 
ture calendula  each  4  parts,  and  glycerin  1(5  parts.  With  this  the  skin  may  be  kept 
constantly  moistened. 

The  expressions  of  dermatitis  produced  by  heat  may  vary  from  an  efflorescent  rash 
to  complete  destruction,  and  will  be  treated  of  under  the  following  head: 

(299) 


300 


SURGICAL  AFFECTIOXS  OF  THE  TISSUES 


BURNS  AND  SCALDS. 

The  term  "hurn"  is  ai)|)lic(l  to  lesions  produced  l)_v  flame  or  dry  heat,  while  moist 
heat  (i.  e.,  boiHn<];  materials  or  steam)  causes  injuries  known  as  "scalds."  Between 
the  two  there  is  hut  Httle  essential  difference,  exce))t  that  with  the  latter  ther(>  is  usually 
loosening  of  the  hair  of  the  part,  and  sometimes  much  looscnin<rof  the  epidermis  as  well, 
so  that  it  is  easily  detached  in  more  or  less  large  ])atclies.  Whether  heat  is  relatively 
feeble  but  prolonged,  or  higher  in  degree  and  of  shorter  duration,  the  results  of  dry  heat 
are  al)out  the  same.  Some  differences  will  exist  according  to  wlietiier  the  part  is  ex])oscd 
to  actual  flame  or  to  hot  or  melted  material,  sufhciently  hot  perhaps  to  cause  complete 
charring  or  carbonization  of  a  part. 

Fig.  97 


Burn  by  electric  current  from  "live  wire"  carrying  12lJ()  V(;lt>.     (Original  J 

Similar  injuries  are  produced  by  concentrated  caustics,  acids,  or  alkalies,  while  such 
materials  as  phosphorus  or  sulphur  profluce  deep  burns.  The  burn  profluced  by  light- 
ning is  rarely  deep,  although  it  may  be  extensive  (Fig.  97).  Persons  coming  in  contact 
with  live  wires  sustain  burns  which  partake  much  of  the  nature  of  the  electric  dis- 
charge, and  are  sometimes  of  a  character  to  deserve  the  term  ''hrush-hurn."  Formerly 
burns  were  divided  by  Dupuytren  into  six  or  seven  degrees,  but  this  classification  is  too 
cumbersome  and  artificial  to  be  acceptable.  Morton's  classification  is  now  every- 
where accej)ted,  l)y  which  they  are  divided  into  three  degrees:  (1)  Dermatitis  without 
vesication.  (2)  Vesication  even  to  the  formation  of  l)ull<e.  (3)  Destruction  of  the 
skin,  with  or  without  that  of  the  deeper  parts,  which  may  include  actual  carbonization 
of  a  limb. 

Burns  may  vary  within  the  widest  imaginable  limits.  To  an  extensivi'  burn  of  the 
surface  may  be  added  the  features  j^roduced  by  inhalation  of  smoke,  steam,  or  flame; 
accordingly  the  eyes  and  the  mucous  membrane  of  the  nose  and  mouth  suffer,  the  parts 
becoming  chemotic  and  disfigured,  so  as  to  make  the  individual  unrecognizable.  Burns 
constitute  one  of  the  most  painful  and  distressing  injuries  known  to  the  surgeon,  par- 
ticularly when  the  area  is  large  and  the  case  is  complicated  l)y  injuries  which  necessitate 
more  or  less  prolonged  rest  in  bed.  When  the  body  is  burned  completely  around  it  is 
difficult  to  ensure  rest  without  the  use  of  anodvnes. 


nURXS  AM)  SCALDS  301 

S/idfl:  is  a  iiiark(>(l  fi-atiiro  of  every  serious  case  of  Inirn  or  scald,  and  alhuinin  (juic-kly 
a|)|M'ars  in  llic  urine  in  these  eases.  U Irrraf ion  of  the  (hioilcn inn  miiy  ioWow  vxtvns'wc 
injuries  of  this  kind,  and  is  occasionally  the  cause  of  death.  It  is  to  he  attributed  to 
a  toxic  action  produced  l)y  absorption  of  |)Utrid  material  coiniected  with  the  surface 
slon^'liin^'  process.  A  teni|)orary  dialx'tes  is  sonietiuies  noted.  Laryn<,ntis,  bronchitis, 
and  |)ncuinonia  may  occur  from  inhalation  of  steam  or  smoke,  while  the  inhalation  of 
(lame  may  briufj  about  a  rapid  nlrnin  of  the  f/Zo/Z/.v,  which  may  necessitate  tracheotomy 
as  an  early  anil  emergency  measure.  It  is  <;;enerally  stated  that  a  burn  of  the  second 
defjree,  which  even  involves  half  of  the  surface  of  the  body,  may  prove  fatal;  while  this 
is  not  invariably  the  case,  it  is  too  freijuently  true,  and  may  afford  aid  in  profjnosis. 

Burns  of  the  .second  deijree  are  always  followed  by  e.xudation  with  formation  of  blebs, 
usuallv  within  a  few  hours.  In  the  more  serious  ea.ses  the  exudate  may  be  bhuKJy. 
Burns  of  the  third  det;ree  are  necessarily  followed  by  more  or  less  gangrene,  and  this 
fact  alVonls  the  reason  for  the  radical  treatment  reconunended. 

Treatment.  By  the  time  the  surgeon  is  called  to  treat  a  burn  the  first  indications 
are  usually  relief  of  j)ain,  and  perhaps  .stimulation  for  shock.  The  circumstances  at- 
tending such  injury  generally  leave  the  patient  in  an  excited  mental  condition,  and  for 
several  obvious  reasons  it  would  be  well  to  use  sufficient  anodyne  to  tran(juilliz(;  and 
give  comfort.  An  excellent  application  in  emergency  cases  is  a  saturated  solution  of 
sodium  bicarbonate,  or  it  may  be  dusted  over  the  affected  surface. 

The  un])leasant  visceral  complications  that  follow  burns  are  due  to  absorption  of 
decomposing  fluids  or  tissues,  so  retained  or  so  in  contact  with  readily  absorbing  surfaces 
as  to  produce  a  more  or  less  violent  degree  of  toxemia.  In  this  way  are  to  be  explained 
delirium,  convulsions,  or  coma,  as  well  as  the  ulcerative  and  toxic  intestinal  symptoms 
which  constitute  the  distressing  complications.^  For  this  reason  the  radical  method  of 
prevention  is  the  best;  hence  whenever  there  is  any  prospect  of  sloughing,  or  when  even 
the  epidermis  is  so  burned  as  to  make  it  appear  that  it  will  soon  separate,  the  best  method 
of  treatment  is  to  anesthetize  the  patient  and  then  with  a  stiff  brush  and  antiseptic  soap 
scrub  the  part  and  remove  everything  that  is  at  all  loose,  if  necessary  even  using  a  wire 
brush,  scissors,  or  a  razor.  Beneath  every  sloughing  area  toxic  absorption  will  go  on, 
and  it  will  be  far  better  to  have  fresh  raw^  and  bleeding  surfaces  than  those  which  cover 
sources  of  danger;  the  resultant  scar  will  not  be  any  greater,  while  the  subsequent  course 
of  the  case  will  be  favorably  influenced.  Exquisitely  tender  surfaces  thus  have  their 
sensibility  blunted,  and  the  comfort  of  the  patient  is  greatly  enhanced  by  thorough  cleans- 
ing and  sterilization;  moreover,  dressings  will  not  need  to  be  so  frequently  changed. 
A  soothing,  antiseptic  ointment  should  be  applied ;  there  are  few  better  than  the  ordinary 
ointment  of  zinc  oxide,  to  which  may  be  added  bismuth  subnitrate  and  orthoform.^ 
Treatment  of  this  kind  would  probably  not  need  to  be  repeated,  and  the  duration  of 
the  trouble  would  be  reduced  toone-cjuarter  or  one-third  of  the  time  which  would  otherwise 
be  required.  When  actiuil  carbonization  has  occurred  amputation  is  generally  necessary. 
Diluted  solutions  of  ichthyol  have  proved  satisfactory,  and  the  dressings  should  be 
covered  with  some  imjjermeable  material,  so  as  to  exclude  the  air.  Another  advantage  is 
that  the  amount  of  subsequent  tlischarge  is  limited,  and  thus  there  is  less  need  for  fre- 
quent change  of  dressings.  In  extreme  cases  there  is  no  method  which  gives  so  much 
comfort  and  certainty  as  continuous  immersion  in  tcarm  water;  to  this  may  be  added 
common  salt  or  some  other  antiseptic,  but  the  water  alone  is  sufficient,  if  changed  fre- 
quently.    In  burns  covering  a  great  part  of  the  body  this  treatment  is  the  most  service- 

'  The  Poisons  Produced  in  Superficial  Burns. — The  intoxication  which  often  proves  fatal  in  from  a  few  hours  to 
a  few  days  after  an  extensive  burn  of  the  surface,  with  its  attendant  delirium,  albuminuria,  hematuria,  vomiting 
of  blood,  diarrhea,  etc.,  is  very  similar  to  the  acute  intoxications  produced  by  bacterial  products.  The  sympa- 
thetic ner\-ous  system  is  seriously  involved  in  both.  These  toxins  are  evidently  the  result  of  hemolysis,  and  it 
has  been  shown  that  they  are  slow  poi.sons,  especially  for  nerve  tissue,  apparently  eliminated  by  the  intestines 
and  kidneys,  which  thus  suffer  during  the  process  of  elimination.  This  is  a  more  rational  explanation  than  the 
theories  of  thrombosis  or  of  alterations  in  the  red  corpuscles,  which  would  not  account  for  duodenal  ulcers,  necroses 
in  the  Malpighian  bodies  of  the  spleen,  etc.  These  poisons  are  formed  in  the  burnt  area  and  not  externally;  hence, 
if  this  burnt  area  be  removed  immediate  death  may  be  prevented,  whereas  if  it  be  permitted  to  remain  for  a  few 
hours  it  may  be  too  late.  The  poisons  seem  to  be  produced  in  the  sAiVi,  as  the  burning  of  the  muscle  is  not  followed 
by  any  such  degree  of  intoxication.  They  seem  to  be  neither  ptomain  nor  pyridin  derivatives,  but  rather  resemble 
the  poison  of  snake  venom.  Pfeiffer  believes  them  to  be  derived  from  the  splitting  up  of  proteids  altered  in 
composition  by  the  heat  of  the  burn. 

2  Cargile  membrane  makes  an  excellent  covering  for  burns  whose  surfaces  have  been  cleaned  of  sloughs  and 
which  are  granulating.  It  adapts  itself  perfectly  to  all  irregularity  of  contour,  may  be  snugly  applied  and  not 
chanijed  until  necessity  requires  it. 


302 


SURGICAL  AFFECTIONS  OF  THE  TISSUES 


able.  It  should  be  employed  until  the  .sloujjhs  have  separated  and  surfaees  are  J2;raiui- 
lating  and  ready  for  skin  graftinj)^.  This  implies,  of  course,  immersion  of  the  entire 
body  in  a  bath-tub,  the  body  lying  on  a  sheet  fastened  to  the  sides  of  the  tub.  The 
advantage  of  brewers'  yeast  dressing,  when  sloughs  are  present,  has  been  previously 
emphasized  in  the  chapter  on  Ulcers  and  Ulceration. 

The  disfigurement  caused  by  a  superficial  burn  will  fade  after  a  few  months.  In 
cases  where  the  skin  has  sloughed  there  is  a  tendency  to  cicatricial  contraction  as  soon 
as  granulations  begin  to  form,  and  the  tendency  then  is  to  the  formation  of  disfiguring 
scars.     About  the  limbs  the  flexor  muscles  will  always  overcome  the  extensors,  and 

bridle-like  deformities  will  be  formed 
^'"-  ^^  at  flexures  of  the  joints.     These  are  to 

be  prevented  so  far  as  possible  by 
two  measures — proper  splinting  and 
early  skin  grafting.  About  the  face 
splints  cannot  be  used,  but  one  of  the 
grafting  methods  should  be  used. 

A  tendency  in  the  scars  of  old 
burns  is  to  formation  of  keloid  (see 
below)  and  epithelioma.  The  writer 
has  seen  epitheliomatous  ulcers  cov- 
ering at  least  an  area  of  a  scpiare 
foot,  which  had  formed  upon  the 
sites  of  burns  received  years  pre- 
viously. In  one  case  of  this  kind  it 
was  necessary  to  remove  the  entire  upper  extremity;  even  then  the  disease  recurred  and 
finally  destroyed  the  patient   (Fig.  98). 

Burns  ])roduced  by  caustic  acids  or  alkalies  call  for  a])j)ropriate  chemical  antidotes  at 
first  and  later  essentially  the  same  treatment  as  that  already  mentioned.  In  cases  of 
severe  burn  there  is  danger  f)f  neglecting  the  ordinary  rules  of  general  treatment,  which 
consist  in   niaintainino;  elimination  and  nutrition. 


Kpitlieiioma  f')lli)\viriK  ulcer  due  to  burn.      (Lexer.) 


FROSTBITE. 


Effects  similar  to  those  produced  by  heat  are  caused  also  by  cold,  varying  from  a 
superficial  dermatitis  with  its  surface  irritation,  its  possible  vesication,  and,  later,  des- 
quamation, to  complete  freezing  of  an  extremity  or  a  part  {e.  g.,  the  nose,  or  the  ear), 
which  may  be  followed  by  gangrene.  Portions  which  are  not  frozen  beyond  the  point 
of  restoration  of  vitality  undergo  a  marked  reaction  and  become  swollen  and  discolored, 
save  in  rare  instances  where  they  shrivel.  Gangrene  is  not  so  immediate  a  process  as 
in  a  severe  burn,  as  it  takes  a  number  of  hours,  sometimes  days,  for  the  establishment 
of  the  so-called  line  of  demarcation,  by  which  the  dead  tissue  is  separated  from  the  living. 
On  one  side  of  this  line  putrefaction  goes  on  rapidly,  as  in  moist  gangrene  from  any 
cause;  on  the  other  side  there  is  active  circulatory  disturbance,  with  phagocytosis,  bV 
which  the  line  becomes  more  marked;  no  portion  of  tissue  on  the  distal  side  of  this  dead 
line  can  be  saved.  The  location  of  the  lesion  and  the  exigencies  of  the  case  will  indicate 
where  amputation  should  be  made.     (See  chapter  on  Gangrene.) 

Treatment. — A  rapid  restoration  of  warmth  to  the  part  is  most  undesirable.  The 
thawing-out  process  in  a  case  of  .severe  freezing  should  be  begun  in  cold  or  ice-cold  water. 
Crude  petroleum  at  a  temperature  of  00°  F.  has  been  recommended  as  a  substitute  for 
cold  water,  and  immersion  may  be  continuous  for  several  hours.  A  rubbing  with 
alcohol  and  water  may  be  substituted  for  the  cold  water,  and  then  a  gradual  restoration 
to  the  ordinary  temperature  f)f  the  air.  Unless  this  treatment  be  skilfully  managed  there 
may  be  such  a  rapid  reaction  as  to  be  painful  and  even  injurious.  By  the  time  there  is 
any  active  exudation,  or  putrefaction  has  begun,  an  absorbent  dry  dressing  and  suitable 
antiseptics  may  be  used. 


DEIUIATITIS  OF  RADIO  ACTIVI-:  OUICIN 


;i()3 


DERMATITIS  OF  RADIO-ACTIVE  ORIGIN. 


The  coiiiiiion  expression  of  tliis  I'oriii  of  skin  afl'ectioii  is  called  a  hnni.  'I'liis  is  soiiu'- 
\\\\\\)l  more  than  its  name  im|)lies,  for  it  is  understood  that  the  active  factors  are  the 
ultraviolet  ravs,  or  the  rays  beyond  the  color  refjion  of  the  spectrum;  that  it  is  not  due  to 
llie  heat  rays  is  shown  hy  the  intense  huniinif  that  is  fre(|uently  seen  in  the  Arctic  regions. 
In  the  skin  of  the  young  and  tender,  .•oiiihuni  is  sometimes  followed  hy  vesication  and 
desquamation;  ordinarily  it  simply  j)ro(luces  the  latter.  Any  soothing  ointment  or 
solution  is  usually  .sufficient  for  the  treatment  of  sunburn,  which  should,  however,  include 
avoidance  of  the  exciting  cause. 

Fig.  99 


"Ji-ray  burn, 


result   of  nine  exposures   in   nine   days.       Extensive   necrosis  and  sloughing,  with  an 
intractable  ulcer.     (From  collection  of  Dr.  G.  W.  Wende.) 


Much  more  intense  actinic  effects  are  produced  by  the  .r-rays,  leading  sometimes 
to  complete  destruction  of  the  skin.  These  phenomena  are  usually  called  x-rati  derma- 
titis. They  vary  from  local  discomfort,  with  itching,  loss  of  hair  on  hairy  surfaces,  and 
jjartial  anesthesia,  with  later  a  glossy  appearance,  to  edema  of  the  cellular  tissue,  by  which 
anatomical  outlines  are  effaced.  The  natural  color  of  the  skin,  owing  to  pigmentation, 
apj)ears  dark.  If  the  exciting  cause  be  stopped  before  or  as  soon  as  this  stage  is  reached 
complete  recovery  is  possible,  save  that  hair  does  not  always  grow  from  the  surface  which 
has  lost  it.  The  a--ray  treatment  should  be  pushed  up  to  this  stage.  Careful  manage- 
ment is  now-  necessary,  especially  should  any  surface  irritation  like  chafing  occur.  That 
a:-ray  burn,  so  called,  may  result  from  .r-ray  exposure  made  some  time  previously  seems 
to  be  established  by  a  case  reported  to  me  by  Dr.  L.  L.  McArthur,  of  Chicago,  where 
he  had  to  do  skin  grafting  u])on  a  lesion  of  this  kind  which  did  not  appear  imtil  fifteen 
months  after  the  last  exposure. 

The  stage  of  danger  is  characterized  by  extreme  itching  with  multiform  eruptions  in 
successive  crops,  desquamation,  formation  of  minute  vesicles,  and  ulcers;  or  the  process 


304  SURGICAL   AFFhCTIOXS  OF   TIIF   TISSUES 

may  he  more  acute  and  the  skin  begin  to  slough.  Small  lesions  will  become  confluent, 
and  large  excavations  may  be  formed.  The  .sloughing  process  is  usually  slow,  and 
liy  ii  are  produced  ulcers  characterized  by  extreme  {)ain  and  discomfort  and  a  lack  of 
tendency  to  heal. 

These  ulcers  are  exquisitely  sensitive  and  ap])licati()ns  intended  for  relief  are  of  them- 
selves most  distressing.  Everything  al)()Ut  such  an  ulcer  seems  sluggish,  while  small 
areas  which  have  apjiarently  healed  break  down  again;  healthy  scabs  are  not  formed 
and  granulations  are  extremely  indolent. 

Treatment. — In  the  treatment  of  these  lesions,  so  long  as  they  are  mild,  the  sur- 
geon should  confine  himself  to  soothing  applications  and  rest ;  at  the  same  time  discon- 
tinuance of  .r-ray  exposures  and  even  avoidance  of  light  seem  to  be  essential.  Any 
ojierator  threatened  with  such  trouble  should  wear  thick  rubber  gloves  during  all  his 
work.  The  local  treatment  of  this  lesion  is  not  essentially  different  from  that  described 
in  the  chapter  on  Ulcers  and  Ulceration,  but  the  surfaces  are  often  .so  erethistic  as  to 
demand  either  anodyne  applications,  containing  such  remedies  as  orthoform,  anesthesin, 
or  even  cocaine,  or  else  they  need  radical  treatment  with  a  sharp  spoon. 

Sloughing  surfaces  should  be  treated  with  brewers'  yeast  until  the  surface  has  become 
healthy.  Picric  acid  in  solution  has  been  recommended,  a  saturated  solution  being 
dihued  seven  or  eight  times  before  using. 

The  WTiter  has  rarely  seen  any  more  distressing  or  obstinate  lesions  than  presented 
in  some  of  these  cases.  In  speaking  of  epithelioma  it  has  been  stated  that  some  of 
these  ulcers  are  prone  to  thus  degenerate.  It  seems  an  extreme  contradiction  in  physics 
that  the  agent  used  so  frequently  in  the  treatment  of  superficial  cancers  should,  when 
used  to  excess,  produce  lesions  which  themselves  become  cancerous.  It  has  been  the 
writer's  privilege  to  witness  amputation  of  all  of  one  hand  and  a  large  part  of  the  other, 
in  the  case  of  a  well-known  colleague,  who  carried  the  .r-ray  treatment  to  excess,  and  until 
he  suffered  to  this  extent.  Careful  and  discriminating  judgment  is  therefore  necessary 
in  the  management  of  vacuum  tubes. 

Since  radium  has  come  into  use  it  has  been  found  to  exercise  a  deleterious  effect  upon 
the  skin.  The  radium  emanations  are  known  to  influence  living  cells  and  tissues,  and 
their  inhibiting  effect  upon  the  growth  of  larvse  has  been  well  established.  The  pro- 
hibitive price  of  radium  preparations  will  make  these  lesions  rare.  After  exposure 
there  appears  an  erythema  followed  by  an  active  dermatitis,  which  so  closely  resembles 
lesions  above  described,  in  their  early  stages,  that  one  description  will  suffice  for  both. 
ISIoreover,  the  treatment  of  a  radium  burn  differs  in  no  essential  respects  from  that  of 
an  x-ray  burn. 


ACUTE  INFECTIONS  OF  THE  SKIN. 

Furuncle  or  Boil.  -  A  furuncle  is  a  ])hlegmon  having  its  origin  in  a  hair  follicle 
and  involving  a  siuall  area  of  skin  and  subcutaneous  tissue.  The  infection  is  produced 
by  one  of  the  ordinary  j^yogenic  organisms,  which  have  easy  access  to  the  base  of  the 
follicles.  Sometimes  these  organisms  are  of  imusual  virulence,  but  ordinarily  there 
is  a  local  condition  which  favors  the  infection,  while  it  may  be  encouraged  by  a  general 
diathetic  condition,  such  as  diabetes.  The  lesion  is  usually  single,  but  may  be  multiple. 
Boils  appear  sometimes  in  groups  or  in  crops,  and  when  the  condition  has  become 
chronic  it  is  called  furunculosis,  which  may  be  local  or  general.  A  boil  commences  as 
a  tender  papule,  which  rapidly  enlarges  into  a  conical  swelling,  .sometimes  of  considerable 
size.  Arotmd  it  there  is  an  area  of  dusky  discoloration,  while  the  ajx-x  becomes  qtiite 
dark.  Pus,  travelling  in  the  direction  of  least  resistance,  comes  more  or  less  readilv 
to  the  surface,  the  ajx^x  of  the  boil  yielding  and  pus  finally  escaping,  if  not  evacuated 
by  incision,  tisually  with  a  small  amount  of  necrotic  ti.ssue,  which  may  Ih'  sufficiently 
large  to  justify  the  term  "core."  With  the  esca|x>  of  pus  the  throbljing  pain  is  much 
relieved.  A  furuncle  arising  in  tissues  where  swelling  is  not  easily  treated,  as  in  the 
nose,  the  external  meatus,  and  also  in  the  axilla  and  the  perineum,  will  produce  an 
abnormal  amount  of  pain. 

Treatment. — The  domestic  treatment  of  boils  consists  of  poultices,  usually  made  of 
hot  flaxseed.  These  are  always  nauseous  applications,  and  tend  to  favor  the  develop- 
ment of  similar  trouble  in  adjoining  follicles.     An  equally  comforting  application  can 


ACUTE  ISFECTIOSS  OF    THE  SKIS 


:m^ 


Itc  made  witli  a  |)ic<'('  of  spoiiiijiopiliiu',  or  a  coiiiprcss,  saturated  in  an  antiseptic  solution, 
and  eovt-red  with  rubber  tissues,  outside  of  which,  if  necessary,  a  hot-water  bottle  may 
be  appiietl.  Itiasinuch  as  it  is  tension  which  ])n)(luces  pain,  rcu-lii  incision,  which  can 
be  made  utider  a  little  freezin<:;  sprav,  or  with  cocaine,  will  fjive  the  <;reatcst  relief.  T'his 
may  be  j)ractised  even  before  pus  has  appeared.  After  such  incisions  the  same  moist 
applications  maybe  ap|>lii"d.  Incisions  should  be  made  as  soon  as  pus  is  shown  to  be 
present.  The  aj)pearance  of  a  whitish  |)oint  at  the  a])ex  of  the  furuncle  will  always 
indicate  the  presence  of  pus  beneath. 

(Inicnil  liinnirii/o.ii.t  has  almost  always  an  underlyintj;  diatlu^sis  as  a  cause,  and  this 
should  be  souj^ht  out  and  treated  accordin*;  to  its  nature.  In  the  absence  of  reco<>nized 
constitutional  conditions  the  writer  has  never  found  anythin<j  ecpial  to  aromatic  sulphuric 
acid,  fjiven  in  10  or  12-drop  doses,  with  tincture  of  arnica  in  teasj)oonful  doses,  to  be 
freely  diluted  with  water. 

Carbuncle.— This  differs  from  a  furuncle  in  the  extent  of  the  hxal  infection,  in- 
volvement of  subcutaneous  tissue,  and  the  amount  of  necrosis  which  it  produces.  It  is 
in  most  instances  a  more  serious  affair,  life  often  being  destroyed  by  the  extent  of  the 
resulting  necrosis  and  the  amount  of  toxins  produced.  It  begins  as  a  local  process,  but 
always  with  constitutional  disturbance,  and  sometimes  even  with  a  c  hill.  The  affected 
surface  rapidly  assumes  a  brawny  hardness,  and  the  infiltration  is  often  extensive;  pain 
is  severe  and  throbbing;  the  surface  becomes  more  dusky  in  a])]X'arance,  numerous 
pustules  apj)ear,  development  of  all  the  features  of  a  serious  carl)uncle  usually  taking 
place  in  a  few^  days.  T.,ater  it  begins  to  soften  and  the  skin  gives  way  at  several  points, 
at  each  of  which  a  small  drop  of   pus  is 

discharged,  while  after  removing  this  there  i'l'^--  loo 

may  be  seen  white  necrotic  tissue  beneath. 
The  sloughing  process  extends  deeply, 
generally  to  the  deep  fascia,  and  this 
itself  occasionally  succumbs.  A  person 
may  have  a  distinct  carbuncular  lesion 
where  the  area  primarily  involved  is  not 
much  larger  than  that  of  a  five-cent 
piece;  on  the  other  hand,  in  debilitated 
or  dissipated  subjects,  a  lesion  of  this 
kind  may  become  as  large  as  a  dinner 
plate,  w^iile  the  sloughing  process  may 
expose  the  underlying  bone.  This  is 
often  the  case  on  the  back  of  the  neck 
and  trunk.  A  carbuncle  may  occur  in 
any  part  of  the  body,  but  is  usually  seen 
on  the  back;  when  upon  a  limb  it  gen- 
erally involves  the  extensor  surface.  It  is 
especially  serious  and  dangerous  when 
occurring  upon  the  face,  as  septic  throm- 
bosis may  readily  extend  to  a  cranial 
sinus  and  rapidly  kill.  It  was  formerly 
believed  that  carbuncles  of  the  lip  always  terminated  fatally;  while  this  is  not  necessarily 
true  it  will  indicate  the  seriousness  of  the  condition    (Figs.  100  and  101). 

Treatment. — There  are  few  lesions  where  both  constitutional  and  local  treatment  need 
to  be  more  judiciously  combined.  Many  of  these  patients  are  diabetic,  and  then  it 
assumes  malignant  tendencies.  Others  are  syphilitics  or  alcoholics,  whom  dissipation 
has  reduced  to  a  condition  of  serious  malnutrition.  The  urine  should  always  be 
examined  for  sugar  and  albumin,  and  whatever  indications  it  may  afford  carefully 
followed.  Septic  intoxication  and  infection  may  so  rapidly  depress  the  already  weakened 
patient  as  to  call  for  stimulants  and  tonics,  and  pain  may  be  so  severe  as  to  justify  the 
use  of  anodynies. 

The  local  ireaiineni  should  consist  of  soothing  applications  until  the  extent  of  the 
plastic  exudate  has  declared  itself,  after  which  it  should  be  more  radical.  It  is  better, 
therefore,  to  excise  under  an  anesthetic,  the  area  which  ordinarily  would  require  days 
or  weeks  to  slough.  The  most  satisfactory  treatment  is  the  radical.  The  knife,  the 
scissors,  and  the  sharp  spoon  constitute  the  best  means  of  combating  this  disease. 
20 


Carbuncle  of  the  neck.      (Lexer.) 


306  SURGICAL  AFFECTIONS  OF   THE   TISSUES 

In  other  respects  the  treatment  was  discussed  when  dealing  with  septic  infection. 
Nothing  will  so  hasten  the  sloughing  and  cleaning  up  process  as  brewers'  yeast.  The 
writer's  custom  is  to  make  a  thorough  excision  of  the  affected  area  and  treat  the  f)art 
with  yeast  for  some  days.     About  the  lip  and  face  the  sharp  spoon  should  take  the 

Fig.  101 


Anthrax  carbuncle  of  forearm.     (Lexer.) 


place  of  the  knife,  but  even  there,  if  the  case  be  attacked  early,  tissue  can  be  saved  and 
disfigurement  reduced  to  a  minimum.  The  method  used  by  some  of  injecting  5  per 
cent,  carbolic  solution  is  less  satisfactory,  although  the  measure  above  recommended 
is  a  rather  severe  operation  and  usually  requires  complete  anesthesia. 

CHRONIC  INFECTIONS  OF  THE  SKIN. 

Tuberculosis. — Most  of  the  skin  lesions  formerly  described  as  scrofulous  are 
now  known  to  be  expressions  of  tuberculosis.  So,  also,  are  some  of  the  papillomatous 
growths  and  the  chronic  ulcers,  which  do  not  assume  distinctive  form. 

Lupu.s  vulgaris  is  perhaps  the  most  common  of  these  cutaneous  lesions,  especially  in 
certain  parts  of  the  world.  It  is  seen  more  often  among  the  young  than  the  old. 
The  lesions  begin  with  a  papule,  which  becomes  the  well-known  lupus,  smaller  nodules 
coalescing  and  forming  eventually  a  brownish-red  patch,  whose  borders  are  somewhat 
elevated  and  scaly.  This  lesion  usually  goes  on  to  ulceration,  particularly  in  those  parts 
of  the  body  where  it  is  kept  moist  or  frequently  irritated.  It  is  in  these  lesions  that 
a  healing  or  cicatrizing  tendency  is  seen  at  one  point  and  progressive  ulceration  in 
another.  Ulceration  does  not  always  occur,  but  the  paj^ule  just  described  sometimes 
undergoes  spontaneous  absorption,  the  tissue  atrophying,  losing  its  peculiar  skin 
functions,  and  the  scar  being  depressed  and  scaly. 

Lupus  vulgaris  is  to  l)e  distinguished  from  lupus  exedens,  referred  to  under  Epithelioma. 
It  is  often  mistaken  for  the  latter,  and  a  differential  diagnostic  table  has  already  been 
given.     (See  p.  293.) 

Verruca  necrogenica,  as  it  used  to  be  called,  is  now  known  as  verrucose  tuberculosis. 
It  consists  of  cutaneous  warts,  surrounded  by  an  erythematous  zone  or  patch,  which 
tend  to  break  down,  and  covered  with  scabs,  intermixed  with  pustules.  The  lesion 
rarely  proceeds  to  complete  ulceration.  It  occurs  especially  upon  the  hands  and 
exposed  parts  of  those  who  hanrlle  cadavers  or  carcasses.  The  lesion  is  usually  slow  and 
sometimes  disappears  sjwntaneously. 

On  or  about  the  mucocutaneous  borders  of  individuals  suffering  from  tuberculosis 
there  appear  small  ulcers,  secreting  a  thin,  puruloid  material.  The.se  are  seen  especially 
about  the  nose,  the  mouth,  the  anus,  and  the  vulva.  These  lesions  should  be  regarded 
as  local  infections  from  a  constitutional  source.  They  are  often  sensitive,  show  little 
tendency  to  heal,  and  are  sources  of  danger  to  others.  They  should  receive  radical 
treatment. 

Under  the  term  scrofuloderm  are  included  a  variety  of  subcutaneous  tuberculous 
nodules  which  spread  and  involve  the  skin.  They  begin  in  the  superficial  lymph  nodes. 
The  overlying  skin  becomes  bluish  and  gives  way,  while  an  ulcer  remains  which 
discharges  more  or  less  puruloid  material.  The  edges  of  these  ulcers  arc  frequently 
undermined  for  a  considerable  distance.  These  are  ordinarily  chronic  lesions,  which 
sometimes  undergo  a  spontaneous  recovery,  leaving  disfiguring  and  discolored  scars, 
usually  irregular  and  more  or  less  striped  or  banded. 


cnh'ox/c  i.\Fi:cTi()ss  of  tiif  ski.\ 


307 


Soiiu-  of  the  scrofiiNMlcniis  arc  included  under  tin;  erytlieiiui  iiiduratuin  of  Hazin 
lesions  wlueh  a|)|)ear  mostly  on  the  calves  of  the  left's  of  voun^r  women,  consistinir Of 
deep-seated  nodules,  which  break  down  into  deep  ulcersi^  having  elevated  and  over- 
hanjrin^'  edges.  Again,  there  is  the  so-called  lichen  scrofulosc^ruin,  i.  e.  a  papnlar 
eruption  seen  in  the  young,  esjH'cially  thcjsc  who  show  (jther  evidences  of  t'uherculosis 
It  consists  of  rounded  groups  of  pai)ules,  usuallv  on  the  sides  of  the  trunk,  at  first  bright 
in  color,  new  papules  appearing  as  the  old  ones  fade.  In  addition  there  is  the  i)ustular 
scrotulodcrin,  which  crusts  over,  heals,  and  leaves  small  cicatrices. 

In  all  of  these  lesions  the  tuhercle  bacilli  can  be  usuallv  demonstrated.  There  are 
other  skill  lesions  m  which  no  bacilli  can  be  demonstrated,  which  are  suj)r)osed  to  be 
due  to  the  toxins  generatc<l  in  tuberculous  foci  elsewhere.     Ilallopeau  suggests  calling 


1m<:.  102 


Fig.  103 


Lupu.s  of  .skin  (hypertrophicu-s  et  exulcerans). 
Finally  healed  by  excision  and  plastic  operation. 
(Lexer.) 


Lupu.s  vulgari?.     (Hardaway.) 


all  tuberculous  skin  lesions  tuberculides  and  to  group  them  as  follows:  (a)  Those 
in  which  bacilli  are  present,  bacillary  tuberculides,  and  (b)  tho.se  arising  from  tuberculous 
to.xins,  toxic  tuberculides. 

Among  the  latter  he  describes  what  he  calls  folliculitis,  i.  e.,  small  papules,  firm,  at 
first  red,  then  elevated,  becoming  nodules,  appearing  on  the  extremities,  and  gradually 
producing  crater-form  ulcers  covered  with  black  crusts,  leaving  small  pock-like  scars. 
This  condition  is  chronic,  lasting  years.  In  the.se  patients  the  skin  is  furfurated,  showing 
a  sluggish   circulation. 

Treatment. — Inasmuch  as  tuberculous  skin  lesions  tend  to  spread  and  to  recur,  they 
need  radical  treatment — i.  e.  the  sharp  spoon,  the  scissors,  and  caustic.  Ordinarily  it  is 
be.st  to  scrape  the  affected  surface,  to  trim  away  all  unhealthy  edges,  and  then  to  apply 
a  strong  caustic  for  a  brief  space  of  time,  thereby  .sterilizing  it  and  .searing  the  mouths 
of  the  absorbents  which  may  have  been  opened*  by  the  scraping.  Treatment  for  tw-o 
or  three  days  with  brewers'  yeast  will  usually  suffice  to  put  the  surface  in  a  healthy 
condition,  after  which  it  may  be  skin-grafted  or  treated  by  any  of  the  ordinary  plastic 
methods. 


308 


SURGICAL    AFFFJ'TIOSS  OF   TIIF    TISSIFS 


Rhino  scleroma. — The  bacillus  of  rhinoscleroma  was  (Icscribed  in  the  chapter 
on  Iiiflaiiiniation,  under  the  heading  Pyogenic  Organisms.  It  is  a  specific  infection, 
primarily  of  the  skin,  which  aj)pears  invariably  u])on  the  nose.  It  begins  either  in  the 
skin  or  mucous  membrane,  or  both,  and  having  once  thoroughly  invaded  the  tissues 
g»^)ws  in  all  directions.  It  shows  no  tendency  to  heal,  l)ut  gives  to  the  tissues  a  distinctive 
brawny  induration.  From  the  nose  it  extends  to  the  palate,  pharynx,  and  antrum, 
making  steady  encroachment  upon  the  parts  which  it  affects,  distorting  the  features, 
ol)structing  respiration,  and  often  causing  pain  l)y  pressure  on  the  sensory  nerves. 
Its  first  appearance  is  characterized  by  nodules,  frecjuently  cov(>red  with  dilated  blood- 
vessels. Unless  it  .can  be  seen  and  recognized  early  it  is  a  wellnigh  ho[)eless  condition 
with  which  to  contend.  Extirpation  of  the  affected  tissue  is  the  only  satisfactory  method 
of  dealing  with  it.  It  is  a  different  disease  from  rhinophyma  described  elsewhere. 
(See  Figs.  7  and  8,  p.  55.) 

Mycosis  FungOldes. — This  form  of  skin  infection,  of  somewhat  uncertain  origin, 
is  met  in  shape  of  fungoid  nodules,  and  likely  to  involve  the  u})per  part  of  the  body; 
they  tend  to  increase  in  number  and  size,  to  infiltrate,  often  to  ulcerate,  sometimes 
to  disappear  by  spontaneous  absorption,  but  in  severe  cases  cause  death,  either  by 
malnutrition  or  sepsis.  Tumors  are  thus  formed  which  attain  the  size  of  a  child's 
head.     As  soon  as  surface  infection  or  ulceration  begins  the  breaking-down  process 

Fig.  104 


Ulcerating  gumma  of  skin,  cicatrizing  in  certain  areas.     (Lexer.) 

is  rapid;  there  is  early  involvement  of  the  lymph  nodes,  and  the  general  health  begins 
to  suffer.  The  tendency  in  almost  every  case  is  to  fatal  termination.  Cases  may 
run  from  a  few  months  to  fifteen  years,  however,  before  this  stage  is  reached.  By  some 
authors  the  disease  is  considered  as  a  peculiar  form  of  sarcoma.  It  is,  however,  generally 
regarded  as  a  granuloma,  whose  specific  organism  has  not  been  ascertained. 

Actinomycosis,   Syphilis,   Leprosy,  and  Glanders  should  be  included  among 

the  chronic  infections  of  the  skin,  and  have  been  described. 

Radesyge. — Radesyge  is  a  granulomatous  involvement  of  the  skin,  peculiar  to 
certain  parts  of  Europe,  ])articularly  Norway,  which  has  been  by  some  considered  to 
be  an  expression  of  leprosy,  by  others  to  be  a  disease  by  itself.  It  is  generally  held 
that  the  lesions  which  have  passed  under  this  name  are  really  expressions  of  cutaneous 
sypliilis. 

Framboesia;  Yaws. — This  is  an  endemic  tropical  disease,  of  which  we  see  our  nearest 
specimens  in  the  West  Indies,  and  involves  especially  the  negro  and  Oriental  races. 
It  begins  with  an  eruption,  papules  maturing  in  fungoid  form,  being  met  with  most 
often  at  mucocutaneous  borders,  but  appearing  anywhere  upon  the  surface.  It  is 
specific  and  inoculable,  having  a  ])eriod  of  incubation  of  about  two  weeks,  and  becoming 
generalized  in  from  fifteen  to  twenty  weeks.  The  papules  increase  in  size,  become 
covered  with  yellow  crusts,  ^^■hich  fall  oft"  and  expose  a  rough  surface  which  discharges 
an  offensive  puruloid  material.  After  remaining  in  this  condition  for  an  indefinite  time 
the  lesions  spontaneously  improve  and  may  disapjjear,  leaving  only  pigmentetl  spots 
to  mark  their  previous  sites.     Beyond  local  cleanliness  and  antiseptic  applications  the 


CllliOSIC    IXFh'Cl'lOXS  OF    TIIH   SKI.V 


309 


lesions  rf(|uir('  l>u(  littk-  tivadiiciil.     1 1'  ;iiivtliiii<;'  more  is  adciiiplcil  it  siiould  he  thoroiijijli 
and  fll'cclcd  witli  the  cuuterv  or  (lie  sliar|)  spoon. 

Mycetoma. Mvcctoina  is  nnnv  coinnioiily  known  ns  Madura  foot,  or  sometimes 
the  jiDujus  joot  oj  India.  It  |)revuils  especially  in  Soiitliern  India  and  about  Madras, 
anil  is  apparently  confined  to  that  part  of  flie  i:;lol)e.  Nevertheless  it  has  been  reported 
from  Alj^iers  and  from  South  America.  It  is  a  sj)ecific  infection  of  the  foot,  Ix'fijinninfi; 
in  the  skin;  it  rarely  occurs  on  (he  hands,  (he  scro(um,  etc.  It  leads  (o  (he  formation  of 
an  infecdous  iijranuloma,  which  t^Tadually  des(roys  tlu>  texture  and  identity  of  the  tissues, 
and  finally  demands  ampu(a(ion  or  ahladon  of  (he  par(. 

Russian  hacteriolo^'ists  have  discovered  j)arasi{es  resemhlinii;  (he  pro(o/,oa  which  tliev 
have  found  in  the  fijranulations  and  ulcerations  of  the  Delhi  boil.  'I'hcy  were  also 
occasionally  seen  in  the  leukocytes.  By  these  observers  these  parasites  have  been 
repirde(l  as  active  aj];ents  and  have  been  given  the  name  ovoplasma  orientale. 

Oriental  Boil.  This  also  is  a  slow  infection  of  the  skin,  met  with  especially 
in  Southern  India,  where  it  is  known  as  the  Bi.shra  Jruiion  and  t\w  Alcpjn)  ov  Dellii 
boil  J  It  a])pears  mainly  on  the  unprotected  parts  of  the  body  at  first  as  apaj)uleand 
then  a  nodule,  which  enlarges,  ulcerates,  usually  tends  to  heal  spontaneously,  and  leaves 
an  ineffaceable  scar.  It  is  practically  a  granuloma  of  the  skin,  is  auto-inoculable,  and  is 
best  treated  by  com|)lete  excision. 

Guinea  Worm,  or  Filaria  Medinensis.— This  worm  is  about  one  line  in  diameter 
and  two  or  three  feet  long,  and  is  found  generally  throughout  the  tropics.  The  embryo 
is  taken  into  the  intestines  with  drinking  water  and  migrates  to  the  skin,  beneath  which 
it  develoj)s.  The  male  worm  has  never  been  discovered.  What  is  known  of  the  evidence 
of  its  presence  jiertains  only  to  the 

female.     When  fully   developed  it  ^'"'-  ^^^ 

can  be  felt  in  a  coil  beneath  the  I 
skin.  It  produces  local  inflam-  ^ 
mation,  a  vesicle  forms,  and  the 
head  of  the  worm  then  protrudes. 
When  it  is  exposed  it  can  be  fre- 
quently extracted  by  gentle  traction, 
removing  as  much  each  day  as 
protrudes.  Christie  has  suggested 
to  destroy  the  worm  by  electrolysis, 
and  others  inject  into  the  vesicle 
some  antiseptic,  by  which  the  worm 
is  killed,  it  being  afterward  ab- 
sorbed w'ithout  difficulty  (Fig.  105). 

Blastomycetic  Dermatitis. — This  is  a  true  protozoan  infection  of  the  skin,  first 
described  by  Wernicke  in  1S92,  which  has  now  become  quite  generally  recognized  and 
described.  The  parasite  is  a  very  small,  spheroid  protozoan,  and  is  found  in  the  skin 
elements,  as  well  as  in  the  pus  and  debris  discharged  from  the  lesions.  It  has  been  suc- 
cessfully cultivated  and  inoculated.  It  is  classed  among  the  yeast  fungi.  It  produces 
lesions  very  much  like  some  of  those  met  with  in  syphilis,  tuberculosis,  and  mycosis 
fungoides.  Indeed  it  may  be  necessary  to  use  the  microscope  in  order  to  complete 
the  diagnosis,  which  is  best  accomplished  by  teasing  a  small  portion  of  tissue  on  the  slide 
in  liquor  potasste  (Hardaway). 

The  lesions  begin  usually  as  small  papules,  which  may  later  coalesce  and  become 
covered  with  a  fine  scab.  Around  these  there  develop  thickened  borders,  with  fungus- 
like projections.  Between  the  little  elevations  pus  may  form,  or  an  exudate  occur  in 
sufficient  quantity  to  dry  into  a  large-sized  crust.  Here,  as  in  lupus,  cicatrization  may 
be  going  on  at  interior  points  w-hile  the  lesion  is  encroaching  around  the  margin.  The 
affection  is  slow,  and  the  ulcer  may  attain  a  size  of  several  inches  in  diameter. 

The  treatment  consists  in  radical  measures,  i.  e.,  strong  caustics,  curetting  or  complete 
extirpation  with  the  knife,  which  may  be  followed  by  more  or  less  plastic  work,  as 
reqiiired. 

Coccidioidal  Granuloma. — Under  this  name  is  described  a  rare  form  of  granulo- 
matous lesion  of  the  skin,  whose  exciting  cause  is  not  one  of  the  ordinary  bacteria,  but 

»  Delhi  boil  is  now  known  to  be  another  of  the  local  infections  of  exposed  surfaces,  occurring  especially  about 
the  lower  extremities  and  the  genitals,  due  to  the  invasion  of  one  of  the  trypanosomas,  its  actual  pathology 
having  been  only  recently  demonstrated. 


Guinea-worm  bleb  just  cut  off.   (Bryant.) 


310  SURGICAL  AFFECTIONS  OF   THE   TISSUES 

a  form  of  mold — one  of  the  varieties  of  uulium.  The  cHnical  manifestations  of  this 
lesion  resemble  those  of  blastomycetic  dermatitis,  save  that  in  the  latter  the  primary 
focus  of  infection  is  always  found  in  the  skin  and  remains  there  localized,  whereas  cocci- 
dioidal granulomas  may  occur  as  well  in  the  deeper  tissues  or  viscera  as  upon  the  skin; 
in  fact,  the  skin  lesions  of  the  latter  may  be  descril^ed  as  oidiumijco.sis  in  distinction  from 
blastomycosis.  It  produces  miliary  skin  nodules  which  closely  resemble  tuberculous 
lesions,  and  may  even  caseate  or  assume  an  acute  type  and  break  down  rapidly.  The 
lesions  are  progressive,  with  a  tendency  to  dissemination,  both  by  the  lymph  and  the 
blood  currents.     The  lynipli  nodes  are  usually  early  affected  and  often  suppurate. 

Cysticercus,  or  Taenia  Solium,  may  be  found  in  the  subcutaneous  tissue  in 
the  shape  of  small  nodules,  covered  by  unaffected  skin.  When  young  these  tumors 
are  tense  and  elastic,  but  are  subject  to  calcareous  changes.  They  occur  frequently 
on  the  back. 

EchinocOCCUS  Cysts  are  also  found  in  the  skin,  where  they  may  attain  a  size  which 
will  make  them  fluctuate.     The  treatment  for  all  such  lesions  is  complete  eradication. 

Trophoneuroses.  Perforating  Ulcer  of  the  Foot.— This  has  already  been  alluded 
to  in  the  chapter  on  Ulcers  and  Ulceration.  The  lesion  ap})arently  begins  as  a  thick- 
ening or  callosity,  usually  beneath  the  head  of  the  first  metatarsal  bone,  at  a  ])oint  where 
much  pressure  is  made,  owing  to  the  natural  position  of  the  foot.  Beneath  the  thickened 
skin  there  develops  an  adventitious  bursa,  in  which,  or  in  the  skin  itself,  the  first  degenera- 
tion may  take  place.  The  result  is  a  deep  ulcer,  with  overhanging  borders,  and  a  thin, 
often  foul  discharge.  The  lesion  is  not  painful,  and  patients  are  less  likely  to  spare  the 
foot.  It  is  usually  associated  with  some  central  spinal  disease,  or  with  a  peripheral 
neuritis.  It  is  more  common  in  those  patients  who  have  had  disease  leading  to  loss 
of  sensation  in  the  foot. 

The  treatment  consists  in  excision  of  the  ulcer  down  to  healthy  tissues,  with  careful 
protection.     Skin  grafting  is  often  found  successful. 

Ainhum. — Ainhum  is  essentially  a  disease  of  the  negro  and  of  tropical  climates.  It 
usually  begins  in  the  little  toe  or  little  finger,  and  goes  on  to  spontaneous  amputation, 
the  result  of  an  anemia  caused  by  the  formation  of  a  sclerotic  ring,  which  encircles  the 
digit  and  shuts  off  the  blood  supply.  It  is  an  anular  scleroderma,  or  keloid,  which 
produces  the  disturbance. 

CYSTS  OF  THE  SKIN. 

The  most  common  cysts  of  the  skin  are  the  sebaceous,  known  also  as  steotomas,  which 
result  from  obstruction  of  the  ducts  of  sebaceous  follicles,  and  accumulation  therein 
of  sebaceous  secretion.  They  are  found  where  these  glands  abound,  and  may  attain 
the  size  of  a  hen's  egg  or  larger.  They  are  frequently  infected  and  suppurate,  or  their 
contents  may  undergo  slow  change  and  lose  their  original  characteristics  by  the  time  they 
are  evacuated.  Peculiar  changes  occur  in  rare  instances,  since  they  may  calcify,  or 
their  bases  serve  even  for  the  development  of  cutaneous  horns,  while  in  the  other  direction 
they  not  infrequently  undergo  malignant  degeneration.  In  some  of  these  cysts  a  small 
opening  can  be  found,  through  which,  on  pressure,  fatty  or  butter-like  contents  can  be 
exposed.     When  their  contents  begin  to  putrefy  the  odor  becomes  offensive. 

Another  variety  of  the  skin  cyst  is  the  so-called  atheroviatovs,  which  is  more  allied  to 
the  cutaneous  dermoid,  and  whose  contents  are  often  nearly  pure  cholesterin.  Some- 
times they  contain  hair  or  other  epithelial  products.  They  occur  usually  in  the  scalp. 
These  are  essentially  inclusion  cysts  and  purely  epiblastic  products.  When  infected 
their  contents  putrefy  and  smell  badly.     (See  Fig.  88,  p.  285.) 

Treatment. — The  treatment  for  any  cysts  of  the  skin  consists  in  extirpation  of 
the  sac.  It  is  sufficient  to  split  them  thoroughly  with  a  sharp,  curved  bistoury,  and  then, 
on  either  side,  to  seize  the  edge  of  the  divided  sac  with  forceps  and  enucleate  it.  All 
this  can  be  done  under  local  anesthesia.  The  cavity  should  be  thoroughly  disinfected 
and  not  too  tightly  closed. 

Under  the  name  Cock's  peculiar  tumor  some  English  writers  have  alluded  to  the 
offensive  ulcerated  surface,  with  raised  edges,  which  is  left  after  the  contents  of  these 
cysts  have  undergone  putrefaction  and  escaped  by  breaking  down  of  the  surface.  Such 
a  lesion  is  on  the  border-land  between  mere  ulceration  and  malignancy. 


HYPERTROPHIES  AM)  BENIGN   TUMORS  OF   T/Ih'  .S'A'/.V 


311 


HYPERTROPHIES  AND  BENIGN  TUMORS  OF  THE  SKIN. 


Fio.  ior> 


Distorted    foot,    from 
pressure      and       bunion. 


Corns.  C/ari,  or  coni.s',  viirv  in  dciisily.  A  soft  corn  (iiftVrs  from  a  hard  one 
only  in  that  it  is  located  where  it  is  softened  by  moisture  of  the  j)arts.  A  hard  corn  is  a 
reduplication  or  callosity,  conical  in  shape,  representinii;  fijreat  hypertrophy,  with  coiiden- 
.sation  of  surface  epithelium.  Beneath  old  lesions  of  tiiis  kind  will  frecjucntiv  he  fouiul 
small  cysts,  while  nerve  fibers  become  entanfrled,  and  these  liltle  lesions  are  souielimcs 
exceedinifly  sensiti\'e.  'i^licy  fre(|uently  become  inflamed,  the  process  proceedinir  lo 
suppuration  or  ulceration. 

Bunions. —When  beneath  such  an  indurated  area  of  skin  there  forms  an  adventitious 
bursa,  or  a  natural  one  becomes  involved,  the  lesion  is  called  a 
bunion.  These  are  more  frequent  over  the  joints  of  the  toes, 
where  they  sometimes  cause  intense  discomfort.  The  bursje 
sometimes  connect  with  the  joint  cavity,  and  should  one  suppurate 
the  other  necessarily  becomes  involved.  An  infection  of  either  of 
these  lesions  causes  local  and  ])()ssibly  fatal  disturbance.  I  have 
seen  death  from  pyemia  follow  infection  of  a  bursa  beneath  a 
soft  corn  (Fig.  lOf)). 

These  lesions  are  not  uiet  with  amono;  the  savage  races  or  those 
who  go  barefooted.  They  are  essentially  products  of  the  footwear 
affected  in  modern  society.  Were  shoes  made  to  fit  the  natural  foot 
and  not  to  constrain  it  in  abnormal  positions,  corns  and  bunions 
would  be  practically  unknown. 

Treatment. — Preventive  treatment  is  the  most  important  and 
pertains  to  properly  adapted  footw^ear.  Unfortunately  the  treat- 
ment of  these  minor  lesions  is  too  frecjuently  left  to  charlatans  and 
so-called  chiropodists,  who  may  give  temporary  relief  in  many 
instances,  but  have  no  knowledge  of  either  the  nature  of  the  diffi-  (^Erichsen.) 
culty  or  its  proper  surgical  treatment. 

Soft  corns  will  usually  disaj^pear  if  the  parts  can  be  kept  clean  and  dry.  Hard  corns 
are  essentially  callosities,  which  should  be  pared  down  or  trimmed  ofi  until  the  surface 
is  almost  ready  to  bleed.  It  may  then  be  painted  with  a  collodion  containing  20  per 
cent,  of  salicylic  acid  and  a  little  alcohol.  If  this  mixture  be  applied  to  the  surface  of 
a  clean  and  dry  corn  it  can  often  be  peeled  away  with  the  corn  after  a  few  days.  When 
it  is  desirable  to  soften  any  callosity  of  this  kind,  previous  to  paring  or  trimming  it,  it 
can  be  done  by  applying  for  a  few  hours  a  mixture  of  equal  parts  of  glycerin  and  liquor 
potasste;  this  will  so  soften  a  callosity  as,  when  applied  over  night,  to  make  it  endurable 
through  the  following  day. 

Bunions  are  so  often  associated  with  hypertrophy  of  the  underlying  bone  as  to  entitle 
them  to  consideration  under  deformities  of  the  feet.  The  most  pronounced  expressions 
are  usually  seen  in  connection  with  hallux  valgus  (q.v.),  and  their  treatment  comprises 
excision  of  the  bunion  and  its  underlying  bursal  sac,  along  with  exsection  of  the  joint. 
By  this  radical  local  measure  complete  relief  is  usually  afforded. 

Cutaneous  Horns. — These  have  the  consistence  of  an  ordinary  nail,  are  epiblastic 
products,  varying  in  size,  length,  color,  and  shape.  They  have  been  alluded  to  in  the 
chapter  on  Tumors.  Sutton  has  divided  them  into  sebaceous,  which  occur  most  often 
upon  the  head  and  spring  from  an  old  sebaceous  cyst  (see  above) ;  warty  horns,  which 
much  resemble  them;  cicatricial  and  nail  horns,  which  are  instances  of  exaggerated 
growth  of  the  finger-nails. 

Treatment. — A  simple  excision  of  the  growth  with  its  base  is  all  that  is  needed  in  these 
cases. 

Warts;  Verrucse. — These  constitute  one  variety  of  papillomas,  the  overgrowth  hav- 
ing its  original  site  in  the  prickle-cell  layer  of  the  rete.  The  most  common  form  occurs 
upon  young  subjects  on  the  exposed  parts,  as  the  face,  hands,  and  feet.  These  are 
usually  multiple;  they  frequently  occur  upon  the  surface,  and  retain  dirt  in  such  a 
manner  as  to  be  nearly  always  recognizable  on  the  surrounding  skin.  They  frequently 
disappear  with  as  little  known  reason  as  that  which  caused  their  appearance. 

Dilated  papillary  growths,  like  a  fringe,  are  sometimes  seen  about  the  face  and  neck 
of  elderly  people.  These  have  been  known  as  filiform  warts,  while  Unna  gave  them 
the  name  fibrokeratomas. 


312 


SURGICAL   AFFECTIOXS  OF   THE   TISSUES 


A  form  described  as  the  scborrltrir  warf  occurs  upon  the  face  and  elsewhere  in  eklerly 
people.  It  is  frecjuently  pigmented,  may  itch  intolerably,  and  is  perhaps  the  form  which 
most  often  undergoes  malignant  degeneration.  To  the  acuminate  form  of  wart,  which 
is  usually  soft,  and  most  often  met  with  as  a  venereal  wart  about  the  genital  region,  has 
been  given  the  name  condijloma.  These  appear  in  either  sex,  grow  rapidly,  are  covered 
with  a  puruloid  secretion,  bleed  easily,  and  assume  often  such  shape  and  resemblance  as 
to  give  rise  to  expressions  "strawberry  growth,"  "raspberry  growth,"  etc.  They  are 
always  produced  by  irritation,  usually  in  connection  with  one  of  the  venereal  diseases, 
and  are  generally  due  to  lack  of  cleanliness.  They  may  grow  luxuriantly  and  over  a 
considerable  area,  and,  when  aj^pearing  on  the  surface  of  the  vulva,  conceal  completely 
the  parts  underneath.  They  also  occur  in  connection  with  the  mucous  patches  of 
tertiary  or  hereditary  syphilis,  })ut  have  essentially  the  same  structure,  no  matter  how 
produced. 

Treatment. — In  the  treatment  of  ordinary  warts  nothing  is  better  than  absolute  clean- 
liness. A  dry  wart  touched  daily  with  formalin  solution,  or  covered  with  collodion 
containing  1  to  2  per  cent,  of  corrosive  sublimate,  will  usually  shrink  and  become 
detached  in  a  few  days.  Thorough  excision  of  any  true  wart  is  sufficient  to  finally 
dispose  of  it.  If  the  wart  be  cut  through  it  is  likely  to  bleed  profusely,  since  its  vessels 
are  larger  than  those  of  the  surrounding  skin.  Any  growth  of  this  kind  can  also  be 
destroyed  by  the  actual  cautery,  or  by  one  of  the  strong  caustic  agents,  which,  however, 
should  be  used  with  great  care. 

Venereal  tcarts,  condylomas,  are  best  treated  radically,  either  with  the  actual  cautery 
or  with  sci.ssors  and  sharp  spoon.  Local  anesthesia  is  always  advisable  in  order  that 
this  may  be  thoroughly  done.  In  instances  of  extensive  growths  of  this  kind  a  general 
anesthetic  may  be  ])rofitably  given. 

MoUuscuni  Contagiosum. — Molluscum  contagiosum,  sometimes  known  as  epithe- 
lial molhi.'tcniu,  is  a  name  apjilied  to  small  warty  growths  more  or  less  embedded  in  the 
skin,  from  which,  by  pressure,  some  epithelial  debris  can  be  forced  out.  The  lesions 
are  rarely  single  and  yet  rarely  numerous.  They  may  be  met  upon  any  part  of  the 
body,  especially  upon  exposed  portions.  They  are  doubtless  results  of  skin  infections 
by  various  organisms.  The  best  treatment  is  excision,  although  they  may  be  split  and 
cauterized  and  thus  made  to  shrivel,  or  the  same  effect  may  be  produced  by  electrolysis. 

Fig.   107 


Keloiii  occurring  in  a  laparotomy  scar.     (Lexer.) 


Keloid. — This  has  already  been  mentioned  under  the  heading  Fibroma,  in  the 
chapter  on  Cysts  and  Tumors.  It  deserves  further  mention  here,  however,  because  of 
the  disfigurement  produced  by  keloid  scars,  and  because  the  s])ontaneous  expressions 
of  the  disease  may  occasionally  demand  surgical  intervention.     In  cicatricial  tissue  it 


PLATE  XXIX 


Keloid.     (Hardaway.) 


iiYPEirruorniKs  axd  bkxicx  tumors  of  the  skin  313 

ofti'ii  follows  (lie  scars  left  hy  hums  or  oxcision  of  tulu'rculoiis  lesions.     Since  suhcuta- 
neous  sutures  have  heen  introduced  there  is  less  keloid  than  there  was  years  aj^o  (Fi^.  107). 

Treatment.  The  surface  iiKhcation  is  always  for  excision  or  eradication,  but 
one  cannot  ^nve  the  slifjhtest  <;uarantee  against  recurrence  in  even  worse  form  in  the 
same  scar.  Electrolysis  may  have  a  beneficial  effect  on  some  of  the  lesions,  l)Ut  will 
only  occasionally  j)rove  satisfactory.  A  miinber  of  years  afi^o  f/iio.sinamin  was  intro- 
duced, and  has  perhaps  given  a  larj^er  measure  of  success  than  any  other  remedy.  It 
is  used  in  5  or  10  j)er  cent,  .solution,  which  is  injected  into  and  around  the  fjrowth,  and 
may  lead  to  gradual  absorption  of  the  hyj)ertrophied  ti.ssue.  The  pain  which  the  injec- 
tion ])roduces  does  not  last  long  and  I  have  seen  many  excellent  results  follow  its  u.se. 

The  same  injections  may  be  resorted  to  in  general  keloidal  disea.se,  which  is  seen  most 
often  in  the  colored  race.  In  negroes  it  may  follow  traumatism  of  the  skin  surface,  and 
attain  the  size  of  a  saucer  or  |)late.     (See  Plate  XXIX.) 

Neurofibroma.  Fil)n)ma  of  the  skin  may  happen  at  any  time  and  is  likely  to 
develo])  in  the  finer  branches  of  the  cutaneous  nerves,  where  it  will  constitute  a  small 
tumor,  known  as  painful  fiubcuiancfnis  iuhrrclr.  These  little  timiors  attain  the  size  of 
a  pea  and  appear  between  the  skin*  and  superficial  fascia.  Sometimes  they  are  painful 
and  are  always  tender.  Unle.ss  thoroughly  removed  they  tend  to  recur.  Nevertheles.s 
com])lete  removal  is  the  only  remedy. 

Fibroma  Molluscum. — A  much  larger,  softer,  and  more  complex  tumor  is  that 
known  by  X'irchow  as  p.broma  mnUuscum.  These  tumors  may  attain  large  size,  and  may 
be  single  or  multiple.  Over  four  thousand  of  these  lesions  have  been  counted  on  one 
subject.  They  develo])  from  the  connective  tissue  of  the  cutaneous  nerves,  and  in- 
volve later  the  globular  and  follicular  structures  of  the  skin,  softening  and  undergoing 
such  changes  as  to  deserve  the  adjective  molluscum.  Changes  analogous  to  these  lead 
to  what  has  been  described  as  dermatolysis,  i.  e.,  hypertrophy  of  the  skin,  with  loosening 
of  the  subcutaneous  tissue,  by  which  it  is  thrown  more  or  less  into  folds.  Another  clinical 
expression  of  the  same  condition  has  been  known  as  pachydermaiocclc,  in  which  pendu- 
lous masses  of  skin  hang  from  various  jiarts  of  the  body,  especially  the  face  and  neck, 
and   undergo  pigmentation  and  other  changes. 

Treatment. — These  lesions  can  be  excised,  always  witli  temporary  cosmetic  improve- 
ment, l)ut  not  always  with  a  guarantee  against  recurrence  of  the  trouble. 

Scleroderma. — This  name  is  given  to  a  leathery  induration  of  the  skin  occurring 
in  circumscribed  areas,  which  have  been  called  "morphea,"  or  in  diffuse  patches,  which 
shade  oflF  into  surrounding  normal  skin.  The  first  indication  is  a  stiffening  accompanied 
by  some  thickening  and  hardness.  Sometimes  the  affection  is  painful,  and  the  brawny 
hardening  which  it  produces  makes  it  irksome  and  uncomfortable.  The  skin  thus 
affected  can  not  be  picked  up  between  the  fingers,  and  is  more  or  less  adherent  to  the 
tissues  beneath.  When  the  difficulty  is  ])ronounced  the  sweat  and  sebaceous  glands 
cease  to  functionate.  If  it  occur  about  a  joint  the  movement  of  the  latter  may  be  inter- 
fered with,  even  to  the  extent  of  producing  ankylosis.  Wherever  it  appears  there  is 
impediment  to  motion  and  flexibility  of  the  parts  beneath.  The  tendency  usually  is  to 
spontaneous  disappearance  with  atrophy.  AVhile  subsiding  at  one  locality  it  may  recur 
in  another.  Upon  the  hands  it  may  effect  such  great  disturbance  of  function  as  to 
produce  what  has  been  described  as  "sclerodactylia."  The  skin  over  bony  prominences, 
when  irritated,  may  break  down;  ordinarily  it  does  not  go  on  to  ulceration. 

Pathology. — The  pathology  of  scleroderma  is  very  obscure.  Whether  it  depend  upon 
primary  disturbances  of  circulation,  both  of  blood  and  lymph,  or  whether  it  is  produced 
by  cellular  hypertrophies  has  not  been  determined. 

The  characteristic  induration  of  this  disease  is  not  imitated  in  other  affections  except 
scleroma  neonatorum,  but  it  may,  nevertheless,  be  confused  with  the  infiltration  of  tuber- 
culosis, of  syphilis,  or  of  malignant  disease.  While  the  disease  persists,  in  most  cases  it 
is  not  often  fatal. 

Treatment. — It  is  to  be  treated  mainly  by  tension,  the  general  and  constitutional  con- 
ditions by  massage,  and  inunction  with  soothing  oils  or  with  the  ichthyol-mercurial 
ointment.  It  has  been  successfully  treated,  as  is  keloid,  by  the  subcutaneous  use  of 
a  10  per  cent,  alcoholic  solution  of  thiosinamin.  The  ultraviolet  rays  and  even  the 
.r-rays,  used  judiciously  and  carefully,  may  also  be  of  service. 

Rhinophyma. — This  form  of  tumor  is  to  be  differentiated  from  rhinoscleroraa, 
the  latter  being  due  to  a  peculiar  specific  bacillus,  while  rhinophyma  is  a  filth   disea.se, 


314  SURGICAL  AFFECTIOXS  OF   THE   TISSUES 

due  to  hypertrophy  of  the  sebaceous  structures  of  the  nose  from  obstruction  of  the 
sebaceous  ducts.  It  is  often  seen  among  alcoholics,  perhaps  less  frequently  at  home 
than  abroad.  Pathologically  it  consists  of  enormous  and  irregular  hypertrojjhy  of  the 
sebaceous  gland  elements  and  connective  tissue  of  the  skin  of  the  nose.  Each  hvper- 
trophied  gland  secretes  in  proportion  to  its  increase  in  size,  and  even  the  vessels  of  the 
part  become  engorged.  In  consequence  there  results  a  lobulated,  distorted,  most  dis- 
agreeable appearance,  which  often  becomes  exceedingly  offensive.  The  tumors  thus 
formed  sometimes  increase  to  a  size  sufficient  to  interfere  with  breathing  and  with 
feeding.  The  resulting  nasal  enlargement  is  usually  trilobed.  The  first  impetus  to 
the  overgrowth  comes  sometimes  from  such  cutaneous  irritation  as  frostbite,  or  local 
irritation  of  some  kind. 

Treatment. — The  treatment  of  rhin()j)hyma  consists  in  the  unrestricted  use  of  sci-ssors 
and  the  sharp  spoon,  with  the  preservation  of  .so  much  of  the  integumentary  structure 
as  may  serve  to  cover  the  reduced  dimension  of  the  nose.  These  lesions  will  bleed  freely 
at  first,  but  bleeding  is  usually  easily  checked.  When  a  plastic  covering  of  the  defect 
is  impossible,  the  surface  maybe  left  to  granulate,  with  a  certain  feeling  of  .security  that 
the  cicatricial  contraction  following  will  reduce  the  enlargement  to  normal  propor- 
tions. 

Xanthoma. — This  name  is  applied  to  a  macular  lesion,  papillary  or  tuberculous, 
marked  l)y  the  appearance  of  yellowish  spots,  occurring  singly  or  in  groups,  often  about 
the  eyelids,  but  seen  anywhere  upon  the  skin.  AVhen  occurring  in  papules  it  is  called 
xanfJtoma  planum;  when  in  nodules,  xanthoma  tuberosum.  There  is  a  variety  met  with 
in  dial)ett\s  which  is  temporary  and  usually  disappears  spontaneously. 

Treatment. — The  treatment  for  xanthomatous  jiatches  is  either  electrolysis  or  complete 
excision,  under  local  anesthesia. 

Keratosis. —  Keratosis  is  a  term  applied  to  thickening  of  the  normal  epidermis, 
occurring  in  limited  areas,  the  skin  being  transformed  into  tense  or  almost  horny  tissue. 
The  form  which  occurs  in  elderly  individuals  is  called  keratosis  senilis.  It  occurs 
upon  the  face,  the  hands,  and  forearms,  but  may  be  seen  on  any  part  of  the  body.  The 
involved  areas  become  discolored,  sometimes  by  true  pigmentation,  more  often  by  a 
deposit  of  dirt.  As  long  as  e])ithelial  reproduction  occurs  away  from  the  basement 
membrane  the  lesions  are  simj)le  and  innocent,  but  in  elderly  people  it  requires  but 
little  irritation  to  provoke  a  down-growth  of  epithelium,  and  then  the  development  of 
epithelioma  is  rapid. 

Treatment. — These  reduplicated  epithelial  elements  can  be  kept  soft  by  an  application 
of  equal  parts  of  glycerin  and  liquor  potassje.  After  being  softened  they  may  be  easily 
scraped  down  to  a  normal  level,  but  will  later  reform.  If  they  begin  to  ulcerate  they 
should  be  excised.  Should  excision  be  declined  the  area  may  be  treated  with  the  thermo- 
cautery or  with  one  of  the  caastic  pastes. 

Vascular  Growths. — These  have  already  been  mentioned  in  the  chapter  on  Tumors, 
unfler  the  head  of  Angioma.  So  far  as  the  skin  is  concerned  they  usually  occur  in 
the  shape  of  nevi  (called  strawberry  growths)  or  the  more  disseminated  form,  some- 
times involving  considerable  areas,  commonly  known  as  "port-wine  marks,"  which 
are  essentially  cutaneous  telangiectases,  are  almost  always  of  congenital  origin,  and 
frequently  appear  in  complete  form  even  at  birth.  They  may  occur  raj^idly  or  slowly. 
An  isolated  nevus  should  be  treated  by  complete  excision.  Large  vascular  areas,  or 
port-wine  marks,  are  best  treated  by  repeated  electrolysis.  If  treated  early  they  are 
sometimes  eradicated  by  the  local  use  of  sodium  ethylate. 

The  so-called  yiei^us  pigmentosus,  or  pigmented  mole,  is  generally  of  congenital  origin, 
and  may  or  may  not  be  accompanied  by  vascular  changes.  It  is  not  infreqtiently 
covered  with  hair,  and  sometimes  forms  a  patch  of  considerable  size,  often  upon  the 
face.  These  lesions  occasionally  occtir  in  such  form  as  to  entitle  them  to  be  styled 
nevus  verrucosus  or  nevus  pilosus.  Occurring  upon  the  back  or  trimk  they  are  usually 
disregarded.     When  upon  the  face  they  should  receive  surgical  treatment. 

Treatment. — Excision  is,  of  course,  the  best  method  of  treatment  unless  a  disfiguring 
scar  be  feared.  This  can  usually  be  prevented  by  proper  plastic  methods.  When  ex- 
cision seems  inadvisable  electrolysis  is  the  next  best  method  of  attack.  No  matter  how 
vascular  may  be  the  lesion  itself,  the  vessels  a  short  distance  from  the  margin  of  these 
growths  are  rarely  dilated,  and  hemorrhage  is  not  a  feature  which  need  deter  one  from 
radical  treatment. 


flYPERTROPIflES  A.\D  lihWKlN   TdMORS  OF   TIIK  SKIN  315 

Lymphangioma.  Tliis  lias  also  Ih-cm  (icscrihcd  ill  (lie  cliaitfcr  on  'riiiiiors.  A 
circiiinscrilu'd  loriii  is  occasionally  foiiii<l  in  or  IxMicatli  the  skin.  It  occurs  early  in 
life,  constitutes  a  more  or  less  sessile  tumor,  wliicli  collapses  on  pressure,  fills  slowly, 
its  surface  heinf;  often  irrej^ular,  warty,  or  horny.  Should  the  surface  he  injured  lymph 
will  escajK-  rather  than  blood.  An  extended  form  of  it  constitutes  one  kind  of  elephan- 
tiasis. (See  chapter  on  Lymphatics.)  Any  septic  infection  of  a  grow'th  of  this  character 
is  likely  to  result  .seriously  and  at  once. 

Treatment.— The  best  treatment  is  excision  iiiidcr  tlionmi^di  aseptic  precautions; 
next  to  this  is  deslructioii  with  the  caiilery,  which  will  Icail  to  resiiltiii(r  sloii^liiiio-  and 
cicatrization. 

Malignant  Disease.  .Ml  forms  of  cancer  may  a])pear,  primarily,  in  or  upon  the 
skill,  h'roni  the  ordinary  surface  epithelium  sprintjs  fpifhrliotita;  from  the  jrlandular 
elements  possibly  rouud-ccU  carcinoma;  and  from  the  mesodermic  elements  any  of  the 
radical  varieti(\s  of  .sarcoma,  while  endothelioma  is  less  common. 

Epithelioma. — This  is  a  frequent  infection  of  the  skin,  which  may  arise  primarily 
as  an  ori<,nnal  lesion,  usually  following];  surface  irritation,  or  secondarily,  either  as  the 
extension  of  similar  disease  from  other  parts  or  of  (le»;eneration  of  previously  innocent 
ej)ithelial  tumors.  K})ithelial  outi2;rowth,  so  long  as  it  he  an  oufgroirf/i,  and  do  not 
transii;ress  the  limits  of  the  hasemeiit  meml)rane,  is  essen- 
tially innocent  in  character;  hut  so  soon  as  growth  in  '  '  '"^ 
the  downward  direction  begins  we  have  the  beginning  of 
a  skin  cancer,  which  may  proceed  to  fatal  extent  if  not 
promptly  recognized  and  properly  treated.  These  growths 
vary  very  much  in  rapidity  and  malignancy.  Occurring 
upon  surfaces  which  are  kept  constantly  moist  and  warm 
they  develop  more  rapidly,  as  upon  the  tongue,  within  the 
vulva,  rectum,  etc.  The  slowest  form  of  growth  of  this 
kind  is  the  so-called  rodent  ulcer.  Epithelioma  which 
begins  in  or  upon  the  skin  or  mucous  membrane  tends 
to  spread  to  and  involve  everything  in  its  neighborhood; 
even  bone  and  cartilage  succumb  to  its  ravages,  and.  be-  Epithelioma. 
coming  involved,  lose  all   their  characteristics   and  melt 

away  in  the  surrounding  ulcer.  This  produces  in  the  course  of  time  hideous 
and  serious  developments.  No  tissue  is  exempt  from  its  ravages,  and  yet  life  may  be 
prolonged  for  many  years,  even  when  the  face  is  almost  entirely  eaten  away.  Epithe- 
lioma and  rodent  ulcer  have  been  described  in  the  c-hapter  on  Tumors. 

jMore  deeply  seated  carcinomas  of  the  skin  infiltrate  in  both  directions  alike,  and 
grow  downward,  sometimes  in  cylinder  form,  thus  giving  rise  to  a  clinical  type  called 
cijUndroma.  Lenticular  carcinoma  is  also  described  as  differing  from  the  ordinary 
epithelioma,  in  that  it  exhibits  a  true  alveolar  structure.  This  form  is  rare,  and  is  dis- 
tinguished from  the  common  form  by  the  absence  of  the  so-called  "pearly  bodies," 
which  characterize  common  epithelioma.  The  lenticular  form  is  most  often  seen  in 
recurring  cancer  of  the  breast,  or  in  the  vicinity  of  scars  showing  where  deep-seated 
cancer  had  existed. 

Diagnosis. — Ejiithelioma  in  its  various  forms  should  be  distinguished  from  skin  lesions 
due  to  syphilis  and  tuberculosis.  A  diagnostic  table  has  been  given  (see  p.  293)  by  which 
diagnosis  as  between  it  and  lujius  may  ordinarily  be  made.  The  lesions  of  syphilis  are 
usually  multiple  and  accompanied  by  other  manifestations  which  stamp  their  character. 
There  is,  moreover,  usually  a  history  which  will  be  suggestive  if  not  actually  helpful. 
In  cases  of  actual  doubt,  as  upon  the  tongue  and  elsewhere,  the  therapeutic  test  may 
be  applied.  If  resorted  to,  it  should  be  vigorously  made.  When  mercurial  inunction 
is  thoroughly  practised,  and  the  internal  administration  of  the  iodides  effects  no  im- 
provement within  three  weeks,  the  hypothesis  of  syphilis  may  be  abandoned. 

All  cancerous  lesions  tend  to  advance  and  to  destroy  in  spite  of  all  local  measures. 
There  never  appears  about  them  any  indication  of  a  tendency  toward  cicatrization,  and, 
while  the  edges  of  malignant  ulcers  may  be  thickened  and  everted,  the  more  central 
portions  are  always  excavated.  They  cause,  moreover,  involvement  of  the  adjoining 
lymphatics,  although  this  may  be  said  as  well  of  syphilitic  and  tuberculous  lesions. 

Treatment. — Concerning  the  treatment  of  epithelioma  and  other  malignant  skin  dis- 
eases there  is  little  to  be  said  which  has  not  already  been  summarized  in  the  general 


316  SURGICAL  AFFECTIONS  OF   THE   TISSUES 

considerations  concerning  the  treatment  of  cancer.  Radical  excision  of  the  original 
lesion,  in  its  early  stages,  will  usually  lead  to  final  recovery.  If  there  be  involvement  of 
the  lymphatics  the  indication  is  ma(le  thereby  more  jxjsitive  for  cleaning  out  all  infected 
areas,  while,  at  the  same  time,  the  prognosis  Is  rendered  le.ss  favorable.  There  comes 
a  time  in  the  history  of  all  these  cases  when  excision  can  be  recommended  only  as  a 
palliative  measure,  i.  e.,  when  it  may  be  regarded  as  useless.  In  the  more  hopeless 
cases  benefit  will  but  rarely  be  obtained  from  the  use  of  .r-rays,  ultraviolet  light,  or 
radium. 

Paget's  Disease. — Paget's  disease  includes  lesions  now  regarded  as  a  precancerous 
■■^tar/f,  which  appear  upon  the  breasts  and  around  the  nipples  of  women  during  the 
middle  decades  of  life.  Something  similar  is  .seen  in  other  parts  of  the  bodv  and  in 
both  .sexes,  but  it  is  most  common  around  the  nipple  on  one  side.  For  a  long  time  it 
appears  as  an  ordinary  eczema,  which,  however,  does  not  tend  to  heal  but  to  spread, 
while  the  skin  beneath  becomes  more  or  less  infiltrated.  A  gradual  retrocession  of  the 
nipple  is  usually  .seen.  Certain  discomfort  accompanies  the  lesion,  which  may  go  on 
indefinitely  until  it  becomes  unmistakably  cancerous.  This  is  a  precursor  not  so  much 
of  round-cell  cancer  (scirrhus)  as  of  epithelioma.  Eczema  of  the  nipple  if  to  be  regarded 
with  suspicion,  especially  when  occurring  after  the  menopause.  Until  diagnosis  is 
fairly  established  it  is  best  treated  with  soothing  applications.  So  soon  as  the  cancerous 
stage  has  been  determined  the  breast  should  be  removed.     (See  Plate  XXVI.) 

Other  forms  of  malignant  or  border-land  tumors  which  occur  upon  the  skin  are 
chimney-sweeper  s  cancer,  paraffin  cancer,  and  that  met  with  in  aniline  workers.  Chim- 
ney-sweejx^r's  cancer  was  the  name  ajjplied  to  epithelioma  of  the  scrotum  occurring 
among  a  class  of  laborers  whose  occupation  is  now  almost  entirely  extinct.  It  began 
usually  as  papilloma  and  merged  into  epithelioma.  Among  workers  in  paraffin  and 
coal-tar  factories  there  is  an  analogous  lesion,  the  result  of  surface  irritation,  the  skin 
becoming  dry,  thickened,  covered  with  acne-like  pustules,  and  then  with  papillomas 
which  ulcerate  and  frequently  change  over  into  true  epitheliomas. 

Sarcoma. — Only  the  outer  layers  of  the  skin  are  truly  epiblastic.  In  the  depths  of 
the  integument  mesoblastic  elements  enter  largely,  and  from  these  various  forms  of 
sarcoma  may  develop.  These  have  already  been  treated  in  the  chapter  on  Tumors. 
They  may  be  single  or  multiple,  and  a  general  disseminated  sarcomatosis  is  occasionally 
observed.  It  corresponds  to  miliary  tuberculosis,  but  presents  many  distinctive  lesions 
in  the  skin,  by  which  it  may  l>e  easily  recognized.  A  form  of  multiple  pigmented  sar- 
coma involving  the  hands  Is  represented  in  Fig.  109.  These  growths  are  almost  always 
tender  on  pressure  and  more  or  less  painful.  They  coalesce  and  finally  form  fatal 
lesions. 

Melanoma. — This  term  was  introduced  by  ^'irchow,  who  made  it  cover  all  pigmented 
growths.  By  common  consent  it  is  today  limited  to  tumors  of  the  skin  and  uveal  tract 
which  contain  pigment;  metastases  may  occur  in  any  or  all  of  them.  They  occur  as 
malignant  degenerations  of  nevi,  moles,  and  other  small  growths.  Pathologists  are 
still  disputing  as  to  whether  they  should  be  considered  sarcomas  or  endotheliomas. 
The  coloring  matter  which  they  contain  is  amorphous,  finely  granular  material,  lying 
between  the  cells  in  moles,  but  occurring  free  in  the  tissues  and  blood  and  even  in  the 
urine.  It  is  soluble  in  strong  alkalies,  from  which  it  can  be  recovered  as  melanic  acid, 
containing  a  small  proponion  of  sulphur.  Of  its  origin  nothing  is  positively  known. 
It  seems  to  be  generally  accepted  that  the  deposit  of  pigment  is  not  of  itself  a  causative 
agent  of  the  growth  of  the  tumor,  but  that  the  growth  of  cells  and  their  pigmentation 
are  coincident  processes.  Johnston  has  offered  much  evidence  lately  to  the  effect  that 
growths  from  nevi  are  really  of  endothelial  origin.  Hutchinson  has  described  melanotic 
whitlow.  (See  below,  the  Xails.) 

INIelanoma  is  a  pigmented  ulcerating  neoplasm,  which  posse.s.ses  at  first  only  a  local 
malignancy  like  that  of  rodent  ulcer;  the  more  it  assumes  the  endotheliomatous  tA-pe 
of  growth  the  more  it  tends  to  disseminate  and  to  prove  fatal. 

The  melanoma  arising  from  a  mole  or  nevus,  thus  known  as  melano-endothelioma, 
begins  to  increase  in  size  and  becomes  more  full,  as  well  as  to  assume  a  darker  tint. 
For  a  variable  time  it  is  a  single,  rather  firm,  gradually  growing,  flat  tumor,  rarely 
ulcerating,  but  sometimes  exuding  a  thin  dark  fluid.  Suddenly  there  apjx'ars  rapid 
local  spread  as  well  as  dissemination.  The  latter  may  l>e  first  noted  in  the  adjoining 
lymph  nodes.     Thus  numerous  secondary  tumors  may  be  felt  in  and  beneath  the  skin, 


.s7\7.v  M'ri:\i).\(;i:s,  iimu  .\\i>  .\.\n.s 


•M7 


at  first  colorless,  l)('coiiiiii<i;  more  or  less  rapidly  |)ii,niiciit('(l.  Metastasis  iiiav  take  place 
to  every  orpin  in  the  body,  l)Ut  usually  the  liver  and  luiifrs  -less  often  tJK-  hrain — are 
involved.  In  one  tase  known  to  tlu>  writer  tin-  heart  was  a  mass  of  nodules  of  this  same 
seeondarv  eharaeter. 

Another  expression  of  the  same  serious  eonthtion  is  seen  in  a  lesion  called  hv  the 
French  malif;nant  lenti<;o,  which  also  l)ef]rins  with  pifrmcnted  spots,  on  the  feet  (if  old 
men,  sometimes  upon  the  face.  These  lesions  catise  thickeninir  of  the  skin  and  earlv 
ulceration. 

Rodent  ulcer,  which  is  one  form  of  epithelioma,  occasioiuilly  assumes  the  melanotic 
type,  and  is  called  melano-ei)itheli(jma. 

Fi-;.  109      . 


Fibrosarcoma  of  hands.     (Hardaway.) 


The  most  marked  collection  of  pigment  in  the  human  body,  within  small  space,  is 
along  the  uveal  tract  within  the  eye,  and  orbital  melanomas  are  not  infrequent.  Begin- 
ning within  the  sclerotic  they  rapidly  perforate  this  dense  membrane  and  spread  to 
adjoining  tissues,  while  dissemination  and  metastasis  occur  early  and  rapidly. 

Treatment. — For  melanoma  there  is  but  one  successful  treatment,  and  this  is  successful 
only  when  practi.sed  early,  i.  e.,  complete  excision  or  destruction.  Every  mole,  nevus, 
or  other  skin  lesion  which  shows  the  slightest  tendency  to  changes  noted  above  should 
be  promptly  excised,  along  with  a  wide  area  of  its  surrounding  tissue.  It  maj/  be  thus 
possible  to  make  a  radical  cure.  Neither  .r-rays  nor  any  other  less  radical  method  of 
treatment  will  have  the  slightest  effect.  The  treatment  of  any  case  left  to  itself  until 
mistake  in  diagnosis  is  impossible  will  probably  be  of  little  avail. 


SKIN  APPENDAGES;  HAIR  AND  NAILS. 

The  only  lesions  of  the  hair  and  hair  follicles  that  concern  the  surgeon  are  those  which 
have  been  described  under  the  head  of  Syphilis  of  the  Skin,  or  some  of  the  congenital 


318  SURGICAL  AFFECTIONS  OF   THE   TISSUES 

growths,  such  as  plexiform  neuroma,  lymphangioma,  etc.,  whose  surfaces  arc  frequently 
pigmented  and  hairy,  and  may  call  for  excision,  along  with  the  undi-rlying  tumor. 

The  Nails. — Onychia  im|)lies  any  disturbance  of  the  nail  border  and  matrix.  Simple 
onychia  occurs  frequently  in  the  fingers  of  marasmic  children.  It  is  evidenced  by  soft- 
ening and  swelling  of  the  skin  around  the  nail,  by  more  or  less  pain,  disturbance  of  cir- 
culation beneath  the  nail,  which  becomes  finally  loosened,  sometimes  leaving  a  foul 
ulcer.  This  ulceration  may  extend  and  involve  nearly  the  whole  finger.  It  may  occur 
in  one  or  in  several  fingers.  Lesions  of  this  kind  are  regarded  as  local  infections,  occur- 
ring usually  in  vitiated  constitutions.  It  is  a  common  expression  or  comj)lication  of 
syphilis;  when  of  such  origin  it  yields  readily  to  treatment;  at  other  times  it  is  often  slow 
and  tedious.  Except  in  specific  cases,  where  mercurials  locally  and  internally  will 
usually  be  sufficient,  the  treatment  should  be  radical  and  should  consist  of  thorough 
exposure  of  the  ulcerating  and  fungous  surfaces,  thorough  curetting,  and  the  use  of 
suitable  caustics  and  antiseptic  dressings. 

Onychia  Maligna. — Onychia  maligna  implies,  according  to  some  writers,  a  more  dis- 
tinctive type  of  phlegmonous  lesion,  while  the  term  has  also  been  applied  to  malignant 
ulcers,  sometimes  pigmented  (see  Melanoma  above)  and  sometimes  of  more  ortlinary 
type.  In  either  type  of  lesion  granulation  tissue  may  be  exuberant  and  fungating, 
and  it  is  possible  that  at  times  there  will  be  doubt  in  diagnosis.  The  finger-tips,  with 
their  peculiar  tactile  sensibility,  should  never  be  sacrificed  imnecessarily,  yet  any  malig- 
nant lesion  calls  for  amputation  of  the  finger. 

Ingrowing  Toenail. — This  is  due  almost  invariably  to  ill-fitting  footwear,  the  toes 
being  crowded  into  too  narrow  shoes,  with  too  high  heels.  The  real  lesion  is  not  so 
much  an  excessive  growth  of  the  nail  as  overgrowth  and  overriding  of  the  skin  margin 
around  the  matrix.  It  is  painful  and  annoying,  sometimes  even  disabling.  The  macera- 
tion of  a  perspiring  foot  in  a  warm  and  tight  shoe  serves  to  aggravate  the  difficulty. 
Palliative  treatment  is  afl"orded  by  chiropodists  and  quacks,  who  pack  cotton  beneath 
the  etlge  of  the  nail  and  keep  patients  under  treatment  for  indefinite  periods,  never 
remedying  the  footwear  and  never  curing  the  case.  In  sim})le  cases  it  is  usually  sufficient 
to  excise  a  portion  of  reasonably  healthy  skin  on  either  side  of  the  terminal  ])halan.x, 
in  order  that  by  cicatricial  contraction  the  skin  may  be  drawn  away  from  the  nail  border. 
Serious  and  long-standing  cases  are  best  treated  by  avulsion  of  the  nail,  which  may 
be  usually  performed  under  local  anesthesia  or  by  the  aitl  of  nitrous  oxide  gas.  The 
blade  of  a  knife  or  scissors  is  driven  under  the  centre  of  the  nail  sufficiently  to 
ensure  its  passing  completely  beneath  the  hidden  matrix.  The  nail  is  then  split  in  the 
middle,  each  half  seized  at  its  split  border  by  strong  forcejys,  and  by  a  rapid  movement 
torn  loose  from  its  bed.  The  border  of  the  skin  should  be  scraped,  after  which  a  simple 
dressing  suffices,  providing  the  operation  has  been  performed  with  proper  antiseptic 
precautions. 

TATTOO  MARKS. 

Many  an  individual  is  tattooed  in  youth  who  would  gladly  be  relieved  of  the  discolora- 
tion later  in  life.  Tattoo  marks  are  difficult  to  erase.  The  following  is  a  method  at- 
tributed to  Ohmann-Dumesnil :  "Wash  the  skin  with  soap  and  water,  then  with  eight 
or  ten  fine  cambric  needles,  tied  together  and  dipped  in  glycerole  of  papoid,  tattoo 
the  stained  skin,  driving  the  needles  into  the  tissues  so  as  to  deposit  the  digestive 
in  the  corium,  where  the  carbon  is  located.  Repeat  as  necessary.  The  pigment  is 
liberated  by  the  digestant." 


CHAPTER    XXVIII. 

SURGICAL  DISEASES  OF  THE  FASCIJ^;  APONEUROSES;  TENDONS  AND 
TENDON  SHEATHS;  MUSCLES  AND  BURSy?^:. 

Fasci.k  ;ui(1  ;ij)()iUMir(),sos  are  sucli  iion-vasciilar  and  iiKliU'civiit  tissues  that  they  have 
practically  no  primary  diseases,  excej)t  such  (ihrous  and  nialij^nant  tumors  as  have  their 
origin  in  tiiem;  nevertheless  they  sufi'cr  in  a  variety  of  morbid  processes.  They  lose 
vitality  and  break  down  under  the  influence  of  both  acute  and  chronic  septic  infections. 
By  virtue  of  their  resistant  structure,  when  they  slough  they  break  down  slowly  and  the 
process  ends  usually  with  the  help  of  scissors  and  forceps.  Many  an  old  suj)purating 
lesion,  especially  of  the  hand  and  foot,  is  kept  active  by  the  fact  that  dense,  fibrous  tissue 
remains  concealed,  which  ought  to  have  separated.  Under  the.se  circumstances  free 
incisions  should  be  made  and  all  necrotic  tissue  trimmed  away. 

Pus  which  has  formed  ben(>ath  these  fibrous  investments  will  give  pain  largely  in  |)ro- 
jK)rtion  to  the  intensity  of  the  })roce.ss  and  the  unyielding  character  of  the  fascia';  hence 
the  urgency  of  early  incision  in  case  of  deep  phlegmon.  ISIoreover,  the  direction  of 
least  resistance  may  cause  pus  when  confined  to  travel  where  its  presence  is  most  unde- 
sirable, as  from  the  neck  beneath  the  deeper  muscle  planes  down  into  the  thorax. 
When  ])us  escapes  from  beneath  firm  tissue  it  is  usually  by  a  small  opening,  after  which 
it  may  spread  out  again  beneath  the  skin  before  finally  escaping.  This  condition 
has  l)een  called  "  collar-bidfon  ab.sce.ss."  Care  should  be  exercised  in  opening  the  super- 
ficial collection  not  to  miss  the  small  opening.  The  fascia  must  be  split  sufficiently 
to  permit  of  thorough  cleaning  out  of  whatever  collection  there  may  be  beneath  it. 

In  the  presence  of  cicatricial  contraction  of  the  skin,  in  shortening  of  muscles  by 
chronic  spasm,  as  in  wryneck,  or  in  certain  deformities — for  instance  of  the  foot — 
numerous  signs  of  a  shortening  or  contraction  of  fascia?  and  aponeuroses  are  seen.  In 
many  instances  of  club-foot  it  thus  becomes  necessary  not  merely  to  divide  tendons 
but  to  make  extensive  incisions  through  the  plantar  aponeurosis  or  elsewhere,  in  order 
to  release  sufficiently  the  parts  whose  extension  is  desired.  Underneath  the  joint  con- 
tractures which  have  been  produced  by  burns  and  their  resulting  scars  similar  conditions 
will  be  found,  which  in  old  and  extensive  cases  constitute  bridles  of  dense  tissue  that 
make  it  almost  impossible  to  release  the  parts. 


DUPUYTREN'S  CONTRACTION. 

Dupuytren's  contraction  presents  the  most  .serious  and  insidious  appearance  of  .slow 
but  almost  irresistible  contraction  of  fibrous  elements  which  the  human  body  presents. 
It  is  produced  by  contraction  of  the  palmar  fascia,  with  its  numerous  minute  prolonga- 
tions, rather  than  by  flexor  tendons.  It  is  seen  in  the  hands  of  men  who  from  the 
nature  of  their  occupations  are  subject  to  much  irritation  of  the  palmar  surface.  It 
begins  nearly  always  in  the  fourth  or  fifth  fingers,  but  may  spread  to  and  involve  all 
the  digits  and  even  the  thumb.  The  view  held  by  Adams  and  others  that  it  is  a  chronic 
hyperplastic  inflammation,  with  scar-tissue  contraction  of  the  palmar  fascia  and  of  the 
adjoining  connective  and  fatty  tissue,  which  does  not  involve  them  evenly,  but  only  at 
certain  points,  is  correct,  at  least  when  small  nodules  may  be  felt  in  the  palm  which  are 
the  precursors  of  the  disease.  Either  hand  may  be  affected,  but  generally  both  are 
involved.  It  is  found  in  from  1  to  2  per  cent,  of  tho.se  who  depend  upon  their  hands  for 
their  support.  Deformity  may  proceed  to  pressure  dislocation  and  finally  to  ankylosis. 
Its  causation  then  is  very  obscure;  it  is  rarely  the  result  of  definite  injury,  but  follows 
continued  irritation  of  the  surface.  It  seems  to  have  a  local  origin,  and  yet  it  is  fre- 
quently associated  with  the  gouty  diathesis  to  such  an  extent  that  the  prolonged  use  of 
alkalies  will  relieve  some  cases.     The  first  significant  sign  of  the  condition  is  the  forma- 

(319) 


320 


SURGICAL    AFFECT  loss  OF   TJIF   TISSUES 


tiori  of  small  rKxIules  in  the  palm  of  the  hand,  aa  stated,  and  thLs  usually  precedes  the 
finder  contraction  by  a  year  or  two. 

Treatment. ^There  is  considerable  difficulty  in  treating  these  ca.ses  satisfactorily. 
Coo{>cr  advix-d  subcutaneous  division  of  the  tense  bands  and  forcible  stretching  of  the 
fingers;  this  rarely  proves  sufficient.  Adams  advocated  multiple  sections  made  with 
a  small  tenotome,  which  is  more  effective.  The  best  method  is  that  of  Kocher,  which 
consists  in  e.xcision  of  the  fascial  bands  by  longitudinal  incisions  along  the  cords,  and 
the  dissection  of  the   skin    from   the  underlying  fascia.     The  cord   Ls   carefully   dis- 

FiG.  110  Fig.  Ill 


Dnpuytren's  contraction.    (Adams.) 


Dupnvtren's  contraction  of  palmar  fascia,  showing 
contracted  fingers.    (Burrell.; 


sected,  with  its  prolongations  and  then  completely  removed,  while  the  margins  of  the 
skm  wounds  are  clo.sed  with  sutures.  The  more  thoroughlv  the  dissection  is  i>erformed 
the  more  satisfactory  the  result.  The  fingers  should  be  "straightened  and  kept  from 
contraction  by  the  u.se  of  a  mechanical  device.  In  desperate  cases  the  entire  skin  of 
the  palm  has  Fjeen  removed,  with  the  diseased  fascia,  and  a  plastic  operation  made  with 
skm  taken  from  the  thigh  or  the  chest,  the  flap  being  sutured  in  place  but  not  detached 
completely  for  ten  to  twelve  davs. 

Two  somewhat  allied  conditions  involving  the  hand  and  the  foot  are  the  so-called 
lock  or  trigger-finger  and  hammer-toe. 


LOCK  OR  TRIGGER-FINGER. 

Lock  or  trigger-finger  implies  a  peculiar  obstruction  to  free  movement  of  the  finger, 
which  requires  e.vtra  effort  and  then  is  overcome  quickly,  as  if  a  knot  had  been  slipped 
through  a  small  opening.  It  is  supposed  to  be  due  to  a  thickening  of  the  tendon  at  .some 
point,  as  by  a  small  fibroma,  which  l)ecomes  entangled  along  the  course  of  the  sheath, 
through  which  it  is  moved  with  rlifficulty.  It  is  probably  due  to  a  local  irritation,  as 
in  the  case  of  Dupu^-tren's  contraction.  Injury-  to  the  tendon  sheath  may  also  produce 
a  -imilar  ronriition. 

Treatment.— Should  it  fail  to  respond  to  rest  and  massage  the  sheath  should  be 
opened  and  the  cau.se  of  the  difficulty  .sought  out  and  removed. 


TllSDOSYSO  I  ITIS  321 


HAMMER-TOE. 

HaiiHinT-toc  produces  (Icroriiiity  witli  iiioic  or  less  ankylosis.  An  aiifflc  is  fornu-d 
iH'twcrn  the  first  ami  socond  |)liaian<rcs,  and  tin-  ti|)  of  (he  toe  is  made  to  bear  more  than 
its  ])ro|)ortion  of  weiirJit.  This  deiormit y  is  in  large  degree  due  to  the  use  of  shoes  which 
are  too  short.  In  conse(|uence  there  will  develop  over  the  protruding  joint  a  corn  or 
bunion. 

Treatment. — Should  tlic  trouble  come  on  in  childhood  the  toes  should  be  fastened 
to  a  straight  splint  and  shoes  for  a  time  abandoned,  while  later  they  should  be  properly 
adapted  to  the  needs  of  the  case.  In  troublesome  eases  complete  excision  of  the  involved 
joint  gives  satisfaetory  results. 


SURGICAL  DISEASES  OF  THE  TENDONS  AND  TENDON  SHEATHS. 

TENDOSYNOVITIS. 

Acute  inflammation  of  a  tendon  sheath  i.s  known  as  tendovaginitis  or  tendosynovitis. 
It  always  implies  an  infeetion,  and  occurs  about  the  hands  and  feet.  It  is  a  frequent 
complication  of  felons.  Many  felons  begin  in  such  a  manner  that  it  is  difficult  to  decide 
which  part  of  the  fibrous  structiu'cs  of  the  finger  is  first  involved.    Infection  having  once 

Fig.   112 


Cicatricial  contraction  and  deformity  resulting  from  consequences  of  neglected   i.hlegiuon  and 
osteomyelitis  of  hand.    (Lexer.) 

occurred  within  a  tendon  sheath  will  travel  rai)idly  until  it  ineets  with  a  natural  barrier. 
The  frequency  of  these  lesions  makes  it  important  to  recall  here  the  anatomy  of  the 
tendon  sheaths  of  the  hand.  There  is  a  common  palmar  tendon  cavity,  which  connects 
with  the  thumb  and  little  finger  and  the  space  above  the  annular  ligament,  but  communi- 
cation with  the  first,  second,  and  third  fingers  is  ordinarily  destroyed.  This  accounts 
for  the  apparent  vagaries  of  cases  where  infection  beginning  in  the  thumb  spreads  to 
the  little  finger  before  the  others  are  involved.  It  will  also  show^  the  location  where 
incisions   should   be   made. 

Suppurative  Tendosynovitis.— Suppurative  tendosynovitis  needs  prompt  interven- 
tion, as  adhesions  may  result  from  retention  of  exudate,  or  lest  necrosis  of  tendon 
occur  from  perversion  of  its  nutritive  supply.  Ordinarily  it  is  the  result  of  a  local  in- 
fection, perhaps  through  a  small,  trifling  surface  irritation,  but  it  results  occasionally 
as  a  metastatic  expression  of  gonorrhea,  or  distinct  septic  infection.  A  gonorrheal 
tend(jsynovitis  is,  however,  less  likely  to  su])purate,  but  more  likely  to  assume  the  plastic 
form  and  interfere  with  function  by  producing  adhesions  between  a  tendon  and  its 
sheath.  The  combination  of  virulent  bacteria  and  susceptible  tissues  will  produce  local 
destruction  in  almost  as  short  a  time  as  in  the  appendix.  The  pain  is  intense,  because 
of  the  inelasticity  of  the  structures. 

Treatment. — Every  appearance  of  this  kind  calls  for  early  incision,  by  which  not  only 

the  skin  but  the  tendon  sheath  as  well  should  be  freely  incised.     An  incision  at  either 

end  of  the  involved  sheath,  with  flushing  and  drainage,  may  save  a  tendon  and  preserve 

function.     Incision  should   not   be   delayed,  as   destruction   may  have   occurred  and 

21 


322 


SURGICAL   AFFECTIOXS  OF   THE   TISSUES 


Fig.   113 


deformity  }>e  the  result.  When  the  eommon  palmar  sheath  is  involved  a  lon^  incision 
from  the  base  of  the  index  fincjer,  around  the  base  of  the  thuml)  and  up  the  wrist  to  a 
point  considerably  above  the  annular  ligament,  will  afford  considerable  relief.  It  will, 
moreover,  shoncn  the  time  of  ultimate  restoration  of  function. 

Chronic  Tendosjniovitis. — Chronic  tendosynovitis  may  be  the  result  of  rheumati.sm, 
in  which  case  it  assumes  the  plastic  form,  or  of  g(morrhea ;  the  same  being  true  of  a  tuber- 
culous invasion,  which  may  vary  much  in  intensity.  In  the  subacute  forms  the  depo- 
sition of  tubercles  may  lead  to  a  plastic  outpour 
which,  being  detached  by  constant  motion  of  the 
parts,  Ls  broken  into  ma.sses  whose  minute  portions 
become  rounded  off  by  friction  and  condensed  by 
time,  and  appear  as  the  so-called  "melon-seed  or 
rice-grain  bodies."  Some  of  the  i?ame  material 
may  be  found  adherent  to  the  walls  of  such  a 
cavity.  In  slower  forms  there  is  less  tendency  to 
plastic  outp>our,  but  much  more  to  the  formation 
of  granulation  tissue,  such  as  is  seen  in  tulx'rculons 
lesions  in  all  parts  of  the  body.  When,  therefore, 
a  case  of  this  general  character  presents  we  have 
the  signs  of  local  tuberculosis,  or  of  dropsy  of  the 
tenflon  sheaths,  with  the  fluctuation  somewhat 
modified  by  the  presence  in  the  fluid  of  rice-grain 
or  melon-seed  bodies.  Should,  in  such  a  case,  an 
acute  infection  be  added  we  will  have  the  chronic 
symptoms  merged  suddenly  into  acute.  A  ten- 
dovaginitis of  this  type  appears  as  a  ridge  or 
swelling  along  the  course  of  one  or  more  tendons. 
It  will  be  elastic  and  fluctuate  in  proportion  to 
the  distention  of  the  sheath.  When  the  palmar 
bursa  is  involved  there  is  usually,  in  the  palm  of 
the  hand,  a  bag  of  fluid  which  may  be  forced 
above  the  wrist  by  pressure,  while  frequently  the 
little  bodies  above  described  are  recognizable  by  the  sensations  (crepitas)  which*  they 
prodiice.  The  plastic  t}-pe  rarely  proceeds  to  suppuration  or  ulceration  unless  second- 
arily infected.     The  granulation  type  proceeds  to  ulceration  and  destruction. 

Treatment. — Treatment  of  the  rheumatic  and  gonorrheal  forms  is  at  first  rest,  wiih 
later  passive  and  forced  motion,  in  order  to  break  up  adhesions  and  prevent  tiieir 
re-formation.  If  one  wait  too  long  he  meets  with  great  difficulty  in  these  efforts  anrl  thr 
cases  become  e.xceedingly  tedious.  Forcible  motion  should  be' practised  under  nitrous 
oxide  anesthesia  and  should  be  repeated  every  two  or  three  days.  ^Meanwhile  massage 
should  be  employed.  If  pain  or  reaction  be  extreme  ice<-old  applications  should  be 
applied.  Extreme  swelling  may  be  combated  by  the  use  of  a  rubber  glove.  If  this 
be  worn,  ichthyol-mercurial  ointment  should  be  u.sed  beneath  it.,  in  order  to  promote 
absorption. 

Treatment  of  the  tuberculous  cases  is  often  disappointing.  Xon-operative  measures 
afford  but  temporary  benefit,  while  operation  to  be  effective  should  be  thorough.  It 
should  consist  of  free  incision,  with  exposure  in  whole  or  in  part  of  the  affected  channel 
or  cavity,  thorough  cleaning  out  of  its  contents,  removal  of  all  edematous  or  tuberculous 
tissue  or  granulations,  and  the  u.se  of  an  antiseptic  as  strong  as  it  can  be  emploved. 

The  now  op.ionir  serum  treatment,  now  being  placed  on  trial  as  this  work  goes  to 
press,  promises  much  in  the  treatment  of  all  these  septic  affections,  though  detailed 
statements  would  be  premature. 


Suppurative  tendosynovitis  (felon"),  with 
sloughiug  tendons  and  necrotic  bone.  Unfor- 
tunately poulticed  for  two  weeks.     (Lexer. ) 


TENDOPLASTY. 


It  was  a  step  in  advance  in  surgical  technique  when  Stromeyer  and  Dieffenbach, 
in  1842,  introduced  the  method  of  subcutaneous  division  of  tendons  and  aponeuroses, 
and  showed  how  easily  contracted  tendons  could  be  lengthened  by  tenotomv.  From 
their   time    until   somewhat  recently  tenotomy  has  held  its  place  in  the  treatment  of 


TKNDOPLASTY 


323 


Fig.  114 


Fio.   115 


Fig.  116 


Fig.   117 


Fig.  118 


// 


// 


Fig.  119 


Fig.   120 


Fig.  121 


i 


Illustrating  various  methods  of  dealing  with  tendons  in  tendoplasty.    (After  Vulpius.) 


324 


SlRdlCM.   AFFKCTIOSS  OF   THE   TISSCFS 


various  (Icfoiiuitirs,  and  until  Auffor,  (Jluck,  Ilott'a,  and  others  liave  taught  the  surgical 
profession  what  can  he  don(>  hy  various  plastic  and  suture  methods  in  overcoming 
defects  and  atoning  for  loss  of  function  in  paralyzed  muscles.  To  the  surgery  of  tendons 
and  muscle  terminations  have  been  added  the  further  resources  of  tendon  suture,  i.  e., 
tenorrliaplii/,  and  fcndopla.s-fi/,  by  which  latter  something  more  than  the  mere  suture  is 
meant,  /.  c,  the  plastic  rearrangement  and  grafting  of  tendons  one  upon  another.* 

Tendon  .suture  is  practised  as  an  v-mergency  measure  when  one  or  more  tendons  has 
been  accidentally  divided,  this  being  considered  now  as  much  a  j)art  of  the  surgeon's  duty 
as  to  close  any  other  ])art  of  the  wound.  No  additional  resource  or  expedient  is  needed, 
it  being  necessary  only  to  observe  the  ])rinci])les  of  ase])sis,  which  should  be  maintained 
in  every  case.  A  tendon  raggedly  divided  should  be  cleanly  cut  and  its  edges  brought 
together  with  formalin-gut  or  freshly  boiled  silk.  A  series  of  divided  tendons  should 
he  treateil  after  the  same  fashion,  matching  the  ends  as  closely  and  completely  as  possible. 
After  uniting  the  tendon  ends,  if  the  case  be  clean,  the  tendon  sheath  should  be  closed 
and  the  ])arts  put  at  rest,  in  such  a  position  that  no  tension  is  made  upon  the  injured 
sinew  until  it  is  seen  to  have  united. 

It  was  a  great  service,  in  which  |)erhaps  Gluck  figured  most  conspicuously,  to  show 
that  when  tendon  ends  could  not  be  neatly  coapted  an  animal  material  could  be  inter- 
posed in  such  a  way  as  to  serve  as  a  trellis  along  wliich  cells  could  group,  or  around  which 


Fig.  122 


Fig.  123 


■C^ 


l\ 


Shortening  a  tendon. 


they  might  organize,  and  thus  gradually  and  finally  become  a  part  of  the  complete 
tendinous  cord.  Silk  and  catgut  have  best  served  this  purpose,  and  new  tendons  have 
gradually  formed  around  these  artificial  substitutes,  to  the  length  of  10  Cm.  In  every 
fresh  case  where  there  has  been  such  loss  of  original  structure  as  to  justify  a  measure  of 
this  kind,  or  in  certain  old  cases  where  tendons  have  long  since  sloughed  away,  it  may 
be  possible  to  resort  to  these  expedients. 

It  has  been  possible  tt)  trau.splnnt  fresh  tendons  from  the  smaller  animals  and  to  see 
them  serve  the  same  purpose  in  a  satisfactory  manner. 

Among  these  methods  of  tendo])lasty  is  tendon  grafting,  by  which  a  part  or  all  of 
the  tendon  of  an  active  muscle  is  inserted  into  the  terminal  j)ortion  of  a  paralyzed  muscle 
and  thus  made  to  assume  to  a  greater  or  less  extent  the  purjiose  and  function  of  the 
latter;  in  other  words  it  assists  in  ingeniously  diverting  the  activity  and  direction  of  a 
given  muscle  to  a  purpose  different  from  its  original  intent.  By  this  diversion  a  more 
equal  or  equable  distribution  of  muscle  force  is  attorded  the  ])arts  into  which  the  affected 
muscles  are  inserted.  For  its  successful  performance  only  those  muscles  which  are  still 
active  can  be  utilized.     Among  the  simplest  of  cases  where  this  expedient  can  be  used 


'  The  method  of  transplanting  one  tendon  upon  another  is  to  be  credited  to  Nicoladoni,  who  perfected  it  in 
1882.     Later  it  fell  into  disuse,  but  was  revived  in  this  country,  especially  by  Goldthwait,  of  Boston,  in  1896. 


TENDOPLASTY 


325 


ar«'  (liosf  produced  \)\  (rauinatic  and  ix'riphcral  paralyses,  or  traumatic  loss  oi"  a  j^ivcn 
teiulon  or  a  set  of  tciidous.  It  is  rarely  to  he  |)ractised  us  au  einert^eucy  measure,  but 
as  au  expedient  to  be  availed  of  later.  It  finds  its  <);rea(est  usefulness  in  eases  of  long 
standing.  It  is  e(puilly  apj)lieable  where  muscles  and  tendons  have  been  divided  by 
injury,  or  j)aralyz;ed  by  injury  to  their  nerve  supply,  as  well  as  where  deformities 
arc  produced  by  chronic  neurotic  disturbance,  by  scars,  by  excessive  callus,  etc.  It 
proves  e(|ually  serviceable  in  paralyses  of  sj)inal  origin,  particularly  those  due  to  anterior 
poliomyelitis. 

'I'cndon  grafting  will  serve  both  as  a  substitute  in  cases  of  lost  function  and  as  a  pro- 
vision against  future  deformity.  In  cases  of  the  ordinary  ])aralyses  of  children,  tendo- 
piasty  should  be  deferred  for  several  months  after  the  occurrence  of  the  paralysis.  In 
the  ease  of  growing  children  it  is  desirable  not  to  wait  too  long,  as  other  objectionable 
features  may  present  themselves.  In  the  congenital  and  hereditary  paralyses  and  in 
conditions  like  athetosis  or  the  dystrophies  of  syringomyelia,  meningocele,  etc.,  also 
in  such  conditions  as  habitual  dislocations  of  the  patella,  much  can  be  accomplished 
by  a  carefully  planned  tendoplasty.  It  will  be  easily  seen  then  how  wide  a  field  of  use- 
fulness lies  before  one  who  familiarizes  himself  with  the  recent  technique  of  tendon 
surgery. 

Fig.  124 


Fig.  125 


Two  methods  of  tendon  implantation  and  fixation.    (After  Vulpius.) 
Fig.   126  Fio.   127  Fig.  128 


B/AL  AWT 


TIBIAL  ANT. 


Transplantation  of  a  portion  of  the  anterior  tibial  tendon,  into  the  bone  or  into  the  opposed  group 

of  muscles.    (After  Vulpius.) 


So  far  as  technical  considerations  are  concerned  these  operations  should  be  performed 
only  with  the  minutest  attention  to  asepsis.  When  this  has  been  secured  a  permanent 
dressing  may  be  applied,  the  limb  being  left  in  the  position  most  desired,  and  maintained 
there  for  several  weeks.  F'or  this  plaster  of  Paris  makes  the  best  support.  The  use 
of  the  rubber  bandage  will  permit  the  operation  to  be  l)loodlessly  made,  by  which  it  is 
greatly  facilitated.     If  careful  suturing  be  practised,  there  will  be  but  little  tendency  to 


326  SURGICAL  AFFECTIONS  OF  THE  TISSUES 

subsequent  oozin^  or  interference  with  repair.  Fine  (liseriniiiiation  is  always  needed 
in  the  matter  ot"  adjusting:;  tlie  len<fth  of  tendon  ends  and  the  point  of  their  fixation.  A 
useless  tendon  which  has  been  long  stretched  over  a  curved  joint  will  have  become 
elonirated,  and  the  tendon  to  be  appled  to  it  should  be  affixed  farther  down  than  would 
be  otherwise  necessary.  The  disposition  of  the  upper  j)ortion  of  the  useless  tendon 
and  muscle  may  also  call  for  serious  attention.  It  is  rarely  necessary  to  extirpate  them. 
They  are  already  atrophied,  and  to  remove  them  would  be  to  still  further  reduce  the 
dimensions  of  the  part.  The  excluded  portions  can  thus  be  simply  discarded.  When 
there  has  been  deformity  with  more  or  less  pseudo-ankylosis  the  malposition  should  be 
forcibly  redressed  and  the  tendon  grafting  deferred  until  a  subsequent  time;  the  latter, 
to  be  successful,  should  be  performed  alone. 

Incisions  are  usually  made  along  and  over  the  course  of  the  tendons  to  be  exposed, 
but  not  so  close  that  the  cutaneous  scar  can  interfere  with  the  tendon  sheath.  The 
lower  end  of  a  paralyzed  muscle  will  appear  very  dift'erently  from  that  of  one  which 
is  healthy;  in  the  former  instance  the  tissue  w^ill  have  lost  its  muscular  character,  and 
will  be  yellowish  white  and  fatty.  A  fascia  which  has  been  stretched  out  of  sha]:)e  may 
be  sutured  in  folds  and  will  serve  of  itself  to  give  support  and  shape  to  the  part  which 
is  renewed. 

The  methods  of  uniting  tendons  are  so  numerous  that  they  can  be  better  estimated 
by  a  glance  at  the  accompanying  diagrams   after  Vulpius   than  by  description   (Figs. 

124  to   128).     It  is   not  necessary  to  utilize 
^'"-  ^'■^^ ^  all  of  the  tendon  of  a  healthy  muscle,  as  it 

can  be    split   and  a    portion  diverted  to  its 

~— ~— — ^—  new  function.     It  is  not  to  be  expected  that 

1.1  tendons  thus  arranged  will   perfectly  serve 

their  purpose   the  first  time  they  are  used. 

There   must  elapse  a  period    of  education 
of  the  nerves  and  muscles  whose  relations 

are  thus   altered,  and   improvement  in  the 
I use  of  the  parts   thus  operated  will  ac-crue 

for  months  and  even  years.     It  is  desirable 

that  tendon   surfaces  th.us   a})plied  to   each 

other    be    made    broad     and    extensive    in 
^_____^  order    that  their    adhesion    may    be    more 

1 _^^  firm. 

■  v      ••  A   modification  of   tendon  grafting   con- 

Showing  methods  of  lengthening  tendons.  (BurreU.)     sists    in    implanting    the    tendon   end   into 

the  periosteum  instead  of  into  some  other 
tendon.  There  are  various  ways  of  making  this  implantation,  either  by  sim])le  suture 
or  by  boring  into  the  bone  or  canalizing  under  a  periosteal  bridge.  Fig.  120  illustrates 
how  the  tend(m  of  the  tibialis  anticus  can  be  utilized  in  b(jth  ways.  It  will  thus  be  seen 
that  a  tendon  can  be  given  either  tendinous,  periosteal,  or  osteal  im{)lantation.  Ten- 
dons thus  utilized  rarely  undergo  necrosis  or  degeneration.  So  long  as  the  possibility 
of  infection  be  excluded  almost  anything  can  be  done  with  these  structures,  in  sj)ite  of 
their  apparent  lack  of  vascularity  and  vitality. 

There  are  times  when  it  is  necessary  to  lengtJien  a  tendon  as  well  as  to  shorten  it. 
Fig.  129  illustrates  methods  by  which  both  of  these  measures  can  be  performed.  Analo- 
gous methods  have  been  practised  with  muscles  themselves,  although  here  the  circum- 
stances are  different  and  nothing  similar  can  be  accomplished.  Portions  of  the  pecto- 
ralis  major  have  been  grafted  into  the  biceps  for  paralysis  of  the  latter. 

Liberating  the  ring  finger  in  tmmcian.s,  by  dividing  the  accessory  tendons  of  the 
extensor  communis  digitorum,  is  an  expedient  suggested  some  years  ago  by  Brinton. 
It  is  made  by  an  incision  less  than  a  cjuarter  of  an  inch  long,  through  the  skin  and  fascia, 
just  below  the  carpal  articulation  of  the  metacarjial  bone  of  the  ring  finger,  and  above 
the  radial  accessory  slij),  ])arallel  with  and  on  the  radial  aspect  of  the  extensor  tendon  of 
that  finger.  The  point  of  a  narrow  blunt-pointed  bistoury  is  then  inserted  flatwise 
beneath  the  accessory  slip  down  to  a  point  just  in  front  of  the  knuckles  of  the  ring  and 
middle  fingers,  where  the  blunt  point  should  be  felt  beneath  the  skin.  The  bistoury  is 
now  turned  upward,  the  middle  finger  strongly  flexed,  and  the  ring  finger  extended  so  as 
to  make  the  slip  tense  when  it  is  divided.      The  accessory  slip  on  the  other  side  of  the 


GANGLION  327 

extensor  tendon  is  similarly  ilixidctl  llii'onj:;li  a  distinct  incision.  Sniijf  compression  is 
made  with  a  haiidajic  over  tlie  wounds,  with  the  thumb  free,  and  alter  two  <hiys  the 
paliiMit  is  permitted  to  use  the  lingers  in  j)iano-[)laying  in  order  to  prevent  reunion  of 
cut  snrlaces. 

MYOTOMY    AND    TENOTOMY. 

Myotomy  is  a  measure  sehlom  practise(L  It  is  |)erformed  either  sul)cutaneously  or 
by  open  incision.  Tcnotomi)  is  iiuHcated  whenever  contracted  tendons  need  simj)ly  to 
be  divided,  either  in  elironie  orthope(Uc  eases  or  after  injuries  or  o])erations  wlien  it  is 
desired  to  put  museles  temporarily  at  rest.  The  tenth)  Achillis  has  thus  been  divided 
to  prevent  the  consequences  of  muscle  spasm  when  dealing  with  certain  fractures, 
es()ecially  compound  fractures  of  the  leg.  There  are  obvious  advantages  obtaining  in 
subcutaneous  tenotomy  when  pro])erly  j)erformed ;  the  freedom  from  hemorrhage, 
the  minuteness  of  the  opening,  the  ra|)idity  of  healing,  are  all  in  its  favor.  It  is  ])er 
formed  with  a  small-l)ladc(l  knife,  known  as  the  tenotome,  with  either  sharp  or  bltmt 
j)oint,  tlu>  cutting  portion  being  froin  1  to  2  Cm.  in  length.  The  sliarp-j)ointed  tenotome 
suffices  for  its  own  insertion,  the  l)lunt  one  being  used  after  an  opening  has  Ijcen  made 
with  a  sharp  one.  The  puncture  is  made  obliquely  through  the  skin,  which  should  be 
drawn  a  little  aside  from  the  site  of  the  deeper  opening  in  order  that  it  may  be  hermeti 
cally  closed  as  it  slips  back  into  place.  Whether  the  cutting  blade  should  be  turned 
outward  or  inward  will  depend  largely  on  the  preference  of  the  operator  and  the  location 
of  the  tendon.  In  some  locations,  as  about  the  hamstring  tendons,  the  puncture  should 
be  made  with  the  sharp  instrument  and  the  deeper  tenotomy  with  the  blunt  one.  If 
the  tendons  alone  have  been  divided  there  will  be  trifling  hemorrhage  and  the  puncture 
can  be  occluded  without  entrance  of  air.  Similarly  an  aponeuwiomi)  may  be  |)erformed. 
Not  only  may  the  tendons  be  divided  by  the  open  method,  but  everything  else  which 
resists.  This  is  practised  more  in  contracted  knee-joint  and  in  club-foot,  when  operated 
on  by  Phelps'  method,  than  anywhere  else.  Special  indications  for  the  operation  will 
be  given  in  other  parts  of  this  work. 

GANGLION. 

This  term  is  applied  to  a  cyst  of  new-formation,  which  occurs  in  connection  with 
the  sheath  of  a  tendon,  having  a  lining  membrane  continuous  with  the  sheath  and 
containing  thick,  gelatinous,  mucoid  fluid.  It  is  termed  "weeping  .sinew."  It  is 
often  seen  on  the  liack  of  the  wrist  in  connection  with  the  extensor  tendons,  but  may 
occur  in  various  parts  of  the  body.  It  probably  begins  as  a  hernia  of  the  synovial  mem- 
brane through  a  weak  spot  in  the  tendon  sheath,  which  tends  to  increase  in  size,  weak- 
ening surrounding  structures  by  pressure,  and  interfering  more  or  less  with  the  function 
of  the  tendon  whose  sheath  is  involved.  These  cysts  sometimes  connect  with  joint 
cavities,  especially  those  occurring  behind  the  knee-joint ;  as  a  rule,  however,  they  do 
not.  At  first  they  constitute  merely  a  disfigurement;  later  they  produce  natural 
impairment  of  function.  In  the  majority  of  cases  the  sac  becomes  finally  shut  off  from 
the  tube  with  which  it  originally  connected. 

When  these  lesions  are  new  they  may  be  successfully  dealt  with  by  forcible  rupture, 
such  as  can  be  made  by  firm  pressure.  When  old,  or  when  rupture  has  failed,  they 
should  be  treated  by  incision,  practised  the  same  as  a  tenotomy,  by  moving  the  skin  to 
one  side,  pricking  the  sac,  turning  the  blade  of  the  tenotome  so  as  to  permit  the  fluid 
to  be  emptied  by  pressure,  and  then,  by  manipulating  the  point,  irritate  and  do  some 
damage  to  the  sac  lining.  Such  provocation  as  this  will  be  followed  by  a  hemorrhage, 
and  the  resulting  clot  may  obliterate  the  sac  by  organization  and  cicatricial  contracton. 
This  failing,  excision  is  the  only  expedient  which  promises  success.  The  slightest 
operation  upon  a  ganglion  should  be  done  under  aseptic  precautions. 


328 


SURGICAL  AFFECTIONS  OF  THE  TISSUES 


FELON,  OR  WHITLOW. 


Fig.  130 


Felon,  or  whitlow,  was  discussed  in  the  ])revious  chapter,  especially  the  form  which 
has  its  oriffin  around  the  root  of  the  nail.  It  often  originates  in  tendon  sheaths  and 
even  in  bone  or  elo.se  to  it.     It  is  so  often  accompanied  by  a  sui)purative  thcriii.s,  i.  e., 

tend(i.synovitis  of  destructive  form,  es])ecially  when 
not  primarily  incised,  that  the  necessity  for  early 
treatment  needs  to  be  emphasized.  It  gives  ri.se 
to  excessive  j)ain,  with  throbbing,  and  to  swelling 
of  livid  hue  and  inten.se  degree,  "^l^he  parts  in- 
volved are  too  essentially  fibrous  and  resisting  to 
yield,  hence  the  intensity  of  the  pain.  Deep  in- 
cision at  the  earliest  moment,  for  the  purpose  of 
relieving  tension,  is  the  only  proper  treatment.  To 
temporize  with  hot  poultices,  etc.,  is  to  invite 
necrosis  and  sepsis.  This  incision  may  be  made 
witli  local  anesthesia.  Even  though  little  pus  be 
obtained  the  relief  of  tension  will  afford  the  greatest 
comfort  (Figs.  130,  1.31  and  132). 

A  more  striking  examj)le  of  similar  trouble  is 
that  which  gives  rise  to  palmar  abscess,  the  sup- 
purative process  extending  up  the  wrist  beneath 
the  annular  ligament,  and  down  into  the  little  finger 
antl  thumb.     Thi.s  is  not  infrequently  the  result  of 


Felon  of  thumb.    (Burrell.) 


Fig.  131 


Fig.  132 


Neglected  suppurating  ihecitis  resultiug  in 
palmar  abscesss.     (Burrell.) 


Same,  dorsal  aspect.    (Burrell.) 


infection  of  callosities  in  the  palm  of  the  hand.  Infection  may  travel  rapidly,  and 
when  confined  beneath  resisting  structures  will  prove  exceedingly  destructive;  the 
muscles  of  the  forearm  may  melt  down  and  great  permanent  damage  be  done. 


uri'Triu:  of  the  muscles 


329 


Here,  as  wlu-ii  the  fiiiii;('r  alone  is  involved,  eurly,  tree,  and  dccj)  incision  will  jjrovo 
the  salvation  ol'  (lie  |)ar(.  These  incisions  should  he  nuide  as  indicated  in  Fij:;s.  I'.VA 
and  134,  /.  c,  parallel  with  the  nerves,  tendons,  and  vessels,  all  ol'  which  should  he 
spared,  as  well  as  the  palmar  arch.     Should  the  latter  he  divided,  the  vessel  ends  may 


Fig.  133 


Diagram  of  palmar  incisions. 
Fig.  134 


Diagram  of  dorsal  incisions.     (Burrell.) 

he  ligated  or  the  wound  packed.  If  cavities  be  left  by  the  destructive  process  they 
should  be  opened  and  the  part  treated  by  continuous  immersion  in  warm  water,  or  the 
openings  may  be  packed  with  gauze  saturated  in  brewers'  yeast.  A  few  days  of  this 
treatment  will  clean  up  all  sloughs. 

SURGICAL  DISEASES  OF  THE  MUSCLES. 

CONTUSIONS  OF  THE  MUSCLES. 

Muscles  react  like  other  tissues  under  the  influence  of  contusions.  Hemorrhages 
not  too  copious  are  gradually  absorbed,  and  muscle  tissue  repairs  itself,  as  indicated 
in  the  chapter  on  Wounds  and  their  Repair.  Much  outpour  of  blood  into  a  muscle 
will  temporarily  seriously  impair  its  function,  while  pigmentation  or  ecchymosis  may 
result  after  a  few  hours  or  days,  according  to  the  depth  of  the  injury.  There  is  the 
same  liability  to  suppuration  after  infection  of  muscles  as  elsewhere.  A  large  hematoma 
can  scarcely  form  within  a  muscle,  save  in  consequence  of  a  rupture  of  a  considerable 
portion  of  its  substance.  Straitis  and  .iprains  of  lesser  degree  of  violence  provoke 
impairment  of  function  proportionate  to  their  severity.  In  nearly  every  instance  there 
is  a  certain  amount  of  rupture  of  muscle  fiber  and  outpour  of  blood. 


RUPTURE  OF  THE  MUSCLES. 

Complete  rupture  across  a  muscle  is  unusual.  It  may  occur  in  the  belly  of  the  muscle 
or  near  one  of  its  terminations.  A  tendon  may  be  torn  out  of  a  muscle  or  may  itself 
snap.  These  accidents  are  almost  invariably  accompanied  by  symptoms  that  indicate 
both  the  nature  and  location  of  the  injury.  A  severe  strain  followed  by  intense  pain, 
with  a  sensation  of  yielding,  leaves  little  doubt  as  to  what  has  happened  Unless  the 
muscle  lie  deeply  its  parting  may  be  appreciated  by  palpation,  though  the  depression 


330  SURGICAL  AFFECTIOXS  OF  THE   TISSUES 

or  interval  may  be  obliterated  by  the  outpour  of  blood.  The  lar<:je  tendons  of  the  arm 
and  shoulder  have  been  ruj)tured  by  a  violent  effort,  the  abdominal  muscles  by  con- 
tusions and  by  such  efforts  as  wrestling,  the  sternomastoid  by  excessive  traction  during 
force])s  delivery,  and  the  tendons  of  the  legs  and  ankles  by  jumps  during  such  games 
as  lawn  tennis,  etc.;  while  the  frecjuency  with  which  the  muscles  of  the  ])erineum  and 
even  the  sphincter  ani  are  torn  daring  ])arturiti()n  is  well  known.  It  is  also  well  known 
that  muscles  are  wealaMied  by  the  exantluMuas  and  the  infectious  diseases. 

Treatment. — An  injury  of  this  kind  and  of  moderate  degree  seen  early  may  be  treated 
by  physiological  rest  and  position.  (See  chapter  on  Treatment  of  Wounds.)  When, 
however,  there  is  marked  impairment  of  fimction,  such  as  will  follow  the  yielding  of 
one  or  more  tendons  or  muscle  insertions,  then  suturing  offers  the  greatest  promise 
of  a  cure.  When  the  quadriceps  tendon  is  torn  away  from  the  })atella  or  the  tendo 
Achillis  from  the  heel,  prompt  suture  under  aseptic  precautions  will  save  a  long  period 
spent  in   partial   recovery  of  function. 

Occasionally  one  or  more  tendons  will  be  completely  amtlscd,  as  when  a  finger  is 
torn  out  of  the  hand  antl  brings  with  it  one  or  more  of  the  tendons  belonging  to  it.  In 
accidents  of  this  kind  six  to  twelve  inches  of  tendon  and  muscles  may  be  lost.  In  such 
a  case  nothing  can  be  done  except  to  care  for  the  wound  resulting  from  the  injury. 

DISLOCATION  OF  TENDONS  AND  MUSCLES. 

Tendons  and  muscles  are  occasionally  dislocated,  that  is,  forced  from  their  normal 
positions.  Accidents  of  this  kind  usually  occur  with  the  long  teiulon  of  the  biceps, 
which  is  torn  from  its  bicipital  groove;  the  peronei  and  the  posterior  tibial  in  the 
leg,  the  extensor  muscles  of  the  thigh,  and  those  of  the  back  of  the  wrist.  The  lower 
angle  of  the  scapula  is  normally  held  down  by  a  small  portion  of  the  latissimus  dorsi; 
should  this  be  displaced  the  scapula  rises  somewhat  in  wing  form.  These  injuries 
lead  to  more  or  less  loss  of  function,  and,  when  they  become  disabling,  may  justify  opera- 
tion, which  would  include  incision,  exposure  of  the  tendon  in  its  abnormal  position,  and 
its  restoration  to  its  proper  place  where  it  should  be  held  by  sutures.  Such  opera- 
tion should  be  followed  by  enforced  physiological  rest  of  the  part. 


HERNIA    OF  MUSCLES. 

Hernia  of  muscle  is  the  name  applied  to  the  escape  of  muscle  through  a  ruptured 
fascial  or  aponeurotic  covering.  Such  a  protrusion  will  be  recognized  only  during  the 
contraction  of  the  muscle  and  will  disappear  at  other  times.  When  the  diagnosis  is 
made  the  edges  of  the  rent  in  the  fascia  should  be  united  by  sutures  and  the  part  put 
at  rest. 

WOUNDS   OF  MUSCLES. 

Woimds  of  muscles  in  no  way  differ  from  other  woimds  which  have  been  considered 
in  the  chaj^ter  on  W'ounds  and  their  Treatment.  If  circumstances  permit  there  is 
every  indication  for  the  suture  of  a  divided  muscle  in  order  that  its  function  may 
be  less  imjjaired  after  the  wound  is  healed.  These  sutures,  when  inserted,  should  be 
made  to  separately  include  the  divided  fascia  or  aponeurosis  with  which  the  injured 
muscle  is  in  relation. 

MYALGIA. 

There  are  numerous  painful  affections  of  muscles  knoMTi  as  mj/algia.  It  is  ques- 
tionable whether  a  rheumatism  of  muscle  fiber  ever  occurs.  That  which  patients 
describe  as  muscular  rheumatism  is  not  that  which  it  is  termed.  Sometimes  it  is  the 
result  of  previous  exudate  between  muscle  fibers,  sometimes  the  result  of  hemorrhage 
of  interstitial  type.  Muscles  thus  affected  are  more  or  less  tender  and  give  pain  when 
used.  It  will  usually  be  found  that  there  is  some  marked  toxic  condition,  such  as  uric 
acid,  syphilis,  or  lead  poisoning,  behind  it. 


MYOSITfS  31^1 

Treatment.  Many  of  dir  muscle  pains  of  wliicli  |»alicnls  coinplain  after  operation, 
wiiieli  are  also  toxic,  are  relieved  hy  (lie  adininist ration  of  aspirin  in  ().">(  Jin.  dosi-s.  'I'lie 
injection  of  u  small  amount  of  atropine  into  the  hody  of  the  muscle  will  oflen  ifive  relief. 
'l1ios(>  rcMuedies  which  hasti'ii  elimination,  including;'  hoi  haths  and  massage,  are  often 
of  great  value. 

MYOSITIS. 

This  may  he  tinn-inflainDiatori/  and  he  due  (o  |)rolono;e(l  u.se  of  a  nuMuher,  as  in  writers' 
cramp;  or  fo.vic,  as  in  lead  palsy;  or  tntiiiiKttic,  caused  hy  minute  lacci-ations  and  hemor- 
rhage. 'I'he  more  acute  forms  may  !)(>  due  to  extension  from  neighhoring  foci  or  to  direct 
infection.  .V  form  of  infection  involving  hoth  nuiseles  and  tendon  sheaths,  and  lately 
recognized,  is  the  postgonorrheal.  It  has  hecMi  shown  that  gwiorr/ud  may  j)ro(hice 
an  active  disturbance  in  synovial  sheaths  and  in  muscle  stnictnn's  and  a  f/oiiofoccii.s' 
mi/ositis,  as  well  as  a  qonococcus  irndovaf/nnhs,  are  now  well  recognized.  These  do 
nor  always  j)roceed  to  su|)puratIon,  but  may  ])rovoke  loss  of  function  foi-  sonic  time. 

The  sujjpurative  form  of  myositis  is  seen  more  often  after  ly|)lioid  and  gonorrhea 
than  after  the  other  inttM-nal  infections,  but  may  occur  after  any  of  them.  In  these 
cases  abscess  results  in  the  belly  of  the  muscle  involved,  whili'  the  j)us  evacualed  will 
show  tile  appropriate  organism.      It  is  met  with  less  often  in  endocarditis  and  erysipelas. 

Any  or  all  the  active  and  destructive  infections  may  occur  primarily  in  muscle  struc- 
ture. They  are  usually  the  result  of  an  extension,  although  they  maybe  even  in  this 
way  very  disastrous.  The  amount  of  muscle  destruction  that  may  be  seen  in  a  limb 
after  an  infected  and  neglected  compound  fracture  is  astonishing. 

Myositis  Calcificans. — Calcification  and  o.ssificalion  of  nuiseles  are  alike  due  to 
deposition  of  calcium  salts,  but  under  diU'erent  circumstances.  il///o.s7"//.v  ralcijirau.s 
may  be  the  result  of  tuberculous  disease  following  caseation,  as  it  does  in  lymph  nodes 
and  in  other  parts  of  the  body,  or  occiu'ring  as  a  general  deposit  (hroughout  the  muscles, 
essentially  an  infiltration,  as  is  seen  in  the  muscles  of  the  legs.  Myosilis  otisijicaiis 
implies  a  formation  of  true  bone  in  muscle  substance.  A  peculiar  form  arising  in  (he 
adductor  longus  results  from  the  j)ressure  of  the  limb  against  the  saddle;  (his  has 
been  known  as  rider's  or  cavalri/ man's  hone.  Something  similar  in  the  deltoid  has  been 
called  (//•/'//  hone,  because  usually  seen  in  soldiers  who  carry  their  weajjons  upon  (he 
shoulders;  wiiile  a  form  which  occurs  in  the  brachialis  anticus  has  been  ref(>rred  to  as 
jcnccr's  hone,  and  one  in  the  calf  muscles  as  (((tiicrr's  hone.  It  occurs  in  two  types,  one 
of  which  is  characterized  by  ossification  in  succession  of  the  various  muscles,  (his  occur- 
ring first  in  the  trapezii,  latissimi,  and  rhomboidei.  In  e.\])lana(ioii  of  these  lesions,  it 
has  been  suggested  that  all  of  these  coiniective  mcsoblastic  tissues  may  manifest  certain 
atavistic  tendenc-ies  ana  thus  revert  to  bone.  The  question  is  certainly  not  one  of  peri- 
osteal origin.  Binnie  has  shown,  in  a  remarkable  case  re})orted  by  himself,  that  ossi- 
fication is  both  of  the  fibrous  and  cartilagiiu^us  type,  ^^nly  hi  the  localized  forms  can 
the  periosteum  be  suspected.  In  these  it  may  be  that  there  has  been  (le(aclimen(  of 
some  of  its  tissue  or  escape^  of  some  of  its  cells  into  the  muscle  area.  The  ossifying  l(\sions 
of  surrounding  muscles  will  sometimes  interfere  with  the  motions  of  joiii(s  after  (hey 
have  been  injured.  Any  localized  calcareous  or  ossific  deposit  which  can  be  recognized 
may  be  removed. 

Myositis  Syphilitica. — This  occurs  in  gummatous  form,  no  muscles  being 
exempt;  those  of  the  tongue  are  most  frequently  involved.  It  is  seen  also  in  the  sterno- 
mastoid.  Not  infrequently  these  gummas  liave  been  mistaken  for  malignant  tumors. 
Sometimes  they  degenerate  and  sometimes  suppurate.  A  lesion  of  this  kind  will  usually 
be  multiple,  but  it  may  have  enough  infiltration  around  it  to  be  difficult  of  recognidon. 
Lesions  of  this  kind  are  also  seen  in  hereditary  cases.  A  more  distinctively  in(ers(i(ial 
affection  of  muscles  leads  sometimes  to  their  contracture,  as  seen  about  the  arms, 
beginning  with  malaise  and  incocirdination,  and  extending  to  disabling  lesions.  These 
will  yield  to  ])rop(M-ly  directed  antisyphilitic  treatment. 

Myositis  Tuberculosa.— This  "afl'ect ion  is  usually  the  result  of  extension  from 
ailjoining  foci.  As  in  the  case  of  syphilis  it  may  assume  the  infiltrating  or  the  gumma- 
tous type.  It  is  more  frequently  encountered  than  the  muscular  ex])ressi()ns  of  syphilis; 
it  does  not  yield  nearly  as  readily  to  treatment,  and  calls  for  excision  of  the  affected  area 
and  for  cauterization  or  other  protection  as  against  re-infection. 


332  SURGICAL   AFFECTIONS  OF   THE   TISSUES 


PARALYTIC  AFFECTIONS  OF  MUSCLES. 

More  or  less  permanent  j)ciraly.sis  is  sometimes  the  result  of  contusion  or  direct 
injury  of  a  nerve  trunk.  Thus  the  ])aralysis  of  the  deltoid  which  follows  injury  to  the 
circumflex  nerve  in  connection  with  tlislocations  of  the  shoulder  is  a  frequent  accident. 
It  does  not  rec|uire  continued  pressure  upon  the  nerve  to  produce  this.  It  may  follow 
a  dislocation  reduced  within  a  few  moments.  Again,  paralysis  of  the  arm  muscles  is 
occasionally  the  result  of  pressure  made  by  crutches.  It  has  been  known  to  occur  from 
similar  pressure  while  the  patient  was  uj)on  the  operating  table  with  his  arm  hanging 
over  the  table's  edge.  This  is  an  accident  which  should  be  carefully  avoided.  More- 
over, it  follows  sometimes  from  mere  violent  muscle  effort.  The  condition,  while  simj>le 
in  its  etiology,  is  difficult  and  sometimes  im];ossible  to  cure. 

Treatment. — The  treatment  should  consist  mainly  of  massage  and  electricity,  with 
the  elimination  of  all  j)ossibility  of  toxemia.  The  resources  of  tendoplasty  (.see  above) 
should  also  be  con.sidered,  as  well  as  those  of  neuroplasty. 

ATROPHIES  AND  CONTRACTURES  OF  MUSCLES. 

Muscuhir  paralysis  is  always  followed  by  atroj)hy,  wliii  li  will  lead  to  marked  diminu- 
tion in  size  of  the  part;  when  the  atrophy  concerns  a  single  muscle  or  muscle  group  it 
will  frequently  be  followed  by  deformity  due  to  action  of  the  opposing  muscles.  Tonic 
.spasm  of  muscles  unopposed  may  lead  to  contractures,  often  with  ankylosis.  The 
degree  of  deff)rmity  which  is  produced  may  eventually  require  amputation  of  a  limb. 

Other  forms  of  contractures  are  produced  either  as  the  result  of  central  or  spinal 
scleroses  or  as  expressions  of  irritative  sj)asm  provoked  by  a  neighboring  bone  or  joint 
trouble.  The  two  types  may  cause  similar  deformities,  which  vary  widely  in  their 
etiology.  The  former  are  seen  in  certain  cases  of  brain  and  spinal-cord  diseases,  the 
latter  especially  in  connection  with  tuberculous  arthritis.  Inasmuch  as  the  flexors  are 
stronger  than  the  extensors  these  defcjrmities  consist  largely  of  hyperflexion.  Ultimately 
the  shape  and  growth  of  bones  and  the  nutrition,  appearance,  and  function  of  the  part 
are  influenced. 

Muscle  atrophy  which  is  the  result  of  confinement  in  one  position,  as  after  the  treat- 
ment of  fractures,  is  of  minor  importance  and  tends  to  disappear  spontaneously  as 
soon  as  function  is  resumed. 

Treatment. — In  most  of  the.se  instances  patience  may  be  easily  overtaxed  while 
waiting  the  tardy  results  of  massage  and  such  correction  as  a])))aratus  may  afford.  Very 
frequently  the  additional  help  of  an  anesthetic,  with  forced  movements,  often  with 
tenotomies  and  sometimes  with  tendon  grafting,  will  be  refjuired.  When  contractures 
can  be  foreseen,  as  th:-y  may  be  in  connection  with  many  lesions  which  produce  them, 
such  as  burns  and  others  not  specifically  mentioned,  they  should  be  guarded  against 
l)y  splints,  apparatus,  or  whatever  may  best  serve  the  purpose. 

PARASITIC  AFFECTIONS  OF  THE  MUSCLES. 

The  parasitic  affections  of  muscles  are  rare.  Trichinosis  rarely  produces  tumors 
which  come  imder  the  surgeon's  hands.  Still  there  may  result  from  it  a  form  of  myo- 
sitis with  formation  of  cysts  which  may  so  far  interfere  with  muscle  function  as  to  demand 
removal.     II i/dafid  n/.sifi  and  rj/siircrciis  are  extremely  rare,  especially  in  this  country. 

DISEASES   OF  THE   BURS.E. 

There  are  two  types  of  bursfe  in  the  body:  first,  the  subnifaneous,  or  mvcmis,  which 
are  loose  sacs  containing  a  clear  mucoid  fluid.  They  develop  regularly  when  bony 
prominences  are  exposed  to  friction  and  develop  adventitiously  wherever  undue  irri- 
tation is  produced.  Thus  beneath  every  bunion  there  will  be  found  a  good-sized  and 
thickened  f>ursa. 

Synovial  hnr.srr,  the  second  type,  are  met  with  in  close  y)roximity  to  joints,  and  Itetween 
tendons   which   play  upon  each  other.     They  frequently  c(»mmunicate  with  the  joint 


PLATE   XXX 


Foreign  Body  (Broken  Needle)  in  Foot.  Buffalo  Clinic.  (Skiagram  by  Dr.  Plum^ 
mer.)  Illustrating  the  Value  of  this  Method  of  Exactly  Locating  a  Foreign  Body  and 
Involving  the  Tissues  Considered  in  Chapter  XXVII. 


1)Isi-:asj:s  of  tjii-:  inmsK 


333 


Fig.  135 


wliicli  tlu'v  oviM'lic,  and  infection  may  ousily  .spread  from  one  to  the  other.  'I'hev  are 
lial)le  to  tranmatism,  either  extrinsic  or  intrinsic,  the  former  from  cliadn^ror  more  direct 
injnry,  the  latter  hy  e.xces.sive  muscle  exertion.  Wlien  infected  they  su|)|)nrate,  formin<^ 
al)scesses  of  conventional  U\^('.  As  the  resnll  of  contusions  they  are  fn'Cjuently  (illed 
with  Mood,  in  which  case  ihci-c  is  a  />///-.sv//  hciitdtonui.  Artilc  hiirsili.s-  usually  merges 
into    localized    abscess. 

Cliroiiir  hnr.'iiti.s-  constitutes  a  circumscrihed  collection  of  fluid,  often  with  thickeninj]f 
of  the  bursal  sac,  and  freciuent  dej)osition  of  products  of  exudation.  Here,  too,  pu.s 
may  form  a.s  the  result  of  infection,  while  calcification  .sometimes  takes  j)hice  in  old  ea.ses. 
A  chronic  bursitis  is  likely  to  be  either  of  sy])hilitic  or  tuberculous  ori(;in.  It  is  usually 
,s(>en  beneath  old  bunions,  and  in  the  pre])atellur  bursa,  which  is  e(jualiy  exposed  to 
irritation,  and  which  also  o;ives  rise  to  hoii.iriiinid'.s-  Icnrr.  This  lesion  used  to  be  considered 
as  always  of  .syphilitic  character,  but  this  is  far  from  correct. 

IIi/f/roiiKi,  or  li  1/(1  raps,  is  a  term  i're((uently  ap])lie(l  to  these  localized  collections  of 
(lui<l.  The  former  is  more  likely  to  be  of  tuberculous  origin,  and  the  retained  fluid 
may  contain  rice-<i;rain  bodies.  A  chronic  bursitis,  orifjinally 
of  traumatic  origin,  may  become  infected  and  present  a 
tuberculous  lesion,  or  it  may  be  influenced  if  not  caii.sed  by  a 
.syj)hilitic  diathesis,  es])ecially  about  the  knee,  where  these 
conditions  generally  occur.  Other  bursa^  Avhich  j)roduce  dis- 
turbances that  eventually  take  the  patient  to  a  surgeon  are 
m(>t  with  in  the  following  locations:  beiirath  flic  /igavtenfiim 
pairlJ(i\  which  will  give  a  ])rominence  on  each  side  of  the  liga- 
ment, j)articularly  when  the  knee  is  flexed;  over  the  tuberele 
of  the  tibia;  beneath  the  quadriceps  extensor  tendon,  whic  h 
will  cause  a  .swelling  two  or  three  inches  above  the  upper 
border  of  the  patella;  between  the  tendon  of  the  semimembra- 
nosus and  inner  head  of  the  gastrocnemius ,  which  will  present 
in  the  pojiliteal  space  as  a  somewhat  globular  swelling; 
beneath  the  deltoid;  beneath  the  gluteus  muscles,  where  the 
tendons  pass  over  the  great  trochanter;  between  the  tendo 
Achillis  and  the  calcis;  over  the  outer  malleolus,  occurring 
in  tailors  by  virtue  of  the  position  in  which  they  work.  Large 
bursa*  often  develop  on  the  outer  sides  of  club-feet,  on  the  ends 
of  amputation  stumjxs,  and  wherever  there  is  prolonged  irri- 
tation of  mild  degree.'  ^  ^     ^  _       Hygroma  of  a  prepatellar  bursa 

The  treatment  of  acute  bursitis  is  that  of  threatening  [••  housemaid's  kuee").  (Lexer.) 
phlegmon  in  any  other  part  of  the  body.     As  soon  as  the 

presence  of  pus  can  be  determined,  or  even  before,  a  free  incision  should  l)e  made. 
Such  an  incision  should  not  be  entirely  closed  after  evacuation  of  the  sac,  but  shoukl  be 
permitted  to  heal  by  granulation. 

Chronic  bursitis,  whether  with  or  without  formation  of  granuloma,  is  best  treated  by 
excision,  when  the  sac  has  become  thickened  and  a  new  formation  has  practically  occurred. 
Housemaid's  knee,  for  instance,  like  bunion,  is  more  satisfactorily  treated  by  a  clean 
excision  of  all  diseased  tissue  than  by  any  other  less  radical  method.  Every  tuberculous 
lesion  of  this  kind  should  be  rigorously  extirpated,  and  every  .syphilitic  lesion  should 
be  treated  by  constitutional  as  well  as  by  local  measures,  the  former  being,  save  in 
exceptional  instances,  the  more  important  of  the  two.^ 

'  A  bunion  is  in  many  instances  due  to  flat-foot,  causing  ttie  great  toe  to  turn  out.  This  condition  should  be 
remedied  by  the  usual  arch,  or  raising  the  inner  border  of  the  shoes.  Four  out  of  the  five  tendons  attached  to 
the  great  toe  tend  also  to  draw  it  outward.  If  the  tripod  of  the  foot  can  be  restored  without  operation  this 
shf)uld  be  done. 

-  The  Radical  Cure  of  Bunions.—The  term  bunion  is  generally  used  to  indicate  a  painful  swelling  over  the  inner 
aspect  of  the  ball  of  the  great  toe;  it  is  never  seen  on  the  feet  of  those  who  go  barefooted,  but  is  the  result  of 
badly  fitting  .shoes,  almost  all  of  which  crowd  the  great  toe  outward,  thus  making  its  base  more  prominent  and 
exposing  it  to  irritation  and  pressure.  The  inner  border  of  the  foot  is  nearly  a  straight  line,  but  shoes  are  rarely 
made  to  conform  to  this.  The  result  of  the  consequent  partial  dislocation  of  the  toe,  and  of. the  pressure  made 
at  its  base,  is  chronic  periostitis,  and  the  development  of  a  bursa.  It  becomes  greatly  thickened  and  forms  a 
small  tumor,  usually  sensitive  and  painful.  The  dislocation  often  proceeds  to  such  a  degree  that  the  great  toe 
lies  across  the  others,  either  over  them  or  under  them,  in  .such  a  position  as  to  receive  and  deserve  the  name 
hnllux  vahius,  which  is  generally  given  it  when  this  is  pronounced.  There  is  nothing  to  do  but  to  e.xsect  the  head 
of  the  first  metatarsal  bone,  and  at  the  same  time   excise  the  bursa  and  some  of  the  overlying  and  thickened  skin. 


j^^mM 


CHAPTER    XXIX. 

SURGICAL  DISEASES  OF  THE  HEART  AND  VASCULAR  SYSTEM. 

A  GENERATION  ago  a  chapter  on  the  surgery  of  the  heart  woukl  have  been  regarded 
as  a  surgical  fantasy.  Today  the  subject  is  not  only  a  li\e  one,  but  experience  is  con- 
stantly accumulating  as  to  the  value  of  surgical  intervention  in  diseases  of  the  heart  and 
pericardium. 

MALPOSITIONS   OF  THE   HEART. 

The  heart  may  be  displaced  by  congenital  or  acquired  causes.  Malpositions  of 
the  former  type  may  vary  from  dextrocardia,  where  the  heart  is  placed  upon  the  right 
side,  and  may  be  accompanied  by  a  general  or  partial  transposition  of  the  viscera,  to 
those  cases  where  there  are  defects  in  the  diaphragm  or  the  chest  wall,  through  which 
the  heart  protrudes.  Dextrocardia  has  an  interest  for  the  surgeon,  as,  for  example, 
in  the  following  case  under  the  writer's  observation:  Disease  on  the  left  side  which 
simulated  appendicitis,  in  which  the  diagnosis  was  confirmed  by  finding  the  heart  upon 
the  right  side,  and  later  by  operation.     It  was  a  case  of  complete  transposition. 

The  acquired  malpositions  may  be  due  to  intrinsic  or  extrinsic  causes.  They  are 
pressure  effects,  usually  found  in  connection  with  intrathoracic  aneurysms  and  other 
tumors  or  collections  of  fluid,  or  may  be  due  to  change  in  the  shape  of  the  spine  in  pro- 
nounced curvatures.  Occasionally  the  heart  is  hindered  in  its  action  by  pressure  from 
beneath  the  diaphragm.  These  cardiac  flisjilacements  are  surgically  interesting  when 
the  cause  can  be  removed  by  operative  measures. 

WOUNDS  OF  THE  HEART. 

Wounds  of  the  heart  are  mainly  of  the  punctured  or  gunshot  type.  It  was  formerly 
considered  that  injuries  of  the  heart  were  essentially  fatal.  This  has  been  disproved 
by  human  and  comparative  observations.  As  far  back  as  1855,  Carnochan  reported 
a  case  of  gunshot  wound  of  the  heart  where  the  bullet  was  found  in  the  heart  substance 
after  the  patient  had  lived  eleven  days.  The  museums  contain  many  illustrations  of 
penetrating  wounds  of  the  heart  or  of  foreign  bodies  in  it,  some  of  which  had  remained 
embedded  for  many  years.  Nevertheless  the  fact  remains  that  the  majority  of  wounds 
of  the  heart  are  fatal,  either  by  arrest  of  its  activity,  by  shock,  by  the  outpour  of  blood 
between  it  and  the  pericardium  or  outside  the  latter,  or  later  by  processes  which  con- 
sume at  least  a  few  days,  either  infective  or  degenerative.  Other  things  being  equal 
the  larger  the  wound  the  more  dangerous,  while  an  injury  to  the  heart  muscle  which  has 
not  opened  one  of  its  cavities  is  less  dangerous  than  one  which  perforates  them.  A  punc- 
tured wound  made  by  a  small  stiletto  or  knife-blade,  or  even  by  a  needle  n-ed  for  homi- 
cidal purposes,  may  leave  but  small  trace  and  not  prove  fatal,  save  through  injury  to 
one  of  the  cardiac  vessels,  especially  a  coronary  artery.' 

In  practically  all  of  these  injuries  there  will  be  evidence  of  some  external  violence. 
It  is  of  advantage  to  asceratin  the  nature  of  the  accident  and  the  character  of  the  missile 

1  Illustrating  the  surgery  of  foreign  bodies  in  the  heart,  Jordan  has  reported  tlie  case  of  a  young  woman  who  stated 
that  she  had  received  a  blow  on  the  front  of  the  chest  the  previous  day ,  and  showed  on  examination  a  small  projecting 
point  in  the  lower  part  of  the  third  left  intercostal  space  about  half  an  inch  from  the  sternimi,  which  was  tender 
to  the  touch  and  seemed  to  move  or  pulsate  with  the  lieart.  It  gave  to  the  finger  the  sensation  of  a  hard  substance 
beneath  the  skin  without  any  external  marking.  Upon  making  an  incision  and  dissecting  ijartly  through  the 
muscle  the  broken  end  of  a  black  steel  pin  came  into  view.  After  removal  with  forceps  it  proved  to  be  a  shawl 
pin,  one  and  one  half  inches  long,  with  its  glass  head  broken  off.  The  patient  remembered  having  had  such  a  pin 
in  her  bosom  at  the  time  of  the  accident.  On  the  following  day  she  had  pericarditis.  She  apparently  recovered, 
but  had  a  relapse,  and  died  on  the  twenty-fourth  day,  the  autopsy  showing  pericarditis. 
(334) 


WOrXDS  OF   THE   HEART 


335 


Fifi    IKC, 


or  iiistniiiKMit.  H"  the  depth  of  |)(Mi(ti;i(ioii  of  a  kiiitV-hladf,  for  instance,  can  he  ascer- 
tained more  accurate  coiiclusioiis  can  l)c  drawn.  The  s|)ecial  indications  of  cardiac 
injury  |)i*rtain  to  (hstnrhance  ot"  its  own  function,  that  is,  cniharrassinent  and  uncertainty 
of  action,  hcHows  sounds,  enhirfjcd  area  of  (hiincss  owinjf  (o  distention  of  the  peri- 
canhnni  with  hhxxl,  dysj)nea,  and  (hstress,  and  sonietinies  pain  and  synco|)e.  Tliese 
svniptonis  and  siji'iis  do  not  a|)pear  instantaneously,  hut  increase  in  severity. 

Treatment.  In  such  an  einer<2;i"ncy  everythinij  possihle  shouhl  he  done  to  rcheve 
the  cniharrassnicnt  of  tlie  heart's  action — the  head  siiould  he  kept  low,  the  hody  ah.sohitely 
(piict,  and  nervous  excitement  shouhl  he  aUayed  at  once  with  a  full  dose  of  morphine. 
Heart  stimulants  sliould  not  he  given.  Ice  ai)))lied  over  the  chest  will  helj)  cpiiet  cardiac 
activity.  If  the  patient  he  not  failing  too  rajjidly  operation  is  advisal)le,  and  should  be 
done  in  a  well-e<|uipped  hosj)ital,  with  trained  assistants.  The  purpose  of  the  oj)era- 
tion  is  to  ex])ose  the  iiijurcHl  portion  of  the  heart  suhstance  and  close  it  with  suture;  at 
least  to  remove  the  fluid  or  ])artially  coagulated  hlood  within  the  pericardium.'  As  it  is 
not  always  possihle  to  expose  the  heart  without 
opening  the  pleural  cavity,  there  should  he  at 
hand  not  only  the  means  for  a  tracheotomy, 
hut  an  api)aratus  hy  which  artificial  inflation 
of  at  least  one  lung  can  he  effected.  Pncv- 
iiKttir  cabinets  have  been  devised  for  this  pur- 
])()se,  especially  hy  Sauerhruch,  where  a  differ- 
ence of  ])re3sure  can  he  maintained  hetween 
the  outside  and  the  inside  of  the  cabinet,  so 
that  the  chest  may  be  widely  opened  and  the 
lung  not  callapsed;  hut  such  a  cabinet  is 
available  in  few  places  in  the  United  States. 
The  improved  Fell  apparatus,  by  which  a 
mask  is  kept  over  the  face  and  presijure  main- 
tained with  the  foot  through  a  bellows,  has 
been  found  useful.  Even  in  the  absence  of 
such  apparatus  the  sin-geon  should  not  abstain 
from  the  effort,  though  it  may  appear  less 
jH'omising. 

In  the  operative  procedure  one  may  feel  in- 
clined to  utilize  the  already  existing  wound, 
either  as  a  part  of  his  incision  or  for  exploratory 
purposes,  or  he  may  decide  to  disregard  it.  The 
o})eration  consists  in  raising  an  osteoplastic 
flap  on  the  chest  wall,  by  which  the  pericar- 
(liinn  and  then  the  heart  are  exposecl.  The  incision  through  the  skin  is  extended 
to  the  hone  and  only  enough  of  the  soft  structures  separated  from  the  ribs  and 
cartilages  to  expose  them  sufficiently  for  division.  Ordinarily  it  would  he  preferable 
to  divide  the  third,  fourth,  and  fifth  costal  cartilages  at  their  rib  terminations,  and  then 
to  turn  up  the  flap  with  its  base  at  the  sternum,  though  the  procedure  can  he  reversed 
to  almost  as  good  advantage.  The  cartilages  and  the  ribs  may  be  divided  with  the  costo- 
tome  and  the  rest  of  the  structures  with  stout  scissors.  The  flap,  having  been  gently 
elevated  at  the  edge,  is  separated  from  the  underlying  cellular  tissue  and  pericardium 
until  its  sternal  margin  has  been  reached.  When  detached  it  may  be  sprung  upward, 
and  thus  a  comjilete  window  is  made  in  the  chest  wall.  When  more  room  is  desired 
bone  and  cartilage  may  he  cut  away  with  a  rongeur. 

The  ])ericardium  being  thus  exposed  may  he  found  muc-h  distended  or  altered  by  the 
iml)ihition  of  hlood.  It  should  he  opened"  to  an  extent  suflScient  to  permit  evacuation 
of  its  bloody  contents  and  sufficient  exposure  of  the  heart  to  permit  not  merely  inspection 
but  suture  of  any  wound  in  the  heart  substance.   This  is  exceedingly  difficult  on  account  of 

>  Suture  of  Heart  Wounds. — Stewart  has  tabulated  60  cases  of  suture  of  the  heart  reported  up  to  May,  1904, 
with  a  remarkably  high  recovery  rate  of  38  per  cent.  (Amer.  .lour.  Med.  Sci.,  October,  1904).  Of  the  60  cases 
55  were  stab  wounds  and  5  were  gunshot  wounds,  2  of  the  latter  recovering.  In  4  of  the  cases  the  coronary  artery 
was  injured,  and  only  1  of  these  recovered.  The  injury  occurred  through  a  puncture  while  suturing  the  heart,  and 
an  extra  suture  was  necessary  in  order  to  control  it.  Of  the  60  cases  the  left  ventricle  was  wounded  thirty  times, 
with  30  recoveries.  The  right  ventricle  was  wounded  21  times,  with  7  recoveries.  The  operation  has  only  been 
practised  for  about  ten  years.     The  results  re|)orted  certainly  justify  its  performance  in  all  cases  of  this  kind. 


Result  after  thoracotomy  for  heart  wound. 
(E.  J.  Meyer.) 


336  SURGICAL   AFFECTIOXS  OF   THE   TISSUES 

motions  of  the  hoart,  and  the  insertion  of  sutures  will  he  as  (Hfficuh  as  trvin^  to  hit  a  flying 
target.  Nevertheless  it  may  he  done  in  many  cases.  Unless  imperative,  a  coronary 
artery  should  not  he  included  in  the  heart  suture.  Hemorrhage  from  the  heart  being 
checked  the  pericardium  is  then  to  be  united,  preferably  with  hardened  catgut  sutures, 
with  or  without  drainage.  In  most  instances  the  former  is  the  better  plan,  and  the  drain 
may  be  of  the  cigarette  type,  that  is,  gauze  wrapped  in  oiled  silk. 

Should  it  be  found  that  the  ])ericardium  alone  is  injured  and  not  the  heart  the  case 
may  be  regarded  in  a  more  favorable  light. 

There  are  sufficient  cases  on  record  where  procedures  analogous  to  the  above  have 
been  practised  to  justify  the  attemj)t  in  every  case.  Hardened  animal  sutures  may 
be  used  in  the  heart  substance,  and  the  interrupted  method  will  probably  prove  the 
better.  A  suture  which  will  hokl  firmly  for  three  or  four  days  will  suffice,  as  has  been 
proved  on  animals. 

RUPTURE  OF  THE  HEART. 

Rupture  of  the  heart  can  scarcely  be  considered  a  surgical  condition,  though  it  has 
frequently  been  one  of  medicolegal  interest.  It  may,  however,  afford  a  stidden  and 
unexpected  termination  to  surgical  cases.  The  cardiac  muscle  may  be  so  softened  by 
the  poisons  of  diphtheria  and  other  acute  infections  as  to  be  greatly  weakened,  even 
though  an  intubation  or  tracheotomy  has  apparently  afforded  security. 

TUMORS    OF    THE    HEART. 

Primary  malignant  tumors  of  the  heart  are  very  rare.  Secondary  and  metastatic 
manifestation;  are  much  more  frequent.  True  primary  sarcoma  has  been  rejieatedly 
observed,  and,  with  the  exception  of  endothelioma,  is  practically  the  only  ])nmary  can- 
cer that  could  appear  in  this  location.  Carcinoma  is  found  only  as  a  secondarv  deposit, 
with  which,  however,  the  heart  may  become  so  involved  as  to  permit  of  terminal  rupture. 

THE  PERICARDIUM. 

This  closed  sac  is  interesting  to  the  surgeon  in  cases  where  it  becomes  filled  A\ith  air; 
with  blood,  as  the  result  of  injury  (see  above) ;  with  fluid,  as  in  acute  pericarditis,  or  with 
pus,  as  a  later  stage  of  the  latter,  with  its  consequent  pi/o pericardium.  "With  the 
introduction  of  the  aspirating  needle  it  is  possible  to  draw  off  collections  of  serum  or 
pus,  and  paracentesis  of  the  pericardium  is  now  a  conventional  minor  operation.  It  is 
managed  in  the  same  way  and  with  the  same  instruments  as  when  the  pleural  cavity 
is  involved.     It  is  ordinarily  safe,  and  affords  much  relief. 

The  surgeon  may  go  even  farther  than  this  and  practise  cardiccntesis,  as  the  writer 
did  once  by  accident  while  hospital  interne.  After  introducing  the  needle  and  with- 
drawing three  or  four  oun  es  of  pus  he  discovered  that  he  had  given  great  relief,  which, 
however,  was  only  temporary.  The  autopsy  two  days  later  revealed  that  he  had  passed 
the  needle  point  through  the  pericardial  sac  into  the  heart  wall  and  had  ta])ped  the 
abscess  therein.  This  was  in  1877,  and  was  probably  the  first  time  that  the  heart  wall 
was  ever  thus  entered. 

Now  the  operator  goes  .still  farther  than  this  and  practises  intentional  cardicentesis 
in  cases  of  engorgement  of  the  right  side  of  the  heart  connected  with  lung  disease  which 
is  threatening  death  from  dyspnea  with  an  overstrained  heart.  In  such  cases  the  needle 
may  be  introduced  just  above  the  fourth  rib,  from  one-half  to  one  inch  to  the  right  of 
the  sternum,  or  entrance  can  be  effected  just  above  the  fifth  rib  in  an  upward  direction. 
From  100  to  250  Cc.  of  blood  may  be  withdrawn. 

For  ordinary  tapping  of  the  pericardium  the  needle  is  inserted  two  inches  to  the  left 
of  the  median  line  and  in  the  fourth  or  fifth  left  interspaces,  pushing  it  carefully  until 
resistance  is  no  longer  felt  and  fluid  flows  through  the  tube.  For  either  of  these  purposes 
the  patient  should  be  recumbent,  unless  the  distress  in  this  position  is  too  great,  in  order 
that  the  heart  may  fall  away  from  the  chest  wall.  Aspiration  can  be  repeated  in  ca.se 
it  gives  relief.     Little  or  no  harm  seems  to  ensue  from  the  wound  which  a  needle-point 


THE  .\irri:h'fi:s  337 

will  make  111)011  the  heart  suhstaiicc.  As  the  sac  is  profrrt'ssivcly  ('iii|)ti('<l  the  needle- 
point should  he  <;raduall_v  withdrawn.  When  aspiration,  r.\i)l()rat()ry  or  therapeutic, 
reveals  the  presence  of  |)ns,  the  well-known  rule  will  apply,  /.  r.,  that  pus  left  to  itself 
will  do  more  harm  than  will  the  surjijeon's  knitV.  I'\)r  jnoperieurdium  there  is  hut  one 
successful  tri'atment  when  as|)iration  fails,  and  that  is  open  incision  and  draina<^e.  This 
is  not  so  severe  a  measure  as  exposure  of  the  heart,  as  it  may  not  even  reciuire  the  removal 
of  one  costal  cartilajfc,  althou<fh  it  would  prohahly  he  better  to  take  out  at  least  one, 
since  the  shajx-  of  the  pericardial  cavity  will  chan<,re  to  such  an  extent  after  it  is  emj)tie<| 
as  to  raise  the  ojKMiin^  to  a  hifijher  level  than  is  <>;iven  it  at  first.  Open  incision,  then, 
with  drainage,  in  these  cases  is  no  lon<rer  an  experiment  hut  a  life-saving  procedure. 
It  will  i)rove  successful  in  at  least  half  of  the  cases,  which  otlicrwi.se  would  certainly 
perish  without  it. 

PNEUMOPERICARDIUM. 

Pneumopericardium  implies  the  j)resence  of  air  in  the  pericardial  sac,  a  condition  of 
which  (here  ai'e  now  about  K)  cases  on  record.  The  air  nearly  always  enters  through  an 
ulcerative  j)erforation  from  adjoining  parts  or  through  a  wound,  yet  in  5  of  these  cases 
no  ()|)ening  could  be  found.  In  these  it  was  probably  due  to  the  j^resencc  of  a  gas- 
forming  bacillus,  such  as  may  also  cause  pneumothorax  under  certain  circumstances. 
Tlu-  perforation  was  in  the  esophageal  wall  in  7  cases,  in  4  cases  it  was  the  result  of 
softening  of  a  lymj)h  node,  while  in  other  instances  it  has  followed  abscess  of  the  left 
lobe  of  the  liver,  i)leuropneumonia  and  gastric  ulcer  ])erforating  through  the  diaphragm. 
Of  the  8  cases  of  ju'iietrating  wound  from  without,  1  included  the  small  puncture  made 
by  ])aracentesis,  while  in  7  cases  there  had  been  fracture  of  the  ribs  or  the  sternum, 
with  wound  or  laceration  of  the  lung  or  the  pericardium. 

The  most  characteristic  sign  is  a  splashing,  gurgling  sound,  synchronous  with  the 
heart  beats,  such  as  the  French  have  called  the  "water-wheel  bruit."  These  sounds 
are  louder  than  in  hydropneumothorax,  and  are  heard  distinctly  over  the  heart.  The 
area  of  precordial  dulness  will  change  with  position. 

In  unmistakable  cases  operation  is  indicated,  the  trap-door  exj)osure  being  the  best, 
the  inner  end  of  the  fifth  and  sixth  ribs  being  elevated.  Irrigation  and  drainage  will  be 
necessary.  It  is  encouraging  to  know  that  11  of  the  40  cases  above  mentioned  have 
recovered. 

CARDIOLYSIS. 

Cardiolysis  refers  to  the  operative  release  of  the  heart  from  adhesions  which  have 
formed  between  it  and  the  pericardium  or  the  chest  wall.  When  with  every  contrac- 
tion the  heart  itself  is  subjected  to  the  strain  of  an  adhesion  the  work  proves  excessive 
and  it  will  finally  succimib.  It  has  been  suggested  by  D(4orme,  Peterson,  and  Simon  to 
either  temporarily  resect  the  chest  wall,  open  the  pericardium  and  break  down  or  divide 
the  adhesions,  or  else  to  resect  those  bony  portions  of  the  chest  wall,  ?'.  e.,  the  sternum, 
cartilages,  or  ribs,  which  are  so  inflexible  as  not  to  yield,  not  removing  the  bands  but 
making  them  harmless.^ 

THE  ARTERIES. 

There  are  few  parts  of  the  body  which  adhere  more  closely  to  the  normal  standard 
than  do  the  larger  arteries.  Even  here  malformations  and  congenital  defects  are  met 
with.  In  calculating  the  chances  of  a  given  procedure  the  surgeon  should  consider  the 
condition  of  the  venous  and  lymphatic  systems  before  deciding  to  operate  on  a  portion 
of  the  arterial  system.  This  is  particularly  true  when  ligating  the  femoral  artery  for 
elephantiasis  of  the  leg. 

Thrombosis  and  embolism  have  already  been  considered  in  the  chapter  on  the  Blood. 
Nevertheless  it  may  be  well  to  remind  the  student  at  this  point  that  thrombus  means  a 
blood  clot,  while  thrombosis  refers  to  the  process  of  its  formtion;  that  embolus  means 

'  Those  interested  in  the  modern  surgery  of  the  lieart  and  lungs  should  consult  Rickett's  recent  work  on  thig 
subject. 

23 


33S 


SURGICAL   AFFh'CTIO.XS  OF   TIIF   TISSUES 


soiiiL'thin^  which  has  passed  into  the  bh)()(l  curri'iit  of  an  arirrv  and  jjluggcd  it,  the 
obstruction  usually  hv'wv^  a  fra<i;nicnt  of  <'lot  or  tissue,  thouijjh  it  may  he  a  ch-oplet  of  fat 
or  a  hul)hle  of  air.  Kniholi,  hke  thrombi,  may  be  sterile,  and  in  this  respect  imiocent, 
or  it  may  be  com})oscd  of  material  loaded  with  sej)tie,  tuberculous,  or  cancerous  germs. 


Fig.  137 


Anastomosing  circulation  in  sar- 
torius  and  pectineus  of  dog,  tliree 
montljs  after  ligature  of  femoral. 
(After  Porta.) 


Fig.  138 


Collateral  venous  circulation,  from  a 
woman  aged  forty-seven, under  the  care 
of  W.  W.  CiuU,  in  whom  the  inferior 
vena  cava  was  completely  obstructed 
from  cancer.  (Uuy's  Hosp.  Mus.,  Draw- 
ing 44^«.) 


Fig.  139 


Direct  anastomosing  vessels 
of  right  carotid  of  goat,  five 
mouths  atter  ligature.  (Atter 
Porta.) 


The  readiness  with  which  vessels,  both  arteries  and  veiiis,  lend  themselves  to  the 
exigencies  of  extra  work  has  long  been  recognized,  and  the  natural  provision  for  collateral 
circulation  is  one  of  which  surgeons  have  for  centuries  availetl  themselves.  On  the 
contrary,  vessels  which  are  no  longer  needetl  or  whose  function  is  lost  will  imdergo  atrophy 
almost  to  obliteration;  thus  after  am])utation  of  the  thigh  the  corresponding  iliac  vessels 
become  much  reduced  in  size  (Figs.  137,  138  and  139). 


ARTERITIS;  ENDARTERITIS. 

That  arterial  walls  are  resistant  is  shown  by  the  fact  that  they  are  usually  the  last 
tissues  to  yiekl  to  gangrene.  Whether  a  ]>rimary  acute  arteritis  often  occurs  is  a  (juestion 
of  less  interest  in  this  place  than  the  fact  that  even  arterial  w^alls  will  succumb  to  infection 
and  that  secondary  hemorrhages  from  ulcerative  processes  are  by  no  means  rare.  The 
pathological  processes  which  occur  in  the  various  structures  of  the  heart  are  repeated 
in  the  arterial  walls;  thus  there  may  be  a  pcriarfrrifift  corresponding  to  pericarditis,  a 
mcsartcriti.s'  which  in  many  ways  resembles  myocarditis,  and  an  oularfmfi.s'  which 
corresponds  more  or  less  clo.sely  to  endocarditis,  and  all  of  these  in  their  acute  or  chronic 
forms.  The  acute  forms  which  concern  the  surgeon  are  due  usually  to  the  ))resence 
of  infected  emboli,  which  have  the  same  effect  U]X)n  the  arterial  walls  that  infected 
thrombi  have  upon  the  venous  walls,  i.  e.,  they  lead  to  occlusion,  infiltration,  and 
suppuration. 

Of  the  more  chronic  types  those  produced  by  syphilis  are  the  most  common.  Here 
it  is  usually  the  outer  and  inner  coats  which  suffer  most.  Tuberculous  infection  of  an 
artery  is  of  frequiMit  occurrence  and  pertains  only  to  those  vessels  Avhich  are  in  intimate 
relation  with  ])revious  tuberculous  lesions,  while  the  sy|)hilitic  forms  are  diffuse  and 
generalized  and  as  likely  to  involve  one  part  of  the  body  as  anothcM-.  It  is  well  known 
that  arteritis  in  various  degrees  of  intensity  may  be  met  with  in  most  of  the  infectious 


AM'JURYSM 


339 


(li.scasi'.s.  \\'lic(licr  they  arc  title  (o  tlic  liviiiij;  ^a-niis  or  to  toxins  t^ciicratcd  duriiii''  the 
process  tDiicerns  iis  at  this  |)oint  hut  Httle.  It  is  ol"  iiiij)ortaiK-e,  however,  to  reuhze 
that  vessels  so  (■om|)roiiiiseil  may  thus  receive  tlieir  first  impetus  to  (iegeneratiou  and 
suhse(piently  form  aneurysm.  The  dcffeneratlve  types  of  jj;reatest  interest  to  the  surfrcon 
are  /(iffi/  dnjcucratiou,  which  occurs  in  the  interior  rather  than  the  exterior,  and  ralci 
p'calion,  whicli  is  rather  an  involvement  of  j)erij)hcral  vessels  and  which  occurs  mainly 
in  the  middle  and  (he  outer  coats.  The  latter  may  he  limited  or  may  involve  an  entire; 
vessel.  WluMi  the  radial  arteries  are  involved  the  condition  may  he  a|)])reciated  at  the 
wrist.  Calcification  frc(|ucntly  follows  other  degenerations,  especially  fatty,  of  the 
intima,  and  then  may  he  seen  in  the  interior  of  an  artery.  A  true  ossification  has  been 
described,  but  is  exceedinji;ly  rare. 


ARTERIOSCLEROSIS. 

ArtcM-iosclerosis  is  a  term  o;encrally  a|)|)lied  to  a  combination  of  these  dej];enerations, 
with  thickening  and  diminution  of  caliber.  ""I'lie  chanffes  combined  are  comprehended 
in  the  term  aflicroma,  which  is  seen  as  a  localized  lesion  in  nodules  or  plaques  in  the 
aorta  and  larfijer  vessels  and  in  diffuse  form  in  the  smaller.  Atheroma,  as  a  complex 
tlegeneration,  constitutes  an  interesting  study,  as  it  leads  to  well-marked  changes  in 
the  vessel  walls,  which  are  softened  at  points  by  fatty  changes,  the  little  mass  of  (lebris 
resulting  being  called  an  atheromatous  abscess  (an  unfortunate  name),  which  may  empty 
into  the  vessel,  leaving  a  small  cavity  and  opening  known  as  the  athermnatous  ulcer. 
Around  this  occur  usually  the  calcific  changes  above  described.  The  disturbance  and 
the  roughening  thus  produced  lead  to  the  formation  of  fibrinous  thrombi,  which  attach 
themselves  firmly  at  these  points.  When  to  such  a  weakening  of  the  vessel  wall  as  is 
thus  produi-ed  are  added  the  elements  of  compensatory  cardiac  hyj)ertrophy,  and  the 
sudden  changes  of  blood  pressure  produced  by  certain  occupations  and  alcoholic  and 
other  excesses,  it  will  be  seen  how  atheromatous  patches  constitute  points  of  least  re- 
sistance, where  blood  pressure  may  cause  a  vessel  wall  at  least  to  bulge  and  thus  to  afford 
the  beginnings  of  an  aneurysm;  while,  by  combination  of  various  processes,  final  rupture 
may  result. 

The  conditions  are  not  so  very  different  in  the  more  diffuse  forms,  especially  in  patients 
who  have  not  only  a  tendency  to  vascular  disease  but  to  increase  it  by  the  addetl  toxemias 
of  gout  and  syphilis,  of  various  excesses  and  bad  habits,  in  which  not  only  do  arterial 
coats  suffer,  but  the  heart  muscle  and  lining  as  well.  The  relations  then  of  systematic 
toxemias  to  arterial  disease  and  finally  to  surgical  conditions  are  not  so  circuitous  as 
may  at  first  appear. 

ANEURYSM. 

An  aneurysm  is  a  tumor  coinviunicatinfj  ivith  an  artery  and  containing  circulatincj  or 
coagulated  blood,  or  both.  It  may  be  formed  entirely  from  the  wall  of  the  vessel,  or  some 
portion  of  it  may  be  formed  l)y  surrounding  tissue.  Several  varieties  of  aneurysm  are 
indicated  by  descriptive  adjectives.  They  are  divided,  first,  into  true  and  false,  the 
former  being  composed  of  all  the  vascular  coats  and  being  small  and  infrequent;  the 
false  aneurysms  imply  those  in  which  the  entire  arterial  wall  does  not  participate.  Aneu- 
rysms inside  the  body  cavities  are  called  internal,  and  those  involving  the  limbs  external. 
The  terms  spontaneous  and  traumatic  apply  here  as  elsewhere.  Fusiform  aneurysm 
implies  a  spindle-like  dilatation  of  the  vessel  in  somewhat  regular  form.  The  saccu- 
lated aneurysm  is  essentially  a  pouch  protruding  from  one  side  of  the  vessel  with  which 
it  communicates.  When  the  sac  ru})tures  the  aneurysm  becomes  diffuse.  If  the  outer 
coat  gives  way  and  the  inner  protrudes  there  is  a  hernial  aneurysm.  The  dissecting 
aneurysm  is  one  formed  by  separation  between  the  arterial  coats,  so  that  blood  coagulates 
or  flows  between  them.  Such  an  aneurysm  tends  to  assume  a  sacculate  form  and  to 
rupture.  A  varicose  aneurysm  is  a  sac  through  which  an  artery  and  adjoining  vein 
communicate.  A  cirsoid  aneurysm  corresponds  to  a  varix  on  the  venous  side  of  the 
circulation,  and  implies  dilatation  of  an  artery  and  its  branches.     (See  Figs.  140  to  145.) 

The  formation  of  an  aneurysm  implies  previous  disease  of  the  bloodvessel  or  trauma- 
tism, by  either  of  which  its  coats  must  have  been  weakened  or  divided.     The  previous 


340 


SURGICAL   AFFECTIONS  OF   TIIF   TfSSUFS 


Fig.  141 


Fig.  142 


Tnic  aneurysm  ;  the  sac  formed     False  aneurysm;  the  sac  formed  by    Traumatic  aneurysm  ;  the  sac  formed  by  the 
by  all  the  coats.  (Holmes.)  the  outer  coat  only.  (Holmes.)  tissues  around  the  vessel.  (Holmes.) 


Fig.  143 


Fig.  144 


Fig.  145 


Dissecting  aneurj'sm..  Hernial  aneurysm  ;   the  sac  Sacculated  aneurysm  of  ascending-  aorta. 

(Holmes.)  formed  by  the  inner  coat  only.  Death  by  pressure.   (Erichseu.) 

(Holmes.) 


.i.\7;rA'r,s'.u 


341 


Fig.  146 


disease  wliieli  leads  to  (his  cliaiifi^e  is  either  of  sypliilitic  or  other  toxic  ori<:jin,  and  usiiallv 
of  tlie  type  ol'  tlie  eiuhirteritis  ah'eady  alluded  to,  or  its  eotitiiuiatioii  into  atheroma. 
A  so-called  atheromatous  ulcer  may  lead  to  f^iving  way  of  the  ititima  and  the  passaj^e 
of  hlood  hetweeu  the  coats  of  the  vess(>l.  It  is  in  this  way  that  most  dissecting  aneurvsms 
are  formed.  ( )n  the  other  hand,  violent  strain  may  stretch  the  vessels  already  weakened 
i)y  increasing  hlood  j)ressure,  or  those  conditions  which  induce  ahnormally  high  hlood 
|)ressure  may  produce  it  by  slow  processes.  Lastly  a  vessel  may  he  partly  divided, 
as  hy  a  bullet  or  stab  wound,  or  its  adjoining  supports  may  have  been  weakened  bv  dis- 
ease or  by  accident  to  such  an  extent  that  it  constitutes  a  weakening  of  the  arterial  wall. 
The  result  of  this  will  be  expansion  in  the  direction  of  least  resistance  and  the  formation 
of  a  sacculaird  aneurysm. 

As  a  morbid  condition  spontaneous  aneurysm  seems  to  be  less  frecpicnt  now  than  in 
the  |)ast.  Certain  features  pertain  to  all  cases,  the  most  essential  l)eing  a  pulsating 
tumor,  giving  j)hysical  signs  of  its  presence  by  pressure,  which  causes  j)ain,  sometimes 
paralysis,  and  nearly  always  absor])tion  of  surrounding  tissues  as  the  tumor  exj)ands. 
Piil.s'ation  is  characteristic  and  pathognomonic  of  aneurysm,  but  an  aneurysmal  sac 
may  have  become  so  filled  with  clots  as  to  minimize  the  j^rominencc  of  this  symptom. 
The  same  is  true  of  the  ancurt/smal  hruii  or  murnuu-  which  is  heard  on  auscultation. 
This  sound  and  pulsation,  especially  of  the  fxyavsilc  tyjie,  when  present  will  rarely 
deceive.  They  may,  however,  be  simulated  by  a  solid  tumor  which  overlies  a  large 
vessel  and  transmits  its  pulsation  or  even  some  of  its  murmur.  P]ven  in  this  case  the 
significant  expansile  character  of  the  pulsation  will  be  lacking. 

The  prorjrcsft  of  an  aneurysni  may  be  checked  by  spontaneous  or  surgical  processes, 
but  no  vessel  involved  in  this  way  can  return  to  its  previous  condition.  As  the  vessel 
exj)ands  the  tendency  is  to  fortification  of  its  weakened  walls  by  coagulation  of  the  blood 
aroimd  the  periphery  of  the  sac.  This  process  may  be  a  continuous  one  or  may  occur 
at  intervals  in  such  a  way  as  to  produce  laminated  coats  of  blood  clot,  com})lete  or 
incomjilete,  which  in  certain  specimens  can  be 
l)eeled  off,  one  after  another,  much  as  an  onion 
can  be  peeled,  the  innermost  portion  repre- 
senting the  most  recent  coagulum.  In  this 
way  an  aneurysm  is  strengthened  and  thickened, 
and  rupture  postponed  for  an  indefinite  period. 
On  the  other  hand,  as  the  aneurysmal  tumor 
grows  slowly  but  steadily  it  tends  to  make  way 
for  itself  at  the  expense  of  every  other  tissue 
in  the  body.  The  hardest  bone  will  disappear 
before  the  constant  advance  of  such  a  growth, 
and  this  permits  aneurysms  which  have  had 
their  origin  in  t'he  thorax  to  develoji  into  large 
extrathoracic  tumors  whose  walls,  lacking  resist- 
ance, become  thinner  and  finally  give  way, 
death  from  hemorrhage  being  the  result.  In 
fact,  rupture  is  the  natural  tc7idenci/  of  such 
lesion,  the  question  being  whether  it  may  be 
averted  by  spontaneous  or  non-operative 
methods,  or  whether  it  should  be  subjected  to 
operation    (Fig.  14()). 

Aneurysms  may  be  minute  and  multiple,  or 
single  and  large.  The  former  are  seen  in  the 
brain  in  connection  with  syphilis,  and  in  the 
mesentery  (Fig.  147).  No  artery  in  the  body  is 
necessarily  exempt,  though  obviously  the  larger 
arterial  trunks  are  the  more  frequent  sufferers. 

Spontaneous  cure  bv  natural  methods  is  brought  about  in  one  of  the  following  ways: 
(a)  Bv  consolidation  of  laminated  clots,  (b)  A  portion  of  the  clot  may  become  detached 
and  plug  the  vessel  on  the  distal  side,  effecting  the  same  occlusion  there  that  is  produced 
with  a  ligature ;  in  some  cases  the  vessel  may  be  occluded  above  the  sac  by  a  clot  from 
the  heart,  (c)  That  which  occurs  naturally"  may  l)e  caused  by  accident  as  the  result  of 
some  trifling  injurv.     (d)  The  clot  contained  within  the  sac  may  have  become  infected, 


Tlioracic  (aortic)  ancui  >-^iii.      I' 
external  ru|)ture. 


342 


SURGICAL   AFFECTIOXS  OF   THE   TfSSlfES 


so  that  suppiiriition  with  necrosis  of  the  sac  contents  is  prochiced.  In  connection  with 
this  tliere  is  sufficient  acute  arteritis  to  occhide  tlie  vessel,  and  the  resuhing  al)scess 
within  the  sac  may  be  openeil  and  its  contents  cleared  out.  This  method  is  extremely 
rare  and  can  only  terminate  ha})pily  when  the  surgeon  intervenes  promptly. 

In  an  aneurysm  in  which  spontaneous  cure  has  occurred  there  may  be  progressive 
condensation  of  its  contents,  obliteration  ;ind  partial  reduction  in  size,  and  a  slow  process 
of  absor])tion. 

Tlie  importance  of  collateral  circulation,  in  recovery  from  aneurysm,  cannot  be  over- 
estimated, as  only  by  taking  advantage  of  it  is  it  possil)le  to  furnish  blood  for  the  needs 
of  the  part  affected.  There  is  no  vessel  with  which  the  surgeon  can  interfere  where 
natural  provisions  in  this  direction  ap])ear  insufficient  (Fig.  14.S). 

Certain  conditions  predispose  to  aneurysm  of  the  idio])atliic  type,  such  as  ar/r,  with 
its  accompaniment  of  arteriosclerosis;  .sypliilif,  with  its  well-knoAvn  tendency  to  chroiiic 
endarteritis;  occwpaiion  and  sex,  in  that  it  is  most  frequent  in  those  who  are  liable 
to  violent  exertion  and  dissipation,  because  of  the  well-known  tendency  to  arterial 
structural  changes  after  excesses  of  all  kinds.  Again,  aneurysm  may  be  the  secondary 
result  of  embolism  when  an  embolus  leads  to  a  local  arteritis  with  disorganization. 


Fig.   147 


Fig.  148 


Multiple  aneurysms  of  the  mesenteric  arteries.    (Eppinger.) 


Change  in  the  trunk  after  ligature;  with 
anastomosing  vessel.    (Erichsen.) 


-For  surgical    purposes  there  is  no  better   classification  than  the 


Classification. 

one  u.sed  by  Eve: 

1.  Sacculated  aneurysm. 

(a)  Hernial; 

(b)  Diffuse,  being  a  form  of  false  aneurysm. 

2.  Fusiform,  cylindrical,  or  fuhular  aneurysm. 

3.  Dis.'ieciing  aneurysm,  which  may  become 

(a)  Sacculated; 

(b)  Diffuse  and  false;  or 

(c)  Circumscribed. 

4.  Traumatic  aneurysm. 

(a)  Circumscribed; 

(6)  Diffuse; 

(c)  Arteriovenous. 

5.  Arterial  varix,  cirsoid  or  racemose  aneury.im. 

6.  Angioma  or  aneurysm  by  anastomosis. 

1.  Sacculated  Aneurysms. — The  sacculated  arc  the  most  common.  They  assume 
various  shapes  and  dimensions,  and  may  be  .seen  anywhere  in  the  body.  The  opening 
between  the  sac  and  the  main  vessel  may  vary  in  size.  These  sacs  are  usually  strengthene(l 
by  j)lastic  exudate  in  and  around  them,  and  condensation  of  surrounding  tissue.  In 
thickness  they  vary  from  1  Cm.  to  the  thinnest  which  will  sustain  blood  pressure.     In 


AX /'Jinn- SM 


343 


old  scars  may  Im*  found  a  stratiform  or  lavcr-likc  iirraiif^cmciit,  especially  where  the 
blood  stream  is  less  active.  Should  spontaneous  cure  take  place  th(;  sac  may  he 
obliterated,  while  later  caleilic  or  other  ehanifcs 
in  the  old  scar  may  occur.  When  the  outer 
portion  of  such  a  sac  has  disap|)eared  and  the 
inner  coat  is  j)ushe(l  out  so  as  to  assume,  ap- 
parently, a  secondary  aneurysmal  arraufjement, 
tli(<  condition  is  r(>ferred  to  as  a //^'/v(/r;/ aneu- 
rysm. W  lien  the  ordinary  sacculation  g\\'vs 
way  as  the  result  of  necrosis,  of  pressure  from 
within,  or  loss  of  su])|)ort  from  without,  the 
ojK'ninij;  first  made  is  usually  small  and  the 
extravasation  outside  (h(>  true  sac  will  depend 
upon  the  nature  and  resistance  of  the  surround- 
ing tissues.  In  this  way  a  difjuse  aneurysm  is 
formed,  wiiicli  is  one  of  the  varieties  of  false 
ancMUTsm. 

2.  Fusiform  Aneurysms. — Fusiform  aneu- 
rysms are  more  or  less  tubular  and  sj)indle- 
like  dilatations  of  arterial  truid-cs,  in  whose 
walls  may  occur  the  changes  common  to  ail 
these  lesions,  the  dilatation  rarely  being  suffi- 
ciently large  to  permit  of  laminated  coagula 
unless  a  sacculation  occurs  later  at  some  par- 
ticular portion  (Fig.  149). 

3.  Dissecting  Aneurysms. — The  dissecting 
aneurysms  are  nearly  always  expressions  of 
])revious  atheromatous  changes,  by  which 
l)lood  is  forced  between  the  arterial  coats, 
.sejjarating  them  and  causing  them  to  bulge  at 
one  or  more  points  into  sacculations  or  distor- 
tions. In  a  /a/.sr  ancurifsm  there  is  no  true 
arterial  coat;  the  sac  is  made  up  of  surround- 
ing tissue. 

4.  Traumatic  Aneurysms. — Traumatic  aneu- 
rysms  are   generally  sacculated    by   the  time 


Fusiform  aneurysm  of  popliteal  artery,  duo  to 
arterial  disease  (man  aged  59),  requiring  ampu- 
tation of  thigh  on  account  of  gangrene.     (Lexer.) 


Fig.  150 


Traumatic  aneurysm  of  axillary  artery.    (Paik.) 


344 


SURGICAL   AFFIiCTIOXS  OF   TIIF   TISSCES 


thev  come  under  the  .sur(ieon'.s  ()l)servalion.  Tlu-y  are  cireuinscrihed  and  diffuse. 
According  to  their  acje  and  other  circumstances  they  may  contain  (jld  and  dense  himinated 
clots  as  well  as  those  which  are  fresh  and  stratified.'  :\Iuch  will  deiK-nd  upon  whether  the 
artery  has  been  extensively  injured  or  only  slightly  punctured,  and  also  upon  the  loca- 
tion and  distensibilitv  of  the  surrounding  tissue.  Such  a  case  seen  in  a  fresh  state  will 
show  infiltration  of 'blood  and  ecchymosis  (Fig.  150).  Arierioretwus  aneurysms  are 
now  seldom  seen.  When  venesection  was  more  frequently  performed  the  artery  and  one 
of  the  veins  at  the  bend  of  the  elbow  were  often  thrown  into  communication,  as  the 
result  of  the  indifferent  performance  of  this  operation  and  the  use  of  the  old-fashioned 
lancet.  "When  the  communication  is  direct  such  a  condition  is  known  as  an  aneu- 
rysmal varix;  when  indirect  and  through  the  sac  it  is  called  a  varicose  aneurysm  (Figs. 
151,  152  and  153.) 

Fig.  151  Tig.  152 


;\.    (Bryant.) 


Fig.  15.3 


Varicose  aneurysm  removed  from  its  connections. 


(F.richsen.) 


Arteriovenous  aneurysm  at 
bend  of  elbow:  a,  brachial 
artery;  b,  radial  artery;  c,  basilic 
vein;  d,  median  basilic  vein;  e, 
aneurysmal  sac;  /,  dilated  vein. 
(Lenoir.) 


Fig.  154 


Cirsoid  aneurysm.   (Bruns.) 


5.  Cirsoid  or  Racemose  Aneurysms. — 
Cirsoid  or  raccni()>c  anciirysms  consti- 
tute vascular  tumors  of  irregular  shape 
and  outline,  according  to  the  extent 
of  the  arterial  system  involved. 

n.  Angioma  or  Aneurysm  by  An- 
astomosis.— The  difference  between 
angiomas  and  cirsoid  aneurysms  is  more 
artificial  than  natural.  When  a  single 
vessel  is  involved  with  all  its  branches 
it  constitutes  an  elongated  tumor  and 
partakes  of  the  nature  of  a  varix.  When 
the  growth  is  a  collection  of  small 
arteries  the  condition  is  then  known 
as  an  angioma.  Between  these  there 
may  be  all  varieties  of  vascular  changes. 
Fig.  1.54  illustrates  a  ca.se  of  this  kind 
in  the  scalp,  while  Fig.  1.55,  contributed 
by  Parker,  illustrates  a  congenital  in- 
volvement of  the  vessels  of  an  entire 
limb,  with  overgrowth  of  the  same  from 
increase  of  blood  supply. 


AMJCh'YSM 


345 


Diagnosis. —  An  ancurvsin  so  coiistitiitcil  as  to  he  easily  palpated  can  searcely  lie  mis- 
taken lor  a  lunior  of  any  other  kind.  It  can  he  reeoj^nized  hy  its  eirennis(  rihed  natnre; 
its  pnlsation,  which  is  always  of  the  ex|)ansih'  type;  its  hrnit,  which  is  synchronons  with 
svstole.  It  can  he  eni|)tied  l)V  pressure,  fills  somewhat  slowly  it'  pressjire  is  made  above 
it,  hut  more  rapidly  if  pressure  is  made  below  it,  heinif  in  this  respect  the  counter})art 
ot"  a  venous  anijioma.  Its  size  and  rapidity  of  ])ulsation  are  influenced  hy  position,  and 
its  location  is  usually  that  of  one  of  the  large  arterial  trunks.  'I'he  murmur,  heard 
through  the  stethoscope,  is  sometimes  more  than  a  mere  hrnit, 
and  may  he  of  a  tumultuous,  almost  roaring  character,  the 
sounds  being  modified  by  the  smoothness  or  roughness  of  the 
interior  blood  chaimel  as  well  as  by  the  thickness  of  the  parts 
outside.  .Naturally  the  sounds  can  be  altered  by  j)ressure. 
The  overlying  integument  is  at  first  unchanged,  but  if  an  aneu- 
rysm is  working  its  way  toward  the  surface  and  threatening 
ru|)ture  the  skin  w'ill  be  stretched  and  discolored  and  may 
finally  ulcerate.  Blood  j)re.ssure  as  measured  by  the  sphyg- 
momanometer is  not  altered  in  a  liml)  which  is  affected  by 
aneurysm. 

Signs  and  symptoms  which  are  not  local  are  also  j)roduced  in 
most  cases,  their  variety  being  great  and  (lejXMiding  upon  the 
location  of  the  primary  disturbing  cause;  for  examj)le,  there 
is  generally  edema  with  venous  congestion  of  parts  situated 
distally,  these  features  being  .so  extreme  in  some  ca.ses  as  not 
only  to  threaten  but  even  to  occasion  gangrene.  By  jiressure 
upon  nerves  both  pain  and  paralysis  are  produced  and  important 
functions  impaired. 

The  tendency  in  all  aneurysms  is  to  increase  in  size  and  cause 
atroj)hy  or  disai)])earance  of  the  ti.ssues  upon  which  they  exer- 
cise their  present  influence. 

Regional  Indications.  Innominate  Aneurysms. — Innomi- 
nate aneurysms  usually  appear  behind  the  right  sternocla- 
vicular joint.  As  they  increase  in  size  they  cau.se  pain  and 
edema  of  the  right  arm  and  the  right  side  of  the  face,  cough, 
dyspnea,  and  dysphagia.  As  the  swelling  increases  it  rises 
above  the  rib  and  sternum,  pushing  forward  the  sternomastoid 
and  the  clavicle.  After  being  displaced  the  bones  and  carti- 
lages in  front  begin  to  disajjpear  by  erosion,  and  the  growth 
makes  its  way  to  the  surface,  where  pulsation  can  be  easily  seen 
as  well  as  felt  and  heard.  In  proportion  to  their  increase  other 
significant  pressure  symptoms,  with  venous  turgescence,  will  occur.  Innominate 
aneurysms  can  sometimes  be  differentiated  from  aortic  by  the  sign,  described  by  Porter, 
of  tracheal  tugging.  This  is  elicited  by  causing  the  patient  to  sit  up  and  bend  the 
head  forward,  after  which  the  cricoid  is  grasped  and  drawn  forcibly  upward,  thus 
stretching  the  trachea.  If  with  each  cardiac  impulse  a  well-marked  tugging  sensation 
be  felt  it  may  be  attributed  to  the  pulsation  of  an  aortic  aneurysm. 

Subclavian  Aneurysms. — Subclavian  aneurysms  of  the  first  j)art  of  the  vessel  present 
similar  features,  only  that  the  bruit  is  propagated  down  the  axillary  artery  rather  than 
up  the  carotid,  and  is  not  influenced  by  carotid  pressure,  while  the  pressure  symptoms 
are  limited  mostly  to  the  arm.     In  axillary  aneurysm  the  radial  pulse  is  more  delayed. 

Carotid  Aneurysms. — Carotid  aneurysms  are  not  always  easy  of  early  diagnosis, 
as  at  the  root  of  the  neck  solid  tumors  often  transmit  a  deceiving  pulsation  and  convey 
an  exaggerated  vascular  .sound.  They  may  also  give  rise  to  the  same  pressure  symptoms 
as  do  subclavian  aneurysms.  Non-vascular  tumors  do  not  have  an  exjiansile  pulsation, 
nor  is  the  arterial  sound  conveyed  upward  along  the  carotid  as  in  true  aneurysm.  In 
aneurysms  of  the  external  carotid  there  may  be  paralysis  of  the  tongue  as  well  as  diffi- 
culties in  speech  and  deglutition.  Aneurysms  of  the  internal  carotid  tend  to  extend 
inward  rather  than  outward.  Intracranial  aneurysms  are  ilifficult  of  diagnosis,  but 
they  usually  give  the  symptoms  of  brain  tumor,  with  possibly  a  bruit  that  may  be  heard 
and  described  by  the  patient  himself,  especially  in  certain  positions  of  the  head. 

Wardrop  used  to  formulate  the  diagnostic  features  of  certain  aneurysms  at  the  base 


Cirsoid  aneurysm  of  fem- 
oral artery  and  telangiec- 
tasis, with  lengtliening  of 
affected  limtj  from  hypernu- 
trition.      (Parker.) 


346 


SURGICAL   AFFl'JCTinxs  OF   THK   TISSUES, 


Fig.  156 


of  (he  lUH'k,  as  follows:  Iniioniiiiatc  aiuMirysnis  (fciu'rally  inouojiolizc  tlic  cpistcnial  notch 
or  i-atluT  its  riylit  side,  takiiiif  up  this  wiiok'  s])ace,  even  thougli  not  risino;  Wi^^h.  They 
first  j)ivsent  to  iht-  inner  side  of  the  ri<:jht  sternonuistoid,  while  carotid  aneurysms  aj)pear 

in  the  interval  between  the  .sternal  and  clavicular  heads, 
and  subclavian  aneurysm  to  the  outer  side  of  this 
muscle. 

In  the  abdomen  tlu>  aorta  is  most  'frecjuently  involved, 
and  sometimes  its  lari^er  branches.  An  aneurysm  of  the 
renal  or  mesenteric  arteries  can  easily  be  mistaken  for 
an  aortic  aneurysm.  The  aorta  ])ro])er  terminates  at 
the  level  of  the  umbilicus.  A  pulsating  tumor  below 
this  level  should  belong  to  one  of  the  iliacs.  Recog- 
nition will  depend  largely  upon  the  thinness  of  the  ab- 
dominal wall  and  the  absence  of  fat.  In  many  cases 
expansile  pulsation  can  be  detected  even  here,  while 
the  ])ain  is  radiated  along  the  well-known  branches  of 
the  sympathetic,  and  the  location  to  which  it  is  referred 
may  be  of  aid  in  deciding  the  part  of  the  aorta  most  in- 
volved. Aortic  pulsation  is  commimicated  by  growths 
overlying  it,  and  the  surgeon  is  liable  to  be  deceived  by  a 
certain  abnormality  of  the  natural  pulsation  through  this 
trunk,  as  it  is  often  exaggerated  and  appears  i)athological 
when  it  is  not.  Abnormal  pulsation  of  the  abdomined 
aorta  tvas  first  described  by  Cooper,  and  has  served  as  a 
topic  for  surgical  essays  ever  since.  Schedc's  test  may 
be  a]>plied  here  to  advantage:  if  firm  pressure  be  mad(> 
simultaneously  upon  both  femoral  trunks  the  extra  blood 
pressure  thus  caused  inside  the  tiunor  will  give  rise  to 
pain,  whereas  in  the  absence  of  aneurysm  it  produces 
no  such  effect. 

Iliac  and  femoral  aneurysms  may  be  made  difficult  of 
recognition  by  obesity,  but  the  bruit  can  almost  always 
be  heard,  and  this,  with  such  extra  aid  as  the  rectal  or 
vaginal  examination  may  afford,  coupled  with  pressure  symjMoms  confined  to  one 
limb,  will  usually  facilitate  diagnosis.  Fig.  157  illustrates  what  featiu'es  a  tumor  of  this 
kind  may  j^resent  when  locatt'd  in  the  upper  part  of  the  thigh. 

Treatment. — Tlu>  general  jnu-pose  of  the  treatment  of  aneurysms  is  to  favor  coar/u- 
lati(ni  and  to  effect  a  cure  in  this  way.     In  the  pre-antiseptic  era  it  is  not  strange  that 


Varicns  of  saiiheiious  and  branches 
(phlebectasis).  (I,exer.)  Compare 
with  Fig.  153. 


Fig.  157 


Sacculated  aneurysm  i)f  femoral  artery.      (Parmenter.) 


men  resorted  to  the  method  of  starvation,  by  which  the  coagulability  of  the  blood  was 
much  increased,  or  to  the  rest  treatment,  with  the  use  of  cardiac  sedatives,  by  which  the 
heart's  activity  and  power  were  greatly  reduced.  Nor  was  it  strange  that  non-operative, 
yet  mechanical,  methods  were  used,  in  order  to  minimize  the  danger  attending 
operative  procedures.  With  the  confidence,  however,  which  Lister  and  his  followers 
have  given,  it  is  generally  conceded  that  with  an  aneurysm  which  can  be  made  accessil)le 


A\I<:uRys^r 


m 


Fio.  158 


by  an  oprnition  radical  inctliods  arc  nioiv  .salisfactory.  To  tlic  surgeon  hclonj;-  all 
ancurvsms  c\<('|)(,  iH'rlia|).s,  those  of  the  aorta  and  the  innominate,  and  even  these 
have  not  been  exempt  from  suri^ical  methods.  The  followinj^;  ojx'rativi-  measures  are 
worthy  of  discussion  in  these  cases:  (1)  Liijatmc.  (2)  Open  operation.  (3)  K.riir- 
paiion.  (4)  Opcninfj  and  nuture.  (5)  Introduction  oj  rvirc,  with  or  witliovt  cIcctrohjxiN. 
1.  Lii;;ation  includes  the  application  of  a  lifjature  in  one  of  the  followinf;  situations: 
(a)  Proximal  ligation  (Anel's)  at  a  convenient  point  shortly  above  the  sac;  (J))  proximal 
ligatioii  (Hunter's)  at  a  distance  from  the  sac;  (c) 
distal  ligation,  either  of  the  main  trunk  just  below 
tlu>  sac  (Brasdor's)  or  of  the  highest  main  branch 
given  off  below  the  sac  (Wardroj)'s).  Thus 
proximal  ligation  could  be  practised  in  case  of 
aneurysm,  either  of  the  external  or  internal  caro- 
tid, by  tying  the  main  trunk,  or  in  the  case  of 
j)opliteal  aneurysm  (Hunter's  suggestion),  by  tying 
the  fi'moral  in  Hunter's  so-called  canal.  Brasdor's 
distal  ligation  may  be  illustrated  by  ligature,  in 
Hunter's  canal,  of  the  femoral  for  aneurysm  in 
the  groin,  while  Wardr()j)'s  modification  would 
consist  in  tying  one  of  the  tibials  for  pojjliteal 
aneurysm,  or  one  of  the  lesser  carotids  for  aneu- 
rysm of  the  common  trunk.  Should  ligation  be 
(letermined  upon,  circiunstances  will  dictate  where 
the  ligature  should  be  applied,  and  the  surgeon 
will  tlecide  the  character  of  the  suture  material. 
The    methods    of   attack   upon    the  large  vascular 

trunks  will  be  considered  later.  Inasmuch  as  it  takes  time  to  establish  collateral  cir- 
culation, attention  should  be  given  to  physiological  rest,  as  well  as  to  all  (jther  general 
measures  calculated  to  make  any  o})eration  successful. 


Ariel's 
operation. 


Distal 
o|>erati()n. 


Fig.  159 


Brachiocephalic  aneurysm;  Brachiocephalic  aneurysm;         Brachiocephalic  aneurysm; 

ligature     of     the    subclavian         liKature  of  the  carotid  only.       ligature  of  the  subclavian  and 
only.  carotid. 

Different  schemes  for  application  of  the  ligature  according  to  the  necessities  of  the  case.     (Krichsen.) 

2.  Open  division  was  first  suggested  in  the  fourth  century  by  Antyllus.  It  soon  fell 
into  disuse  and  was  taken  up  during  the  middk^  of  the  past  century  by  Syme,  to  whom 
the  operation  has  been  frequently  credited,  although  it  was  really  the  revival  of  an 
antique  method;  but  Syme  gave  it  so  much  of  his  anatomical  exactnes.s  and  brilliancy 
of  operative  skill  that  he  almost  made  it  his  own.  The  method  was  essentially  one  by  long 
and  free  incision,  through  which  the  interior  of  the  sac  was  fully  exposed,  its  contained 
clots  turned  out,  its  vascular  openings  jilugged,  while  a  ligature  was  applied  above  and 


348 


SUIidlCAL   AFFECT fONS  OF   TIIF   TISSVKS 


Kiii.  IGO 


Aneurysm  of    the   00111111011   carotid  successfully 
treated  by  coinijlete  extirpation.     (Park.) 


below  in  order  to  prevent  further  arterial  eoiiinuiiiieatioii.  i'erfornied  before  the  days 
of  anesthesia  or  of  antise})sis  it  was  an  exeeedin<:;ly  l)old  proeetlure,  yet  in  Syme's  hands 
it  gave  brilliant  results. 

3.  The  open  divimm  has  been  replaced  by  the  more  })erfeet  procedure  of  extirpation 
of  the  sac,  based  upon  the  general  principle  that  an  aneurysm  is  a  tumor  and  should  be 
extirpated,  the  parts  being  sutured  and  expected  to  heal  promptly.  It  constitutes  in 
nianv  cases  the  ideal  method  of  treatment.  There  could  be  but  one  improvement  on 
it,  namelv,  that   suggested  by  IVIatas,  of  arteriorrliapJij/,  as  one  of  the  radical  methods 

which  is  often  applicable  to  aneurysms  of  the 
extremities,  or  to  those  where  rupture  has  oc- 
curred or  is  imminent.  The  part  should  be 
made  bloodless,  as  in  this  way  perfect  control 
can  be  secured;  should  this  be  impracticable, 
the  vessel  should  be  ligated  above  the  aneurysm 
before  proceeding  to  its  excision.  This  done, 
and  the  vessels  secured  above  and  below,  the 
wound  may  be  closed  as  after  any  other  opera- 
tion, and  in  this  way  radical  cure  achieved 
within  a  few^  days. 

Fig.  160  illustrates  a  recent  case  of  this  kind 
in  the  author's  hands,  where  an  aneurysm  of  the 
common  carotid,  of  about  the  size  of  a  lemon, 
was  treated  in  this  way,  the  patient  leaving  the 
hospital  in  eight  days,  and  having  no  im])leasant 
c()m])lications. 

4.  Open  diinfiio7i  ivith  arteriorrhapluj  has 
been  jiroposed  by  IVIatas  and  ISIurphy  and  in 
their  hands  has  been  successful.  Its  greatest 
usefulness  is  found  in  traumatic  aneurysms 
of  long  standing  where  the  arterial  opening  is  usually  small  and  the  vessel  wall 
healthy,  so  that  after  excision  of  the  sac  a  sufficient  amount  of  aneurysmal  wall  or  stump 
may  be  retained  in  order  to  afford  a  firm  surface  for  union.  The  circulation  being 
controlled  the  sac  is  exposed,  opened,  and  dissected  down  to  a  location  near  the  arterial 
opening.  Here  the  arterial  walls  are  trimmed  and  freshened,  turned  in  or  rolled  in, 
and  a  row  of  sutures  applied,  one  line  apart,  through  the  outer  and  middle  coats.  INIatas 
suggests  that  after  the  suture  is  complete  the  size  of  the  vessel  should  1k>  less  than  its 
normal,  in  order  that  pressure  may  be  reduced  at  this  point  and  more  perfect  union  follow. 
The  method  may  also  be  resorted  to  in  certain  fusiform  aneurysms,  where  the  arterial 
wall  is  still  sufficiently  healthy  to  sustain  sutures.  Here  an  elliptical  piece  can  be  excised, 
or  it  may  be  possible  to  infold  the  coats  of  the  sac  and  ap]^ly  sutures  through  a  series 
of  folds,  on  the  same  principle  that  they  are  a])plied  in  cases  of  dilatation  of  the  stomach. 
Arterial  suture  as  practised  in  these  cases  is  similar  to  the  Lembert  suture  used  in  intes- 
tinal surgery.  It  is  necessary  to  support  the  tissues  around  the  sutured  artery  by  other 
buried  sutures  in  such  a  manner  as  to  fortify  them  against  yielding  of  the  arterial  coats. 
For  these  radical  methods,  either  by  excision  or  this  combined  with  suture,  the  arterio- 
venous aneurysms  afford  an  inviting  class  of  cases.  The  parts  having  been  made  blood- 
less and  the  vessels  separated,  sutures  may  l)e  applied,  if  there  be  sufficient  room  for  them 
without  too  much  occlusion  of  the  vessels,  which  would  afford  but  little  advantage  over 
ligatures. 

In  spite  of  what  has  been  said  about  the  rarity  of  these  lesions,  which  is  true  in  civil 
life,  it  has  been  shown,  during  recent  wars,  that  bullets  of  small  caliber  having  high 
velocity  have  produced  instances  of  this  character. 

5.  For  cases  so  situated  as  to  make  any  of  the  above  methods  inexpedient  there  is 
still  the  more  or  less  promising  method  of  treatment  by  the  introduction  of  vnre,  coupled 
perhaps  with  the  use  of  the  electric  current,  ami  the  injection  of  gelatin  solutions.  While 
ligation  of  the  abdominal  aorta  has  been  practised  with  temporary  success  it  has  not  yet 
proved  so  encouraging  as  to  justify  its  performance,  save  in  exceptional  cases,  but  into 
any  intrathoracic  or  intra-abdominal  aneurysm,  which  appears  to  be  otherwise  inoper- 
able, a  number  of  feet  of  fine  steel  wire  may  be  introduced,  in  the  attempt  to  coil  it  up 
irregularly  within  the  sac  and  thus  to  afford  a  sort  of  skeleton  framework,  upon  which 


si'TCh'h'  OF  iiij)<)i)vi:ssi-:i.s 


340 


coiiffula  will  more  readily  i'oiiii  and  In  wliich  tlicy  may  hv  rctaiiu-d.  In  sonu'  cases 
the  end  of  this  wiiv  has  been  attached  to  the  neffative  j)ole  of  a  fi;alvanic  battery,  the 
other  j)ole  hein*:;  aflixed  to  an  external  electrode,  and  a  weak  ijalvanic  current  has  l)een 
passed  for  a  |)eriod  of  say  from  five  to  thirty  minutes,  the  time  varyiniij  in  accordance 
with  the  stren<i;th  of  the  current.  By  this  j)r<)cedure  coaifulation  is  mucii  encourafijed. 
In  cases  of  intra-ahdoniinal  aneurysm  the  abdomen  may  be  opened  and  the  sac  more 
or  less  com|)U>tely  e\|)osed,  after  which  this  insertion  may  be  more  minutely  performed. 

Occasionally  sur<i('ons  have  exposed  an  aortic  aneurysm  and  endeavored  to  externalize 
or  exclude  it  by  produein<j;  adhesions  around  it,  while  some  portion  of  the  sac  is  exposed 
to  the  outer  world.  After  adhesions  have  formed  such  methods  of  treatment  can 
be  repeated  as  may  be  desired.  'I'hey  may  also  be  combined  with  the  subcutaneous 
use  of  2  per  cent,  sterile  gelatin  solution,  or  this  may  be  thrown  into  the  sac  in  small 
amounts,  ll  is  true,  however,  that  cases  of  this  character  are  desperate,  and  while  life 
has  been  in  j)erhaps  half  of  the  operated  cases  more  or  less  prolonj^ed,  but  few  instances 
of  final   recovery  have  been  recorded. 

The  after-treatuKMit  consists  of  physiological  rest  of  the  part  ojK'rated  upon,  and  rest 
and  abstention  from  violent  exertions  of  any  kind.  During  this  time  elimination  should 
not  be  n(>glected,  emotional  excitement  should  be  avoided,  and,  in  the  ])resenee  of 
syphilitic  disease  or  a  well-founded  suspicion  of  it,  conventional  antis])ecifics  should  be 
administered  in  sufficient  amounts.  When  the  aneurysm  is  of  traumatic  origin  and  there 
is  no  general  vascular  or  cardiac  disease,  there  will  be  a  quick  restoration  of  the  integrity 
of  ])arts  as  well  as  of  their  usefulness.  INIassage  and  an  elastic  bandage  will  be  useful, 
in  order  to  atone  for  the  results  of  a  disturbed  circulation. 


SUTURE   OF   BLOODVESSELS. 

This  is  almost  a  new  topic  in  surgery,  especially  suture  of  the  arteries.  Surgeons 
have  learned  that  the  walls  of  the  arteries  and  of  the  veins,  when  not  too  much  diseased, 
will  tolerate  sutures  and  unite  easily.  The  larger  the  vessel  the  easier  it  is  to  apply 
a  suture,  as  its  walls  are  thicker  and  the  method  easier.  The  greater,  too,  will  be  the 
need  of  suture  when  the  vessel  is  an  important  one.  Small  vessels  are  relatively  so 
unimportant  as  not  to  demand  so  formal  a  procedure'.  The  vessels  to  which  the  method 
is  most  a))plicable  are  the  common  carotitl,  the  subclavian,  axillary,  brachial  and  femoral, 
with  their  accompanying  veins,  including  the  common  jugular.  It  is  a|)plicable  when 
it  is  an  injury  to  the  vessel  which  has  necessitated  an  operation,  or  when,  during  its  per 
formance,  some  trunk  has  been  torn  out  or  torn  open,  as  in  separating  adhesions.  It  is 
serviceable,  also,  when  both  artery  and  vein  have  been  involved,  as  in  the  groin,  where 
the  danger  of  gangrene  of  the  limb  would  be  enhanced  if  both  the  outflow  and  the 
inflow^  of  the  blood  were  shut  off. 

Fig.  161 


End-to-end  suture  of  a  divided  artery,  permitting  a  certain  degree  of  invagination.      (After  Murphy.) 

Lateral  suture  of  injured  bloodvessels  may  be  regarded  as  a  standarfl  procedure,  as 
it  is  nearly  always  possible  to  temporarily  control  the  circulation  on  both  sides  of  the 
field  of  operation,  either  by  elastic  constriction  or  temporary  ligation  or  clamping.  For 
this  purpose  fine  silk  makes  the  best  suture  material.  It  should  be  threaded  into  round 
needles  and  the  sutures  should  include  only  the  two  outer  coats.     After  completing 


350  SURGICAL   AFFECT  loss  OF   THE   TISSUES 

the  .suture  the  distal  provisional  closure  of  the  vessel  should  be  first  removed.  As  the 
blood  backs  up  in  the  artery  it  will  test  the  efficacy  of  the  sutures.  Should  there  be  no 
kakatje  the  proximal  clamj)  may  l)e  removed,  and  then  if  the  condition  appear  satis- 
factory the  arterial  sheath  should  be  carefully  closed,  and  over  this  the  other  tissues, 
with  buried  sutures. 

End-to-end  .suture  of  l)lo()dvessels  is  a  recent  measure,  for  which  we  are  indebted  to 
Murphv.  It  is  aj)plicable  to  vessels  which  have  been  divided  circularly  and  completely 
or  almost  comj)letely.  In  the  event  of  the  adoption  of  this  method  the  ends  should  be 
divided  squarely  and  then  reunited  by  sutures  threaded  upon  the  needles,  passing 
through  all  the  coats,  about  1  JMni.  from  the  margin  of  division,  as  well  as  about  the  same 
tlistance  apart.  If  the  upper  end  can  be  drawn  into  the  hnver  one,  and  gently  held  there 
by  a  series  of  U-shaped  stitches,  it  may  be  considered  the  best  method.^     (See  Y'lg.  IGl.) 


LIGATION  OF  ARTERIES. 

Arteries  are  exposed  and  ligatcd  in  their  continuity  for  the  purpose  of  controlling  hemor- 
rhage, either  for  temporary  or  permanent  purj^oses.  The  results  of  permanent  ligature 
have  been  described  in  the  chapter  on  Wounds.  The  application  of  a  ligature  should 
be  so  made  as  to  thoroughly  break  up  the  intima  without  serious  injury  to  the  other  coats 
of  the  vessel.  Coagulation  and  organization  of  the  thrombus  soon  produce  a  permanent 
occlusion  and  obliteration.  It  is  a  mistake  to  endeavor  to  tie  the  ligature  too  tightly. 
HardiMied  catgut  or  freshly  boiled  silk  make  the  best  ligature  material.  It  is  seldom  a 
(lifHcult  matter  to  find  the  desired  artery  upon  the  normal  individual  or  upon  a  cadaver. 
In  sonic  cases  in  i)ractise  the  tissues  through  which  search  must  be  made  will  be  found 
infiltrated  with  blood  or  otherwise  altered,  ami  the  discovery  of  and  attack  upon  the  vessel 
may  be  thus  made  very  trying.  The  vessel  when  exposed  in  its  continuity  will  be  recog- 
nized by  the  sense  of  touch  rather  than  that  of  sight,  and  almost  the  entire  maneuver 
may  be  made,  by  touch  alone,  by  one  whose  tactile  sensibility  has  been  well  trained  and 
without  any  clear  view  of  the  vessel.  The  arteries  which  are  thus  exposed  have  their 
own  sheaths,  especially  the  larger  ones,  which  should  be  opened  with  care,  not  alone  to 
avoid  injury  to  the  vessel  itself,  but  in  order  that  the  amount  of  separation  may  be 
as  slight  as  possible,  as  the  sheath  is  necessary  for  support  and  for  nutrition.  Having 
exposed  the  vessel  and  divided  the  sheath  the  ligature  is  introduced  with  a  blunt,  curved 
needle  attached  to  a  handle,  and  known  as  an  aneurysm  or  artery  needle.  It  is  made 
to  carrv  the  ligature,  or  it  is  so  insinuated  and  brought  out  from  behind  the  vessel 
that  the  ligature  may  be  threaded  into  its  eye.  Caution  should  be  exercised  that 
nothing  but  the  artery  itself  is  included;  this  Is  especially  necessary  in  the  neck,  where 
the  relations  between  the  large  vessels  and  the  nerves  are  very  intimate.  As  a  general 
rule  the  needle  should  not  be  threaded  until  after  it  has  been  passed.  The  knot  should 
be  tied  in  the  depths  of  the  wound,  and  the  vessel  should  not  be  disturbed  by  efforts 
to  secure  the  knot.  If  the  operation  have  been  done  as  it  should  it  will  not  be  necessary 
to  drain  such  a  wound,  but  it  may  be  closed  by  buried  and  superficial  sutures.  When 
one  (jf  the  limbs  has  been  involved  in  this  operation  it  should  be  kept  absolutely  at 
rest,  in  a  somewhat  elevated  j)osition,  and  warm  ajiplications  made,  in  order  that  the 
warmth  j^reviously  maintained  by  the  free  circulation  of  arterial  bl(;od  may  not  be 
allowed  to  drop  too  low. 

Innominate  Artery. — The  innominate  had  been  tied  between  thirty-five  and 
forty  times,  up  to  1<)05.  A  number  of  patients  have  survived  the  operation,  and  died 
within  a  few  weeks  of  cardiac  and  arterial  disease.  Some  have  progressed  a  number 
of  weeks,  with  rapid  recovery  from  the  operation  and  temporary  improvement 
sufficient  to  justify  this  ojjcration  in  ajiparcntly  favorable  cases.  This  vessel  and  the 
carotid  also  should  be  tied,  in  order  that  the  resulting  clot  may  be  more  perfect  and 
that  there  should  be  no  return  pressure  made  upon  the  aneurysmal  sac.  The  incision 
is  made  along  the  anterior  border  of  the  sternomastoid  down  to  the  clavicle  and  then 

>  There  are  now  before  the  profession  three  methfxls  of  repairing  arteries — by  inraginaiion,  by  suture  of  the  two 
outer  coats,  by  the  throuqh-nnd-throuqh  method — each  of  which  has  its  advantages  and  disadvantages.  Tlie  presence 
of  sutures  in  the  interior  of  the  vessel  does  not  seem  to  produce  coagulation,  even  tlu)Ugh  the  intima  of  the  vessel 
is  injured  by  the  passage  of  the  same.  Nevertheless  sutures  must  be  kept  out  of  the  blood  stream.  Liability 
to  secondary  hemorrhage  is  reduced  if  a  double  line  of  sutures  can  be  tised. 


Lic.vrios  OF  Mrri:ini:s  351 

aloii^'  llic  iiiiuT  third  of  tliis  hour,  thus  l'oiiiiiii«>;  a  llaj)  whose  Irt'e  cdtjcs  arc  10  (!iii.  in 
Itii^'th.  The  stt-nuil  and  clavicuUir  lioads  of  llic  sti-nioinastoid  aiv  dividi-d,  while  the 
sternohyoid  and  sternoinastoid  are  separated  from  the  stermini,  can;  heiiij;  taken  es|)e- 
eially  of  the  anterior  ju^uhir  vein,  which  may  he  douhie  li<;ated,  if  necessary,  and,  in 
the  div|)cr  (hssi-etion,  of  the  |)neumo<i;aslric  and  the  recnrrcnt  hiryii<jcal  nerves,  which 
w  ind  around  the  innoniinati',  and  tlic  |)hiciiic,  wliich  is  in  close  relation  witli  it.  In  view^ 
of  the  <>reat  cn<,'or^fcniciit  which  the  aneurysm  may  pnxhicc  in  the  veins  of  the  neck  it 
would  he  a  <fri>at  hel|)  in  this  o|)cration  to  follow  Crile's  su<j;<i:;estion  for  removal  of  goitres, 
placino;  the  patient  in  the  semi-u])ii^dit  position  and  having;  him  wear  the  pnemnatic 
suit,  in  order  that,  hy  suitable  j)ressure  from  without,  the  blood  pressm-e  may  be  kept 
at  the  i)roper  dej;ree,  while,  at  the  same  time,  the  veins  of  the  neck  are  emptied  by  gravity. 
Tlie  carotid,  havin<f  been  fou nil,  is  traced  downward  and  will  lead  to  the  innominate  and 
tlic  sac.  When  the  ligature  i.s  ready  to  be  drawn  ti<^ht  the  table  should  be  lowered  and 
tile  pneumatic  pressure  in  the  suit  reduced. 

()l)viously  the  dei-per  the  surgeon  dissects  the  more  difliculties  he  will  encounter. 
The  innominate  artery  is  crossed  by  the  left  innominate  vein,  which  maybe  in  the  way, 
w  hile  all  the  t)ther  vessels  may  be  so  nuicli  disUubed  as  to  alter  thcii'  relations  and  make 
their  recognition  difficult.  The  gradual  progress  of  the  aneurysm  may  liave  caused 
the  tissues  to  become  matted  to  each  other  and  thus  lose  their  identity.  The  innominate 
having  been  found  is  traced  downward  behind  the  sternum  and  a  suitable  base  is  sought 
for  the  ligature.  This  search  may  be  aided  by  changing  the  position  of  the  })atient's 
head,  and  with  the  assistance  of  artificial  light.  In  the  dej)ths  of  the  wound  the  veins, 
the  vagus,  and  the  })leura  can  only  be  avoided  by  care  in  keeping  the  ])oint  of  the  artery 
needle  in  contact  with  the  artery.  If  necessary  gentle  traction  on  the  carotid  trunk 
may  aid  by  lifting  the  sac  antl  making  its  isolation  more  easy. 

As  suggested  by  Bardenheuer  the  uj)per  end  of  the  sternum  may  be  removed  with 
sufficient  of  the  inner  end  of  the  clavicle  to  facilitate  aj^proach.  This  has  been  done  in 
this  country  by  Burrell.  The  aneurysm  needle  is  passed  fiom  without  inward  and 
from  below  upward,  in  order  to  avoid  injury  to  the  pleura.  An  artery  needle  made 
with  a  flexible  tip,  which  may  be  bent  to  suit  the  exigencies  of  the  case,  will  make  the 
most  difficult  part  of  the  work  more  easy.  The  ligature  should  not  be  tied  too  tightly, 
and  for  this  purpose  silk  is  the  j)referable  material.  Strips  of  ox  aorta  and  other  animal 
materials  have  been  used,  but  if  the  knot  is  not  too  tight  no  harm  will  be  done  to  the  artery 
wall.i 

As  stated  above,  the  common  carotid  should  also  be  tied  at  the  conclusion  of  the  other 
ligation.  These  cases  should  be  drained  with  a  few  strands  of  catgut.  Absolute  rest 
is  an  essential  of  the  after-treatment. 

The  Common  Carotid. — The  common  carotid  may  be  tied  above  or  below  the 
omohyoid.  The  carotid  divides  at  the  level  of  the  thyroid  prominence,  and  it  is  more 
easily  exposed  above  the  omohyoid  than  l)elow.  It  may  be  reached  by  an  incision, 
10  Cm.  in  length,  along  the  anterior  border  of  the  sternomastoid,  whose  centre  should 
be  at  the  level  of  the  intended  ligature.  The  sternomastoid,  after  exposure,  is  drawn 
outward  and  the  other  muscles  inward;  bleeding  veins  are  secured;  the  artery  recognized 
by  its  pulsation;  its  sheath  opened,  preferably  on  the  inner  side,  and  the  needle  passed 
from  within  outward,  the  operator  taking  pains  to  avoid  the  descendens  noni.  The 
internal  jugular  is  more  likely  to  be  in  the  Avay  and  to  need  retraction  on  the  left  side 
than  on  the  right.     In  this  operation  when  the  omohyoid  is  exposed  it  is  retracted  uj)ward. 

Tlirough  this  exposure  temporary  occbmon,  either  by  provisional  ligation  or  the 
emj^loyment  of  Crile's  clamps,  may  be  practised 

I^igature  above  the  omohyoid  is  performed  in  the  same  way,  the  veins  being  divided 
and  secured.  The  omohyoid  is  now  drawn  downward  and  the  other  muscles  sej)arated 
as  above.     The  so-called  carotid  tubercle  is  the  anterior  projection  of  the  transverse 

1  Sheen  (Annals  of  Surgery,  July,  1905)  reports  a  succe-ssful  case,  his  method  being  as  follows:  Median  incision 
from  the  cricoid  to  one  inch  below  the  sternal  notch,  exposure  of  the  carotid  and  innominate,  then  a  silk  ligature 
carried  around  the  innominate  distally  and  tied  with  Balance's  stay-knot;  pulsation  ceased,  to  later  reappear.  A 
second  similar  operation  also  failed.  A  third  operation  was  performed  through  a  five-inch  transverse  incision 
above  the  clavicle,  the  artery  being  twice  ligated  proximally.  Sheen  advises  that  ligature  should  always  be  of 
silk,  that  the  incision  should  be  central,  with  horizontal  and  vertical  division  of  the  manubrium;  that  the  carotid 
should  also  be  tied;  that  two  ligatures  be  placed;  that  drainage  i.s  inadvisable,  and  that  next  to  sepsis  as  a  cause 
of  death  stand  cerebral  lesions.     Statistics  are  thirty-six  cases  of  ligature,  with  a  mortality  of  78  per  cent. 


352 


SURGICAL   AFFECTIOXS  OF   THE   TISSUES 


process  of  the  sixth  vertehra,  and  the  Hfjature  is  usually  applied  at  the  point  where 
the  vessel  can  be  felt  pulsatinf;  upon  this  prominence.  The  same  care  should  be  exer- 
cised in  avoiding  the  descendens  noni.  Nelaton  is  reported  to  have  said  that  it  would 
take  a  man  four  miTUites  to  bleed  to  death  after  opening  the  carotid  arterv,  but  it  should 
take  only  two  minutes  to  tie  it. 

The  External  Carotid. — The  incision  now  is  placed  higher,  from  the  angle  of  the 
jaw  to  the  level  of  the  cricoid  cartilage,  still  along  the  anterior  border  of  the  sternomastoid, 
which  is  to  be  retracted  outward.  The  posterior  belly  of  the  digastric  will  now  apj)ear, 
with  the  hypoglossal  nerve  below  it,  both  being  carefully  avoided.  The  great  cornu 
of  the  hyoid  being  sought  and  found,  the  artery  is  iound  opposite  its  tip,  and  ligated 
between  the  superior  thyroid  and  the  lingual  branches,  or  perhaps  l)elow  the  latter.  The 
sujierior  laryngeal  nerve  which  jiasses  behind  the  vessel  is  to  be  scrupulously  excluded. 
Excision  of  the  cxiernal  carotid  has  been  recommendetl,  especially  by  Dawbarn, 
for  the  pur{)ose  of    cutting  off  the  blood    supply    from  certain  inoperable   cancers  of 

the  tongue,   face,  and  jaws.     He  regards 
Fig.  162  mere   ligature   as    insufficient   and    insists 

that,  since  anastomosis  is  perfected  too 
soon  after  the  other  procedures,  it  is  neces- 
sary to  completely  excise  a  portion  of  the 
vessel.  He  does  this  first  on  the  side  most 
affected,  and  then,  say  a  few  weeks  later, 
attacks  the  other  side.  He  advises  to  ligate 
the  external  carotid  just  beyond  its  origin, 
to  divide  it,  to  seize  the  upj^er  end  in  for- 
ceps, and  then,  controlling  the  vessel,  to 
isolate  it  up  to  a  point  where  it  disappears 
in  the  substance  of  the  carotid,  tying  each 
branch  as  it  is  exposed.  He  would  again 
tie  it  just  below  the  orgin  of  the  internal 
maxillary  and  temporal  branches. 

The  internal  Carotid.— The  internal 

carotid  is  very  rarely  attacked  in  this  way. 
It  lies  at  first  to  the  outside  and  back  of 
the  external  carotid,  and  here  it  may  be 
sufficiently  exposed  to  admit  of  ligation. 
The  incision  does  not  differ  essentially 
from  that  for  the  external  carotid.  After 
the  vessels  are  exposed  the  external  branch 
should  be  drawn  inward,  the  diagastric 
ujnvard,  or  divided,  if  necessary,  and  the 
needle  passed  from  without  inward,  avoid- 
inff  the  jugular  and  the  vagus  (Fig.  162). 

The    Lingual    Artery. — The    lingual 

artery  may  be  conveniently  tied  before  some  of  the  radical  ojierations  on  the  tongue, 
and  it  is  also  tied  in  cases  of  cancer  in  order  to  shut  off  nutrition.  Incision  is  made 
2  Cm.  above  the  hyoid,  parallel  with  it,  from  the  middle  line  nearly  to  the  angle  of 
the  jaw.  Through  this  the  submaxillary  gland  will  be  exposed  and  should  be  retracted 
upward  and  out  of  the  way.  The  fascia  is  then  divided,  and  the  posterior  border  of 
the  mylohyoid  identified.  The  digastric  tendon  is  then  drawn  upward  from  the  hvo- 
glossus,  upon  which  it  rests.  The  hypoglossal  nerve  is  now  seen,  the  artery  lying  behind 
it.  It  is,  therefore,  necessary  to  divide  the  hyoglossus  by  a  short  incision  in  order  to 
reach  the  vessel.  The  most  important  precaution  is  to  avoid  injurv  to  the  nerve 
(Figs.  16.3  and  164). 
Other  Arteries  of  the  Face  and  Head.— The  facial  may  be  tied  through  an 

incision  nearly  identical  with  that  for  the  external  carotid,  or  at  the  margin  of  the  lower 
jaw  1  to  2  Cm.  in  front  of  the  angle.  The  temporal  may  be  attacked  through  a 
vertical  incision  over  its  course  between  the  tragus  and  the  condyle.  Branches  of  the 
facial  nerve  cross  the  artery  at  right  angles  to  it;  these  should  be  avoided.  The  occipital 
may  be  tied  close  to  its  origin,  through  the  same  incision  as  that  for  the  external  carotid, 
or  behind  the  mastoid,  through  an  incision  commencing  at  its  tip,  carried  backward  and 


Aneuryptn  of  the  rigclit  internal  carotid.    (Peacock.) 


I.ldATIOS   OF   MiTFh'lhS 


353 


upward.  It  will  \)v  lu-ci'ssary  licrc  (o  divide  (lie  posti-rior  fibers  of  (he  steriioinastoid, 
ol'  the  s|)leni(i.s,  and  j)erha|)s  of  (he  trachelomastoid.  The  vessel  is  then  recognized  by 
its  pulsation  hrtwccn  the  nuistoid  and  the  transverse  portion  of  (he  atlas. 

The  Vertebral  Artery. — The  vertebral  artery  is  tied  throuj^di  an  incision  coninienc- 
ing  at  the  clavicle,  extcndiu<j  aloujj;  the  outer  border  of  the  steriioinastoid,  some  of  whose 
clavicular  fibers  nnist  be  divided.  This  inuscle  and  the  anterior  jii<fiilar  veins  being 
drawn  to  (he  inner  side,  (he  (ransverse  processes  of  (he  si.\(h  and  sevendi  ver(ebra'  should 
be  found  in  the  sj)acc  between  the  scalenus  anticus  and  the  longus  colli.     The  artery 


Fig.  163 


"'V*.. 


Fig.  164 


Surgical  anatomy  of  the  neck;  ligation  of  the  carotid,  lingual,  and  facial  arteries.    (Bernard  and  Huette.) 

should  be  found  below  the  seventh  cervical  vertebra  as  it  enters  the  foramen  intended 
for  it.  The  vein  lies  in  front  of  it,  the  pleura  close  to  it,  and  on  the  left  side  the  thoracic 
duct  is  not  far  away. 

The  Inferior  Thyroid  Artery. — The  inferior  thyroid  artery  may  be  tied  through 
an  incision  along  the  inner  border  of  the  sternomastoid,  which  is  retracted  outward, 
the  carotid  being  found  and  also  retracted  outward.  The  artery  lies  a  little  below  the 
level  of  the  sixth  vertebra,  whose  transverse  process  may  be  easily  found.  It  passes 
inward  and  to  the  rear  of  the  carotid,  close  to  whose  main  trunk  the  ligature  should  be 
applied,  in  order  to  avoid  the  recurrent  laryngeal. 
23 


354 


SURGICAL   AFFECTIOXS  OF   THE   TISSUES 


The  Subclavian  Artery. — This  is  best  tied  by  makinfj  an  incision  2  Cm.  above 
the  chivicle,  lH''2;iiinino;  nearly  at  its  sternal  joint,  and  extending  outward  to  the  anterior 
border  of  the  trapezius.  In  exposing  it  the  eervieal  branches  of  the  superficial  nerves 
should  also  be  divided.  The  external  jugular  lies  here,  near  the  posterior  border  of  the 
sternomastoid,  and  winds  around  it  to  empty  into  the  internal.  Unless  it  can  be  avoided 
it  should  be  carefully  tloul)le  liga  ed.  The  omohyoid  should  appear  at  the  inner  angle 
of  the  wound  and  may  be  drawn  out  of  the  way  in  either  direction.  The  suprascapular 
artery  and  perhaps  one  or  two  other  vessels  may  cross  the  wound  and  require  retraction. 
It  is  usually  necessary  to  remove  considerable  adipose  tissue  in  which  these  vessels  lie. 

I'lG.  165 


Fig.  166 


>^' 


iSurgical  anatomy  and  ligation  of  the  axillary  and  subclavian  arteries.     (Bernard  and  Huette.) 

The  brachial  plexus,  of  course,  will  be  encountered.  The  scalenus  anticus,  which  should 
be  followed  down  to  its  tubercle  of  attachment  on  the  first  rib  is  of  special  importance.  To 
its  inner  side  is  the  internal  jugular,  with  a  somewhat  bulbous  enlargement.  In  front 
is  the  subclavian  vein  and  behind  the  muscle  is  the  artery.  The  phrenic  nerve  passes 
down  upon  the  anterior  surface  of  the  scalenus  anticus,  and  the  thoracic  duct  ascends 
close  to  it,  opening  into  the  angle  between  the  subclavian  and  internal  jugular  veins. 
While  it  is  not  impossible  nor  even  impracticable  to  apply  a  ligature  to  the  subclavian 
on  the  inner  side  of  the  scalenus  anticus  it  is  rarely  necessary,  and  the  ligation  is  almost 
invariably  performed  to  its  outer  side,  in  the  free  part  of  its  trunk.  There  must  be 
sufficient  space  in  which  to  work  with  safety,  and,  when  necessary,  adjoining  muscles, 


LK.ATIOX  OF   ARTElilES 


855 


i.  e.,  stcrnomiistoid  and  trapezius,  may  bo  divided  to  any  necessary  extent.  'V\w  i)atient 
should  always  he  placrd  in  such  a  i)()siti()n  that  the  shouhler  is  ])ulled  well  down,  witis 
the  arm  passed  behind  the  back,  while  the  neck  is  stretched  by  extending  the  head  to 
the  opi)()site  side.  The  artery  needle  should  be  passinl  from  above  downward  and  from 
behind  forward,  the  vein  being  carefully  held  out  of  its  way.  The  |)atient  should  wear 
the  Crile  pneumatic  suit,  in  the  semi-elevated  i)osition,  in  order  that  the  vems  m  the  neck 
mav  be  less  cnooroed  (Figs.  165  and  !()()). 

The    Axillary  Artery.— The  axillary  artery  is  practically  tic-d  ui  its  third  i)ortion, 
beyond  the  lesser  pectoral.     The  incision  is  made  through  the  middle  of  the  axilla,  over 

Fig.  167 


Fici.  168 


Surgical  anatomy  of  the  axilla  and  ligation  of  the  axillary  artery.    (Bernard  and  Huette.) 

the  course  of  the  vessel,  the  deep  fascia  exposed  and  divided,  the  eoracobrachialis  and 
musculocutaneous  nerve  retracted  outward,  and  the  artery  recognized  with  the  tinger- 
tip.  It  should  be  so  cleared,  especially  from  the  median  nerve,  as  to  be  easily  raised 
upon  the  blunt  hook.     The  accompanying  veins  should  not  be  enclosed  m  the  ligature 

(Figs.  107  and  1G8).  .,      „        t    •       .i.         •  i  n     ^f 

The   Brachial  Artery  .-The   brachial   artery   is   easily   found   m    the   middle   ot 

the   arm,  near  the  inner  edge  of  the  biceps,  whose   inner  border  is  \dentified.      ihe 

median  and  other  nerves  should  not  be  brought  into  view.     The  parts  will  be  relaxed  by 


356 


SURGICAL   AFFECTIONS  OF   THE   TISSUES 


flcxiuff  the  forearm.     The  voiiie  comitcs  sliould  he  etirefully  exehuled  from  the  li(i;ature 
(Fjors.  !(;•)  and  170). 

The  Radial  Artery. — The  racHal  artery  is  the  direct  extension  of  the  Ijraehial 
and  passes  underneath  a  nearly  straight  line  to  the  neighboriiood  of  the  sea|)hoid  bone. 
High  up  in  the  forearm  it  may  be  exposed  between  the  suj)inator  longus  and  pronator 
teres,  being  found  beneath  the  former.  In  the  middle  portion  of  the  forearm  it  may 
be  exposed  along  the  ulnar  border  of  the  supinator  longus,  and  lying  u])on  the  pronator 
radii  teres.  At  the  wrist  it  may  be  exposed  with  perfect  ease,  where  it  is  usually  out-i 
lined  when  feeling  the  pulse  (Figs.  171  and  172). 


Fig.  169 


Fill.  170 


Surgical  anatonay  and  ligation  of  the  brachial  artery.     (Bernard  and  Huette.) 

The  Ulnar  Artery. — The  ulnar  artery  is  the  larger  of  the  two  main  trunks,  and  is 
rarely  tied  in  the  upper  part  of  the  arm,  lying  too  deep  for  easy  exposure.  Should  it 
be  divided  by  a  wound  of  this  region  the  opening  may  be  enlarged  sufficiently  for  its 
detection  and  double  ligation  (Figs.  171  and  172). 

Of  the  large  vessels  of  the  trunk  the  ahdominal  aorta  has  been  tied,  although  it  is  ques- 
tionable whether  this  would  ever  be  a  justifiable  operation,  as  all  recorded  cases  have 
succumbed  from  one  cause  or  another. 

The  Common  Iliac  Artery. — The  common  iliac  artery  is  best  tied  by  an  incision 
commenced  ])arallel  with  Poupart's  ligament  and  curved  upward  and  outward.  The 
abdominal  muscles  and  fascia  having  been  divided,  with  the  least  possible  injury  to  their 
fibers,  the  peritoneum  is  detached  from  the  iliac  fascia,  the  patient  being  turned  upon 
the  side  in  such  a  way  that  gravity  may  assist  in  the  exposure  of  the  vessel  behind  the 


IJ  CAT  I  OS  OF   Ah'TKh'IKS 


357 


poritoiKMim.  A  necMllo  of  medium  lcnp;th,  and  sfron*;,  wifli  oMiqiio  lateral  eur 
he  passed  from  witliiii  outward,  llie  vein  lyino;  heliiiid  the  artery  on  the  rifflit 
to  hs  inner  side,  and  Ix-hiiitl  on  the  left  side.  In  the  fossa  thus  h)rmed,  and  I 
the  i)soas,  will  he  found  not  only  the  common  trunk  hut  the  external  eutane 
rmmint;  downward  and  outwanl,  and  also  the  iliac  l)raneh  of  the  iliolumhar 
The  operator  may  decide,  for  some  reason,  to  open  th(<  ahdomen  directly, 
thr()Uj,di  from  front  to  rear,  drawing  aside  the  intestinal  loops,  with  the 
the  'IVndelenhuro;  position,  ex])osinfj;  the  main  trunk  by  a  small  incision  tl 
posterior  p(>ritoneum  and  api)lying  the  ligature  there.  By  this  same  iraji 
nu'thod  the  iutcnial  Uinr  may  i)e  attacked.     Its  course  inward  and  downwj 


ve,  should 
side,  near 
lying  upon 
ous  nerve, 
artery, 
and  to  go 
patient  in 
irough  th(^ 
s'prrifojiral 
ird,  rather 


Fi<;.  171 


¥i<:.  17 


Surgical  anatomy  and  ligation  of  the  radial  and  ulnar  vessels.     U^ernard  and  Huette.) 

than  outward,  makes  it  more  easy  of  attack  in  this  way.  The  ureter,  which  lies  in  front 
of  the  arterv,  should  be  raised,' along  with  the  peritoneum,  in  order  that  it  may  be 
avoided.  This  vessel  has  thus  been  tied  for  hypertrophy  of  the  prostate,  for  inoperable 
cancer  of  the  uterus,  during  excision  of  the  rectum,  and  even  for  the  cure  of  vascular 
tumors  or  aneurvsms  affecting  its  terminal  arteries. 

The  External  Iliac  Artery.— The  external  iliac  artery  is  exposed  without  great 
difficulty  by  a  10  Cm.  incision  about  Poupart's  ligament,  beginning  near  the  pubic  spine, 
extending  outward  and  slightlv  upward.  It  will  probably  be  necessary  to  double  hgate 
and  divide  the  superficial  epigastric  arterv,  after  which  the  outer  border  of  the  conjoined 
tendon  is  to  be  recognized  at  the  lower  and  inner  end  of  the  incision.     The  lower  fibers 


358 


SURGICAL  AFFECTIONS  OF  THE  TISSUES 


of  the  internal  obliqne  are  tli(>n  to  he  divided,  tlie  tniiisversalis  ex|)(),sed  and  transversely 
divided,  after  wliicli  tlie  deej)  <>pi<rastric  artery  will  prohahly  eoine  into  view.  The 
pulsations  of  the  external  iliac  will  now  idenlify'it.     Tlu-  snhperiloiieal  tissue  should  he 


Fiu.  173 


Fi(i.  174 


Fifi.  175 


Surgical  anatomy  and  ligation  of  the  femoral,  external  iliac,  and  epigastric  arteries.     (Bernard  and  Huette.) 
Fig.  176  Fig.  177 


Surgical  anatomy  ami  ligation  of  the  femoral  artery.      (Rernard  and  Huette.) 


LICATIOS   OF  ARTIIRIF.S 


35<) 


carcfiillv  (iHacliiMl  and  the  pcritoiu-uin  <ira(lually  separated  Iroin  tlu-  vessels  and  proj)erly 
retraclod  Beneath  it  the  areohir  tissue  whieh  helps  U)X\n  the  sheath  of  the  vessel  must 
be  avoided,  after  which  the  arterv  needle  niay  1)(>  passed  from  within  outward.  In 
elosiiKT  the  wound  the  deep  lavers  should  be  l)rou<rht  tofjether,  each  by  itself,  in  order 
to  avoid  the  possibility  of  ventral  hernia.  Throuj^h  this  same  incision  both  Wwdcej) 
cpiqastric  and  the  deep  rircmnjlr.r  arirrirs  may  be  exposed  (Fifjs.  173,  174  and  175). 

The  Femoral  Artery.  The  femoral  artery  is  usually  tied  either  at  the  l)ase  of 
Scarpa's  triangle,  just  below  Poui)art's  lijrament,  or  in  Hunter's  canal.  In  the  first 
location  its  puTsation  can  be  easilv  felt  before  dividinjr  il„-  skin,  and  will  serve  as  the 


l'"i(;.  178 


Y\c..  179 


Surgical  anatomy  and  ligation  of  the  posterior  tibial  artery.    (Bernard  and  Huette). 


best  guide  It  reciuires  an  incision  made  downward  over  the  course  of  the  vessel,  from 
the  middle  of  Poupart's  ligament.  In  approaching  it  here  a  number  of  lymph  nodes 
mav  be  encountered,  some  of  which  mav  be  considerably  enlarged.  1  hey  should  be 
disturbed  as  little  as  possible,  unless  involved  in  cancerous  or  serious  septic  disease. 
The  anterior  crural  nerve  lies  to  the  outer  side  of  the  vessel  and  th_e_vein  to  its  inner  side. 
Between  these  h  mav  easilv  be  found  and  tied  (Figs.  176  and  1//). 

In  Hunter's  canal  the  femoral  arterv  may  be  found  nearly  beneath  the  long  saphenous 
vein,  and  near  the  outer  edge  of  the  sartorius.  If  the  leg  be  abducted,  and  the  adduc  or 
magnus  thus  stretched,  the  poshion  of  the  canal,  between  the  latter  and  the  vastus 
internus,  is  easilv  recognized!  The  canal  itself  is  partly  formed  by  fascia  which  should 
be  divided,  while  the  artery  will  be  found  within. 


360 


SURGICAL   AFFECTIOXS  OF  THE   TISSUES 


The  lower  part  of  the  femoral  arterv,  or  practically  the  popliteal  artery,  may  be  found, 
if  necessary,  by  an  incision  in  the  middle  of  the  popliteal  space,  the  ofx-rator  gradually 
workincr  down  by  blunt  dissection  to  the  location  of  the  vessel,  which  is  easily  recognized 
Ijy  its  pulsation. 

"The  Posterior  Tibial  Artery.— The  posterior  tibial  artery  nearly  underlies  a 
line  from  tlic  centre  of  the  jxiplitcal  space  to  a  point  between  the  inner  malleolus  and 
the  heel.  To  expose  it  easily  the  limb,  somewhat  flexed,  should  lie  upon  its  outer 
side,  the  patient  lying  nearly  on  his  face,  and  incision  made  in  the  calf  of  the 
leg,  beginning  at  the  head  of  the  fibula,  after  which  one  may  expcse  the  junction  of  the 


Fig.  180 


Fig.  181 


Surgical  anatomy  and  ligation  of  the  anterior  tibial  and  peroneal  arteries.    (Bernard  and  Huette.) 

two  heads  of  the  gastrocnemius.  Through  this  the  tendon  of  the  plantaris  is  to  be  sought, 
after  which  it  may  be  necessary  to  divide  a  portion  of  the  soleus.  Here  the  vessel  should 
be  sought  by  the  sense  of  touch,  the  operator  seeking  for  its  pulsation.  Lower  down,  and 
in  the  lower  part  of  the  leg,  it  may  be  found  by  incision  along  the  imaginary  line  which 
it  underlies,  lying  on  the  flexor  longus  digitorum,  with  its  accompanying  nerve  on  its 
outer  side.  Still  lower,  at  the  ankle,  it  mav  be  easily  found,  just  behind  the  malleolus. 
(See  Figs.  178  and  179.) 

The  Anterior  Tibial  Artery. — The  anterior  tibial  anery  underlies  a  line  drawn 
from  a  point  between  the  head  of  the  fil>ula  and  the  outer  tuberosity  of  the  tibia,  to  the 
fron*^  auvl  centre  of  the  ankle-joint.     At  almost  any  point  along  this  line  it  can  be  exposed 


ri  {/./■:  Ill  T/s  301 

lu'twrrn  the  tihialis  aiiticus  and  the  coiiiiiioii  extensor  of  the  toes,  the  hitter  l)ein^'  hehl 
(lowmvard  and  outward  and  the  former  upward.  Here  in  tlie  depths  it  may  be  reeo^jnized 
upon  the  interosseous  ineml)rane.  In  the  lower  |)art  of  the  h'<;  the  extensor  pollieis  Hes 
to  its  outer  si(l(>.  Here  the  aceouipanyiiifj  veins  shouUl  he  avoided,  (^uite  low  in  the 
letj  and  in  froiU  of  the  ankle  the  vessel  will  he  found  between  the  tendons  of  the  tibialis 
autieus  and  extensor  pollieis  (Figs.  ISO  aiul  ISI). 

THE  VEINS. 

The  vein.s  are  of  interest  to  the  surgeon  particularly  because  of  the  role  they  play 
in  the  pathology  of  sepsis,  especially  of  pyemia,  and  because  of  their  various  dilatations 
and  even  new  formations  which  ailiiiit  of  none  but  surgical  remedy;  that  is,  varices, 
und«'r  their  various  names  —for  example,  hemorrhoids,  varicocele,  and  nevi. 

The  veins  have  an  endothelial  lining,  between  which  and  circulating,  or  more  especially 
stagnant,  blood  there  exist  jK'culiar  susceptibilities  and  relations  which  cannot  be  well 
described.  The  pathologist  ajipreciates  what  disturbances  of  the  endothelium  will 
provoke  coagulation  of  the  blood  in  contact  with  it,  but  is  not  yet  in  a  position  to  explain 
the  relationsliij).  \'eins,  moreover,  are  provided  with  valves  to  a  more  perfect  degree 
than  are  the  lymphatics,  but  the  valves  often  become  inadequate  for  their  purpo.se,  and 
then  we  have  such  conditions  as  varicosities;  the  fact  that  they  are  usually  .seen  about 
the  rectum  and  the  lower  extremities  illustrating  the  duadvaniages  accruing  from  the 
uprir/hf  posifion  into  which,  by  the  process  of  evolution,  man  has  erected  himself  from 
the  (jua(lruj)edal.  Even  the  myriads  of  years  that  have  elapsed  since  this  change  took 
})Iace  have  not  sufficed  to  afford  sufficient  protection  against  the  added  weight  of  the 
column  of  blood  inseparable  from  it. 

Of  pathological  changes  which  interest  the  surgeon  there  may  be  atrophy  as  the 
result  of  pressure  from  without  or  prolonged  distention  from  within,  even  to  such  an 
extent  as  to  permit  of  rupture  and  serious  or  fatal  hemorrhage.  Fatty  degeneration 
occurs  in  the  serious  intoxications  and  infections.  Calcification  occurs  only  in  limited 
areas  and  is  secondary  to  other  changes  or  to  thrombophlebitis.  True  o.s.seous  patches 
have  been  found  in  the  walls  of  veins,  but  are  great  rarities.  Calcification  occurs  in 
the  portal  and  also  in  the  femoral  veins  and  their  Ijranches.  In  other  directions  vein 
walls  become  hypertrophied,  all  coats  partaking  in  the  change,  enlargement  or  distention 
being  especially  likely  to  occur  where  there  is  most  tendency  to  stagnation.  The  changes 
which  lead  to  the  varicose  condition  include  not  only  absolute  thickening,  Vjut  increase 
in  every  dimension,  the  venous  tubes  becoming  elongated  as  well  as  distended  and 
thickened,  to  such  an  extent  that  they  take  a  spiral  or  curved  course,  sometimes  almo.st 
doubling  on  themselves. 

PHLEBITIS. 

In  all  forms  of  plebitis,  whether  acute  or  chronic,  the  three  venous  coats  are  practically 
inv(jlved  in  the  same  manner.  ^Yith  enlarged  knowledge  of  the  lymj)hatics  it  is  difficult 
to  separate  an  acute  phlebitis  from  a  lymphangitis  of  the  venous  wall.  Only  in  this 
way  can  descending  phlebitis  be  accounted  for,  the  infection  travelling  apparently  against 
the  blood  stream.  This  accounts  for  the  discoloration  along  the  subcutaneous  veins 
when  they  become  involved,  the  same  red  lines  appearing  in  the  skin  as  when  the  lym- 
phatics are  involved.  The  relations  between  the  intima  and  the  blood  have  been 
mentioned  above.  In  cases  of  acute  phlebitis  in  which  the  intima  is  involved  there  is 
coagulation  of  the  contained  blood,  the  clot  and  the  vein  wall  undergoing  changes  which 
simulate  a  tliromhopJilehitis. 

Acute  Phlebitis. — Acute  phlebitis  is  of  infectious  origin.  It  may  be  seen  in  con- 
nection whh  injury,  erysipelas,  childbirth,  and  the  superficial  and  deep  infections,  as 
from  a  hypodermic  injection,  a  pin-prick,  etc.  It  is  also  .seen  in  typhoid,  pneumonia, 
diphtheria,  and  gonorrhea.  In  most  of  these  instances  it  is  difficult  to  trace  the  path 
of  infection.  I  have  seen  death  from  pyemia  following  gonorrhea,  where  the  earliest 
recognizable  disturbance  occurred  in  the  peri-urethral  and  prostatic  veins.  I  believe 
it  to  have  been  my  report  on  these  cases,  in  ISS,"),  which  first  called  attention  to  the  fact 
that  gonorrhea  might  terminate  fatally  by  the  pyemic  jirocess. 


362  SURGICAL   AFFECTIONS  OF   THE   TISSUES 

When  the  venous  system  has  become  involved  in  a  se])tie  ])roeess  of  this  kind  neither 
its  fate  nor  that  of  tiie  patient  can  he  rejrarded  as  secure.  Ocehision,  with  serious  eircu- 
hitory  (hsturhance,  may  permanently  inijjair  function,  while  there  may  be  speedy  death 
from  pycTuia.  This  is  nowhere  more  true  than  iji  those  portions  of  the  venous  system 
havino;  rigid  walls  without  valves,  to  which  is  given  the  name  "sinuses"  (cranial),  in 
which  exactly  similar  processes  may  occur,  which  by  virtue  of  their  location  will  always 
give  rise  to  the  gravest  anxiety.  To  j)hlebitis  occurring  in  these  channels  there  has  been 
given  the  somewhat  distinctive  name  ><inus  pidebitis.  It  nowise  differs  from  the  same 
condition  elsewhere,  save  that  it  is  of  almost  invariably  extra  vascular  origin.  It  takes 
but  a  small  venous  branch,  lying  in  the  midst  of  an  infected  area,  to  commence  the 
process  that  may  extend  from  the  basal  sinus  to  the  vena  cava. 

In  most  of  the  surgical  infections  acute  ])hlebitis  has  an  ex.travascular  origin,  the 
lym])hatics  of  the  outer  wall  communicating  the  infection  to  the  inner  coats,  and  so  dis- 
tributing it  that  coagulation  occurs,  after  which  the  path  of  infection  from  the  contain- 
ing veins  to  the  contained  clot  is  direct.  The  thrombi  thus  formed  may  comjjletely 
or  only  jmrtially  occlude  the  vessel.  As  a  continuation  of  the  lesion  we  have  infiltration 
and  separation  of  the  coats  of  the  vein  from  each  other,  and  finally  their  necrosis.  Thus 
in  the  terms  of  the  pathologist  an  acute  phlebitis  may  lead  to  a  phlebitis  desicans, 
and  this  to  phlebitis  gangrtenosa.  In  every  case  where  the  patient  survives  such  con- 
ditions as  these  the  veins  lose  their  identity  and  become  obliterated  by  the  very  violence 
of  the  process  in  which  they  have  participated. 

A  somewhat  different  type  of  acute  or  subacute  phlebitis  is  produced  by  intravascular 
irritants,  namely,  toxins  or  bacteria  circulating  in  the  blood,  or  to  some  chemical  or 
thermic  agency  which  may  produce  thrombosis,  such  as  extremes  of  heat  and  cold. 
These,  too,  may  lead  to  partial  or  complete  occlusion,  and  the  latter  may  be  followed 
by  calcification  or  the  formation  of  pJilcholiihs.  The  destructive  character  of  the  entire 
process  will,  therefore,  depend  upon  the  nature  and  virulence  of  the  exciting  cause. 
As  between  fatal  septic  infection,  local  gangrene  of  a  part  as  the  result  of  involvement 
of  the  majority  of  its  veins,  or  comparatively  slight  and  temporary  disturbance,  such 
as  edema,  there  may  be  degrees  of  activity,  with  results  varying  between  fatality  and 
evanescent  discomfort. 

Chronic  Phlebitis. — This  is  of  the  proliferative  type  and  is  followed  by  more  or 
less  organization.  Phlebitis  obliterans  is  sometimes  seen  in  connection  with  syphilis 
and  other  chronic  intoxications,  and  with  various  operations  upon  the  veins. 

Symptoms. — Phlebitis  may  occur  without  known  cause  or  may  follow  as  an  expected 
result  from  fleep  or  surface  lesions.  The  deeper  the  involved  veins  the  more  obscure 
the  case.  Involvement  of  superficial  veins,  especially  in  acute  cases,  is  easily  made 
known  by  the  dark-bluish  or  dusky  red  cord  which  occupies  the  place  of  the  previously 
healthy  vein.  As  its  contained  clot  becomes  firmer  the  clot  becomes  harder.  This 
is  accompanied  by  more  or  less  fever,  with  extreme  tenderness,  often  pain.  If 
a  single  vein  only  be  involved  the  disturbance  will  be  Cjuite  local;  if  thrombosis  l)e 
general  there  will  be  edema  of  the  parts  to  which  the  vein  is  distributed.  Involve- 
ment of  certain  veins  implies  the  establishment  of  a  collateral  circulation  through 
others.  If  there  be  no  others  available  then  danger  from  venous  insufficiency  threatens, 
and  it  may  not  be  possible  to  avert  gangrene.  "Milk  leg,''  or  ^o-caWed  pli leg masia 
alba  doleiis  ("painful  white  swelling"),  is  an  expression  of  portal,  pelvic,  and  femoral 
throml)o])hlebitis.  In  many  instances  in  which  it  does  not  kill  it  may  cripple  the 
individual  for  life.  Phlebitis  of  the  deep  veins  can  be  inferred  rather  than  detected. 
Phlebitis  of  the  hemorrhoidal  veins  frequently  follows  inflammation  and  suppuration 
of  piles,  while  that  of  the  pelvic  veins,  especially  the  perivesical,  frequently  follows 
gonorrhea  and  prostatitis.  Mesenteric  phlebitis  and  pi/lephlebitis  frequently  follow  the 
ulcerative  infections  of  the  intestines,  while  in  the  newborn  a  phlebitis  of  the  umbilical 
vein  plays  an  important  part  in  the  mortality  of  infants.  The  cranial  sinuses  are  likely 
to  be  affected  in  connection  with  middle-ear  disease,  while  in  acute  osteomyelitis  there 
are  distinctive  ])ictures  of  the  lesion  in  the  veins  of  the  bone  and  the  marrow.  No 
matter  where  the  lesions  may  centre  they  are  of  the  most  serious  character.  The  role 
6f  the  veins  in  the  production  of  metastatic  foci  has  been  described  in  the  chapter  on 
Pyemia.  The  danger  attending  the  liquefaction  of  a  thrombus  and  the  escape  of  its 
fluid  debris  into  the  general  circulation  stamps  an  acutely  infected  clot  with  a  dangerous 
character.     This  fact  justifies  such  measures  as  are  now  pursued  in  connection  with  the 


INJl^RIES  OF   VRIXS  363 

cniiiijil  simiscs  and  mastoid  disease,  where  lliere  is  not  only  a  sinus  exposed  by  removal 
of  a  j)ortion  of  the  te!n|)oral  hone  hul  ihe  jujrnlar  ojXMied  low  in  the  neck  and  the  entire 
intervening  ehaimel  freed  from  its  piitrefvintf  contents  by  the  probe  aiul  the  irrijijating 
stream,  in  other  words,  a  reeoifnition  of  the  patholo<i;y  of  thromlxjsis  and  sepsis  may 
li-ad  to  the  performance  of  difhcult  operations. 

Treatment.  It  is  dilhcult  to  separate  the  treatmcMit  of  phlebitis  from  that  of  Ivmphan- 
<jitis,  which  o;enerally  accompanies  it.  The  first  essential  is  physioloo;ical  rest  for  the 
part  involved,  such  as  confinement  in  bed,  and  the  least  jjossibje  disturbance  of  the 
indamed  area,  which  should  be  placed  in  the  most  restful  position  and  handled  as  little 
as  })o.ssil)le.  Local  soothinij;  and  evaporating  lotions  may  be  used,  or,  as  seems  to  the 
writer  preferable  in  most  cases,  applications  of  a  10  per  cent,  ichthyol-mereurial  oint- 
ment, or  of  the  Crede  silver  ointment,  neither  of  which  should  be  rubbed  in,  but  spread 
upon  the  skin  and  covered  with  an  imjK>rmeable  material,  "^rhese  will,  after  a  few  days, 
prove  irritatiuiij,  and  a  substitution  of  somethinii;  milder  may  b(>  re(|uired;  but  in  the  acute 
stage  they  will  render  greater  service  than  anything  else.  A  phJchitis  irliirh  lias  been 
provoked  and  /,v  prrpcftiatcd  hij  the  presetur  of  .srpfir  niatrria/  cannot  he  snccrss-jullii  frrafrd 
so  long  as  its  prorokinf/  rausr  remain.  Puerj)eral  sej)sis  which  results  in  jx'lvic  |)hlel)itis 
calls  for  thorough  curetting  of  the  uterus,  while  an  abscess  in  the  jaw  or  about  the  mouth, 
resulting  from  diseased  teeth,  necessitates  the  extirpation  of  the  latter,  providing  the 
jaws  can  be  separated  sufficiently  to  permit  of  it.  What  may  be  needed  in  cases  of 
thrombophlebitis  of  the  cranial  sinuses  has  just  been  mentioned. 

In  any  part  of  the  body  a  vein  which  is  filled  with  a  breaking-down  clot  can  be  j)romptly 
and  judiciously  treated  by  exposure  and  removal  of  the  involved  part,  or  by  free  and 
open  incision,  with  suitable  after-treatment. 

A  chronic  phlebitis  that  produces  such  lesions  as  varices  will  be  dealt  with  under  its 
proper  head. 

INJURIES  OF  VEINS. 

Rupture  of  Veins. — Rupture  of  small  veins  is  the  inevitable  consequence  of  every 
injury  sufficiently  serious  to  be  in  any  sense  disabling,  its  visible  expression  taking 
the  form  at  least  of  ecchymosis,  sometimes  of  distinct  hematoma.  Again,  after  long- 
continued  pressure  by  which  return  of  venous  blood  is  prevented,  certain  degenerations 
take  place  in  the  vein  walls  which  lead  to  their  yielding  on  apparently  trivial  provocation; 
thus  veins  situated  distally  to  large  aneurysms  sometimes  give  way,  while  the  frequency 
with  which  they  rupture  in  large  varices  of  the  limbs  and  in  hemorrhoids  is  everywhere 
recognized.  In  the  days  when  venesection  was  so  frequently  practised,  usually  at  the 
bend  of  the  elbow,  a  traumatic  communication  between  the  artery  and  the  vein  was 
frequently  produced,  with  consequent  anastomosis.  When  this  was  direct,  the  vessels 
being  in  contact  with  each  other,  it  was  an  aneurysmal  varix.  When  there  was  more 
or  less  of  an  intervening  sac,  through  which  the  blood  flowed  from  one  to  the  other,  it 
was  spoken  of  as  a  varicose  aneurysm.  Save  in  rare  cases  produced  by  puncture  or 
gunshot  wounds  such  lesions  are  curiosities.  Should  operation  be  recjuired  the  sac, 
if  there  be  one,  may  be  extirpated,  or  the  vein  may  be  ligated  above  and  below  the 
communication.     (See  above.) 

Air  Embolism. — Air  embolism  may  follow  injury  to  the  large  venous  trunks, 
especially  about  the  head  and  neck.  This  term  implies  the  entrance,  by  aspiration,  of  air 
into  the  veins,  its  bubbles  being  carried  along  to  the  right  side  of  the  heart,  where  they 
are  supposed  to  more  or  less  interfere  with  its  action.  Sometimes  at  the  instant  of  the 
accident  a  sucking  or  gasping  sound  may  be  heard.  Formerly  the  condition  was  con- 
sidered alarming,  but  now  it  is  almost  a  bugbear.  It  is  probable  that  minor  degrees 
of  the  accident  often  occur  without  perceptible  alteration  in  heart  action.  Serious 
disturbance,  however,  is  possible,  especially  if  the  longitudinal  sinus  or  the  common 
jugular  be  extensively  opened,  and  the  patient's  head  is  above  the  level  of  the  body  at 
the  time.  Such  an  accident  might  call  for  artificial  respiration,  and  it  has  been  suggested 
to  aspirate  the  right  side  of  the  heart.  When  its-  danger  can  be  foreseen  precautions 
should  be  taken  by  pressure  on  the  proximal  side  of  the  injury.  Air  embolism  is  said 
also  to  have  followed  parturition,  and  even  exposure  of  veins  in  the  stomach  by  the 
ulcerative  process.     (See  p.  38.) 


304 


SURGICAL   AFFFX'TIOSS  OF   THF   TISSUES 


Treatment. — Most  injured  veins  c-an  lie  tied  in  xitu  and  their  function  left  to  the 
collattral  (in  illation.  Fear  Ls  sometimes  felt  alx)Ut  the  axillary  and  the  femoral  veins, 
and  serious  diseussions  have  arisen  as  to  whether  amputation  might  Ix-  called  for  should 
these  large  channels  be  so  injured  as  to  Ix'  made  useless.  Experience  has  shown  that 
either  of  them  may  Ix-  ligated,  with  nothing  worse  than  temjMjrary  edema  of  the  limh 
bevond.  Should  there  then  occur,  by  accident  or  during  an  operation,  an  opening  of 
these  venous  trunks  one  may  apply  the  ligature,  if  necessary.  Before  resorting  to  this, 
however,  one  may  consider  the  advisability  of  the  application  of  a  fine  suture  to  the 
margins  of  the  wound  in  the  vein,  which  ha-s  l)ecome  a  standard  procedure,  or,  if  the 
o|xning  l>e  small,  and  it  can  Ix^  seized  with  a  hemostat,  it  may  be  left  ?'»  situ  for  two 
or  three  days,  closing  the  wound  around  it,  and  so  supporting  and  protecting  the  part 
with  dressings  that  it  shall  not  be  disturlx-d.  A  small  forceps  or  its  equivalent  may  thus 
be  left  u}x)n  a  cranial  sinus,  a  jugular,  subclaWan,  axillary,  femoral,  or  other  vein  without 
jeopardizing  the  result. 

VARICES  AND  PHLEEECTASES. 


Fig.  1S2 


The  term  phlehedasia  implies  an  extensive  affection  of  a  portion  of  the  venoas  .sy.stem, 
characterized  bv  more  or  less  uniform  enlargement  of  all  its  veins.  A  similar  involve- 
ment of  isolated  veins  is  usually  spoken  of  as  varix.  These 
conditions  may  be  congenital  or  acquired.  Fig.  182  illustrates 
a  congenital  varicose  condition  occurring  in  a  lad  aged  sLxteen 
years.  Such  a  lesion  may  be  explained  by  congenital  defect  in 
some  of  the  deeper  veins,  thus  compelling  the  venous  blood  to 
return  through  the  more  sufjerficial  channels.  These  congeni- 
tal lesions  are  more  common  in  the  lower  extremities,  but 
may  be  seen  in  all  parts  of  the  body.  Varices,  also,  by  ^■irtue 
of  their  exciting  and  contributing  causes,  are  most  common  in 
the  lower  extremities  and  in  the  lower  venous  terminals,  as  in 
the  scrotum,  the  rectum,  etc.  Acquired  varices  usually  im- 
ply pre\ious  lesion  in  the  vein  walls,  sometimes  inflammatory-, 
sometimes  toxic.  The  walls  of  the  veins  thus  become  at 
first  atrophied,  this  condition  being  often  followed  by  irritative 
hyjx-rpiasia,  by  which  finally  the  veins  become  thickened  and 
strengthened,  and  sometimes  calcified.  The  enlargements 
are  irregular  and  sacculations  frequently  form.  In  such 
sacculi  thrombi  may  occur  and  be  followed  by  calcification, 
the  resulting  concretions  being  known  as  phlehoJiths.  The.se 
can  often  be  recognized  through  the  skin  in  old  and  chronic 
cases.  Sometimes  adjoining  sacculi  Ix'come  confluent  and 
there  forms  what  Ls  called  an  arjastomotic  varix.  By  such 
communications  cavernous  conditions  are  produced  which, 
when  placed  subcutaneonsly,  lead  to  peculiar  and  distinctive 
tumor  formations. 

As  already  stated,  the  tendency  to  varices  is  indirectly  the 
result  of  man's  assumption  of  the  upright  position,  by  which 
greater  stre.ss  is  plac-ed  upon  the  valves  and  the  lower  veins 
than  they  are  prepared  to  bear.  Naturally  these  conditions  occur  often  in  tho.se  who 
are  constantly  engaged  in  hard  work  upon  the  feet.  Varices,  then,  are  lesions,  not 
so  much  of  the  leisurely  and  sedentary  as  of  the  active  and  working  classes.  Any- 
thing which  predisposes  to  venous  stasis  may  Ix-  regarded  as  a  contributing  cause — thus 
their  relations  with  weakened  hearts  and  obstructed  lungs  are  indirect,  but  positive. 
Many  women  suffer  in  this  way  as  the  consequence  of  their  first  pregnancy,  with  its 
pre-ssure  ujxjn  the  pelvic  veins;  while  tight  garters,  corsets,  and  Ix'Its  also  predispose 
to  overloading  of  the  lower  veins.  .Slight  but  almost  permanent  causes  of  this  kind, 
through  the  influence  of  gra%'ity,  thus  produce  varices  in  the  course  of  time. 

To  varic-es  in  certain  locations  have  lx*en  given  special  names.  To  such  a  dilatation 
of  the  spermatic  and  pampiniform  plexus  has  been  given  the  name  varicocele.  When 
the  hemorrhoidal  veins  are  involved  the  condition  is  known  as  hemorrhoids  or  piles. 
The  former  is  often  credited  with  being  due  to  the  anatomical  arrangement  of  the  left 


U 


Congenital  varice.-.   (Park.) 


v.\Rir/:s  A\n  I'lir.Eni'.crASF.s  305 

spcnnatic  vein,  tlinui<^li  wliicli  l)|()()(l  is  not  as  directly  poured  into  the  vena  cava  as 
on  the  riti;lit  side,  while  the  relation  of  chronic  consti|)ation,  with  its  ohstrnction  to  the 
circulation  in  the  rectal  walls,  will  account  lor  many  cases  of  hemorrhoids,  and  tho 
disturbance  implied  hy  the  term  cirrhosis  of  the  liver  will  furnish  an  exjjlanation  for  many 
others.  A  similar  condition  in  the  esophatjjeal  veins  has  fjiven  rise  to  the  term  csoplia- 
gral  hemorrhoids.  Most  intlicative  and  extraordinary  exj)ressions  of  closing  of  deep 
circulation  may  he  seen  in  some  instances  of  intrathoracic  and  intra-ahdominal diseases, 
/.  <\,  cases  in  which  the  su|)crfical  veins  of  the  chest  and  thorax  hecome  remarkably 
enlar<;ed.  Such  expressions  as  these  are  to  be  rej^arded  as  natural  clforts  to  obviate  a 
dillicult\-,  and  no  attempt  should  be  made  to  eradicate'  such  varices. 

Symptoms.  In  cases  re(iuirin<j  suro;ical  intervention,  varicose  veins  present  the 
followinjj;  features,  which  are  particularly  indicative;  they  not  only  enlarfre  in  diameter 
but  elonti;ate,  and  conse(|uently  have  to  assume  a  tortuous  arrangement  to  accom- 
modate their  increased  length;  they  eause  a  constant  sense  of  fuhiess  and  discomfort, 
which  often  amounts  to  actual  pain,  especially  after  laborious  effort.  This  pain  is  due 
to  the  distention  of  the  venous  trunks,  to  pressure  upon  cutaneous  nerves,  and  often  to 
disturl)ances  of  nutrition.  In  fact,  nutrition  is  so  often  disturbed  as  to  be  accompanied 
bv  skin  lesions,  which  begin  as  eczema  and  terminate  in  extensive  ulcerations.  So  fre- 
quent is  this  association,  and  so  distinctive  its  typi'.  that  such  ulcers  are  frequently  referred 
to  as  varicose.  If  the  term  be  used  to  imply  the  association  it  perhaps  may  stand;  if 
intended  to  typify  a  peculiar  type  of  ulcer  it  is  obj(>ctionable,  as  the  ulc-er  itself  is 
sim|)ly  such  as  may  happen  on  any  surface  whose  nutrition  is  more  or  less  perverted. 

The  most  common  causes  of  varicosities  in  the  lower  extremities  are  previous  lesions, 
such  as  phlebitis  following  typhoid,  injuries  of  the  limbs  or  trunk,  the  pressure  of  tumors, 
fecal  accumulations,  garters  or  belts,  laborious  work  in  the  upright  position,  and  the 
possible  complications  of  all  cases  from  variation  in  the  original  anatomical  arrangement 
of  veins  and  their  valves;  pregnancy  also  should  be  added  to  this  list. 

The  conilition  is  rare  in  early  life.  Lial>ility  to  it  increases  with  age.  Varices  rarely 
occur  in  the  upper  limbs  in  connection  with  certain  occupations  or  athletic  sports,  c.  g., 
baseball  and  tennis. 

The  measure  of  the  distention  of  veins  can  often  be  taken  by  the  sensation  of  fulness 
and  muscle  cramp.  In  few  surgical  lesions  do  appearances  give  as  much  aid  in 
diagnosis.  This  is  particularly  true  of  superficial  varices.  Varicosities  of  the  deeper 
veins  may  be  suspected  when  patients  complain  of  discomfort,  pain,  cramp,  and  swelling 
of  the  feet  after  hard   work. 

Varices  would  rarely  lead  to  ulceration  were  it  not  for  the  superficial  infections  incurred 
in  many  obvious  ways — sometimes  by  the  finger-nails  of  the  individual,  who  is  constantly 
tempted  to  scratch  or  rub  the  area  in  wdiich  he  feels  such  incessant  discomfort. 

Treatment. — Suital>le  treatment  of  varices  of  the  internal  veins,  varicocele,  hemor- 
rhoids, etc.,  will  be  indicated  in  its  proper  place.  In  this  chapter  only  varices  of  the 
extremities  will  be  considered.  When  a  tendency  to  the  varicose  condition  is  noted 
early,  and  a  cause  can  be  discovered,  removal  of  the  cause  may  be  all  that  is  needed. 
When  the  condition  is  well  established,  and  yet  not  sufficiently  prominent  to  justify  radical 
treatment,  it  should  consist  largely  in  support  by  bandages  or  elastic  stockings,  applied 
discriminatingly,  with  sufficient  pressure  to  prevent  undue  distention  and  not  sufficient 
to  cause  edema.  It  frequently  affords  much  relief  and  prevents  aggravation  of  the 
condition;  on  the  other  hand,  once  the  veins  become  accustomed  to  this  supj)ort  they 
yield  more  readily  upon  its  withdrawal,  and  the  treatment  by  gentle  constriction  once 
begun,  which  is  sufficient  for  many  cases,  can  rarely  be  discontinued,  even  after  a  lapse 
of  time. 

A  maximum  of  rest  and  elevation  of  the  limb  are  requisite  in  the  non-operative  treat- 
ment of  varicose  veins.  The  compression  exercised  by  elastic  stockings  is  of  only  tem- 
porary benefit,  and  is  simply  such  an  assistance  as  is  a  crutch  to  a  crijiple.  The  less 
the  patient  remains  upon  the  foot  and  the  less  he  takes  hot  baths  or  indulges  in  other 
rela.xing  measures  the  better.  Cold  showier  or  tub  baths  are  far  preferable,  with 
massage  of  the  deeper  muscles,  the  large  veins  being  avoided.  Such  a  patient  should 
never  walk  slowly,  but  always  rapidly,  and  rest  as  soon  as  fatigued.  All  diathetic  con- 
ditions should  receive  attention. 

When  it  is  not  possible  to  early  and  speedily  remove  the  existing  cause  there  is  but 
one  cure  for  varices,  and  that  is  by  radical  surgical  treatment.     A  generation  ago  this 


366  SURGICAL   AFFECTIONS  OF   THE   TISSUES 

was  effected  l)y  the  injection  into  the  veins  of  perha[)s  one  of  the  iron  sahs,  in  order  to 
produce  artificial  and  instantaneous  thrombosis,  by  which  hiter  occkision  of  the  vein 
could  be  induced,  l^he  coagulating  effects  were  decided,  and  so  also  were  the  effects 
of  the  germs  introduced  at  the  same  time,  in  the  absence  of  ortlinary  antiseptic  precau- 
tions. Thus  it  resulted  that  the  mortality,  even  after  this  trifling  procedure,  was 
tremendous  and  led  to  its  abandonment.  When  it  had  been  demonstrated,  through 
Lister's  achievements,  that  the  surgeon  could  be  clean  about  such  work,  it  was  learned 
also  that  veins  could  be  more  radically  treated  than  had  been  previously  realized.  With 
the  advent  of  the  antiseptic  era  came  more  effective  and  extensive  operations  u})on  veins. 
Now  we  know  that  with  strict  asepsis  they  can  be  handled  with  absolute  impunity, 
and  open  methods  of  treatment  have  replaced  the  subcutaneous.  No  hesitation  is  at 
present  felt  in  exposing  the  veins  at  one  point,  or  numerous  points,  and  aj^plying  ligatures; 
these,  however,  have  been  foimd  to  be  less  effective  than  a  long  incision  made  over  a 
vein,  with  its  complete  extirpation.  Thus  the  long  internal  saphenous  should  nearly 
always  be  excised,  though  it  take  an  incision  twenty  inches  in  length,  in  order  to  take 
off  the  weight  of  its  column  of  blood.  It  is  ordinarily  a  simple  matter  to  clamp  and  tie 
each  branch  as  it  is  divitled,  and,  after  removal  of  the  principal  trunk,  to  bring 
together  the  entire  incision  with  subcutaneous  or  continuous  sutures.  In  the  same  way 
numerous  incisions  may  be  made  in  the  leg.  It  is  possible,  however,  to  meet  with  so 
many  enlarged  veins  that  the  surgeon  may  feel  that  he  cannot  thus  eradicate  each  one.  In 
such  cases  it  is  my  custom  to  extirpate  the  principal  trunk  or  trunks  involved  above,  and 
then  to  combine  this  with  Schedc's  suggestion  to  completely  or  partly  circumcise  the  leg, 
below  the  knee,  down  to  the  deep  fascia,  cutting  across  every  vein  and  tying  on  each 
side  those  which  bleed  to  any  extent.  After  all  these  veins  are  ligated  the  incision  is 
usually  brought  together  again,  as  above.  By  this  means  all  communication  between 
the  subcutaneous  veins  above  and  below  the  line  of  incision  is  cut  off.  Wound  healing 
is  accompanied  by  a  temporary  edema  of  the  foot  and  leg,  especially  when  these  are 
held  down,  and  by  more  or  less  numbness  of  the  skin  due  to  division  of  the  cutaneous 
nerves;  but  circulation  and  nerve  supply  both  rearrange  themselves  in  time,  and  the 
result  is  usually  satisfactory.^ 

Should  ulcer,  i.  e.,  the  so-called  varicose  nicer,  be  present,  it  may  also  be  attacked 
radically,  and  at  the  same  time  completely,  by  excising  the  affected  area,  tcith  its  indu- 
rated border,  down  to  the  level  of  the  deep  fascia,  and  covering  the  surface  thus  denuded 
with  Thiersch  skin  grafts  from  some  other  portion  of  the  body.  Should  such  an  ulcer 
require  treatment  after  this  fashion  it  is  best  to  attend  to  excision  of  the  infected  area 
first,  in  order  to  clear  away  all  material  which  might  harbor  germs.  The  usual  pro- 
cedure, then,  should  be  excision  of  the  ulcer,  extirpation  of  the  veins,  to  be  concluded  by 
skin  grafting.  A  limb  thus  radically  treated  should  be  included  in  a  comfortable  dress- 
ing, and  then  be  affixed  to  some  splint  or  other  device  by  which  absolute  rest  and  repose 
may  be  maintained. 

In  milder  cases,  where  no  single  large  dilated  vein  seems  to  call  for  extirpation,  it 
may  suffice  to  practise  Schede's  operation  alone.  Experience  has  taught  this  fact,  that 
in  dealing  with  extensive  varices  the  surgeon  is  more  likely  to  err  on  the  side  of  leniency 
than  on  that  of  thoi'oughness. 

VENOUS   ANGIOMAS. 

These  have  already  been  mentioned  in  the  chapter  on  Tumors  as  constituting  one 
variety  of  the  angiomas.  Many  of  them  are  of  congenital  origin.  In  many  instances 
they  jjroduce  erectile  tumors.  They  frequently  occur  in  the  liver,  in  the  thyroid,  and 
other  internal  organs,  as  well  as  on  the  body  surface. 

•  Extirpation  of  the  Internal  Sap/ienous. --Keller  has  quite  recently  suggested  a  new  method  of  extirpating  these 
varicose  veins  without  extensive  scarring.  He  exposes  the  vein  at  two  points  a  considerable  distance  apart,  and 
ties  above  and  below  after  separating  it  from  its  surroundings.  The  vein  is  then  cut  below  the  proximal  end,  the 
upper  end  of  the  section  to  be  removed  split  and  a  strong  ligature  tied  to  it,  care  being  taken  to  include  no  more 
tissue  in  the  ligature  than  will  pass  through  the  lumen  of  the  vessel.  Then  from  the  lower  end  a  wire  loop  or 
probe  is  passed  upward,  a  ligature  is  threaded  into  its  eye  and  the  probe  is  then  withdrawn,  carrying  the  ligature, 
after  which  traction  is  made  upon  the  latter,  the  edges  of  the  vein  being  inverted  into  its  own  lumen,  it  being  thus 
extirpated  by  being  turned  inside  out  and  withdrawn  from  its  sheath.  With  the  internal  saphenous,  when  a 
slight  puckering  is  seen  about  midway  between  the  incisions,  indicating  that  the  anterior  branch  of  the  vessel 
has  been  reached,  a  third  incision  is  made,  the  branch  is  ligated  and  divided,  and  then  the  traction  renewed  until 
the  vein  is  entirely  pulled  through  the  lower  opening.     Several  cases  thus  treated  have  been  very  successful. 


\i:.\<)('s  A.\<;i<)MAs 


367 


A  venous  tumor,  composed  of  f^ood-sized  veins,  distended  perhaps  far  beyond  their  nor- 
mal capacity,  constitutes  a  coin  pound  puri.r,  of  which  the  best  expression  is  a  lieniorrhoid 
or  a  varicocele.  Another  form  is  composed  ahnost  entirely  of  capillary  veins,  which 
are  increasi'd  not  only  in  size  hut  also  in  lunnher.  These  constitute  the  j^rowths  called 
"  niof Iters-'  iiKtrlc.s',"  ''.s-frairhrrri/  (/roirfli.s-,''  etc.  'I'echnically  (hey  are  rrnoii.s-  ncvi,  which 
vary  in  siz(>  from  trifliiifi;  lesions  to  lar^e  tumors  of  varying  sha|K's.  These  f^rowths  are 
always  most  consjjicuous  about  the  hands  and  face,  because  these  are  the  visible  parts 
of  the  body.  They  may,  however,  occur  at  any  point,  but  mainly  about  the  face  and 
the  orbit.  A  diifuse  form,  whose  area  may  be  almost  unlimited,  but  usually  circum- 
scribed, is  that  called  "port-wine  mark,"  which  occurs  more  frequently  about  the  face. 
It  has  been  attributed  to  mental  impressions  durino;  j)re<;nancy,  but  there  seems  little 
to  justify  this  view.  The  affected  surface  is  somc'times  pi<!;mented  and  (generally  more 
hairy.  Surface  markinp;s  of  this  kind  may  accom|iany  that  form  of  ix-uroma  described 
as  plc>xiform  neuroma.  Fi<i;.  1<SI>,  from  Ilolloway,  illustrates  another  form  of  con<renital 
growth  of  this  kind.  These  (ji-owths  rarely  occur  in  the  nasopharynx,  where  they  not 
only  obstruct  but  are  sources  of  actual  danger  from  hemorrhage. 

Fig.  183 


Congenital  venous  nevus.     (HoJioway;. 

Treatment. — The  most  satisfactory  treatment  of  a  limited  growth  of  this  kind  is 
excision,  especially  if  this  can  be  made  at  an  early  age.  The  resulting  scar  will  be  smaller, 
the  healing  more  promj^t,  and  the  result  in  every  way  better.  When  excision  seems 
impracticable  electrolysis  should  be  employed,  one  or  both  poles  of  a  galvanic  battery 
of  six  to  ten  cells  being  connected  with  needles,  which  are  inserted  directly  into  the 
growth,  and  whose  position  is  constantly  changed,  so  that  the  coagulating  effect  of  the 
electric  current  may  be  equably  distributed  throughout  the  growth.  Occasionally  the 
growth  may  be  so  shaped  as  to  permit  of  ligature,  and  it  is  best  employed  either  with  or 
without  the  use  of  a  needle,  after  w^hich  it  may  be  excised  or  will  slough  oflf.  This  is 
essentially  one  method  of  treating  external  hemorrhoids.  Methods  by  injection  of 
coagulants  are  all  open  to  serious  objection,  are  hazardous,  and  should  be  abandoned. 
A  port-wine  mark  may  be  sometimes  treated  by  a  tattooing  process,  which  should,  how- 
ever, be  practised  with  strict  antiseptic  precautions.  Electrolysis  may  also  be  practised 
over  a  small  area  at  a  time.  The  more  destructive  method,  by  use  of  the  cautery,  is 
likely  to  leave  scars  almost  as  conspicuous  as  the  original  condition.  Occasionally  a 
lesion  of  this  kind  will  be  so  shaped  and  placed  as  to  justify  excision  with  an  autoplastic 
operation. 


CHAPTEK   XXX. 
INJURIES  AND  DISEASES  OF  THE  LYMPH  VESSELS  AND  NODES. 

An  appreciation  of  the  pathology  of  the  lymj)hatic  system  requires  a  brief  alhision 
here  to  the  hitest  investigations  and  conclusions  regarding  the  purpose  of  the  lymph 
as  a  fluid  and  the  channels  by  which  it  is  distributed.  Under  the  term  lymph,  Hall 
has  included  four  dift'erent  types:  (1)  Tissue  lymph,  which  fills  the  intercellular  spaces 
throughout  the  body;  (2)  circulating  lymj)h,  which  j)asses  through  the  lymphatic  capil- 
laries into  the  circulatory  system  by  way  of  the  thoracic  duct ;  (3)  chyle,  or  the  peculiar 
circulating  lymph  of  the  intestinal  tract,  which  c-arries  into  the  general  circulation  its  load 
of  nutritive  material;  (4)  serous  lymph,  /.  c,  the  contents  of  the  serous  cavities.  Closely 
related  to  the  latter  are  the  aqueous  humor,  the  cerebrospinal  and  the  synovial  fluids. 
All  these  fluids,  except  chyle,  contain  at  least  95  per  cent,  of  water  and  nearly  4  per 
cent,  of  proteids. 

The  lymph  is  the  only  fluid  which  comes  into  contact  with  all  the  living  cells  of  the 
body;  it  pervades  every  part  of  its  substance  to  such  an  extent  that  it  has  been  said 
that  the  higher  animals  are  essentially  aquatic  because  they  practically  live  in  a  watery 
medium.  Blood  normally  comes  into  contact  only  with  the  endothelial  cells  of  the 
vessels  and  with  those  cells  in  the  splenic  pulp  and  perhaps  other  localities  which  have 
to  do  with  its  elaboration,  and  these  are  but  a  minute  proj)ortion  of  the  total  cells  of  the 
body.  x\ll  the  rest  receive  their  nutrition  and  even  their  oxygen  through  the  lymph, 
which  receives  them  from  the  blood.  INIoreover,  nearly  all  the  waste  materials  of  the 
body  are  emptied  into  the  lymphatic  system,  and  thus  directly  or  indirectly  find  their 
way  into  the  blood  to  be  further  extruded.  Thus,  with  the  exception  of  the  endothelium, 
the  lymph  is  the  medium  of  exchange  between  blood  and  tissue.  In  this  the  lymph 
and  the  lymphatics  play  a  role  which  even  for  the  surgeon  must  be  of  the  greatest 
importance. 

The  amount  of  lymph  which  empties  into  the  vena  cava  from  the  thoracic  duct  repre- 
sents only  that  which  comes  from  the  viscera,  bearing  its  special  load  of  nutritive  material. 
When  we  consider  the  communication  between  the  blood-vascular  and  the  lymph- 
vascular  systems,  the  promptitude  whh  which  material  injected  into  the  tissues  {e.  g.,  salt 
solution)  is  taken  up  by  the  lymj)hatics  and  its  effects  made  known  through  the  blood- 
vessels, we  will  better  appreciate  how  deleterious  material  also  can  be  quickly  distrilnited 
through  the  system.  The  lymph  then  must  be  regarded  as  a  fluid  derived  from  the 
blood  by  combined  filtration  and  osmosis,  which  makes  its  way  back  into  the  blood 
again  with  equal  ease. 

Lymph  vessels  which  are  sufficiently  large  to  be  recognized  have  thin  walls  and  are 
provided  with  valves  like  the  veins,  the  lymph  stream  being  j)ropelled  by  a  ins  a  tcrgo 
from  the  heart.  Any  injury  which  permits  blood  to  escape  will  also  injure  numerous 
minute  lymph  vessels;  in  fact,  in  such  little  maneuvers  as  vaccination  the  attempt  is 
made  to  draw  lymph  alone  and  not  blood.  If  a  large  lymph  trunk  be  divided  there 
may  be  an  outpour  of  lymph,  and  if  this  happen  to  be  the  thoracic  duct  the  external 
escape  of  its  lymph  stream  may  seriously  interfere  with  nutrition.  Injuries  which 
divide  it  within  the  thorax  are  usually  fatal,  but  it  may  be  divided  in  the  neck  by  a 
puncture  or  stab  wound,  or  during  a  deep  operation.  Escape  of  lymph  into  the 
abdominal  cavity  under  similar  circumstances  gives  rise  to  chylous  ascites,  and  when 
into  the  thorax  to  chylous  hydrothorax.  In  the  former  case  repeated  tapping  may  tide 
over  the  emergency  and  lead  to  eventual  recovery;  in  the  latter,  aspiration  or  even  open 
incision  may  be  necessary.  When  the  thoracic  duct  has  been  injured  in  the  neck  it 
may  be  possible  to  close  the  opening  with  sutures  or  to  suture  tissues  over  it.  In  a 
few  instances  final  recovery  has  followed  the  formation  of  a  chylous  fistula.  Injury 
to  this  duct  is  to  be  recognized  by  the  flow  of  milky  (/.  e.,  chylous)  fluid  from  the  wound 
or  from  the  duct  itself.  When  poured  into  the  abdomen  or  the  thorax  the  retained 
(368) 


PLATE  XXXI 


Connects    with 

Superior 

Mediastinal  Glands 


Connects  uiith 
Axillary    Glands 


Diagram  cf  the  Nodco  and  Vessels  cf  the  Head  and  Neck,  showing  the  Regions  that 
are  Drained  into  Each  Group  of  Nodes.  Deep  structures  in  red,  superficial  in  black. 
(Gerrish.) 


-  -3  -5   g. 


X 
X 
X 

w 

< 


o    >- 

a,  5 

^^ 
__   "o 


Q    c 


C    CO 


2  .2 

3  > 
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cn  Q 


PLATE   XXXllI. 


Diagram  of  the  nodes  of  the  trunk  and  their  tributary  vessels.    (F.  H.  G.) 


OCCIASION  OF  1AM  I'll    \  ESSFJ.S 


HOO 


fluid  has  the  same  milky  a|)|H'arance.  It  has  hccii  sn<jffi'st('(l  to  withhold  all  food  in 
order  to  favor  the  sj)oiitaiieous  closure  of  such  an  o|)enin<f,  su|)|)ortint^  the  |)atient 
meanwhile  hv  rectal  nourishment  and  hy  the  introduction  of  milk  into  the  veins.  The 
y\^\\\  lvm|)liatic  duct  is  less  liable  to  injury,  and  such  lesions  on  the  right  side  would  be 
of  less  importance. 


THE  ARRANGEMENT  OF  THE  LYMPH  VESSELS  AND  NODES. 

Inasmuch  as  most  of  the  surgical  infections,  including  cancer,  are  disseminated  by 
means  of  the  lymph  vessels  it  is  necessary  that  the  surgeon  should  know  the  relation  of 
vessels  and  nodes  to  the  other  ])arts  of  the  body.  The  surgical  anat(jmy  of  the  lym|)h- 
atics  can  be  appreciated  by  reference  to  Gerrish's  admirable  diagrams.  (See  Plates 
XXXI,  XXXII,  and  XXXIII.)  They  will  indicate  at  a  glance  what  it  would  take 
pages  to  describe.  The  reader  should  also  make  frecpient  reference  to  these  diagrams 
in  connection  with  studies  of  septic  infection,  tuberculosis,  and  especially  of  cancer. 


1S4 


OCCLUSION  OF  LYMPH  VESSELS. 

Occlusion  of  lymph  vessel ;  may  be  either  congenital  or  acquired.  The  congenital 
type  is  of  extreme  interest  pathologically,  but  perhaps  of  less  interest  to  the  surgeon, 
since  it  rarely  permits  of  a  surgical  remedy.  The  reader  interested  in  this  subject 
should  consult  the  writings  of  Busey,  who 
has  contributed  memorable  monographs 
on  the  general  subject  of  occlusion  of  the 
lymphatics.  The  acquired  forms  have  to 
do  with  various  conditions,  such  as  thick- 
ening of  vascular  walls,  the  pressure  of  exu- 
dates or  of  tumors,  or  even  of  callus,  and 
with  the  specific  infections,  of  which  syphilis 
and  cancer  are  perhaps  the  most  illustra- 
tive. The  result  which  is  brought  about 
by  these  various  causes  is  not  so  much  the 
dilatation  of  the  vessels  as  the  saturation  or 
water-logging  of  the  tissues  on  the  distal 
side  of  the  obstructive  lesion.  The  former 
is  indicated  by  the  formation  of  vesicles  or 
bullpe  which  will  frequently  ooze  or  weep 
continuously.  Should  the  pressure  be  local- 
ized and  circumstances  favor  it,  a  truly 
cystic  collection  of  fluid  may  result.  The 
more  common  type  is  the  so-called  lymph- 
edema, which,  when  chronic,  is  always  ac- 
companied by  hyperplasia  of  the  affected 
tissues,  their  overgrowth  resulting  from  a 
superabundance  of  nutrition,  the  connective 
tissue  apparently  appropriating  the  larger 
amount  of  this  material  for  itself.  There- 
fore with  the  dimensions  of  a  member  enormously  increased  it  will  be  found  that 
almost  every  other  tissue  except  the  connective  has  been  starved  out.  Lymphedema 
differs  from'  that  produced  by  venous  obstruction  by  its  obstinacy  and  the  density  of 
the  infiltration ;  in  fact,  h  has  been  sometimes  spoken  of  as  solid  edema.  If  it  contmues 
for  some  time  there  are  permanent  changes  which  do  not  atlmit  of  later  dispersion,  and 
permanent  enlargement  is  the  result.  The  most  unmistakal)le  expressions  of  this  kind 
occur  in  the  legs  and  the  external  genitals  of  both  sexes  (Fig.  18-1)  • 

When  compression,  position,  massage,  and  such  measures  fail  the  only  other  resort 
is  amputation. 
24 


Lymphedema. 


370 


SURGICAL  AFFECTIONS  OF   THE   TISSUES 


LYMPHANGIECTASIS  AND  ELEPHANTIASIS. 

These  terms  refer  to  dilatation  of  tlie  lymphatics,  with  a  niiiiiinum  of  actual  obstruc- 
tion, often  as  a  sequence  of  some  previous  lesion  which  has  disappeared.  In  some  of 
its  expressions  the  condition  is  a  manifestation  of  a  widespread  general  disease  or  a 
parasitic  infection.  This  is  particularly  true  in  those  forms  due  to  the  presence  of 
filarife  in  the  blood,  in  which  it  is  not  a  question  of  the  ol)struction  of  one  of  a  series  of 
vessels,  but  plugging  of  a  number  of  them  by  the  adult  worms,  which  reside  especially 
in  the  larger  lymph  and  chyle  passages,  sometimes  even  causing  the  appearance  of 
chyle  in  the  urine. 

Elephantiasis  is  an  expressive  term  given  to  any  enormous  enlargement  of  a  part  of 
the  body,  due  to  a  combination  of  causes,  of  which  lymphatic  dilatation  and  obstruc- 
tion together  constitute  the  most  important  feature.  The  so-called  congenital  forms 
may  have  to  do  with  congenital  deviations  from  the  normal  standard,  but  should  be 
differentiated  from  instances  of  gigantism,  which  have  already  been  alluded  to  in 
Chapter  I,  into  whose  etiology  different  factors  probably  enter. 


Fig.  185 


Fig.  186 


r              WBBBBS^T' 

m-   1 

V 

* 

.4t- 

m  ' 

'     'v\> 

\- 

1' 

-i-  „'  :;:..iaay||jga»^ 

^<::»  . 


Elephantiasis  of  leg,  scrotum,  and  penis. 


Elephantiasis  of  hand,  acquired. 


Of  the  acquired  forms  of  elephantiasis,  those  seen  in  the  tropics  are  nearly  all 
expressions  of  filariasis.  Sporadic  instances  are  met  with  in  colder  climates,  and  a 
condition  resembling  it  is  occasionally  observed  for  which  no  existing  cause  can  be 
detected.  Such  a  case  is  illustrated  in  Fig.  186,  which  occurred  in  a  convict  in  the 
penitentiary  in  Buffalo,  who  had  never  been  outside  the  limits  of  the  county,  and 
in  whom  no  parasites  could  be  detected.  Figs.  185,  187,  and  188  illustrate  typical 
instances  of  elephantiasis.  Fig.  188  being  taken  from  a  Klamath  Indian  woman  in  the 
Northwest  Territory,  the  condition  being  similar  to  that  met  with  in  the  tropics. 

The  worms  belong  to  the  nematoids,  the  adult  being  0.03  or  thereabouts  in  length, 
thinner  than  the  diameter  of  a  red  corpuscle,  rarely  remaining  long  in  the  quiescent 


LyMr!f.\\an:rT.\srs  a\[)  i:li:puasti.\sis 


371 


state.  Tli(\v  ('.111  thus  |);i.ss  into  the  (•a|)ill;iri(s,  wliicli  tlicy  may  pliif^.  Tlic  inosijiiito 
is  (lisc(»v(M"i'(l  to  he  llic  iiicdiMiii  ol'  (raii.s])ortatioii,  citlicr  directly  or  indirectly,  tliroiij^Ii 
exposed  (lriid\in^  water,  where  the  insect  de|)osits  her  infected  et:;<;s.  The  adnll  worms 
outside  tile  body  may  attain  a  length  of  1  Cm.  From  the  intestinal  canal  they  |)ass  into 
the  lym|)h  cniiciit  and  aic  carried  until  thcii-  proj^ress  is  checked,  where  they  establish 
a  peruuineut  home  and  breed  and  act  as  local  irritants.  The  embryos  which  they 
])roduce  are  innocent;  it  is  the  adult  and  parent  orjijanisms  tliat  produce  the -(Jaina{;;e. 
Lvm|)h  How  beino;  thus  obstructed  the  area  previously  drained  by  a  fjiven  vessel  will 
undcra;!)  various  chan>:;es  in  the  direction  already  described.  In  |)roporlion,  then,  to 
the  number  of  adult  worms,  and  in  accordance  with  their  location,  will  be  involvement 
of  an  entire  member  or  of  a  more  limited  area,  e.  (j.,  lymph  scrotum  (Fig.  l-ST)  or 
ehvlous  hvdrocele 


Vn..  1S7 


l''i(j.  188 


Elephantiasis  of  scrotum. 


Elephantiasis  of  vulva  (Klamath  Indian  woman). 
(Contributed  by  Dr.  H.  L.  Raymond,  U.  S.  A.) 


As  yet  there  is  no  cure  for  filariasis;  hence  there  is  no  relief  for  elephantiasis  produced 
by  it,  except,  when  localizetl,  to  remove  the  part.  In  the  tropical  forms  it  is  the  lower 
part  of  the  body  which  is  usually  involved.  It  begins  in  a  limb,  usually  in  the  toes. 
It  produces  discomfort  rather  than  actual  pain,  at  least  until  such  time  as  distention  of 
the  parts  becomes  unbearable.  Along  with  lymphatic  engorgement  there  is  a  peculiar 
liability  to  erysipelas,  Avhich  becomes  an  exceedingly  serious  malady  in  tissues  so  satu- 
rated with  lymph,  and  w'ith  such  possibility  for  the  propagation  of  germs.  A  milder 
degree  of  cutaneous  and  subcutaneous  infection  than  is  implied  by  the  term  erysipelas, 
as  used  in  this  work,  may  be  called  erysipeloid  or  cellulitis;  it  is  quite  common  and 
frequently  recurs.  With  each  attack  of  this  kind  the  condition  is  aggravated  and  the 
limits  of  the  lesion  extend.  After  a  time  the  member  becomes  enlarged  to  a  degree 
which  disables,  while  the  skin  itself  undergoes  changes  that  alter  it.s  appearance;  not 
only  is  it  thickened,  but  there  develop  upon  it  papillomatous  projections,  with  infiltra- 


372 


SUmilCAL  AFFECTIONS  OF   THE   TISSUES 


Fig.  189 


tioii  of  tlie  corium,  that  give  it  an  unnatural  appearance  and  feelinjj;.     Epithelial  ])ro 
liferation  is  also  rapid,  and  is  accompanied  by  a  sort  of  caseous  discharge  which  may 
decompose  and  add  extremely  offensive  features  to  these  cases. 

The   management   of  these   cases   becomes   very  difficult.     Total   disability  finally 
succeeds  inability,  and  patients  in  the  last  stages  are  often  bi-dridden.     The  re])eated 

attacks  of  erysi])el()id  should  be  treated 
with  antiseptic  aj^plications  and  eleva- 
tion of  the  part,  but  without  too  much 
compression,  as  germs  may  be  forced  into 
the  circulation. 

In  ele])hantiasis  of  the  lower  extrem- 
ities it  has  been  suggested  to  tie  the 
femoral  arteries,  ho])ing  thereby  to  de- 
prive the  liml)  of  at  least  a  portion  of 
its  fluid  sup])ly.  This  may  be  of  some 
avail  early,  but  when  it  is  done  late  it  is 
likely  to  be  followed  by  gangrene  of  the 
limb,  from  whose  consequences  not  even 
amputation  can  save  the  patient. 

In  the  tropics,  especially  where  the  ex- 
ternal genitals  are  sometimes  involved, 
extensive  oj)erations  have  been  of  great 
service,  and  among  the  surgeons  of  India 
reports  of  operations  of  this  kind  are 
fiequent. 

Elephantiasis  is  most  common  in  men ; 
occurring  in  women  it  is  not  limited  to 
the  external  genitals,  for  the  writer  has 
seen  illustrations  of  the  disease  in  the  legs 
alone.  In  the  Western  Plemisphere  it  is 
met  frecpiently  in  the  Barbadoes,  and  is  called  Barbadocs  leg  (Fig.  1<S9).  The  principal 
dangers  from  operations  on  these  cases  pertain  to  the  risks  of  hemorrhage,  shock,  and 
infection.  Nothing  short  of  amputation  of  limbs  or  ablation  of  the  genitals  is  of  real 
benefit.  In  all  these  operations  the  veins  as  well  as  the  arteries  should  be  ligated, 
and  the  ligatures  used  en  masse,  introduced  with  a  needle.  There  is  usually  copious 
oozing,  and  drainage  should  be  provided. 


Elephantiasis  (  "Barbadoes  leg").    (E.  J.  Meyer.) 


CHYLOCELE. 

This  term  is  applied  to  a  condition  also  referred  to  as  rhj/Ious  hi/drorele.  It  implies 
a  collection  of  milky  fluid  in  the  cavity  of  the  tunica  vaginalis.  Occurring  in  a  patient 
known  to  be  suffering  from  filariasis  it  may  be  diagnosticated  before  exi)loration.  In 
some  instances  where  the  sac  of  fluid  is  less  translucent  than  usual,  if  the  candle  test 
fail  when  applied,  chylocele  may  be  suspected.  Careful  examinati(m  of  the  sac  may 
show  widely  opened  lymph  ve-^^sols  or  lymph  spaces.  It  is  to  be  distinguished  from 
spermatocele,  whose  contents  also  are  milky  fluid,  but  rarely  collecting  to  the  same 
amount.  Chylocele  may  be  treated  by  tapping,  or  by  open  division  or  extirpation  of 
the  sac,  exactly  as  recommended  elsewhere  for  the  treatment  of  hydrocele.  (See 
Fig.  187.) 

Chylocele  is  to  be  distinguished  from  h/mph  seroium,  which  is  a  form  of  localized 
lymphangitis  of  mild  flegree  rather  than  a  circumscribed  collection  of  chylous  fluid. 
It  ])resents  febrile,  not  to  say  inflammatory  features,  and  in  the  chronic  form  the  skin 
will  be  frequently  seen  to  ooze  fluid  c-losely  resembling  lymph,  which  condition  is  called 
lyinphorrhagia.  The  scrotum  rarely  becomes  as  large  as  in  extreme  cases  of  dropsy, 
and  yet  may  assume  an  uncomfortable  size.  This  condition,  like  that  previously  men- 
tioned, is  usually  associated  with  filarife.  It  may  appear,  however,  spontaneously, 
and  after  persisting  for  a  long  time  disappear,  with  as  little  apparent  reason  as  that 
which  produced  it.  When  the  condition  becomes  unbearable  ablation  may  be  practised. 
(See  Fig.  187.) 


MACROCIIi:ilJ.\ 


373 


CHYLURIA 

Tlir  pr(',s(Mi('(»  of  chylo  in  the  urine  fjjivcs  i(  an  appcurance  as  if  (•mnlsified  oil  had 
been  mixed  \vi(li  i(.  It  occurs  witli  or  without  known  reason.  Soineliines  it  co-exists 
with  lesions  like  lymph  scrotum,  etc.;  at  other  times  it  seems  to  neither  pnxhice  nor 
be  accompanied  by  other  disturbances.  Ordinarily  the  urine  or  the  l)l()od  when 
examined  al  iiic/hf — /.  r.,  the  sl(>epin<]j  hours — will  reveal  the  jjathofjenic  or<>;aiiisms, 
I.  c,  filaria\  It  is  a  condition  but  little  influenced  by  treatment,  wliioii  should  be 
symptomatic  in  the  absence  of  special  indications. 


MAGROMELIA. 

The  more  typical  con(j(>nital  forms  of  occlusion  of  lymj)h  v<>ssels  produce  such  clianges 
as  we  see,  for  instance,  in  macrochilia,  where  the  lips  and  cheeks  are  alfecteci;  macro- 


I'Ki,  190 


¥ir..  191 


Macromelia.     (Gerrish. 


Macrogtossia.     (Neisser.) 


glossia,  where  the  tongue  is  too  large  to  be  retained  inside  the  mouth;  and  sometimes 
macrodactylia  and  macropodia,  where  the  fingers  and  hands  or  toes  and  feet  are  in- 
volved (Figs.  190  and  191).  It  is  difficult  to  separate  some  of  these  cases  from  gigantism, 
as  already  stated.  The  more  distinctive  lymphatic  lesions  are  frequently  accompanied 
by  pigmentary,  cutaneous,  or  papillomatous  conditions,  which  stamp  them  as  some- 
thing more  than  mere  expressions  of  disproportionate  growth.  The  patient  of  Dr. 
Gerrish,  whose  condition  is  illustrated  in  Fig.  190,  presented  lesions  which  might  be 
assigned  to  either  of  these  groups.  It  will  usually  require  a  careful  study  to  make  a 
proper  assignment  of  such  cases  as  macromelia. 


MAGROGHEILIA. 

While  this  condition  is  usuallv  regarded  as  an  expression  of  lymphangiectasis,  it 
has  been  shown  that  it  mav  be  due  to  multiple  adenopathy  of  the  mucous  glands  in 
the  lips.     The  lips   are   well  supplied  with  such  glands,  which  lie  beneath  mucous 


374  SURGICAL  AFFECTIONS  OF  THE  TISSUES 

membrane  in  a  mixture  of  more  or  less  oonneetive  and  vaseular  tissue.  When  the  lips 
undergo  marked  hyjjertropliy  in  adult  life,  it  is  very  likely  that  the  afleetion  may  be 
exjjlained  by  the  hypertr()|)hy  of  these  eolleetive  glands,  and  this  is  ])artieularly  true 
when  anything  like  nodular  arrangement  ean  be  detected.  A  recognition  of  this  cause 
will  indicate  the  proper  remedy,  i.  e.,  excision  of  the  affected  tissue.  The  writer  has 
on  more  than  one  occasion  made  an  elliptical  incision  both  from  the  lower  and  upper 
lip  and  accomplished  its  purpose,  with  great  improvement  of  appearance. 


LYMPHANGIOMA. 

Lymphangioma  has  been  described  in  the  chapter  on  Tumors.  It  seems  necessary 
to  allude  to  but  one  expression  of  this  kind  in  this  place,  i.  e.,  the  so-called  hjmpliangioma 
circumscriptum.  This  presents  as  a  cutaneous  area  dottetl  with  vesicles,  sometimes 
regularly,  sometimes  irregularly  distributed,  usually  in  annular  form,  seen  most  com- 
monly on  the  upper  limbs  and  in  the  region  of  the  shoulders.  The  vesicles  occasionally 
become  sufficiently  large  to  be  called  bullae,  while  the  contained  bloodvessels  are  dilated 
and  discolor  the  area  involved,  which  may  also  be  more  or  less  pigmented.  Here, 
as  in  elephantiasis,  there  is  great  liability  to  surface  infection  of  low  grade,  which  may. 
perhaps  be  called  erysipeloid.  The  tissues  gradually  become  thickened  and  covered 
with  scabs  or  warty  collections  of  epithelium.  It  is  met  with  early  in  life,  rather  than 
late,  and  is  supposed  to  be  of  congenital  origin.  It  may  be  distinguished  from  herpes 
by  the  pronounced  vascular  changes  and  by  the  discharge  of  lymph. 

Treatment. — Treatment  has  been  too  often  unsatisfactory  and  the  trouble  often 
re-appears  after  apparent  recovery.  If  the  area  involved  be  not  too  large  complete 
excision  will  probably  prove  the  most  satisfactory  method  of  attack. 


LYMPHANGITIS. 

This  term  applies  rather  to  gross  and  visible  lesions  of  the  larger  lymphatics  than  to 
the  involvement  of  the  ultimate  lymph-filled  ramifications.  When  the  smaller  lymph 
capillaries  and  interspaces  are  involved  the  lesion  takes  the  type  of  an  erysipelas  or 
cellulitis,  l)ut  as  the  collected  products  return  through  the  lymph  channels  from  such 
an  involved  area  they  will  disturb  and  infect  the  lymph  vessels  themselves,  and  this 
leads  to  what  is  called  a  lymphangitis.  Formerly  the  term  sjiontaneous  or  idiopathic 
was  given  to  some  of  these  cases.  Assuming,  as  is  done  throughout  this  work,  that 
there  is  no  true  inflammation  that  is  not  of  microbic  origin,  we  may  expunge  the  term 
"idiopathic"  and  say  that  lymphangitis  is  also  an  expression  of  infection,  and  that  the 
inflamed  vessel  represents  a  channel  through  which  products  of  inflammation  are  being 
conveyed.  Histologically  the  walls  of  these  vessels  become  infiltrated  with  a  coagu- 
lating exudate,  which  may  completely  occlude  the  vessel.  The  bloodvessels  immediately 
adjoining  the  lymphatics  also  become  involved,  and,  being  engorged,  give  rise  to  the 
peculiar  red  lines  or  streaks  which  are  frequently  seen  when  cutaneous  lymphatics 
are  thus  involved,  this  appearance  being  due  to  a  perilymphanc/ifis.  The  infected 
lymph  passing  through  this  channel  is  filtered  out  in  the  first  lymph  nodes  with  which 
it  communicates,  which  themselves  become  thus  infected;  hence  the  rapitlity  with 
which  these  enlarge  and  break  down,  so  that  by  their  own  sacrifice  they  may  perhaps 
protect  the  rest  of  the  body  from  serious  infection.  Under  these  circumstances  sup- 
puration and  necrosis  of  these  lymph  nodes  is  to  be  regarded  as  a  vicarious  destruction 
on  their  own  part. 

Lymphangitis  proceeds  from  the  periphery  toward  the  centre,  and  is  followed  by 
a  certain  amount  of  pain,  with  great  soreness  and  sense  of  stiffness  in  the  parts;  the  skin 
overlying  the  infected  vessels  becomes  reddened  in  streaks,  which  indicate  their  course, 
or  becomes  more  or  less  infiltrated  and  involved  throughout  in  a  form  of  infectious 
dermatitis.  According  to  the  virulence  of  the  germ,  and  the  susceptibility  of  the  indi- 
vidual and  his  tissues,  there  will  or  will  not  occur  suppuration.  This  may  perhaps 
be  averted  by  prompt  treatment.  Should  deep  tenderness  and  pain  take  the  ])lace  of  or 
be  added  to  their  more  superficial  expressions  it  may  be  inferred  that  the  superficial 


LYMPH   NODES  375 

lyinphatics  have  now  iiifcctrd  llic  (l('c])cr  ones,  and  that  (here  is  frrcater  danger  of 
j)ld('l)itis  and  a  i^rncrali/cd  septic  intV'clion. 

Constitutionally,  at  least,  the  expressions  are  those  of  sei)tic  intoxication,  often  of 
true  septicemia  or  se|)tic  infection.  Local  appearances,  increasing];  temperature,  or 
accession  of  cliills  may  indicate  the  presence  of  pus. 

In  j)rop()rtion  to  the  distance  of  the  diseased  ])art  from  the  body  centres  the  [)ro^'nosis 
becomes  more  favorable.  When  an  entire  liml)  is  involved  the  matter  is  very  serious; 
when  in  the  face  or  abdomen,  still  more  so,  the  fear  being  of  septic  j)lilebitis  and  a  fatal 
termination  by  a  more  or  less  ty})ical  pyemic  ])rocess. 

Treatment. — All  cxcitini;  causes,  indudinfr  sloutfliing  tissues,  foreign  bodies, 
j)us,  etc.,  should  be  thoroughly  removed.  Pus,  when  present,  should  be  evacuated, 
and  when  its  presence  is  suspected  suitable  exploration  should  be  made.  Tension 
should  always  be  relieved  by  incision.  In  cases  where  breaking  down  has  already 
begun,  continuous  immersion  in  hot  water  is  beneficial.  Nothing,  however,  will  take 
the  j)lace  of  removal  of  pus  or  necrotic  tissue,  and  this  should  be  first  attended  to  or 
proved  to  be  unnecessary.  In  an  oj)en  and  sloughing  wound  nothing  is  as  satisfactory 
as  brewers'  yeast;  next  to  this  is  hot  water.  Over  an  unbroken  area  which  is  simply 
edematous  and  pits  on  pressure,  may  be  ai)i)lied  the  ichthyol-mercurial  ointment 
(10  per  cent,  ichthyol,  40  per  cent,  mercurial  ointment)  or  the  Crede  silver  ointment. 
This  should  not  be  rubbed  in,  but  smeared  freely  over  the  surface,  and  then  covered 
with  oiled  silk,  twice  daily,  in  acute  cases.  The  surgeon  should  satisfy  himself  as  to 
the  presence  or  absence  of  pus ;  even  when  only  suspected  it  is  advisable  to  make  incision 
early,  as  tissue  and  possibly  life  may  thus  be  saved.  Constitutional  treatment  should 
not  be  neglected.  It  will  consist  in  improving  elimination,  maintaining  nutrition,  and 
overcoming  the  acute  toxemia  due  to  absorption,  the  toxins  being  best  antidoted  by 
alcohol  in  some  palatable  form,  strychnine  and  quinine  being  serviceable,  but  not  so 
valuable.     (See  chajiter  on  Septic  Infections.) 

Chronic  Lymphangitis. — Chronic  lymj^hangitis  is  seen  in  connection  with  the 
slower  infections,  tuberculosis — syphilis,  filariasis,  etc.  Here  the  lymph  vessels  are 
not  involved  so  much  as  the  lymph  nodes.  Chronic  lymphangitis  does  not  occur 
without  a  toxic  or  infectious  process  behind  it. 


LYMPH  NODES. 

For  the  surgeon's  purpose,  at  least,  he  may  assume  that  lymph  nodes  are  never 
enlarged  except  in  the  presence  of  toxemic  or  infectious  processes.  The  role  which  they 
play  as  filters  of  the  fluid  returning  through  the  lymph  vessels  subjects  them  to  daily 
possibilities  of  contamination.  They  may  be  acutely  infected  and  actually  break  down 
by  a  phlegmonous  process,  or  their  lesions  may  be  very  slow,  chronic,  and  intractable. 
The  lymph  nodes,  like  the  leukocytes,  are  among  our  best  friends;  they  serve  as  guard- 
ians at  the  various  portals  of  the  system,  excluding,  sometimes  at  the  risk  of  their  own 
existence,  various  deleterious  elements. 

The  term  "lymph  gland"  should  be  expunged  from  medical  terminology,  the  node 
having,  so  far  as  known,  no  secretion  nor  any  title  to  be  considered  a  gland.  This 
would  mean  abandonment  also  of  the  expression  "lymphadenitis,"  and  so  the  writer 
would  prefer  to  use  the  expressions  lymphitis,  lymphangitis,  etc.,  which  at  least  do 
not  imply  a  wrong  conception  of  the  process.  The  morbid  activity  which  the  lymph 
nodes  present  will  be  an  expression  of  the  general  virulence  of  the  whole  process  which 
has  produced  it.  To  a  tender  enlargement,  in  acute  cases,  there  will  succeed  rapid 
swelling,  with  pain  and  soreness  commensurate  with  the  density  of  the  surrounding 
tissues  and  the  degree  of  tension  thus  produced.  The  result  is  essentially  an  abscess, 
or  multiple  abscess,  which  necessitates  prompt  treatment  by  free  incision,  evacuation, 
and  drainage,  as  does  any  other  abscess.  It  is  as  often  necessary  to  use  a  curette  as  a 
knife,  and  when  so-called  specific  features  are  present,  as  in  chancroidal  bubo,  a  strong 
antiseptic  should  also  be  used.  Under  these  conditions  the  collection  of  lymph  nodes  in 
the  axilla  or  in  the  groin  may  become  involved  in  multiple  abscess,  and  it  is  then  good 
practice  to  make  a  complete  cleaning  out  of  these  regions.  The  ultimate  effect  of 
such  extirpation  is  beneficial,  and   the  patient  does  not  seem  to  suffer  from  the  loss 


376  SURGICAL   AFFECTIONS  OF    THE   TISSUES 

of  the  involved  lyni])h  nodes;  indeed,  it  is  j)r()hable  that  new  ones  form  to  rei)lace  those 
which  are  destroyed. 

The  chronic  ajjcction.s  of  the  /i/niphatics  wliieh  come  under  the  surgeon's  care  are 
exp  essions  of  tuberculosis,  syj)hiHs,  gonorrhea,  cancer,  or  of  some  of  the  other  less 
frequent  surgic-al  diseases.  In  every  one  of  these  instances  the  disease  has  assumed 
constitutional  proportions,  and  the  lymph-node  involvement  will  be  general.  The 
ultimate  fate  of  these  affected  nodes  will  differ  with  the  different  diseases;  in  tuber- 
culosi.'i  they  sometimes  suppurate  by  secondary  infection,  and  they  frequently  caseate, 
or  remain  enlarged  for  indefinite  periods,  often  throughout  life.  Around  them 
will  be  found  an  area  of  infiltration  which  produces  firm  adhesions  and  frequently 
makes  their  extirpation  very  difficult.  The  lymph  vessels  which  connect  the  various 
nodes  will  also  be  involved  in  a  similar  process,  which  adds  to  the  difficulty  of  operation. 
In  many  cases  these  involved  nodes  can  be  felt  where  they  cannot  be  attacked — for 
example,  in  tabes  mesenterica.  If,  under  suitable  climatic  and  constitutional  con- 
ditions, it  be  possible  to  favorably  affect  other  tuberculous  conditions,  these  expressions 
of  the  disease  may  also  subside  or  at  least  cease  to  trouble.^ 

Syphilis  of  the  lymph  nodes  has  already  been  considered,  as  well  as  the  frequency, 
nay,  the  certainty,  with  which  the  lymphatics  become  involved  in  this  disease.  So 
true  is  this  that  any  general  lymphatic  involvement  which  cannot  be  accounted  for  in 
some  other  manner  is  usually  attributable  to  syphilis.  The  condition  of  the  lymphatics 
may  be  considered  a  fair  index  as  to  the  success  and  effect  of  antisyphilitic  treatment, 
for  if,  under  such  treatment,  these  enlargements  subside  conijiletely  it  may  be  regarded 
as  eminently  successful.  On  the  other  hand,  it  is  not  felt  by  many  that  it  is  safe  to 
discontinue  treatment  in  the  presence  of  these  enlargements.  Syphilitic  enlargements 
may,  moreover,  undergo  secondary  infection,  either  acute  or  chronic,  i.  e.,  may  suppu- 
rate or  become  tuberculous.  In  gonorrheal  bubo  the  pus  which  the  lymph-node  abscesses 
contain  will  often  be  found  almost  a  pure  culture  of  the  gonococcus,  thus  illustrating 
the  specificity  of  this  kind  of  infection. 

The  extent  to  which  the  lymjjhatics  are  involved  in  cases  of  cancer  will  often  be 
the  guide  for  the  surgeon  in  advising  removal  or  the  reverse.  The  principal 
advance  in  the  modern  operative  surgery  of  cancer  has  come  through  a  better  working 
knowledge  of  the  area  of  lymph  distribution  of  given  regions.  All  cancerous  lymph 
nodes  which  can  be  reached  should  be  extirpated.  If  others  can  be  discovered  which 
are  beyond  reach  it  raises  a  doubt  whether  the  operation  should  be  performed.  At 
all  events,  in  these  cases  it  should  be  represented  as  a  temporary  rather  than  an  abso- 
lutely curative  resort,  not  only  because  this  is  true,  but  because  the  surgeon  may  need 
to  protect  himself  against  charges  which  may  be  made  later  by  disappointed  patients. 

The  advisability  of  removing  diseased  lymph  nodes  is  often  a  matter  for  serious 
discussion.  There  is  little  to  justify  their  removal  when  the  exciting  cause  cannot  also 
be  taken  with  them.  It  is  a  mistake  to  operate  on  nodes  in  the  neck  and  leave  diseased 
teeth  through  which  the  infection  may  be  spread.  So,  too,  it  is  a  mistake  to  operate  on 
nodes  which  may  prove  to  be  syphilitic.  In  many  instances,  then,  it  is  best  to  apply 
the  therapeutic  test.  In  cancerous  disease  it  can  rarely  be  advisable  to  remove  lymph 
nodes  alone  except  for  purely  temporary  purposes,  as  to  check  hemorrhage,  remove 
breaking-down  material,  or  something  of  the  kind.  In  the  neck,  groin,  or  axilla  the 
operation  is  not  to  be  lightly  undertaken,  for  it  is  made  extremely  difficult  by  adhesion 
of  the  surrounding  structures.  The  surgeon  should  be  prepared  then  for  careful  dis- 
section, which  should  be  made  with  a  not  too  sharp  knife,  and  he  should  be  ready  to 
sew  up  a  rent  in  the  jugular  vein  or  tie  it,  as  it  and  its  large  branches  are  frequently 
so  displaced  and  obscured  as  to  be  injured,  even  by  the  most  careful  operator. 

HODGKIN'S  DISEASE. 

This  is  one  of  many  names  applied  to  a  condition  whose  most  conspicuous  charac- 
teristics are  a  progressive  anemia,  with  enlargement  of  lymph  nodes,  as  well  as  usually 
of  the  spleen,  with  secondary  or  metastatic  growths  in  the  viscera,  bone-marrow,  and 

'  At  date  of  going  to  press  I  do  not  feel  justified  in  lauding  too  highly  the  work  done  by  numerous  workers 
filth  the  opsonins.  Justice  to  wliat  has  been  done  with  and  claimed  for  them  demands,  however,  their  extensive 
trial,  and  suspension  of  any  judgment  not  as  yet  favorable. 


I  [()!)(  ;K  I  \"S  DISK  ASK 


377 


Fig.  192 


olscwluMT.  That  its  cliolo'^y  liillicrlo  has  hccii  coiisidcnMl  ()l)sriir('  and  (hal  its  clinical 
cliaractcristics  vary  in  (liU'civiit  cases  may  be  shown  by  a  |)artial  list  of  tiic  names  by 
which  it  has  been  ])revi()nsly  known:  li/ni plKidnioma,  vkiIkjikiiiI  /;/iii plionia,  infective 
li/iiiplioina,  prog rrs.f ire  (jiandular  lii/pcrfroplti/,  li/niplKmirroiiin,  and  p.sriKlo/ciikori/tlinnia. 
To  the  writer's  mind,  it'  the  disease  is  to  be  known  by  any  other  name  rather  tlian  liiat 
of  tlie  one  who  first  described  it,  it  mitrht  be  caih-d  maUifnanl  lyni|)homalosis,  as  ils 
tendency  is  downward,  in  which  sense  it  is  maH^nant  in  an  ahnost  hopch'ss  dcirfcc. 

The  cliaiif^es  wiiicii  occur  in  the  bh)od  are  at  first  in  the  (hrection  of  siin|)lc  anemia, 
foUowed  bv  marked  rechiction  in  the  number  of  red  cells,  with  poverty  of  hemoglobin 
and  increase  in  the  number  of  leukocytes.  In  the 
anemia  of  extreme  cases  the  red  cells  may  be  re- 
duced 1, ()()(),()()()  per  Cm.,  while  the  leukocytes, 
es|)eeially  the  polynuclear  forms,  maybe  numbered 
by  the  hundreds  of  thousands.  In  one  case  re- 
centlv  under  my  observation  the  leukocytes 
amounted  to  about  300, ()()()  when  treatment  was 
be<jun.  (See  chapter  on  the  Blood.)  It  is  a  dis- 
ease of  early  rather  than  of  later  life,  and  occurs 
more  often  in  males  than  in  females.  The  most 
pronounced  objective  changes  occur  in  the  lym])h 
nodes,  which  enlarge  steadily,  the  swellings  thus 
formed  being  hard  or  soft  according  to  the  rapid- 
ity of  the  disease.  The  swellings  thus  formed  -will 
appear  consj)icuously  in  the  neck  and  will  be  noted 
also  in  the  axilla  and  the  groin.  Careful  examina- 
tion will  show  that  every  lymph  node  in  the  body 
which  is  accessible  is  involved  in  the  course  of  the 
disease.  Sometimes  the  tumors  become  so  large  as 
to  cause  serious  pressure,  and  when  in  the  neck 
perhaps  to  require  tracheotomy  to  prevent  suffoca- 
tion. Fig.  192  illustrates  a  case  under  the  writer's 
observation,  in  which  he  had  to  resort  to  this  emer- 
gency measure.  The  microscopic  picture  of  this 
enlargement  is  that  of  hyperplasia  of  the  tissues 
composing  the  lymph  nodes,  while  the  lymphoid 
cells  are  multiplied  in  number.^ 

Less  conspicuous  but  equally  distinctive  changes  occur  in  the  spleen  in  four-fifths 
of  the  cases,  it  becoming  enormously  enlarged  and  occupying  the  left  half  of  the 
abdominal  cavity,  being  universally  enlarged  and  preserving  its  original  outlines.  This 
splenic  enlargement  sometimes  is  simply  an  hypertrophy,  but  in  many  instances  the 
spleen  itself  will  be  occupied  by  tumors,  i.  e.,  lymphomas,  which  are  scattered  through 
it  and  cause  part  of  its  enormous  dimensions.  Late  in  the  disease  the  liver  also  becomes 
enlarged  and  lymphomas  are  also  scattered  throughout  its  substance.  The  same 
]ym])homatous  or  adenoid  tissue  may  be  met  with  in  many  other  parts  of  the  body,  the 
bone-marroW',  the  alimentary  canal,  the  ductless  glands,  kidney,  lung,  etc. 

Hodgkin's  disease  is  doubtless  closely  related  to  other  varieties  of  leukemia  and  to 
Banti's  disease,  or  splenic  anemia,  all  of  which  should  be  regarded  as  expressions  of 
an  infection  by  organisms  not  yet  dearly  described,  although  their  better  recognition 
and  identification  are  clearly  foreshadowed  in  work  now  under  way.  Death  comes 
as  the  result  of  the  exhaustion  and  poisoning  of  a  terminal  infection,  save  when  it  is 
produced  earlier  by  absolute  starvation  or  suffocation.  To  run  its  entire  course  an 
average  case  consumes  from  e'ghteen  months  to  two  and  a  half  years. 

Diagnosis. — So  far  as  diagnosis  is  concerned  the  microscope  will  serve  a  certain 
purpose  even  early  in  the  disease,  enabling  one  to  recognize  an  increasing  anemia  and 
leukocytosis,  but  not  until  perceptible  enlargement  of  lymph  nodes  and  of  the  spleen 

1  Pathologists  have  long  suspected  that  Hodgkins  disease  and  sarcoma  have,  at  least,  certain  features  in 
common  if  they  are  not  more  or  less  actually  associated  in  character.  Yamasaki  has  recently  reported  several 
cases  of  typical  Hodgkin's  disease  without  any  suspicion  of  tuberculosis,  in  which  there  were  unmistakable 
sarcomatous  formations  in  various  parts  of  the  body,  especially  in  the  viscera,  and  he  believes,  as  do  others, 
that  the  affection  which  begins  as  Hodgkin's  disease  may  later  assume  the  characteristics  of  a  general  sarcomatosis. 


Hodgkin's  disease. 


378  SURGICAL  AFFECTIONS  OF  THE  TISSUES 

is  found  can  the  diagnosis  be  made  absolutely  certain.  One  has  to  (hstincruish  mainly 
between  those  forms  of  leukemia  in  which  lymphomatous  changes  are  not  conspicuous, 
cachexia  of  cancer  and  syphilis,  and  the  condition  of  lymphosarcoma,  as  it  has  been 
called  by  some,  in  which  there  is  the  involvement  of  the  lym))h  nodes  without  the 
characteristic  blood  changes  met  with  in  Hodgkin's  disease.  In  splenomegaly  we  may 
have  enormous  enlargement  of  the  sj)leen  without  the  marked  involvement  of  the  lymph 
nodes.  From  lymphatic  tuberculosis  it  is  to  be  distinguished  by  absence  of  fever,  the 
tendency  to  universal  involvement  of  the  lymphoid  tissues  in  all  parts  of  the  body,  and 
the  absence  of  suppuration  and  caseation  which  occur  so  distinctively  in  tuberculous 
disease. 

Treatment. — Few  drugs  are  of  much  or  any  avail  in  this  disease.  Of  them  all 
nothing  compares  with  arsenic,  which  should  be  given  for  a  long  period  and  pushed 
to  the  physiological  limit.  The  formula  which  was  given  in  the  chapter  on  Cancer  will 
serve  in  the  treatment  of  Hodgkin's  disease  (p.  296,  note).  Next  to  this,  and  especially 
in  patients  with  enlargement  of  the  spleen,  the  .r-rays  are  the  most  effective.  In  one 
case  much  of  this  character,  in  which  I  began  active  treatment  by  both  methods,  I  saw 
in  forty-eight  hours  a  diminution  of  100,000  leukocytes.  This  did  not  persist,  however, 
for  the  proportion  was  later  somewhat  increased,  but  the  immediate  effect  as  well  as 
the  benefit  were  very  pronounced.  All  the  affected  regions  may  be  exposed  to  the 
a--rays,  which  should  be  used  with  great  care. 


TUMORS  OF  THE  LYMPHATICS. 

The  term  lymphoma  has  been  indiscriminately  ascribed  to  various  enlargements  of 
the  lymph  nodes  and  lymphoid  tissue  throughout  the  body,  so  much  so  as  to  have  really 
lost  its  significance.  If  by  the  term  is  meant  simply  a  tumor  of  a  lymph  node  it  will 
usually  fall  under  the  proper  classification  as  being  a  granuloma,  a  syphiloma,  a  car- 
cinoma, etc.  If  by  the  term  is  meant  a  general  involvement  of  lymph  tissue  throughout 
the  body,  such  as  is  seen  in  status  lyniphaticus,  then  it  would  be  best  to  use  some  other 
term.  Finally  it  may  be  questioned  whether  there  is  any  distinctly  marked  lymphoma, 
i,  e.,  a  tumor  of  true  lymphatic  structure,  which  is  not  of  infectious  origin.  The  term 
hpnphnsarcoma  is  still  in  use  and  probably  will  not  be  expunged  until  our  notions  of 
pathology  are  clearer.  The  expression  hpnphadenoma  should  be  discarded.  Multiple 
malignant  lymphoma,  as  stated  above,  is  but  another  name  for  the  condition  ordinarily 
described  as  Hodgkin's  disease.  That  sarcoma  and  endothelioma  may  arise  in  the 
lymph  nodes  is  universally  conceded,  although  as  primary  neoplasms  in  these  localities 
they  are  rare.     Not  much  can  be  said,  then,  that  is  distinctive  about  lymphoma. 

In  a  general  way,  it  may  be  said  of  any  tumors  of  the  lymph  nodes  that  if  isolated 
or  not  too  multiple  they  should  be  extirpated. 


CHAPTEK   XXXI. 

SURGICAL  DISEASES  OF  TIIK  JOINTS  AND  JOINT  STRUCTURES. 

The  joints,  hy  virtue  of  their  function  and  anatomical  relations,  are  liable  to  a  variety 
of  injuries  and  att'ections,  most  of  which  are  essentially  surjjical.  The  joints  most 
sul)j{>ct  to  traumatism  belong  to  the  extremities.  On  the  other  hand,  tlie  deeper  joints 
(r.  g.,  of  the  spine)  are  (piite  prone  to  toxic  and  infectious  diseases  and  less  liable  to 
serious  injury.  The  surgeon  cannot  disregard  the  structure  of  the  joint  when  con- 
sidering the  pathology  of  its  surgical  afi'ections.  More  or  less  completely  protected 
extenuUly,  though  sometimes  with  but  a  thin  coating  of  integument  and  fibrous  textures, 
it  is  composed  largely  of  resistant,  white,  fibrous  tissue,  seen  in  its  ligaments,  of  sj)ongy 
bone  in  the  expanded  bone  ends,  covered  with  cartilage  of  incrustation,  the  articular 
termination  of  the  bone  shaft  not  being  firmly  affixed  until  a  certain  age  has  been 
reached,  while  the  interior  is  lined  Vv'ith  a  serous  membrane  whose  lymj)hatic  connec- 
tions are  most  abundant,  ])ortions  of  which  are  often  loaded  with  fat.  In  certain  joints 
— ])articularly  the  knee — there  enter  separate  considerations  in  the  shape  of  inter- 
articular  cartilages  which  are  not  so  firmly  attached  but  that  they  may  be  sometimes 
displaced. 

Lymphatic  connection  between  the  exterior  and  the  interior  is  often  free,  and  after 
trifling  abrasions  or  infections  of  the  overlying  skin  the  joint  beneath  may  suffer 
seriously  or  even  fatally.  Many  of  the  surgical  diseases  of  the  joints  begin  within  the 
joint  membranes  proper,  i.  e.,  the  synovia.  Numerous  other  expressions,  particularly 
of  tuberculosis,  have  their  origin  in  the  bony  structure  contiguous  to  the  joint  cavity. 

In  any  destructive  affection  of  the  joint  in  childhood  the  corresponding  epiphyses 
are  often  involved.  This  is  also  true  of  fractures  extending  into  joints  or  occurring 
near  them  in  the  young.  Below  will  be  found  a  table  of  the  time  when  the  epiphyses 
are  usually  consolidated  with  the  main  portion  of  the  bone.  In  general,  they  unite 
earlier  in  the  upper  limb  than  in  the  lower,  or,  as  Sappey  puts  it,  the  upper  limb  first 
arrives  at  maturity.  The  following  table  represents  simj)ly  the  average,  there  being 
considerable  variance  on  either  side  of  it  in  different  individuals: 

UPPER  EXTREMITIES 

Clavicle 23d   year. 

Humerus,  upper 20th  year. 

Humerus,  lower     . 17th  year. 

Radius,  upper 16th  year. 

Radius,  lower         20th  year. 

Ulna,  upper 16th  year. 

Ulna,  lower 19th  year. 

Phalanges         18th  to  20th  year. 

LOWER  EXTREMITIES.  ' 

Femur,  head  and  great  trochanter 19th  year. 

Femur,  lower  epiphysis 21st  year. 

Tibia,  upper 21st  year. 

Tibia,  lower 18th  year. 

Fibula,  upper 21st  year. 

Fibula,  lower 20th  year. 

Phalanges         18th  year. 

These  dates  should  be  remembered,  as  an  ununited  epiphysis  may  be  involved  in 
a  necrotic  or  suppurative  process  and  thus  break  down  and  require  removal.  More- 
over, these  facts  will  also  be  of  value  in  considering  fractures,  for  up  to  these  dates 
epiphyseal  separations  will  often  be  met. 

( 379 ) 


380  SURGICAL  AFFECTIONS  OF  THE  TISSUES 


INJURIES  TO  JOINTS. 

Sprains. — A  sprain  is  either  the  resuh  of  a  momentarv  dislocation  of  a  joint,  the 
parts  returning  immediately  to  their  proper  position,  or  else  is  produced  when  a  joint 
has  been  strained  beyond  its  probable  physiological  limit  without  any  true  dis])lace- 
ment.  It  may  be  the  consequence  of  direct  or  indirect  violence,  or  even  of  incessant 
muscular  action.  It  always  implies  a  certain  degree  of  tissue  injury,  which  may 
vary  from  minute  lacerations  of  ligaments,  fasciae,  aponeuroses  and  periosteum,  up  to 
a  ilegree  where  ligaments  are  violently  sundered  or  torn  out  of  their  bony  attachments. 

A  sprain  is  generally  followed  by  hyperemia,  with  its  attendant  phenomena,  as 
described  in  a  previous  chapter,  and  as  long  as  possibility  of  infection  can  be  excluded 
the  resulting  outpour  which  produces  the  extreme  joint  swelling  will  more  or  less  quickly 
disappear. 

In  fact,  as  insisted  throughout  this  work,  the  differences  between  hyperemia  and 
its  consequences,  and  true  inflammation  with  its  results,  can  nowhere  be  more  perfectly 
demonstrated  than  in  such  a  case  as  this.  Even  with  great  damage  and  effusion  there 
can  be  complete  repair,  so  long  as  infection  is  excluded.  Once  the  germ  element 
enter,  the  whole  aspect  is  altered  and  a  serious  feature  is  then  introduced. 

Symptoms. — The  symptoms  of  sprain  are  loss  of  function,  swelling,  pain,  and  later 
ecchymosis.  The  first  is  usually  immediate,  the  swelling  takes  place  rapidly,  and 
ecchymosis  occurs  after  two  or  three  days,  unless  the  joint  be  near  the  surface.'  The 
degree  of  tenderness  will  afford  a  measure  of  the  amount  of  damage  done.  The  swelling 
may  be  produced  either  by  serous  outpour  or  by  hemorrhage,  or  by  both.  Ecchy- 
mosis is  usually  due  to  minute  lacerations,  and  may  spread  to  a  considerable  distance. 
Where  there  has  been  much  outpour  of  blood  into  a  joint  it  sometimes  produces  a  reac- 
tional  hydrarthrosis,  which  appears  only  after  a  week  or  more.  Such  hemorrhage  is 
serious,  and  is  frequently  the  cause  of  more  or  less  pseudo-ankylosis  by  organization 
of  clot. 

Sprain  may  then  be  of  all  degrees  of  severity.  From  the  mildest  of  these  one  may 
e.xpect  perfect  functional  recovery  in  short  time,  while  in  the  more  severe  cases  chronic 
thickening,  with  hydrarthrosis,  tender  areas,  and  muscle  atrophies,  often  persist  for  a 
long  time  or  even  permanently. 

Treatment. — The  ordinary  treatment  of  a  sprain  consists,  first,  in  physiological  rest. 
If  the  swelling  be  already  pronounced  when  seen  by  the  surgeon  he  will  endeavor  to 
promote  absorption  by  elevation,  gentle  compression,  perhaps  with  an  elastic  bandage, 
and  by  cold  wet  compresses.  If  seen  early  and  before  much  swelling  has  occurred  it 
will  often  give  great  relief,  especially  in  certain  joints  (e.  g.,  the  ankle),  to  partially 
immobilize  the  part  by  strapping  it  with  a  series  of  adhesive  strips,  2  Cm.  in  width, 
cut  sufficiently  long  to  encircle  the  foot,  ankle,  and  lower  part  of  the  leg.  The  strapping 
should  be  begun  at  the  base  of  the  toes,  and  each  strap  as  thus  applied  should 
be  made  to  slightly  overlie  the  preceding  one.  It  is  possible  by  neatly  compressing 
the  involved  region  in  this  way  to  almost  prevent  swelling,  and  to  give  such  support 
that  function  is  but  slightly  impaired,  and  pain  reduced  to  a  minimum.  The  objection 
to  plaster  of  Paris  or  the  more  fixed  dressings  is  that  they  are  usually  allowed  to  remain 
too  long.  Far  better  in  most  of  these  cases  is  either  a  splint  or  a  dressing  which  permits 
of  daily  examination.  With  the  subsidence  of  acute  symptoms,  massage  and  passive 
movement  should  be  practised.  There  are  cases  in  AA'hich  swelling  will  be  so  extreme 
that  aspiration  or  even  incision  may  be  advisable  for  the  purpose  of  emptying  the  joint. 

The  surgeon  sees  many  a  case  of  this  kind  after  it  has  become  chronic  and  after 
domestic  or  simple  applications  have  failed.  Most  of  these  ca.ses  require  massage, 
practised  skilfully,  and  with  intelligence,  by  which  absorption  is  much  promoted. 
The  same  result,  as  well  as  relief  of  soreness  or  pain,  follows  the  constant  use  of  cold 
wet  compresses,  perhaps  combined  with  the  use  of  ice-bags.  If  the  material  used  for 
these  compresses  be  dipped  in  solution  of  sodium  or  ammonium  chloride,  say  .5  per  cent., 
the  effect  is  much  enhanced,  while  laudanum  can  also  be  used  upon  them.  Tenderness 
and  localized  pain  in  old  cases  may  be  treated  by  a  succession  of  blisters,  but  can  be 
better  treated  by  the  application  of  the  flying  cautery,  i.  e.,  by  the  light  touch  of  a  glowing 
cautery  point  swept  rapidly  over  the  surface  involved.  This  is  one  of  the  most  powerful 
agents  for  the  relief  of  pain.     Occasionally  the  cautery  point  may  be  applied  more 


j'h'\h"rh'.\Ti.\<;  worxDs  of  tin-:  joists  3,S1 

deeply,    i.    c,    if/nipinicfiirr.      If  localized  collections  of    fluid    form    tliev    iiiav    he    in- 
cised. 

The  sttitenieiils  and  advice  f^iven  in  regard  to  .s|)rain  will  apply  c(|ually  well  to  the 
ordinury  contusions  of  joints. 


PENETRATING  WOUNDS  OF  THE  JOINTS. 

These  are  inflicted  as  are  wotuids  elsewhere,  and,  while  always  serious,  have  an  im- 
portance proportionate  to  the  infection  which  may  have  occurred  with  the  injury  or  after- 
ward. In  practise  it  may  he  assumed  that  the  skin,  like  the  clothin^r  outside,  is  always 
dirty  and  infected,  and  that  every  penetrating  wound  should  l)e  rej^arded  as  an  infected 
wound.  Not  every  wound  in  the  vicinity  of  a  joint  is  penetrating,  and  it  is  advisahle 
to  ascertain  whether  a  joint  cavity  he  actually  o])en,  as  much  of  the  method  of  treatment 
will  depend  upon  this  fact.  The  majority  of  these  injuries  are  of  the  j)unetured  or 
small  incised  variety.  The  actual  joint  opening  is  usually  smaller  than  that  in  the 
skin.  It  may  be  so  small  as  to  escape  observation.  Outflow  of  blood  is  not  pathog- 
nomonic, but  escape  of  synovial  fluid  always  indicates  that  some  serous  cavity,  ])ossibly 
a  bursa  or  tendon  sheath,  has  been  oj)ened.  Immediate  accumulation  of  fluid  within 
a  joint  after  probable  wounding  of  the  synovial  membrane  is  cjuite  suggestive,  as 
it  is  likely  to  imj)ly  that  the  joint  is  filling  with  blood.  After  any  injury  which  may 
loosen  them  the  epiphyses  should  be  carefully  examined,  in  order  to  determine  if  they 
have  been  loosened,  while  it  should  be  estimated,  so  far  as  possible,  whether  the  e))iphy- 
seal  junction  has  been  disturbed  or  is  probably  infected.  The  student  should  remember 
that  punctured  wounds  of  joints  are  not  necessarily  made  from  without  inward.  A 
spicule  or  fragment  of  bone  may,  by  protruding,  produce  exactly  the  same  condition, 
only  in  this  case  there  may  be  a  comj^ound  fracture  to  complicate  it.  Infection  does 
not  invariably  follow  these  injuries.  Their  gravity  is  in  large  degree  measured  by  the 
presence  or  absence  of  a  suppurative  synovitis.  This  does  not  necessarily  instantly 
follow  the  injury,  but  develops  within  the  ensuing  two  or  three  days.  Therefore  the 
fate  of  such  a  joint  is  not  necessarily  determined  by  inspection  within  the  first  few  hours. 
Esmarch's  dictum  regarding  gunshot  wounds  may  here  be  paraphrased.  Tfic  fate 
of  everi/  'punctured  joint  depends  upon  the  man  ivJw  first  takes  care  of  it.  If  the  proper 
thing  be  done  promptly  a  good  result  may  usually  be  obtained. 

The  first  indication  in  every  such  case  is  sterilization  of  the  parts,  including  the  area 
of  the  wound.  If  by  a  small  elliptical  incision  the  wounded  skin  can  be  excised,  it 
may  perhaps  very  much  improve  the  prospect.  A  small  punctured  wound  may  be 
watched  for  a  day  or  two,  especially  if  it  be  believed  that  the  first  attention  were  prompt 
and  antiseptic.  Should  no  unpleasant  features  appear  little  need  be  done  except  to 
apply  ice  externally  and  maintain  rest.  On  the  first  appearance  of  sepsis  or  of  increasing 
trouble  in  the  joint  it  should  be  promptly  incised,  irrigated,  and  drained. 

In  the  larger  openings  of  joints  it  should  be  assumed  from  the  outset  that  infection 
has  occurred.  In  such  a  case  the  Avound  margins  should  be  trimmed,  the  joint  cavity 
thoroughly  irrigated,  and  explored  for  foreign  bodies,  by  enlarging  the  existing  opening. 
After  thorough  irrigation  a  drain  should  be  inserted  for  at  least  a  few  hours.  For 
this  purpose  a  catgut  strand  or  a  drainage  tube  may  be  employed. 

As  soon  as  the  presence  of  pus  (acute  pyarthrosis)  is  made  clear  the  case  takes  on  a 
larger  aspect,  in  that  drainage  not  alone  at  one  point  is  indicated,  but  probably  at  two 
or  three.  Nothing  is  so  disastrous  to  an  involved  joint  as  pus  retained  within  its  hidden 
recesses.  Almost  every  other  consideration  is  sacrificed  to  its  discovery  and  to  afford- 
ing a  means  for  its  escape.  Counteropenings  in  nimibers  sufficient  for  the  pin-pose  are, 
therefore,  indicated,  and  it  will  often  be  best  to  draw  through  the  affected  joint  a  drain- 
age tube,  of  a  size  sufficient  to  prevent  its  occlusion  by  thick  pus  or  debris.  Daily  and 
continuous  irrigation  may  be  practised  to  great  advantage,  or,  as  is  possible  with  the 
ankle,  the  wrist,  or  elbow,  continuous  immersion  may  be  substituted  as  a  still  better 
measure.  Wherever  infection  and  destruction  to  this  degree  have  taken  place  it  may 
be  presumed  that  the  future  of  the  joint  is  seriously  compromised.  There  will,  there- 
fore, be  room  for  display  of  judgment  as  to  when  to  begin  passive  and  when  active 
motion;  moreover,  a  guarded  prognosis  concerning  restoration  of  function  should  be 


382  SURGICAL  AFFECTIONS  OF   THE   TISSUES 

Gun.s-hot  fraciurcf  of  joints  constitute  almost  a  category  hy  themselves.  Under  the 
old  regime,  and  in  the  j)re-antise{)tic  era,  gunshot  wounds  of  joints  condemned  one  to 
amputation  and  loss  of  at  least  the  part  below.  The  mortality  attendin<f  injuries  of 
this  kind,  with  the  resulting  amputations,  during  our  Civil  War,  and  all  others  j)revious 
to  it,  was  extreme.  The  Continental  surgeons  first  ai)preciated  the  value  of  antiseptic 
occlusion,  and  taught  the  rest  of  the  world  that  this  wholesale  sacrifice  of  limb, 
and  often  of  life,  was  unnecessary  and  could  be  avoided.  Reyher's  first  papers  on 
this  subject  revolutionized  previous  views  and  practises,  and  established  on  a  firm 
basis  the  general  principle  of  ■priviary  antiseptic  occlusion  of  those  injured  joints.  The 
accumulated  experience  of  military  surgeons  since  his  time,  as  well  as  of  civil  surgeons 
all  over  the  world,  has  demonstrated  that  if  a  gunshot  wound  of  a  joint  be  afforded 
promjit  antiseptic  occlusion  and  rest  the  chances  are  in  favor  of  restoration  of  function, 
with  a  minimum  of  disturbance  and  a  maximum  of  result.  It  was  because  of  these 
results  that  soldiers  were  provided  with  the  "first  aid  to  the  injured"  packets,  so  that  a 
punctured  wound  might  be  protected  immediately  after  its  reception.  Even  the  com- 
plete tunnelling  of  a  joint,  which  the  Mauser  bullets  so  often  accomplish,  does  not  seem 
to  be  so  serious  an  injury  today  as  was  the  puncture  of  a  needle  or  an  awl  in  the  pre- 
antiseptic  era.  Therefore  the  best  thing  to  do  with  a  gunshot  wound  is  to  practise 
antiseptic  occlusion.  If  it  become  troublesome  it  should  be  treated  in  accordance  with 
the  advice  given  above. 

This  relegates  the  matter  of  amputation  or  of  primary  excision  of  an  injured  joint 
to  those  cases  of  extensive  and  mutilating  injury  where  not  only  the  soft  structures  are 
widely  opened  and  infected,  but  the  joint  ends  of  the  bones  also  are  seriously  involved. 
When  it  comes  to  the  treatment  of  compound  dislocations  it  is  difficult  to  lay  down 
principles  which  shall  be  universally  applicable.  As  a  general  rule  primary  excision 
will  usually  be  indicated,  and  prove  not  only  life-saving  but  limb-saving.  In  compound 
dislocations  of  the  astragalus  its  removal  will  be  nearly  always  indicated.  Only  in 
cases  of  extensive  damage  will  amputation  be  necessary. 

Inasmuch  as  it  is  injectiou,  leading  to  suppurative  synovitis  or  arthritis,  which  gives 
to  all  serious  cases  their  greatest  dangers,  it  will  be  sufficient  at  this  point  to  remind  the 
reader  to  this  effect  and  to  describe  the  condition  itself  a  little  later. 


SYNOVITIS  AND  ARTHRITIS. 

The  various  surgical  affections  of  a  joint  may  be  of  primary  or  secondary  origin,  and 
of  rapid  or  chronic  type.  The  acute  are  usually  expressions  of  serious  infection,  while 
the  chronic  are  frequently  of  toxemic  origin,  including  under  this  heading  manifesta- 
tions of  a  particular  diathesis  or  defective  metabolism.  Others  are  so  exceedingly 
slow  in  their  course  and  are  so  intimately  connected  with  other  indications  of  disease 
of  the  central  nervous  system  as  to  be  called  neuropathic.     (See  below.) 

Nearly  all  the  acute  affections  begin  in  the  synovial  sac  proper.  From  this  they  may 
spread  and  involve  the  adjoining  parts.  The  acute  toxic  lesions  also  arise  within  the 
synovial  cavity,  such  as  those  which  follow  gonorrhea,  typhoid,  scarlatina,  pneumonia, 
influenza,  etc.  Tuberculosis  may  primarily  affect  either  the  synovia,  in  which  case  we 
have  a  condition  corresponding  to  tuberculous  peritonitis,  or  it  may  take  its  origin  in  the 
expanded  bone  ends  or  in  the  epiphyseal  cartilages.  Syphilitic  affections  of  the  joints 
are  rarely  acute.  They  lead  rather  to  chronic  disintegrations  or  hypertrophy.  No 
matter  how  the  lesion  may  have  arisen  it  will  nearly  always  extend  to  and  involve  other 
parts;  thus  in  acute  suppurations  the  articular  cartilages  are  soon  attacked,  while  in 
the  more  chronic  forms,  which  have  their  origin  in  the  bone,  the  joint  cavity  is  slowly 
encroached  upon  and  its  integrity  impaired  or  destroyed. 

So  long  as  the  type  of  joint  disease  be  not  destructive  a  complete  or  nearly  complete 
restoration  of  function  can  be  expected,  provided  suitable  treatment  be  given  early. 
If,  however,  a  case  occur  only  after  fibrinous  outpour  has  organized  into  adhesions, 
muscles  have  withered  from  disuse,  and  the  entire  joint  become  distorted  or  disarranged, 
then  it  may  be  too  late  to  cure,  and  it  is  a  question  then  of  how  much  improvement 
can  be  effected.  Even  after  acute  suppuration,  if  the  case  be  properly  managed  from 
the  outset,  very  useful  joints  can  be  regainecj- 


SYN(>\  IT/S  AM)  AinifhTns  3g3 

Dry  Sjmovitis.  -Ill  synoviti.s,  as  ill  plcmisy,  tlurc  may  he  a  iniiiiiiiiiin  of 
serous  (Hit|>()ur,  siicli  cxiidate  us  escapes  into  (lie  joint  l)eing  exceediiif^ly  rich  in  fibrin 
and  coaji;iilatiiiii;  easily.  'I'liis  material  is  variously  dis|)osed  of,  and  may  form  adhesions 
wliicli  will  limit  motiitn,  or  masses  of  condensed  fibrin  which  may  be  broken  u|)  into 
shreds  or  rounded  oif  into  seed-like  or  rirr-fjrain  bodies.  When  tenderness  subsides 
sulliciently  to  permit  it  these  may  sometimes  be  felt  within  the  joint.  At  other  times 
they  lead  later  to  an  hydrarthrosis,  which  may  j)rove  more  or  less  disablini^  and  re(juire 
subse(|ueiit  operation.  Another  form  u\'  .s-ipi<inifi.s-  .sicca  is  met  with  in  acute  and  pcrha|)S 
chronic  rheumatism,  where  masses  of  fibrin  become  loosened  and  can  be  fell  as  i'orei<rn 
bodies,  or  friii<j;es,  beneath  the  joint  coveriiifi;. 

Acute  Synovitis.  —The  ordinary  acute  synovitis  is  characterized  by  more  or 
less  eifiision,  and  corresponds  to  |)leurisy  with  effusion.  It  is  the  result  usually  of 
external  injury,  or  it  is  combined  with  what  has  already  been  described  as  sprain. 
The  fluid  outpour  is  watery,  is  rarely  blood-stained,  save  in  cases  of  lacerations,  usually 
distends  tlu>  joint  capsule,  often  to  a  |)ainful  deirree,  but  represents  nothiii<f  more  than 
the  c()nsc(|uences  of  hyperemia.  If  this  fluid  collection  can  be  protected  from  con- 
tamination  by  germs  it  will  disa|)])ear  under  suitable  treatment,  with  a  return  to 
almost  normal  original  conditions.  Let  it  once  become  contaminated,  however,  and 
the  ty])e  of  disease  is  quickly  changed,  for  there  will  then  be  an  acute  inflammation 
with  its  attendant  phenomena  and  consequences. 

Treatment. — Cases  of  simple  character  are  of  short  duration,  i.  e.,  one  to  two  weeks. 
If  seen  early  they  should  be  treated  by  gentle  compression  and  the  application  of  ice- 
cold,  wet  compresses.  Heat  applied  at  this  time  may  give  temporary  comfort,  but 
will  encourage  effusion.  Even  if  a  joint  thus  affected  be  not  seen  until  the  swelling 
is  extreme,  wet  c()nij)resses  will  still  ati'ord  the  simplest  and  the  most  comforting  method 
of  treatment,  although  they  need  not  now  be  kept  cold;  in  fact,  gentle  heat  may  now 
])i()mote  absorption.  If  the  comj)resses  be  moistened  in  salt  solution,  to  which  a 
little  alcohol  has  been  added,  the  stimulating  effect  will  probably  be  still  greater. 
Such  a  joint  needs  to  be  placed  at  rest,  save  perhaps  in  the  case  of  an  ankle-joint  or 
wrist-joint,  which  may  be  snugly  strapped  after  injury.  In  some  of  these  latter  cases 
th(^  patient  can  resume  use  of  the  joint  almost  at  once. 

Purulent  Synovitis. — This  rarely  begins  as  a  purulent  condition,  but  may 
be  the  result  of  the  non-infiammatory  and  non-purulent  form.  In  such  a  case  the 
character  of  the  fluid  outpour  soon  merges  into  the  seropurulent,  and  later  become 
almost  nothing  but  pus.  If  the  interior  of  a  joint  could  be  inspected,  under  these 
conditions,  the  intensity  and  extent  of  the  vascularity  and  cellular  changes  going  on 
within  the  synovial  membrane  and  beneath  it  would  present  a  different  picture  from 
that  of  the  non-purulent  form.  The  appearance  of  a  joint  interior,  under  these  cir 
cumstances,  is  similar  to  that  of  a  well-marked  purulent  conjunctivitis.  Articular 
surfaces  are  quickly  eroded  or  perforated,  while  cartilages  thus  once  affected  are 
often  loosened  from  their  attachments  through  necrosis  and  remain  as  foreign  bodies 
in  the  fluid  collection.  Even  strong  ligamentous  tissues  will  melt  down  and  become 
so  weakened  as  to  permit  a  looseness  of  motion  foreign  to  the  natural  joint.  In  fact, 
as  between  purulent  synovitis  and  acute  suppurative  arthritis  it  is  but  a  matter  of  extent 
of  destruction,  not  of  character  of  lesion.  In  this  way  'pathological  dislocations  are  pro- 
duced, sometimes  even  within  a  few  days,  being  the  combined  result  of  destruction  of 
ligaments  and  the  pull  of  muscles  which  are  thrown  into  reflex  spasm  by  the  presence 
of  intra-articular  disease.  Not  only  do  we  see  caries  of  the  exposed  bone  ends,  but 
epiphyseal  separations  are  not  uncommon  in  the  young,  while  every  structure  around 
and  outside  of  the  joint  participates,  even  to  the  extent  of  abscess  formation.  Abscesses 
may  form  without  the  joint  and  work  into  it,  or  the  purulent  collection  within  may 
escape  at  points  of  least  resistance  and  burrow,  forming  perhaps  numerous  foci  at 
some  distance  from  the  joint  first  affected.  If  such  a  case  is  to  be  saved  it  will  require 
numerous  openings  and  counteropenings,  with  free  drainage,  while  even  then  there 
can  be  no  expectation  of  restoring  joint  function.  There  is,  then,  in  these  cases  at 
least  a  sacrifice  of  joint,  sometimes  of  limb,  and  in  neglected  cases  of  life  itself. 

Symptoms. — Of  the  large  joints  only  the  shoulder  and  hip,  especially  the  latter,  are 
placed  so  deeply  as  not  to  permit  of  easy  examination  and  diagnosis.  Pain,  swelling, 
and  loss  of  function,  with  or  without  history  of  injury,  will  predominate  in  well-marked 
cases,  while  very  early  in  most,  and  promptly  in  all,  there  will  occur  reflex  spasm  of 


384 


SURGICAL  AFFKCriOS'H  OF   THE    TISSVES 


those  muscles  whicli  have  to  do  with  motion  of  the  affeeted  parts,  by  which  they  become 
more  or  less  fixed  and  beyond  voluntary  control  of  the  patient.  This  confiition  has 
been  described  by  Sayre  as  "muscles  on  guard."  It  is  a  significant  feature,  anrl  has 
as  much  to  do  with  active  joint  ciisease  as  has  abdominal  rigidity  with  surgical  intra- 
abd(jminal  con(litif)ns.  Swelling  will  be  proportionate  to  the  acuteness  of  the  case. 
Tenderness  is  nearly  always  extreme,  especially  along  the  articular  line.  The  joint 
capsule  is  frequently  distended  to  its  extreme  and  the  normal  contour  of  the  part 
completely  obliterated. 

The  most  common  position  in  which  limbs  are  held  is  midway  between  extremes; 
thus  when  the  knee  is  involved  the  leg  will  become  flexed  upon  the  thigh,  at  about 
75  degrees.  If  the  shoulder  be  at  fault  the  arm  is  maintained  close  to.  the  body.  In 
disease  of  the  elbow  the  forearm  is  carried  midway  between  the  right  angle  and  complete 
extension.  This  is  partly  due  to  the  fact  that  the  flexors  are  always  stronger  than  the 
extensors,  as  it  represents  a  compromise  between  the  antagonism  of  the  opposing 
groups  of  muscles. 

Pus,  when  present,  is  commonly  also  manifested  by  the  usual  signs  of  its  existence. 
There  will  be  pitting  on  pressure  or  edema  of  the  overlying  parts,  while  an  acutely 
inflamed  joint  may  be  at  any  time  so  swollen  as  to  impede  return  circulation  and  lead 
to  edema  of  the  parts  beyond.  To  the  local  signs  of  phlegmon,  then,  we  simply  have 
to  add  in  greater  detail  those  mentioned  above.  Along  with  these  there  will  be  consti- 
tutional septic  disturbances,  usually  proportionate  to  the  gravity  of  the  local  condition. 
The  opj)ortunities  for  absorption  afforded  by  a  large  synovial  surface  are  great,  and 
the  lym))hatics  are  sure  to  carry  toxins  in  abundance.  The  signs,  then,  of  septicemia, 
sometimes  even  of  pyemia,  are  often  pronounced.  In  the  presence  of  a  joint  full  of 
pus  the  prognosis  may  be  regarded  as  exceedingly  grave.  Pain  and  tenderness  seem 
to  bear  but  little  relation  to  the  swelling.  Usually  pain  is  an  expression  of  distention, 
yet  some  of  the  non-inflammatory  forms  of  apparently  milder  type  are  extremely  painful. 
Pain  is  influenced  by  the  position  of  the  joint,  and  the  patient  instinctively  seeks  that 
position  in  which  suffering  is  minimized.  In  a  joint  disorganized  by  the  presence  of 
pus  there  is  less  sensitiveness,  except  on  rough  handling,  unless  the  trouble  have 
extended  far  beyond  the  joint  limits,  and  cellulitis  be  present,  with  suppuration 
threatening.  In  metastatic  joint  abscess  tenderness  rather  than  pain  is  the  common 
rule. 

In  the  presence  of  an  acute  inflammation  in  the  joint  end  of  a  long  bone  the  other 
joint  structures  will  participate  to  an  extent  proportionate  to  its  acuteness.  With  an 
acute  osteomyelitis — e.  g.,  near  the  articular  surface — the 
synovial  membrane  will  participate,  just  as  does  the  pleura 
in  many  cases  of  pneumonia,  and  we  may  look  for  fluid  in  the 
joint  in  one  case  as  we  do  for  fluid  in  the  chest  cavity  in  the 
other.  Moreover,  pictures  of  acute  or  chronic  tuberculous 
affections  of  the  synovia  correspond  very  closely  to  those 
of  the  pleura.  Tuberculous  disease  is  liable  to  spread  in 
every  direction  in  both  diseases.  The  reverse  of  this,  how- 
(  ver,  is  not  true  in  all  diseases  of  the  chest,  and  there  are 
many  synovial  as  well  as  pleural  affections  which  are  con- 
fined to  their  respective  sacs. 

The  same  statement,  almost,  can  be  made  concerning  the 
1-ursfe  and  tendon  sheaths  in  proximity  to  infected  joints. 
Particularly  is  this  true  when  any  of  these  connect  with 
joint  cavities. 

The  metastaiic  forms  of  pyarthrosis,  as  a  collection  of  pus 
within  the  joint  capsule  is  called,  are  more  insidious,  though 
sometimes  equally  destructive.  They  are  by  no  means  con- 
fined to  one  joint,  and  in  pyemia  especially  many  of  the 
joints  will  fjecome  involved.  (See  Pyemia.)  These  second- 
ary affections  seem  to  be  purulent  from  the  outset.  In  gonorrhea  the  effused  fluids 
will  often  })e  found  nearly  pure  cultures  of  the  gonococcus ;  after  typhoid  they  contain 
typhoid  bacilli,  etc.  Such  expressions  are  les.s  frequent  after  pneumonia,  influenza, 
and  the  acute  exanthemas,  but  may  be  .seen  even  after  smallpox.  It  is  often  in  these 
severely  destructive  joint  lesions  that  spontaneous  dislocation  occurs  (Fig.  193). 


Pneumococcus  infection  of 
ankle;  rapid  destruction  of  all 
joint  structures.  Child  aged 
nine  months.     (Lexer.) 


syxoiJTJs  A.\j)  Auriih'iris 


3.S5 


Treatment.  In  I  lie  proscm-c  of  ii  sin(2;lc  joint  lesion  indications  for  treatment  are 
(|iiile  clear.  When  we  have  multiple  and  pyemic  or  i^onorrheal  pyarlhrosis  it  is  often 
exceedingly  didicult  to  determine  what  is  for  the  best  interest  of  the  pati<'nt.  In  {General 
it  may  he  said  that  |)yemia  |)ro<,n-essed  to  this  extent  will  almost  certainlv  l)e  fatal,  and 
we  may  rest  content  with  as|)iratin^  the  aiVected  joints,  or  |)erhaps  in  leaviiifr  them 
alone;  because  we  may  feel  that  they  constitute  hut  a  small  proportion  of  the  meta.static 
foci  wliicli  eventually  determine  death.  On  the  other  hand,  in  other  infections  with 
pyarthrosis  it  would  be  better  to  iispirute  or  to  open  and  drain,  because  these  cases  are 
slow  and  chronic,  and  the  exudate  is  sometimes  so  rich  in  fibrin  as  to  lead  to  quite  firm 
spurious  ankylosis. 

Thus  (JON on- heal  .s-i/norilis-  is  usually  monarticular,  altliou<rh  several  joints  may  be 
involved.  It  is  readily  recoijnized  in  the  presence  of  the  active  disease,  but  there  are 
times  when  recoo:nitioii  is  made  difficult  l)y  the  latency  of  urethral  symptoms  or  the 
concealment  of  their  existence.  The  knee  is  usually  the  joint  most  often  involved; 
next  the  joints  al)out  the  foot,  and  sometimes  the  tendon  sheaths  and  bursa'  adjoining 
them. 

Sijpliilittr  arfhrifl.s  is  a  chronic  and  mildly  but  steadily  progressive  affection.  It 
rarely  assumes  purulent  form  without  some  secondary  infection.  It  is  frequently 
combined  with  gumma  along  the  epiphyseal  border.  In  Iicirdifarij  sijpliUin  numerous 
joints  may  be  involved  in  changes  of  the  rachitic  type. 

(iout  or  some  of  its  allied  rheumatoid  manifestations  may  lead  to  a  dry  form  of 
synovitis,  with  dej)osit  of  urates  or  of  lym])h,  and  the  formation  of  iopJii  in  the  neigh- 
borhood, or  it  may  assume  the  form  of  a  chronic  and  intractable  hydrarthrosis.  The 
acute  forms  are  accompanied  by  great  pain,  with  redness  and  swelling,  peri-articular 
and  intn; -articular.     The  tendency  of  these  cases  is  to  chronicity  and  recurrence. 

General  Treatment. — Upon  the  nature  of  the  condition  will  depend  the  treat- 
ment of  joint  diseases.  The  questions  of  when  to  operate  and  when  to  abstain,  when 
to  enforce  rest  and  when  to  begin  passive  and  when  active  motion,  call  for  discriminating 
judgment.  An  acute  or  even  mild  traumatic  synovitis  should,  first  of  all,  be  protected 
from  becoming  purulent.  Should  injury  be  accom])anied  l)y  a  bruise,  the  greatest  care 
should  be  given  to  antisepsis,  and  the  ])art  sterilized  and  dressed  with  every  precaution. 
Should  there  be  no  external  injury  \ve  may  rely  ordinarily  upon  cold,  wet  compresses, 
with  suitable  elastic  compression  and  physiological  rest.  Should  two  or  three  days 
of  this  treatment  fail  to  bring  about  nearly  complete  resorption  the  aspirator  may  be 
employed  to  withdraw  the  fluid.  If  this  should  be  found  to  be  bloody  or  too  thick 
to  run  through  the  needle,  it  will  be  advisable  to  make  small  incisions  on  either  side, 
under  the  strictest  precautions,  and  to  practise  thorough  irrigation,  by  which  the  joint 
cavity  will  be  completely  cleared  of  foreign  material.  As  soon,  however,  as  the  presence 
of  pus  is  indicated,  or  even  suspected,  the  whole  character  of  the  treatment  should 
change.  The  surgeon  should  now  endeavor  to  be  as  radical  as  possible.  The  more 
purulent  the  collection  the  more  are  free  incision,  irrigation,  and  drainage  indicated 
and  the  more  complicated  the  condition  the  more  he  should  make  counteropenings 
here  and  there,  wherever  joint  pockets  may  be  emptied. 

When  muscle  spasm  not  only  seriously  disturbs  the  patient  but  threatens  to  draw 
the  limb  into  an  undesirable  position  it  should  be  overcome,  either  by  employment 
of  traction  with  weight  and  pulley,  or  by  forcible  reposition  and  fixation  in  suitable 
splints,  such  as  plaster  of  Paris.  Some  of  the  most  extensive  operations  that  are  called 
for  are  necessitated  by  neglect  to  observe  these  precautions  early.  Often  nothing 
will  afford  so  much  relief  as  the  use  of  traction,  with  sufficient  weight,  tiring  out  con- 
tracted muscles,  and  thus  not  actually  separating  joint  surfaces,  but  overcoming  that 
muscle  spasm  which  brings  them  tightly  together  and  thus  gives  pain. 

In  the  more  chronic  form  of  cases  absorption  may  be  promoted  by  elastic  compression, 
by  massage,  by  wet  compresses,  and  sometimes  by  blistering.  Ordinarily,  and  espe- 
cially in  those  cases  characterized  by  pain,  more  can  be  accomplished  with  the  actual 
cautery  drawn  lightly  and  rapidly  over  the  surface  of  the  joint  than  by  blistering.  This 
application  is  referred  to  as  the  fl>/ing  cautery,  and  it  is  one  of  the  most  effective  agents 
known  for  the  relief  of  deep-seated  pain,  as  well  as  of  cutaneous  hyperesthesia.  Its 
use  causes  little  if  any  unpleasant  sensation,  and  should  be  rejjeated  at  daily  intervals 
until  the  primary  object  is  attained. 

Should  aspiration  of  a  distended  joint  be  practised  at  any  time,  one  should  atone  for 
25 


386  SUUaiCAL  AFFECTIONS  OF   TJIF   TISSUES 

the  loss  of  intra-articular  pressure  thereby  produeed  by  external  comj^ression,  preferably 
with  an  elastic  mediinn. 

In  the  writer's  opinion  it  is  not  advisal)le  to  use  a  small  aspiratinj^;  trocar  in  those  cases 
which  are  likely  to  call  for  irritjation.  The  asj)iratin<i;  needle  should  be  confined  to  the 
non-j)urulent  collections  of  fluid,  althouijh  some  surgeons  advise  and  |)ractise  throwing 
into  a  mildly  infected  joint,  through  such  a  needle,  some  reasonably  strong  antiseptic 
fluid  or  enuilsion,  hoping  thus  to  gain  its  bactericidal  cttect  without  external  incision. 

The  active  manifestations  of  disease  being  mastered,  one  addresses  himself  naturally 
to  the  greatest  possi-ble  prevention  of  deformity  and  restoration  of  function.  Indeed, 
these  should  be  kept  in  view  from  the  outset,  although  we  have,  for  a  time,  to  disregard 
them  in  favor  of  more  imperative  indications.  If  ankylosis  a])j)ear  inevitable  the 
joint  should  be  kept  in  that  position  in  which,  when  stiff,  it  will  be  most  useful.  This 
position  will  be,  at  the  elbow,  at  a  right  angle;  at  the  hip  or  knee,  nearly  complete  exten- 
sion. When,  on  the  other  hand,  restoration  of  function  is  hoped  for  it  will  be  obtained 
through  a  combination  of  massage,  active  and  })assivc  movements,  with  the  use  perhaps 
of  some  sorbefacient  ointment,  such  as  the  compound  iclithyol-mercurial,  or  by  the 
nearly  constant  use  of  cold,  wet  compresses,  combined  with  the  other  measures.  The 
greatest  care  should  be  exercised  in  determining  the  time  when  absolute  rest  given  to 
an  inflamed  joint  should  be  changed  to  the  gentle  or  more  forcible  movements  required 
for  restoring  use  to  previously  inflamed  joint  surfaces. 

Chronic  Synovitis  and  Arthritis. — A  chronic  serous  effusion  into  a  joint  is 
given  the  term  lnjdmrthrosi.s.  This  condition  is  never  primary;  it  is  always  the  residue 
of  some  previous  acute  lesion,  or  else  it  is  the  result  of  neiu'opathic  or  rheumatcMd  changes 
going  on  in  and  about  the  joint,  accompanied  by  relaxation  of  membranes  j)ermitting 
passive  distention  with  fluid.  The  contained  fluid  is  ordinarily  pure  serum.  It  may 
contain  a  little  blood  or  numerous  particles  or  shreds  of  fibrin,  while  in  rare  instances 
there  will  be  found  in  it  drops  of  oil  or  even  fat  crystals.  The  degree  of  distention  of  a 
joint  capsule  is  the  measure  of  the  gravity  of  the  case,  as  this  membrane,  like  any  other, 
will  yield  to  gradual  distention,  although  it  at  the  same  time  undergoes  thickening  as 
a  protective  measure.  Thus  the  synovia  may,  under  certain  circumstances,  become 
as  thick  as  the  pleura.  The  result  is  a  tough,  leathery  condition  of  this  membrane, 
which  makes  it  exceedingly  difficult  to  manage.  The  joint  thus  involved  will  appear 
more  j)rominent  than  it  should,  because  of  the  atrophy  of  the  surrounding  structures. 
Accurate  comparisons  can  only  be  made  by  measuring  corresponding  jtjints.  Neigh- 
boring burste  and  tendon  sheaths  often  particijiate  in  the  distention.  These  collections 
are  ordinarily  painless,  or  nearly  so,  but  interfere,  to  varying  extent,  with  the  function 
of  the  joint.  Anatomical  outlines  disappear  or  are  concealed  by  the  bag  of  fluid.  It  is 
rare  that  there  are  any  constitutional  symptoms  except  perhaps  those  of  the  disease  which 
causes  the  disturbance.  The  amount  of  fluid  which  may  be  contained  in  a  long-distended 
knee-joint,  for  instance,  is  relatively  very  large.  The  prognosis  in  these  cases  will  depend 
much  upon  the  underlying  cause,  as  well  as  upon  the  age,  vitality,  and  docility  of  the 
patient. 

Treatment. — Removal  of  the  fluid  is  always  the  indication.  x\fter  reasonable  eft'ort 
has  shown  that  this  is  not  possible  by  the  employment  of  massage,  the  actual  cautery 
and  elastic  compression,  combined  with  functional  rest,  it  should  be  withdrawn  by  the 
as])irating  needle  or  trocar.  The  more  experience,  however,  we  have  with  affections 
of  this  class  the  more  we  will  realize  that  the  interior  of  the  synovial  membrane  is  fre- 
cjuently  studded  with  deposits,  fringes,  etc.,  which  are  not  affected  l)y  mere  aspiration, 
and  the  more  cogent  argument  will  be  gained  for  sufficiently  free  incision  to  permit 
inspection  of  the  interior  of  the  joint,  removal  of  tags  of  tissue,  thorough  washing  out 
and  sponging,  l)y  which  a  change  in  circulation  and  nutrition  is  certainly  affected;  and 
this  may  be  combined  with  excision  of  a  liberal  ])()rti()n  of  the  thickened  membrane, 
by  which  the  dimensions  of  the  joint  may  be  materially  reduced  when  the  opening  is 
sutured.  For  long-standing  cases  of  well-marked  hydrarthrosis,  especially  in  the 
knee,  the  writer  would  urge  this  method  of  treatment.  Drainage,  if  called  for  at  all, 
can  be  made  with  strands  of  silkworm,  or  some  temporary  material  which  will  quickly 
disappear  or  be  promptly  removed.  This  is  particularly  applicable  for  the  milder 
forms  of  tuberculous  synovitis,  in  which  the  joint  is  thus  treated  on  the  same  principle 
that  is  applied  in  washing  out  a  tuberculous  peritoneal  cavity. 


Mrnnuris  DiiFouM a\s  axd  ostiio  .\irriiinris  357 


ARTHRITIS  DEFORMANS  AND  OSTEO- ARTHRITIS. 

UiuU-r  this  nciK'ial  iiaiiic  have  Im-cii  <iT()ii|K'(l  a  miiiil)ci'  of  <'on(litii)ii,s,  iiicliidiii^  the 
so-calli'd  rlicKiiKtloid  urthntis,  and  rct'crriii;^  (o  u  variciy  of  cliroiiic  proifrcssivt!  lesions 
ot"  j(»iiits  which  involve  the  articular  cartihii^cs  and  synovial  incnihrancs,  later  the  hones, 
and  which  |)roduce  more  or  less  loss  of  function  and  deforniity.  Although  ofteu  s))oken 
of  as  "rheumatoid,"  the  condition  has  nothiufj;  to  do  with  rheumatism  as  such,  wluitever 
that  may  Ik-.  It  moreover  presents  no  analofijies  to  the  forms  of  acute  synovitis  already 
di'scrihed.  These  lesions  are  more  common  in  women  than  in  men,  o( currinf^  oftener  in 
those  who  have  hcen  sterile,  and  durin*!;  or  after  the  menopause.  So  far  as  their  etiology 
and  patholojiy  are  concerned,  it  is  true,  th()u<;h  it  seem  trite  to  say  it,  that  they  are 
the  result  of  disturhcd  nutrition,  which  itself  may  he  referred  l)ack  to  perverted  tro|)hic 
inllucnces.  Exposure,  had  hygienic  surroundin<rs,  im])ropcr  food,  mental  perturhation, 
an<l  dejjrcssion  are  more  or  less  potent  factors  in  most  of  the  cases.  In  some  instances 
occurring  in  advanced  age  they  seem  to  be  due  to  changes  ordinarily  regarded  us  senile. 
Wlien  joint  lesions  are  multiple  and  symmetrical,  and  accom])anied  by  other  nutritive 
changi's,  we  may  refer  the  cause  back  to  the  central  nervous  .system.  When  mon- 
articular they  are  more  likely  to  be  the  residue  oi  some  previous  infection  or  injury, 
such  as  gonorrhea,  influenza,  or  an  acute  cxanthem.  If  in  connection  with  the  joint 
manifestations  we  find  the  s})leen  and  lymphatics  enlarged,  then  the  ca.se  may  be 
regarded  as  doubtless  infectious  in  nature. 

The  pathological  changes  within  these  joints  include  almost  every  imaginable  altera- 
tion. I3ones  soften  and  atrophy  at  one  point,  or  at  another  become  enlarged  and 
thickened,  and  throw  out  osteophytic  projections  by  which  the  whole  shape  of  the  joint 
is  materially  changed.  Cartilages  atrophy  here  and  thicken  there,  and  disapjx'ar,  at 
times,  to  an  extent  by  which  bone  is  exposed,  the  exposed  surfaces  frequently  becoming 
polished  or  churnated.  The  position  of  the  joint  and  its  general  contour  may  be 
materially  altered  by  these  changes,  and  marked  deformity  or  notable  enlargement 
result.  Subluxations  are  not  infrequent,  while  the  ligamentous  structures  are  sufficiently 
strong  to  perform  their  function,  and  the  joint  yields  or  "wahblcs."  Meanwhile  the 
synovial  membrane  undergoes  corresponding  changes,  and  becomes  distended  with 
fluid  so  that  hydrarthrosis  is  a  frequent  accompaniment. 

On  the  other  hand,  there  is  another  type  of  analogous  changes  where  the  tendency 
is  atrojjhic  throughout  and  little  if  any  extra  fluid  accumulates.  Such  a  joint  may 
become  smaller  rather  than  larger,  especially  if,  as  in  some  cases,  some  part  of  the  bone 
pract icall y  disappears . 

At  all  events  muscle  atrophy,  sometimes  Avith  pseudo-ankylosis,  sometimes  with  actual 
ankylosis,  will  characterize  most  of  these  cases,  and  muscles  naturally  disappear  as  they 
functionate  less  and  less. 

Pain  is  an  irregular  feature,  some  of  the  lesions  being  quite  painful,  others  almost 
free  fnjui  it.  The  lesions  are  essentially  [)rogressive  in  their  character,  unless  the  whole 
body  condition  and  environment  can  be  changed  for  the  better.  Consecjuently  indi- 
viduals become  more  and  more  crippled.  Muscle  spasm  is  rarely  present,  but  when 
such  changes  occur  in  the  intervertebral  joints  the  individual  becomes  gradually  bent 
over  or  deformed,  partly  because  the  muscles  no  longer  have  strength  to  maintain  the 
erect  posture,  and  partly  from  actual  changes  in  the  bones  and  joints.  Most  of  the 
instances,  however,  are  characterized  by  tenderness,  while  a  general  ini/alfjia  or  malai.se 
is  a  frc(|ucnt  complaint.  There  are  sometimes  exacerbations,  during  which  both  severe 
neuralgic  ])ains  antl  mild  fever  are  quite  pronounced.  Not  infrc(|uently  on  handling 
the  affected  joint  pseutlocrepitus  or  actual  crepitus  will  be  obtained.  Sometimes  the 
joint  surfaces  are  roughened,  and  then  this  sensation  is  most  pronounced.  When  the 
.synovial  membrane  is  proliferated,  in  jpannns  form,  over  the  cartilages,  its  enlarged 
fringes  will  give  a  soft  crepitus  which  is  quite  distinctive.  Fragments  of  these  fringes, 
as  well  as  of  cartilage,  may  become  detached,  and  loose  objects  of  this  kind  in  the  joint 
may  be  recognized  by  the  sense  of  touch. 

While  this  is  going  on  within  the  joint,  adjoining  tendon  sheaths  and  bursa^  become 
more  or  less  involved,  and  even  the  ]x-riostcum  will  undergo  considerable  thickening. 

The  monarticular  type  is  more  frc(|ucnt  in  men  than  in  women,  ami  occurs  more  often 
in  a  large  joint  or  in  the  spine,  in  which  latter  case  it  is  hardly  to  be  considered  mon- 


388 


SCRGICAL   AFFECTIONS  OF   THE   TLSSUES 


articular.  The  cliancres  tliat  may  occur  in  tlic  .s-pinr  arc  distiuctive,  varying  from  trifling 
stiffness  and  limitation  of  motion  to  ])r()nouncc(l  deformity,  by  which,  for  instance, 
not  only  the  kyphosis  of  acute  sy)ondylitis  may  he  imitated,  hut  the  l)ody  fl(>xed  to  an 
angle  with  the  "axis  of  the  pelvis  and  fixed  there,  so  that  the  individual  is  bent  to  nearly  a 
right  angle.  Some  of  the  other  deformities  of  this  condition  are  more  or  less  character- 
istic.    In  the  hands  the  fingers  are  bent  toward  the  ulnar  side,  and  often  strongly  flexed, 


Fig.  195 


Arthritis  deformans,  knee.     (Ransohoff.) 

perhaps  even  overlapped,   thus  giving  the 

hand    a  peculiar    claw-like     appearance. 

The   feet     are    extended     completely,    the 

joints  rigid,  the  toes  turned  outward,  and 

also  overlajjping.     By  such  changes  in  the 

hi{)  and  knee  the   legs  and  thighs   may  be 

flexed  and  the  hips  perhaps  so  ankylosed 

as    to    prevent    separation    of  the    knees. 

While  these  changes   are,  as  stated,  most 

common  in  the  later  years  of  life,  children 

are  not  exempt,  girls  being  more  frequently 

affected  than  boys,  the  condition  coming  on 

at  first  Math  more  or  less  acute  symptoms. 

These    children    will    often    be    found    to 

have  enlarged    spleens  and    lymph  nodes, 

to  show  malnutrition,   while  some  of  them 

will  dis[)lay   certain   symptoms   of  exophthalmic  goitre.     In   other  words,  they  are  in 

that  condition  included  under  the  term  status  lymphaticus,  to  which  subject  the  reader 

is  referred.      (See  p.  163.) 

It  would  appear,  then,  that  we  can  expunge  the  term  chronic  articular  rheumatism, 
since  by  it  is  not  meant  the  ultimate  result  of  an  acute  rheumatic  affection,  but  rather 
one  of  the  vague  conditions  described  above. 

Fig.    195,   taken   from   a  skeleton  in  the  author's  possession,  illustrates  an  extreme 


General  osteo-arthritis,  \vith  multiple    synostoses 
("ossified  man"). 


XEUliOpATnic  JOIST  I)Isj:asIi  3g9 

condition  of  tliis  kind,  cliaraclcri/cil  liy  iiinlliplc  synostoses,  nearly  all  of  tlie  ])riiiei|)al 
joints  lu'injf  involved. 

As  hetweeii  the  terms  Dsfro-arfliritis  and  arthritis  drforinan.s  it  's  not  praetictihle  to 
make  sueli  ueeurate  distinctions  as  shall  be  aci'ej)tal)lc  to  all.  In  a  general  way  the  more 
the  hone  partieii)ates  the  more  we  may  use  the  former  tlesijijnation,  whereas  when  other 
joint  structures  are  chiefly  involved  we  may  resort  to  the  latter. 

In  fjeni'ral,  then,  all  these  conditions  are  evidenced  hy  joint  deformity,  especially  hy 
irre<fnlaiities,  by  more  or  less  effusion,  by  considerable  tenderness,  by  creakinj;  of  the 
joints  when  used,  by  pain  which  is  a  variable  feature  and  may  be  referred  to  nerve  dis- 
turbances, occasionally  by  muscle  spasm,  but  always,  in  cases  of  lon<;standin<;,  by  nniscle 
atro])hy.  A  view  of  tlu'  interior  of  joints  thus  affected  will  frivc  a  com])lex  j)icture  (jf 
atro])hy  here  and  hyj)ei1rophy  there  of  each  or  all  of  the  component  structures  of  the 
joint,  sometimes  with  a  fijradual  overgrowth  of  articular  bone  surfaces,  sometimes  with 
more  or  less  complete  disappearance  of  the  same,  e.  g.,  in  the  acetabulum. 

Treatment. — So  far  as  treatment  of  these  conditions  is  concerned,  it  .should  be 
rccalleil,  first  of  all,  that  the  di.sea.se  it.self  is  exceedingly  chronic  in  its  tendency,  and 
due  to  conditions  which  have  prol)ably  been  of  longstanding.  Constitutional  treatment 
is  as  es.sential  as  local,  and  must  consist  in  restoring  the  environment  and  the  luitrition 
of  the  jxitient  to  normal  standards.  Elimination  is  deficient  in  such  cases,  and  sliould 
l)e  stinuilated  l)y  hot-air  baths,  massage,  antl  such  exercise  as  may  he  po.ssible,  as  well  as 
by  the  use  of  diuretics  and  laxatives  to  the  degree  indicated.  The  local  treatment  may 
consist  also  of  massage,  elastic  compression,  aspiration  in  rare  instances,  the  use  of  wet 
packs,  and,  in  many  cases,  the  use  of  hot,  dry  air.  Various  forms  of  apparatus  are 
now  upon  the  market  by  which  almost  any  of  the  joints  may  be  subjected  to  the  influence 
of  dry,  hot  air  at  a  tenijX'rature  of  2cS0°  F.  When  j)roperly  used,  great  relief  and  im[)rove- 
ment  may  be  expected.  Their  u.se,  however,  calls  for  the  best  of  judgment  and  a  com- 
bination of  the  uieasures  already  mentioned.^ 


NEUROPATHIC    JOINT    DISEASE. 

This  received  its  first  full  and  classical  description  from  Charcot  in  180S.  The  term 
refers  to  joint  lesions  which  follow  and  are  apparently  connected  with  certain  injuries 
and  diseases  of  the  spinal  cord,  or  the  peripheral  nervous  system.  The  non-traumatic 
forms  are  mostly  associated  with  locomotor  ataxia  and  syringomyelia.  Some  of  them 
have  an  abrupt  on.set,  while  others  come  on  very  insidiou.sly.  Pain  is  usually  notable 
by  its  ab.sence,  and  the  involved  joints  show  few,  if  any,  evidences  of  hyperemia  or 
inflammation.  They  become  unnaturally  mobile  and  relaxed  and  usually  much,  some- 
times enormously,  distended  with  fluid.  The  morbid  changes  within  the  joints  comprise 
imaginary  combinations  of  atrophy  and  hypertro})hy,  with  proliferative  formations  in 
bone  cartilages.  Osteophytes  and  exostoses  are  met  with,  and  ossification  may  occur 
in  the  neighboring  tendons  and  ligaments.  Surprising  alterations  take  place  in  certain 
joints;  thus,  as  shown  in  Fig.  197,  the  head  of  the  humerus  may  disappear  and  corre- 
sponding changes  may  occur  in  other  joints.  AVhile  it  is  the  knee  which  suflFers  most 
frequently,  no  joints,  not  even  tho.se  of  the  spine  or  jaw,  are  exempt. 

1  The  following  types  of  arthriti.s  bear  little,  if  any,  relation  to  true  rheumatic  disease,  though  often  spoken  of 
as  rheumatoid: 

The  chronic  villous  form,  most  common  in  the  knee,  purely  local,  without  effusion,  and  gi%'ing  dry  crepitus  or 
creaking  The  joint  fringes  are  numerous,  and  sometimes  vascular  If  the  crepitus  be  marked  and  the  fringes 
too  extensive  the  latter  may  be  relieved  by  operation.  Otherwise  this  form  is  to  be  treated  by  early  local  stimu- 
lation, with  some  support,  at  least  with  a  bandage. 

The  alropiiic  form,  of  unknown  etiology,  causing  progressive  and  finally  crippling  swelling,  with  later  atrophy. 
There  is  little  if  any  fluid  present.  Here  the  changes  occur  in  both  bone  and  cartilage,  with  a  tendency  to  abnormal 
calcification  In  this  form  rest  and  hypernutrition,  especially  with  normal  proteids,  are  called  for,  and  every 
possible  stimulus  to  elimination  through  all  the  emunctories. 

The  hypertropliic  artfiritis,V>y  which  cartilages  are  first  thickened  and  then  ossified,  interfering  with  motion  and 
with  contour  Tliis  form  causes  great  limitation  of  motion  and  sometimes  pressure  on  nerves,  with  referred  pains 
It  seems  to  have  some  relation  to  cold,  exposure,  and  injury.  Detachment  of  jsieces  of  cartilage  is  not  uncommon, 
so  that  there  are  loose  bodies  in  the  joint  cavity.  Treatment  here  consists  of  fixation,  with  improvement  ol 
nutrition  and  elimination.     This  form  may  subside  under  proper  treatment. 

The  chronic,  gouty  arthritis,  with  deposits  of  sodium  urate  in  and  around  the  joint  tissues,  with  perhaps  some 
hone  ab-sorption  beneath  them,  which  are  not  connected  with  the  bone.  In  the  digits  entire  phalanges  may 
disappear  by  absorption.     The  treatment  here  is  essentially  constitutional  and  directed  toward  the  gouty  diathesis. 


390 


SURGICAL   AFFECTIONS  OF   THE   TISSUES 


Locomotor  ataxia  is  a  common  disease,  but  syrino;omycliii  lias  been  regarded  as 
excc'edingly  rare.  Nevertheless,  Schlesinger  has  collected  130  cases  of  it,  in  one-fovirth 
of  which  bone  and  joint  symptoms  were  present.  That  the  nervous  system  is  primarily 
at  fault  is  made  clear,  among  other  things,  by  the  rapidity  of  involvement  occasionally 


Fig.  196 


i'u:.  197 


Charcot's  disease  ot  elbow. 
Fig.  198 


Atropine  disappearance  of  hone  after  chronic  joint  disease. 
Fig.  199 


Tabetic  arthropathy.      (Case  of  E.  A.  Smith.) 


Neuropathic  arthritis  (tabetic  joints).     (Lexer.) 


seen,  where,  for  instance,  an  entire  limb  becomes  edematous,  with  every  indication  of 
severe  disturbance.  In  tabes  the  lower  extremities  suffer  more  often  than  the  others; 
the  reverse  is  true  in  cases  of  syringomyelia.  While  floating  bodies  in  the  joints  and 
ossification  of  th(>  muscles  and  soft  ])arts  are  common  in  arthritis  deformans,  they  seldom 
occur  in  the  neuropathic  lesions.     Suppuration  and  necrosis  are  rare  in  any  of  these 


NEUROPATHIC  JOIST  1)1  SI-:  A  SIC 


391 


forms,  orcun-inp;  more  frccnuMilly  in  the  I'm^vr  (liaii  clscwlicrc,  and  arc  ])r()l)al)ly  due  to 
infection  of  those  areas  where  s(>nsil)iHly  is  lost  and  lriliiii«i  injuries  less  ffuardcd  a^rjiirist. 
The  neuro])athic  lesions  are  more  commonly  symmetrical,  and  are  often  accompanied 
by  a  eretinic  general  appearance  (Figs.  VM\,'\\)7,  19S,  191),  200  and  201). 

The  joint  complications  of  syringomyelia  are  frequently  characterized  by  skm  lesions 
which  tend  to  sui)purate,  by  sudden  edema,  occasionally  followed  by  phlegmon  and 
cvin  necrosis,  also  by  other  disturbances  of  innervation. 


Fia.  200 


Skiagram  of  joints  shown  in  Fig.  199.     (Lexer.) 
Fk;.  201 


Arthropathy  of  syringomyelia.     Left  elbow,  illustrating  disintegration,  etc.,  without  ulceration  or 

suppuration.     (Quenu.) 

Surgical  treatment  of  these  lesions  is  less  discouraging  than  would  at  first  appear,  as 
even  in  these  patients  serious  wounds  heal  readily,  while  in  healthy  tissues  primary 
union  may  occur.  The  wisdom,  therefore,  of  incision,  resection,  or  even  amputation 
may  be  decided  on  their  merits,  and  there  can  be  no  objection  to  open  drainage  when  it 
would  otherwise  be  indicated.  Even  in  cases  of  spontaneous  fracture  proper  treatment 
usually  gives  good  results,  although  the  amount  of  callus  may  seem  disproportionate. 


392  SURGICAL  AFFECTIONS  OF   THE   TISSUES 

In  any  of  the  joints  (listortcd  by  (l('forniin<>;  osteoarthritis  or  neuroj)athie  lesions, 
the  question  of  partial  or  complete  resection  or  exsection  may  he  discussed  upon  its  meriis, 
since  these  operations,  when  duly  indicated,  have  often  given  satisfactory  results,  even 
in  elderly  people. 

Diagnosis. — Differential  dia<>;nosis  will  l)e  made  more  easy  by  the  exclusion  of 
syphilis  and  of  the  acute  or  ordinary  infectious  forms  of  disease.  The  relative  freedom 
from  pain,  the  relaxation  of  the  joint  structures,  the  large  amount  of  fluid  present,  and 
the  age  of  the  patient  will  aid  in  excluding  all  but  the  neuropathic  elements  associated 
with  spinal  disease. 

Treatment. — Treatment  is  rarely  curative;  usually  it  can  be  palliative  at  best. 
Measures  above  mentioned,  when  they  seem  indicated,  coupled  w'ith  mechanical  support, 
by  which  the  parts  may  be  maintained  as  nearly  as  possible  in  their  proper  position, 
will  give  the  best  result.  If  the  disease  be  monarticular,  exsection  will  frequently  give  a 
satisfactory  result.     Multiple  lesions  rarely  permit  of  serious  operations. 


HYSTERIA  AND  HYSTERICAL  JOINTS. 

A  different  form  of  distinctly  neuropathic  joint  affection  is  the  so-called  hysterical 
joint.  This  is  characterized  by  the  absence  of  every  oljjective  and  the  presence  of  nearly 
every  subjective  symptom.  It  occurs  most  often  in  yoimg  women  and  girls,  follows 
perhaps  some  trifling  injury,  and  involves  most  commonly  the  joints  of  the  lower  limbs. 
These  cases  are  characterized  by  a  disproportion  between  the  character  of  the  complaint 
and  the  actual  condition.  Imitation  of  organic  trouble  is  a  predominant  feature  of  all 
hysterical  complaints,  and  is  nowhere  seen  to  better  advantage  than  in  these  cases. 
The  pain,  the  tenderness,  the  loss  of  ability  and  even  the  muscle  spasm  and  muscle 
atrophy  of  genuine  lesions  will  be  simulated.  So  true  is  this  that  diagnosis  largely  rests 
on  the  exaggeration  of  symptoms  which  have  no  apparent  existence.  Ili/pcresthesia 
is  sometimes  extreme,  but  pertains  usually  to  the  waking  hours.  Rarely  is  there  actual 
swelling  or  thickening,  or  any  objective  evidence  whatever  of  disease,  save  perhaps 
muscle  atrophy  due  to  disuse.  It  is  possible  to  have  the  hysterical  element  as  a  com- 
plication of  actual  joint  disease,  but  the  truly  hysterical  joints  usually  are  easily  recog- 
nizable. 

Treatment. — The  treatment  of  such  a  joint  should  be  psychical  as  well  as  physical. 
Sometimes  appeals  to  reason,  at  other  times  to  fear  or  necessity,  will  be  the  wiser  course. 
Restoration  of  self-confidence  is  an  important  feature,  and  these  are  the  cases  where 
any  form  of  faith  cure  will  produce  its  most  brilliant  results.  Many  of  these  cases  are 
bedridden,  and  need  to  have  elimination  stimulated  in  every  possible  way.  They  also 
need  sunlight,  fresh  air,  massage,  and  renewed  use  of  the  parts.  Ilyjx'resthesia  is  best 
treated  by  continuous  application  of  ice-cold  compresses,  intermitted  perha})s  daily  for 
the  purpose  of  using  the  "flying  cautery,"  as  already  described. 


GONORRHEAL  OR  POSTGONORRHEAL  ARTHRITIS. 

This  condition  may  occur  during  the  active  stage  of  gonorrhea  or  after  its  apparent 
subsidence.  It  was  probably  the  discovery  of  the  pathogenic  gonococcus  by  Neisser, 
in  1879,  which  gave  to  this  lesion  an  identity  of  its  own,  and  induced  the  profession 
to  abandon  the  name  gonorrheal  rheumatism,  by  w4iich  it  had  been  known.  It  has 
nothing  to  do  with  rheumatism,  and  should  not  be  linked  with  it  in  name  any  more 
than  in  idea.  In  well-marked  cases  the  gonococcus  will  nearly  always  be  found,  usually 
in  pure  culture,  in  the  joint  fluid. 

It  ai)pears  in  dift'erent  degrees  of  severity,  from  a  mere  hydrojis,  which  is  mild,  accom- 
panied by  slight  tissue  changes,  to  a  ])hlegm()nous  condition,  with  wides])read  destruction 
of  joint  structures  and  serious  constitutional  disturbances.  As  between  these  extremes 
there  may  be  a  pyarthrosis  or  empyema,  which  is  usually  the  result  of  a  mixed  infection. 

As  a  complication  of  urethritis  it  occurs  in  4  or  5  per  cent,  of  cases,  the  percentage 
being  larger  in  children  than  in  adults,  the  knee  being  affected  in  about  one-third  of  these 
cases.  It  is  not  necessarily  monarticular,  however,  and  sometimes  several  joints  will  be 
involved.     Along  with  the  joint  condition  there  will  frequently  occur  cardiac  lesions 


TUHKHCVI.OUS  Airnih'ITIS  303 

(ciulocanlitis)  and  eve  complicatioiis.  In  I'acl,  sonic  of  these  eases  terminate  fatally 
tiin)U<;li  tile  mechanism  of  a  seriously  involved  heart,  i.  c,  septic  endocarditis  or  myo- 
carditis.  When  it  occurs  in  the  ankle  or  in  the  tarsal  joints  the  lijfaments  and  surrounding 
bursa"  are  often  involved.  This  involvement,  unless  recoj^nized  and  |)ro|)erly  treated,  may 
lead  to  serious  deformity,  r.  (/.,  flat-foot  of  the  most  painful  kind.  Nlaiiy  of  those  lesions 
at  the  h<xd  are  accomijanied  by  true  e.xosto.ses,  which  are  often  painful  and  more  or  less 
disabling  ("j)ainful  heel").  Thus,  Jaeger  has  recently  reported  a  gronj)  of  ten  such 
eases.  These  may  re(|uire  excision.  In  general  this  form  of  arthritis  is  characterized 
hy  severe  pain,  often  worse  at  night,  and  a  peculiar  distortion  of  the  swollen  joint, 
because  it  is  usually  complicated  by  a  distention  of  the  adjoining  tendon  sheaths  and 
bursje,  which  is  rare  in  other  forms  of  arthritis.  It  has  been  aptly  stated  that  if  in  these 
cases  the  same  zeal  were  displayed  in  seeking  for  gonococci  that  has  often  been  shown 
in  looking  for  uric  acid  it  would  be  less  often  neglected.  So  far  as  treatment  is  concerned, 
I  desire  in  this  place  only  to  call  attention  to  the  absolute  inutility  of  all  the  .so-called 
antirheumatic  remedies  and  diet.  However,  if  the  urine  be  hyperacid  it  should  be  cor- 
rected by  ordinary  means.  At  first  absolute  rest,  with  the  local  use  of  the  ichthyol- 
mercurial  or  Crede  ointment,  should  be  given.  Such  antiseptics  as  one  has  most  con- 
fidence in  may  also  be  administered  internally  for  their  general  beneficial  effect.  An 
overdistended  joint  should  be  tapped  and  irrigated.  As  soon  as  the  ])resenee  <jf  pus 
can  be  determined,  either  with  or  without  ex})loration,  the  joint  should  be  oj)ened, 
thoroughly  irrigated,  and  drained.  If  this  were  always  done  in  time  the  more  severe 
phlegmonous  and  destructive  cases  would  rarely  occur. 


TUBERCULOUS   ARTHRITIS. 

Tuberculous  disease  of  the  joints  is  one  of  the  most  frequent  of  surgical  lesions.  It 
has  jiroduced  characteristic  a))])(>arances  which  have  been  known  under  the  name  of 
"scrofula  of  joints,"  until  a  clearer  recognition  of  the  pathology  of  the  condition  led 
to  the  abandonment  of  the  term  scrofula.  Tumor  alhus,  or  ivhite  sivelling,  was  another 
term  commonly  aj)[)lied  to  these  lesions,  because  of  the  anemic  appearance  of  the  surface 
of  the  swollen  joint. 

Tuberculous  arthritis  assumes  different  phases  in  proportion  to  the  involvement  of  the 
different  component  structures  of  the  joint.  Some  cases  begin  purely  as  a  tuberculous 
synovitis,  and  may  for  a  long  time  be  limited  to  the  synovial  structures.  Others  begin 
within  the  spongy  texture  of  the  expanded  joint  ends  of  the  long  bones,  the  disease  spread- 
ing from  such  foci  and  involving  everything  in  the  path  which  its  products  take  in  the 
effort  to  secure  spontaneous  evacuation,  products  of  softening  and  infection  travelling 
in  the  direction  of  least  resistance. 

It  has  been  the  writer's  custom  to  always  follow  Savory,  in  his  suggestion  to  students 
to  let  their  mental  pictures  of  consumption  of  the  lungs  and  ])leurje  serve  for  illustration 
in  similar  disease  of  joints.  Thus  the  cancellous  bone  structure  much  resembles  the  lung 
tissue  in  its  spongy  character.  In  both  a  capsule  surrounds  the  mass  of  tubercle,  and 
in  each,  by  breaking  down  of  its  contents,  a  cavity  is  formed.  INIoreover,  the  pleura 
bears  practically  the  same  resemblance  and  relation  to  the  lung  and  the  chest  wall  that 
the  synovialis  does  to  the  bone  end  and  the  joint  cavity;  as  we  may  have  pleuritis  with 
phthisis,  so  we  may  have  synovitis  with  tuberculous  ostitis;  and  as  adhesions  tend  to 
form  in  the  pleural  cavity,  so  also  do  they  in  the  synovial  cavity.  Furthermore,  in  each 
case  obliteration  of  deeper  veins  causes  the  more  prominent  appearance  of  the  subcu- 
taneous veins,  and  as  tuberculous  pleurisy  often  terminates  in  empyema,  so  does  tul)er- 
culous  hydrarthrosis  often  terminate  in  pyarthrosis,  perhaps  with  fungous  ulceration. 
In  almost  every  feature,  then,  the  progress  and  effect  of  tuberculosis  in  the  lung  and  bone 
end  may  be  likened  to  each  other. 

In  some  clinics  bone  and  joint  tuberculosis  constitute  nearly  one-third  of  the  total 
of  cases  treated.  Joints  of  the  lower  limb  are  the  ones  most  frequently  involved  in 
children,  while  in  the  adult  those  of  the  upper  extremity  are  generally  attacked. 
It  is  not  often  that  more  than  one  joint  is  involved  at  one  time.  The  relation  of  trauma- 
tism to  this  disease  has  been  frequently  discussed,  and  is  variously  regarded.  The  dis- 
ease is  more  common  in  those  who  are  predisjiosed  to  it  by  environment  or  by  heredity, 
in  the  latter  case  hereditary  evidences  usually  bein  ■;  well  marked.     In  such  predisposed 


304  SURGICAL  AFFECTIONS  OF  THE   TISSUES 

individuals,  esjX'cially  in  the  early  years  of  life,  severe  injuries  are  usually  promptly 
repaired,  while  the  milder  traumatisms,  which  are  often  frequent  and  to  which  too  little 
attention  is  paid,  seem  often  to  so  far  lower  tissue  resistance  a.s  to  favor  an  infection 
to  which  the  individual  Is  already  favorably  predisposed.  The  true  position  to  take, 
then,  would  apjx^ar  to  be  this,  that  fraurnati.wis  rarely  lead  directly  to  joint  tuberculosis, 
hut  only  indirectly  by  affecting  tissue  susceptibility. 

Thus  lesions  which  Ix-^in  in  the  epiphyses  lead  to  what  is  known  as  osteopathic  joint 
disease,  while  those  which  have  their  origin  in  the  synovia  give  rise  to  the  arthropathic 
forni>.     The  former  are  more  common  in  children  and  the  latter  in  adults  (Fig.  202). 

Pathology. — In  regard  to  the  patholog}-  of  these  conditions  it  drx-s  not  vary  from 
that  nuntiuncd  in  the  earlier  portion  of  this  work  in  connection  with  the  general  subject 
of  Surgical  Tuberculosis.  The  deposit  of  tubercle  in  the  tissue  who.se  resistance  has 
lieen  weakened  Is  followed  by  the  formation  of  granulation  tissue,  which,  so  long  as  the 
germs  survive,  tends  to  increase  and  to  make  room  for  itself  at  the  expense  of  surrounding 
tissue.  At  the  same  time  there  occurs  a  tissue  struggle  by  which  the  attempt  is  made 
to  throw  around  an  active  focus  a  protecting  barrier,  which  in  soft  tissues  consists  of 
condensed  fibrous  and  connective  tissue,  and,  in  bone,  of  a  sclerotic  capsule,  as  though 
the  intent  were  t(j  imprison  the  disturbing  cau.se,  and,  by  completely  enclosing  it,  effect 

Fic.  202 


;  ,'■  ."'^  .•  I 


f 


k    r 


/f- 


#> 


*-'». 

% 


Central  sequestrum.     (Raiisohoff.) 


protection.  When  this  attempt  at  encapsulation  is  successful  spontaneous  recovery 
follows.  It  will  be  made  successful,  to  some  extent  at  least,  by  treatment  whose  most 
important  local  feature  Is  physiological  rest.  On  the  other  hand,  when  the  attempt 
is  unsuccessful  and  the  barrier  Is  tran.sgressed  by  granulation  tissue,  the  lesion  will 
advance  in  the  direction  of  least  resistance,  while  its  progress  will  be  made  known, 
estx-ciallv  as  it  approaches  the  surface,  by  very  significant  signs:  adhesion  of  the  over- 
King  structures  and  finally  of  the  skin,  with  purplish  fliscoloration  of  the  latter.  Finally 
softening  occurs  with  escajx-  of  granulation  tissue,  which,  so  .soon  as  it  is  freed  from 
pressure,  will  grow  more  luxuriantly  and  with  more  color,  constituting  the  fungous 
granulation  tissue,  to  which  German  pathologists  so  often  allude,  or  sri-called  "proud 
flesh."  When  this  appears  upon  the  surface  it  Is  soon  infected  with  pyogenic  organisms, 
breaks  down,  and  an  abscess  cavity  results,  connecting  with  the  original  focus  and  its 
extensions.  This  may  be  so  placed  as  to  lie  outside  the  joint  capsule,  which,  in  some 
respects,  Is  fortunate  for  the  patient.  The  joint  function  may  then  be  compromised  to 
only  a  minor  degree. 

Often  the  direction  of  least  resistance  is  toward  the  joint  ravity,  this  fungous  tissue 
loosening  and  fx-rforating  cartilage  or  periosteum  l)efore  it  enters  the  joint.  Having 
ptmetrated  it  again  it  grows  extensively  until  the  cavity  is  distended,  its  rapidity  of  growth 


TUBERCULOUS  A  RT/fRITIS 


395 


Fi<i.  203 


5-B»:<TV 


(liniiiiishiiifj;  with  tlio  dcfircc  of  pressure  produced  hy  ils  surrouudiufjs.  This  |)?-essure 
will  also  uiake  it  less  vascular,  aud  when  such  a  joint  is  opened  it  at  first  a|)|)eai-s  |)ale 
and  aneniie.  In  j)rop()rtion  as  the  joint  distends  it  loses  iu  motility,  while  should  recovery 
occur  spontaneously  or  as  the  result  ol'  treutnient  this  tissue  will  to  some  extent  disa])j)ear, 
to  he  replaced  hy  adhesions  by  which  pseudo-ankylosis  is  prochiced.  The  extent  of  the 
intra-articular  involvement  will  cause  obstruction  to  the  (leeper  r(>turn  circulation,  and 
thus  is  brought  about  the  prominence  with  which  the  subcutaneous  veins  a]>pear.  The 
def;re(>  of  hydrarthrosis  is  a|)parently  not  limited  except  by  the  distensibility  of  the  joint. 
In  till'  articular  or  arthro|)athic  forms  there  is  always  more  or  less  synovial  outpoui-. 

'^Vo  the  condition  already  desci'ibed  may  be  added  the  destruction  producecl  I)v  suppu- 
ration, inf(>ction  occurrino;  either  throu<j;h  the  circulation,  as  is  (|uite  possible,  or  throuf^h 
some  tridinii'  surface  abrasion.  In  more  chronic 
eases  casintion  may  occur,  es])ecially  in  l)()ne  foci. 
Finally,  as  the  result  of  a  combination  of  morbid 
processes,  there  is  produced  more  or  less  complete 
disorganization,  all  of  which  is  summed  up  in  the 
term  ftihrrriiloii.s-  patiarfJtrifh.  'Vo  that  condition 
in  which  the  articular  surfaces  are  more  or  less 
studded  with  fungous  patches  the  term  panuv.s'  of 
the  joint  is  often  a]ij)lied.  To  reiterate,  then,  as 
between  a  chronic  hydrarthrosis  and  a  destructive 
panarthritis,  perhaps  even  with  necrosis  of  epiphy- 
ses, it  is  but  a  difference  of  degree  and  of  combina- 
tion of  infectious  processes  (Figs.  203,  204,  205 
and  200). 

Among  the  other  consequences  of  panarthritis 
may  be  the  formation  of  acqucstra  in  or  n(>ar  the 
epij)hyses,  and  such  destruction  as  shall  lead  to 
patliologiral  dislocation,  the  latter  being  well  illus- 
trated in  Figs.  204  and  207.  This  dislocation  is 
always  the  result  of  the  pull  of  muscles  thrown 
into  that  condition  of  reflex  spasm  which  is  a 
characteristic  feature  of  this  disease.  It  appears 
conspicuously  at  the  knee,  usually  as  a  back- 
ward subluxation  (Fig.  207),  and  at  the  hip  as  an 
upward  dislocation,  sometimes  with  more  or  less 
apparent  migration  of  the  acetabulum.  Another 
consequence  of  tuberculous  hydrarthrosis,  which 
frequently  persists  even  long  after  the  subsidence 
of  the  acute  stage  of  the  disease,  is  the  occur- 
rence within  the  joint  cavity  of  rice-grain  or 
melon-seed  bodies,  for  whose  presence  it  is  not 
easy  to  accoimt.  The  generally  received  expla- 
nation is  that  they  are  the  result  of  fibrinous  out- 
pour, whose  fluid  portions  have  been  absorbed, 
while  the  remaining  nearly  pure  fibrin  is  broken 
up  into  particles  ami  rounded  off  l)y  attrition  during  the  movements  of  the  joint.  They 
may  accumulate  in  astonishing  amount,  thus  stam|)ing  the  disease  as  having  a 
chronic  rather  than  an  acute  character.  After  a  time  they  provoke  a  fresh  outpoin*  of 
fluid,  as  a  result  of  the  irritation  which  they  produce.  This  fluid  is  at  first  usually 
clear  serum,  but  becomes  turbid  or  seropyoid,  and,  if  infected,  becomes  pure  pus,  in 
which  the  rice-grain  bodies  are  dissolved  or  tlisintegratcd. 

Reroveri/  is  possible  in  many  cases  w'hen  the  lesions  have  not  advanced  too  far.  It 
is  rarely  ideal,  and  usually  leaves  some  evidence  of  its  existence  in  limitation  of  motion, 
thickening,  or  other  recognizable  symptom.  Constitutional  as  well  as  local  measures 
have  much  to  do  with  bringing  about  this  result.  It  is  for  this  reason  that  it  is  so  essen- 
tial to  take  tuberculous-joint  patients  out  of  the  environment  in  which  ordinai'ily  they 
live  and  get  them  outdoors,  exposed  to  sunlight  and  benefited  by  the  best  of  nutrition. 
Rest,  oxygen,  and  hi/pernutrition  are  the  thr(>(>  best  general  measures  for  combating  these 
conditions.     When  recovery  does  occur  it  is  by  the  death  of  all  active  germs,  the  absorp- 


Tuberculous  p.anartliritis.     (Ransohoff.) 


396 


SURGICAL  AFFECTIONS  OF   THE   TISSUES 


tioii  to  varying  (^xtent  of  disease  products,  iiiclu(lin<ij  gratiulatioii  tissue,  and  the  organi- 
zation into  fil)r()us  and  cicatricial  tissue  of  the  unahsorhed  resi(hie.  No  tissue  which 
has  been  actually  disoro;ani/,ed  is  completely  restored.     The  best  that  can  be  IiojxhI  for 


Fig.  204 


Bony  ankylosis  of  knee.      (.liausoholT.) 


Fio.  205 


Fig.  206 


Section  of  bony  ankylosis  of  hip.     (Original.) 


Tuberculous  panarthritis,  illustrating  various 
types  of  degeneration  and  destruction.     (Lexer.) 


is  substitution  of  fibrous  or  cicatricial  tissue.  Function  may  be  more  or  less  completely 
regained.  This  will  depend  largely  upon  how  early  treatment  is  instituted.  In  general 
it  may  be  said  that  there  is  always  hope  for  tuberculous  joints  if  suitable  treaiment  he 
instituted  early  and  if  the  environmevt  can  be  made  satisfactory.     Unfortunately  this 


TVHKRCULOUS   MmiUITlS 


;5!); 


is  not  olU'ii  j)()ssil)l(',  and  the  best  that  can  he  hoped  tor  is  siihsidciicc  of  disease  at  the 
expense  of  more  or  less  ankyh)sis,  |)erhaps  defoniiily,  while,  at  the  worst,  there  inav  he 
loss  of  joint  if  not  of  life.  It  nii^dit  he  misinterpreted  should  it  he  said  that  there  is  one 
kind  of  treatnuMit  for  the  wt-althy  and  another  for  the  poor,  yet  so  nnieh  does  depend 
upon  what  the  i)atient  or  tlu>  parents  can  aH'ord  in  the  way  of  change  of  surroundiiifrs 
that  the  whole  plan  of  tri>atment  often  depends  upon  the  patient's  eireunistanees.  Radi- 
cal measures  may  therefore  be  deemed  best  in  those  who  cannot  ofi'ord  lonj;  delay  and 
temj)orization,  while  at  other  times  exj)ensive  apparatus  and  chanfre  of  residence  may 
bring  about  the  desired  result. 

The  f/rnrra/  appranincr  of  a  luhcmdous  joint  is  one  of  manifest  cnlartfcinent  which 
is  made  more  conspicuous  by  wastin<f  of  the  limb  above  and  below.  Nevertheless  by 
actual  measurement  it  will  usually  be  found  to  have  a  <»;reater  circumference  than  its 
fellow  of  the  o])posite  side.  Its  coverini^  skin  is  pale  and  often  <^listcnin<r,  with  ])rominent 
veins,  while  in  proportion  to  the  distention  by  Huid  there  will  be  more  or  less  distinct 
fluctuation.  When  the  joint  is  evidently  distended  and  does  not  fluctuate  the  inference 
is  that  it  is  filled  with  (granulation  tissue.  There  will  also  be  marked  thickening  of  all 
the  articular  coverings,  the  synovial  membrane  itself  being  often  as  thick  as  sole  leather. 
At  points  where  ])erforation  may  threaten  there  may  be  tlim])ling  and  retraction  of  the 
skin,  with  fixation  and  discoloration. 

Symptoms. —  TuJx'rcuIoin^  joint  (U.sease  is  rhararfrrized  r.s'prridlli/  In/  loss  of  juuclion, 
iniisc/r  spasm,  iniisrlr  atropin/,  pain  and  frndrrncss  of  rather  significant  character,  and 
the  other  joint  fe;itures  already  mentioned.  Loss  of  jnndion  may  be  ])ai'tial  or  complete. 
It  dej)ends  on  the  amount  of  tenderness  and  the  deformity  already  produced  by  muscle 

Fig.  207 


Backward  displacemeut  of  tibia  due  to  the  muscle  spasm  of  a  tuberculous  knee-joint,  with  final  bony 

ankylosis.     (Lexer.) 

spasm.  INIotility  is  more  or  less  restricted  even  under  an  anesthetic.  This  is  induced 
by  actual  limitation  of  motion  by  products  of  exudation,  by  muscle  spasm  and  wasting, 
and  by  the  involuntary  shrinking  of  the  patient  when  tender  joint  surfaces  are  pressed 
against  each  other. 

Muscle  spasm  is  one  of  the  most  significant  features  of  these  cases  as  well  as  almost 
the  earliest.  It  is  of  the  greatest  diagnostic  value,  and,  if  genuine,  should  never  be 
neglected.  It  subsides  under  the  use  of  an  anesthetic,  hence  it  is  not  advisable  to  employ 
anesthetics  for  diagnostic  purposes.  It  produces  at  first  fixation,  without  particular 
deformity,  but  may  lead  later  to  this  or  to  pronounced  subluxation.  It  is  most  helpful 
in  the  early  stages  when  it  does  not  particularly  interfere  with  a  medium  range  of  motion, 
and  seems  to  lock  the  joint  before  the  extreme  of  motility  is  reached.  IMuscle  spasm 
is  pronounced  even  after  muscle  atrophy  is  well  advanced,  and  serves  more  and  more 
to  fix  joints  until  they  are  held  by  adhesions  formed  within.  Muscle  atrophy  in  also 
significant  and  begins  about  the  time  when  diagnosis  becomes  fairly  possible,  i.  e.,  in 
the  early  stage  of  the  disease.  With  the  advance  of  disease  it  becomes  more  pronounced, 
and  a  joint  which  is  fixed  by  intra-articular  lesions  will  stand  out  j)rominently  because 
of  the  iiotable  wasting  of  the  muscles  by  which  ordinarily  it  would  be  moved.  It  is 
this  which  gives  the  elbow  and  knee  especially  their  spindle  shape.    (See  Plate  XXXIV.) 

Pain  is  also  a  characteristic  feature,  especially  that  which  is  produced  by  motion  and 
allayefl  by  rest  and  that  which  is  accompanied  by  involuntary  muscle  spasm,  and  occurs 
during  sleep,  i.  e.,  the  so-called  osteocopic  or  startinrj  pains  of  tuberculous  panarthrdis. 
These  occur  most  distinctively  in  children,  but  may  be  complained  of  at  any  peri()d  of 
life.  Children  thus  affected  will  cry  out  sharply  during  their  sleep  and  appear  for  a 
few  seconds  very  much  distressed,  and  yet  do  not  awaken  sufficiently  to  recall  or  describe 
their  sensations.  The  explanation  of'  this  phenomenon  is  a  sudden  reflex  spasm  of 
the  muscles  by  which  tender  joint  surfaces  have  been  suddenly  pressed  tightly  together 


398  SURdlCAL   AFFECTIONS  OF   TIJE   TISSUES 

and  pain  thereby  provoked.  Soiiietliiiifj;  of  tliis  kind  may  occur  in  syphilitic  hone  dis- 
ease, hut,  taiveii  in  connection  witli  the  other  signs  and  .synij)toins  above  mentioned, 
such  pains  are  practically  pathojjjnomonie. 

The  various  measures  to  wliicii  orthoj)e(lists  and  surgeons  resort  for  employment  of 
traction,  by  splints  or  weights,  are  directed  against  overcoming  muscle  spasm  by  tiring 
out  the  muscles.  It  must  not  be  thought  that  by  any  reasonable  degree  of  traction  joint 
surfaces  are  actually  sei)arated  widely  from  each  other.  All  that  it  is  expected  to  accom- 
plish is  by  a  steady  pull  to  exliaust  the  muscles,  and  prevent  them  from  thus  exercising 
deleterious  j)ressure  l)y  j)ulling  joint  surfaces  together. 

The  pain  com[)lained  of  is  by  no  means  necessarily  limited  to  the  joint  involved;  in 
fact,  some  of  the  most  significant  pains  are  those  which  are  described  as  rcjrrrcd.  These 
furnish  illustrations  of  the  fact,  well  known  to  ])hysiol()gists,  that  irritation  in  the  course 
uj  a  iirrrr  i.s  referred  to  its  disfrihiition;  thus  in  hip-joint  disease  most  (jf  the  j)ain  will 
be  centred  in  the  knee,  and  when  the  knee  is  involved  the  aidvle  will  be  the  part  to 
which  the  patient  will  refer  much  of  his  discomfort. 

There  also  comes  an  overuse  of  the  unaffected  joints  of  a  limb  by  which  the  diseased 
joint  may  be  spared  as  far  as  possible.  The  flexors,  as  a  group,  being  always  stronger 
than  the  extensors,  the  former  will  overcome  the  latter  in  time,  and  these  joint  contrac- 
tures are  a  later  ex'pression  of  chronic  muscle  spasm.  This  is  true  even  when  atrophy 
is  well  advanced. 

Tuberculous  joint  disease  usually  has  at  first  no  particular  constitutional  com])lica- 
tions.  These  conie  on  later  in  proportion  as  the  general  health  suffers  from  the  con- 
finement entailed  by  the  disease.  General  health  will  suffer  (juicker  when  the  lower 
limb  is  involved  than  when  it  is  the  upper.  By  the  time  joint  lesions  are  well  advanced 
careful  observation  will  usually  reveal  a  rise  of  evening  temperature  and  progressive 
anemia.  The  symptoms  included  under  the  term  hectic  are  those  belonging  to  the 
destructive  stage  and  are  due  to  a  combination  of  causes  in  which  auto-intoxication 
figures  largely. 

Diagnosis. — Tuberculous  joint  disease  is  usually  easy  of  recognition,  except  perhaps 
in  the  earliest  stages.  (See  the  general  sul)ject  of  ()rtho])edic  Surgery.)  Differential 
diagnosis  between  this  condition  and  syphilis,  or  between  it  and  hysteria,  has  occasion- 
ally to  be  made,  and  may  at  first  cause  some  difficulty.  An  hysterical  hip  or  knee  may 
so  strongly  simulate  tuberculous  disease  as  to  lead  one  at  first  into  serious  doubt.  Again, 
as  between  the  tuberculous  and  non-tuberculous  forms  of  hytlrarthrosis,  there  may 
often  be  doubt,  even  after  as])iration  and  examination  of  the  fluid.  In  fact,  that  which 
began  as  one  may  terminate  as  the  other.  Fortunately  in  these  last  cases  local  treatment 
is  about  the  same  for  each,  and,  while  the  question  of  dixignosis  may  never  be  absolutely 
satisfactorily  tlecided,  the  j)atient  may  nevertheless  recover  in  either  event. 

Treatment. — The  treatment  of  tuberculous  arthritis  should  be  both  local  and 
general,  one  being  about  as  im]x)rtant  as  the  other.  The  general  treatment  for  this  as 
for  every  other  tuberculous  disease  may  be  summed  up  as  follows:  The  remedies  for 
tuberculous  disease  are  oxi/r/en  and  hyper  nutrition.  The  best  place  for  the  patient  is 
the  place  where  these  means  can  be  procured.  As  explained  above,  this  will,  to  a  con- 
siderable extent,  depend  upon  the  circumstances  of  the  ])atient  or  the  family.  When 
it  can  be  afforded  a  high  altitude  is  almost  as  good  for  joint  tuberculosis  as  for  that  of 
the  lungs.  The  nearest  ai)proach  that  can  be  made  to  it  will  be  the  most  desirable. 
Hypernutrition  will  in  some  cases  consist  almost  in  forced  feeding.  Here  as  elsewhere 
in  tuberculous  disease  it  is  of  at  least  theoretical  as  well  as  of  j)ractical  advantage  to 
saturate  the  system  with  some  bactericidal  remedy,  if  such  there  be,  and  for  obvious 
reasons.  Creosote  or  its  congeners,  in  more  or  less  palatable  form,  seem  at  present  to 
best  serve  this  purpose.  In  addition  to  this  arsenic,  iron,  and  the  iodides,  the  latter 
especially  if  there  be  any  suspicion  of  syphilitic  com])lication,  can  be  used  to  advantage. 
In  proportion  as  patients  become  confined  to  the  house  their  elimination  is  usually 
restricted.     All  measures  then  by  which  elimination  may  be  improved  will  be  indicated. 

The  use  of  tuberculin,  or  some  of  its  modifications,  has  been  occasionally  followed  by 
excellent  results.  It  is  an  agent  to  be  employed  with  great  discretion,  but  is  well  worth 
a  trial  in  those  cases  where  its  effects  may  be  carefully  watched. 

Locally  the  most  important  measure  is  the  enforcement  of  physiological  rest  of  the 
affected  parts.  This  may  ini])ly  confinement  to  bed,  especially  when  the  spine,  the  pelvis, 
and  the  hip  are  affected,  but  should  be  reinforced  b}'  mechanical  contrivances,  by  which 


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TUliFJiCULOllS   MCniUiriS  ;i<)() 

truftioii  or  '' c.vtcn.s-iim"  iii;iv  Ik-  carriccl  out.  'I'lic  |)iir|)().sc  of  traction,  us  mciilioiicd 
above,  is  to  ovt  rcoiiu'  iiiiisck'  s|)a.siii  and  thus  cnsuic  rest.  It  is  ciVoctcd  by  inaiiv  of  the 
orthopedic  apparatuses.  (See  ehupter  XXXI 11.')  ll  may  be  enforced  by  fixed  dres.s- 
iiifijs  of  plaster,  ete. 

With  a  better  appreciation  of  the  patliolo^y  of  (he  condition  nunuirous  methods  wen; 
ileviscd  by  which  the  <i;ernis  should  be  attacked  in  loco.  Thus  various  antiseptics  have 
been  injecti'd  in  varyiuii;  stn-nj^tiis,  either  into  joint  cavities  or  around  them.  Lanne- 
lon<fni'  devised  a  "scl(>rotic  method,"  by  which  /,inc  chloride  solutions  were  injected  into 
the  peri-articular  tissues,  to  so  condense  and  harden  them  as  to  im])rison  and  destroy 
their  contained  <^erms.  The  method,  however,  is  an  extremely  j)ainful  one  and  has 
not  found  o;eneral  favor.  For  a  lon<i;  time  iodoform  was  employed  for  the  same  purj)o.se, 
in  emulsions  of  10  jx-r  cent,  and  2()  per  cent.  stren<i;th,  in  sterilized  glycerin  or  olive  oil. 
It  alfords  a  curious  paradox  that  the  iodoform  itself  must  be  sterilized  })efore  beinjj  thus 
used.  This  I'uuilsion  has  been  injected  into  the  peri-articular  tissues  or  into  joint  cavities, 
which,  when  c()ntainin<>;  appreciable  amounts  of  fluid,  should  be  first  emptied  and 
washed  out ;  all  of  which  can  be  done  ihrouo'h  the  same  small  trocar  used  for  iiitroduction 
of  the  iodoform.  The  verdict  of  sur<i;eons  today  is  rather  against  the  employment  of 
iodoform,  since  they  have  learned  to  not  rely  u|)on  it  because  of  disa])pointnient  s(j  often 
following  its  use. 

Bier,  in  1891,  advised  the  so-called  congestion  treatment  of  tuberculous  joints,  basing 
it  upon  the  fact  that  tuberculosis  does  not  develop  in  lungs  which  are  the  seat  of  venous 
stasis  from  valvular  heart  disease.  He  proposed  to  produce  an  artificial  stasis,  in  the 
joint  struetvn'es  and  about  them,  by  which  living  germs  should  be  destroyed  and  their 
disease  products  enca))sulated,  claiming  that  as  the  result  of  the  hy|)cnMnia  thus  pro- 
duced the  alexins  are  thus  brought  into  more  complete  contact  with  the  bacilli.  The 
method  is  applicable  to  the  limbs  beUnv  the  shoulder  and  hij).  It  consists  in  the  appli- 
cation of  an  Esmarch  bandage  above  the  affected  joint,  a])])lie(l  with  sufficient  firmness 
to  obstruct  the  returning  blood,  but  not  to  interfere  with  the  arterial  supply.  If  there 
be  room  the  limb  is  also  bandaged  below  the  joint  with  an  ordinary  cotton  roller.  This 
congestion  is  kept  up  at  daily  intervals  for  increasing  periods,  b^^ginning  with  perhaps 
half  an  hour  and  continuing  until  it  is  in  operation  at  least  half  of  the  time.  Meantime 
other  methods  of  treatment  are  not  interdicted.  In  the  earlier  stages  of  tuberculous  joint 
disease  this  method  has  given  very  encovu'aging  and  pleasing  results.     (See  Fig.  208.) 

Tuberculous  hydrops  may  be  treated  by  aspiration  and  elastic  compression.  Should 
fluid  distend  the  joint  it  should  be  opened  and  thoroughly  cleaned,  then  closed  and 
perha{)s  drained. 

The  treatment  of  pi/arlhwsis  and  of  peri-articular  cold  abscess  has  long  been  a  mooted 
subject  The  orthopedic  surgeons  still  adhere  to  mildly  or  absolutely  non-operative 
measures,  whereas  the  general  surgeon  prefers  to  adopt  more  radical  methods.  Each 
case  should  be  judged  on  its  ow^i  merits,  and  these  should  include  a  careful  estimation  of 
the  general  condition  of  the  patient.  Should  evidences  of  septic  intoxication  be  present 
or  the  ordinary  general  signs  of  the  presence  of  pus,  then  these  c-ollections  should  be 
opened  and  cleaned  out.  If  hectic  can  be  excluded,  then  other  considerations  will  indicate 
what  is  best.  At  all  events  there  will  be  seen  many  cases  wh(>rc  a  delay  in  o])eration  will 
be  advisable,  in  order  to  permit  of  improvement  of  the  general  condition  by  measures  above 
described.  To  merely  open  U]i  a  tuberculous  focus  and  leave  at  least  two  fresh  raw 
surfaces  exposed  to  contamination  is  rather  to  invite  the  spread  of  the  disease  than  to 
correctly  meet  the  indication.  Every  old  focus  will  be  lined  or  surrounded  with  a  more  or 
less  dense  membrane  formerly  called  pyogenic,  but  now  more  correct  knowledge  shows 
it  to  be  pyophylactic.  (See  p.  113.)  To  leave  this  in  situ  is  to  leave  germ-laden 
walls,  while  to  dissect  it  thoroughly  is  to  make  a  larger,  fresh  raw  surface  and  to 
open  up  innumerable  alisorbent  vessels.  Thus,  whether  it  be  removed  in  whole  or  in 
part,  or  allowed  to  remain,  some  sufficiently  strong  caustic  material  should  be  |)romptly 
employed,  by  which  both  destruction  of  living  residual  germs  and  closure  of  the  mouths 
of  the  absorbents  shall  be  effected.     This  has  been  set  forth  more  fully  when  dealing 

'  The  fundamental  idea  expressed  in  all  of  the  methods  for  enforrinfc  rest  by  trartion  is  of  American  origin,  and 
constitutes  one  of  the  advances  in  surgery  for  which  the  world  is  indebted  to  America.  For  a  long  time  it  was 
referred  to  in  Germany  as  the  American  method,  and  yet  now  the  Germans  claim  so  much  for  it  that  one  of  their 
surgeons  has  written  a  book  of  600  pages  devoted  to  the  employment  of  traction  for  various  surgical  purposes, 
in  which  but  very  little  credit  is  given  to  the  men  who  originated  it. 


400 


SURGICAL   AFFECTIOXS  OF   THE   TISSCFS 


with  cold  ahscvssos  in  orciu-ral,  but  is  of  so  much  ii)i|)ortiiiicc  that  it  may  he  reiterated 
here.  \\  hether  the  actual  cauterv,  pure  carholic  acid,  stroui;  zinc  chloride  solution,  or 
some  other  aiijent  he  used  should  depend  upon  circumstances,  but  everv  portion  of  the 
surface  which  it  is  i)roposed  to  leave  more  or  less  exposed  to  the  possibility  of  infection 
should  be  thus  protected.  In  pro})ortion  to  the  intensity  of  the  caustic  action  there 
will  be  separation  of  more  or  less  cauterized  and  sloufjhinjj  material,  for  whose  escape 
provision  should  be  made;  but  it  will  be  separated  by  the  granulation  process,  aided  l)y 
an  active  jihaf^ocytosis,  and  when  removed  will  leave  a  <;ranulatin<;  surface  which  is  but 
sli<,ditly  al)s()rl)ent.  These  facts  pertain  to  small  incisions  for  drainage  as  well  as  to 
extensive  arthrectomies. 

Thr  operative  freatmeuf,  then,  of  tuberculous  arthritis  varies  from  ta])pin<j,  with  or 
without  drainage,  to  complete  arthrcctomy  or  amputation.  When  the  joints  of  the  foot 
or  ankle  are  extensively  diseased,  and  the  patient,  as  usually  hap])ens,  is  in  poor  condition, 


Calcified  mass  in  ,,1,1  ■■,„1.1  abscess"  about  hip-joint.     (Buffalo  Clinic.     Skiagram  by  Dr.  Plummer.) 


it  niay  appear  that  amputation  will  afford  the  most  complete  relief,  and  that  a  stump 
with  an  artificial  member  will  be  of  much  more  use  to  the  individual  than  a  mutilated, 
tender,  and  disabled  foot. 

To  meision  with  or  without  drainage  is  given  the  name  aiilirofomi/.  When  the  joint 
is  widely  opened  and  portions  removed  with  the  sharj)  s)>oon  or  otherwise,  it  is  known 
as  arthrecUmij.  When  bone  is  removed  irregularly  the  measure  is  called  at//piral  re- 
sechon.  When  entire  bone  ends  are  removed  the' operation  becomes  an  e.r.srrtion  or 
resection.  The  ordinary  arthrcctomy  is  not  sufhcient  when  foci  are  present  in  the 
epiphyses.  Here  at  least  atypical  resection  is  called  for.  Arthrcctomy  mav  jiroperly 
niclude  a  wide  exposure  of  articular  surfaces  and  the  removal  of  the"  thickened  and 
diseased  synovia,  with  its  fringes,  or  with  the  cartilages,  by  which  cancellous 
structure  is  more  or  less  widely  exposed.  When  arthrcctomy  is  undertaken  it 
.should  be  thoroughly  made  and  by  a  large  incision,  since  the  "more  completely  the 
joint  cavity  c-an  be  inspected  and  attacked  the  better  are  the  interests  of  the  patient 
subserved.  All  fresh  or  cold  abscess  cavities  which  connect  with  the  joint  or  lie  in 
contact  with  it  should  also  be  attacked  at  the  same  time,  and  those  which  do  not  com- 
municate with  it  should  be  separately  drained.     While  tlrainage  by  tube  or  other  means 


MOVAIU.E  BODIES  IN   THE  JOISTS  401 

will  usujilly  suffice,  tliiTc  arc  cases  where  the  disease  is  so  exleiisive  that  it  will  pay  to 
|)ack  till"  cavity  with  l)alsain  ^aiize  for  a  few  days,  placing  secondary  sutures  hy  wliich 
the  incision  can  he  closed  after  its  removal.  In  the  shoulder  ami  hip,  for  instance,  such 
u  nietiiod  will  <;ive  satisfactory  results. 

The  advanta<je  of  avoidance  of  resection  is  (he  non-interference  with  the  epiphyses  and 
their  junctions,  thus  permitting  the  growth  of  the  hone  to  continue.  Tlicrrforr  rmnplete 
and  ttfpiral  c.rri.sion.s-  sliouhl  he  pmrti.srd  a.s  .srldoni  as  po.s-.sihlr,  r.s-prnalli/  171  f/roiving 
clii/drni.  They  may  he  practised  to  advantage  even  in  advanced  age,  and  the  writer 
has  seen  satisfactory  results  after  complete  excision  of  tuberculous  joints  in  senile  cases. 
When  operating  upon  a  tuhcrculons  tarsal  joint  the  surgeon  is  likely  to  find  one  or  more 
of  the  tarsal  hones  so  much  involved  in  tiie  tuberculous  disease  that  he  is  compelled  to 
serajx*  it  out  and  thus  leave  a  cavity  almost  the  size  of  the  bone  itself.  Should  he  have 
to  do  this  to  a  series  of  the  bones  it  would  be  better  to  make  a  formal  resection  of  the 
tarsus  or  possibly  an  amj)utation.  The  cavity  should  be  left  open  with  a  sufficiently 
large  incision  so  that  it  may  be  easily  j)acked.  A  cavity  of  this  kind  left  nnf)acked  will 
fill  uj)  with  clot,  which  will  disintegrat<'  and  the  result  will  be  much  less  satisfactory.  In 
the  former  case  there  is  an  open  cavity  which  fills  with  granulations,  l)ut  this  can  be 
kept  accessible  under  observation  and  with  more  effect  and  comfort.  This  is  equally 
true  of  those  cavities  where  both  arthrectomy  and  bone  curettage  have  been  practised. 


MOVABLE   BODIES    IN   THE    JOINTS. 

Several  different  terms  have  been  applied  to  loose  and  movable  bodies,  even  in  the 
various  joints,  depending  on  their  size,  arrangement,  and  appearance.  Thus  we  have 
the  rice-qrain  ot  melon-seed  bodies  {corpora  oryzoidea),  which  have  already  been  described 
and  are  now  supposed  to  indicate  a  form  of  tuberculous  synovitis  which  has  undergone 
a  partial  if  not  complete  subsidence.  Again  we  have  larger  masses  occurring  singly 
or  in  very  small  number,  especially  in  the  knee,  to  which  the  Germans  have  given  the 
significant  name  of  joint  mice.  Also  in  the  knee,  owing  to  its  peculiar  construction, 
another  form  of  movable  body  is  met  with,  i.  e.,  a  displaced  and  more  or  less  motile 
semilunar  cartilage.     This  condition  was  first  described  by  Hey,  and  especially  studied 

Fig.  209 


Floating  bodies — "joint  mice" — from  knee-joint.     (Lexer.) 

by  Allingham,  who  made  it  a  prominent  feature  of  what  he  described  as  "internal 
derangement  of  the  knee."  Lastly,  in  those  joints  in  which  sijnoinal  fringes  occur,  the 
knee  especially,  it  is  held  that  portions  may  become  detached  by  having  been  infiltrated 
and  cast  off  or  broken  loose,  and  thus  form  a  fourth  variety  of  floating  body.  The 
joints  most  often  affected  are  the  knee  and  the  elbow.  In  many  instances  there  is  a 
history  of  injury,  especially  when  the  mass  is  of  considerable  size.  The  theory  of  an 
"osteochondritis  dissecans"  has  also  been  invoked  to  account  for  the  resemblance  between 
some  of  these  bodies  and  the  articular  cartilages.  Some  pathologists  have  held  that 
thev  mav  result  from  the  organization  of  clots,  which  are  subsequently  rounded  off  and 
shaped  by  attritif)n  (Fig.  209).  These  bodies  then  may  consist  of  condensed  fibrinous 
material,  of  cartilage,  of  true  bone,  or  of  hyperplastic  and  fatty  synovial  tassels.  To 
these  may  be  added  rare  instances  of  mucoid  connective  tissue. 

Symptoms. — Rice-grain  bodies  may  be  suspected  in  cases  of  chronic  tuberculosis  and 
often  in  arthritis  deformans,  while  in  many  instances  they  may  be  felt  gliding  beneath  or 
26 


402  SURGICAL   AFFECTIONS  OF   THE   TISSUES 

between  the  joint  structures.  A  perfectly  loose  floating  bodij  will  produce  symptoms 
which  are  quite  distinctive.  They  consist  of  sudden  and  intense  pain,  with  such  muscle 
spasm  as  to  fix  the  joint  and  ])revent  its  use,  thus  "locking  it."  Occurring  at  the  knee 
the  individual  is  instantly  disabled,  but  usually  learns  by  some  peculiar  manipulation, 
with  or  without  assistance,  to  "unlock"  the  joint,  and  after  a  few  moments  to  resume 
its  use.  Such  a  complaint  a.s  this  should  always  suggest  the  condition.  Patients  who 
have  had  it  for  a  long  time  learn  how  to  avoid  it  as  well  a,s  how  to  relieve  it,  and  will 
often  discover  and  be  able  to  indicate  to  the  surgeon  the  existence  of  a  movable  body, 
and  even  to  describe  its  usual  resting  place. 

Partial  or  complete  dislocation  of  a  semilunar  cartilage  in  the  knee  is  usually  the  result 
of  traumatism,  a  distinct  history  of  which  can  generally  be  obtained.  It  may  not  have 
been  discovered  at  the  time,  owing  to  swelling  or  tenderness,  but  will  produce  its  peculiar 
symptoms  later,  i.  c.,  after  use  of  the  joint  is  resumed.  Here,  again,  so  long  as  it  remain 
in  proper  position,  it  interferes  but  little;  with  a  misstep  or  sudden  movement,  however, 
the  patient  is  seized  with  sudden  and  painful  disability.  Here  the  movable  cartilage 
may  be  felt  projecting  near  its  proper  location.  In  such  cases  as  these  it  is  movable 
only  to  a  certain  extent  and  makes  no  free  excursion  about  the  joint.  When  not  detected 
it  may  be  suspected  from  the  description  which  the  patient  gives  of  his  seizures. 

Diagnosis. — So  far  as  diagnosis  is  concerned,  when  a  movable  body  can  be  felt 
all  doubt  is  set  at  rest.  When  it  cannot  be  discovered  its  existence  may  be  inferred  with 
an  accuracy  proportionate  to  the  patient's  description  of  his  difficulties. 

Treatment. — The  treatment  of  rice-grain  bodies  is  essentially  that  of  the  chronic 
hydrarthrosis  and  probably  tuberculous  condition  which  have  led  to  their  formation. 
It  will  consist  usuaHy  in  arthrotomy,  with  thorough  irrigation;  often  in  some  form 
of  arthrectomy.  With  the  larger  floating  bodies,  the  "joint  mice,"  the  most  radical 
measures  are  the  best.  In  most  of  these  instances  there  will  be  some  degree  at  least 
of  hydrarthrosis.  The  joint  cavity  being  distended  and  relaxed,  the  indication  for 
arthrotomy  is  the  more  urgent,  since  it  will  permit  also  of  irrigation  or  of  dry  sponging, 
with  the  same  benefit  with  which  analogous  intraperitoneal  conditions  are  treated  by 
the  same  measures.  The  joint  may  be  opened  by  a  sufficiently  ample  incision,  through 
which  the  foreign  body  or  bodies  may  be  removed.  The  operator  should  not  be  satis- 
fied with  mere  removal  of  one,  but  should  make  a  thorough  search  for  others  which 
may  have  escaped  previous  detection. 

Perhaps  no  operative  measure  in  surgery  better  illustrates  the  advantages  of  asepsis. 
This  operation,  which  now  can  be  flone  with  impunity,  was  in  the  pre-antiseptic  era  one 
which  had  a  discouraging  fatality,  death  resulting  from  septic  infection  in  about  40  per 
cent,  of  cases. 


FOREIGN  BODIES  IN  THE  KNEE-JOINT. 

"Joint  mice"  are  of   sufficient  frequency  and  significance  to  justify  brief  separate 
consideration.     According  to  Connell  these  may  be  grouped  as  follows: 
Those  compo.sed  of  foreign  material,  fatty  tissue,  fibrous  tissue,  etc.; 
Those  composed  of  bone,  cartilage,  or  of  a  mixture  of  the  two. 
Among  the  many  explanations  offered  are  the  following: 

Dry  arthritis,  with  overgrowth  of  the  margins  of  the  cartilages; 
Bony  gro\\'ths,  separation  from  their  attachments; 
Infarct  of  the  articular  cartilage,  with  final  separation; 
Plate  of  bone  formed  outside  of  the  joint  and  then  invaginated; 
Calcification  or  chondrification  of  enlarged  s\aiovial  fringes; 
Irritation  and  growth  of  embryonal  cartilage  or.  bone  cells  in  the  synovial  fringes; 
Concretions  whose  nuclei  are  clots,  torn  fringes,  or  some  foreign  body; 
Some   portion   of  the  articular  cartilages   broken  off  by  injury,  or  damage  and 
subsecjuent  separation. 
Injury  figures  largely  in  the  opinion  of  most  of  the  authorities,  it  being  well  established 
that  an  injured  portion  of  articular  surface  may  become  subsequently  detached  by  a 
fatty  necrosis,  spoken  of  by  Konig  as  osteochondritis  dissecans,  or  by  Paget  as  "quiet 
necrosis."     Others  imagine  that  these  floating  bodies  are  rarely  of  traumatic  o  igin. 
S}Tnptoms  are  usually  marked  and  significant.     There  is  sudden  sharp  and  shooting 


ANKYLOSIS 


403 


pain,  sonictimos  so  severe  as  to  cause  faintness.  Aloiifi;  with  this  there  is  "locking" 
/.  c,  fixation  of  the  joint,  usually  in  the  Hexed  position,  probably  due  to  the  t'ntanglenient 
of  the  floating  body  between  the  articular  surfaces  or  l)etween  the  bone  and  the  capsule. 

It  is  the  smaller  rather  than  the  larger  bodies  which  give  the  most  acute  symj)toms. 
This  "locking"  may  last  for  only  a  few  moments  or  for  a  number  of  hours  and  may 
or  may  not  be  followed  by  acute  efifusion.  When  with  the  above  symptoms  the  presence 
in  the  joint  of  a  movable  mass  can  be  made  out  diagnosis  is  com|)lete.  Some  patients 
discover  the  movable  body  in  their  own  joints  before  they  go  to  the  surgeon. 

When  the  diagnosis  is  established  the  removal  of  the  oil'ending  material  is  imj)erative. 
In  the  j)re-antiseptic  era  this  was  an  extremely  hazardous  operation.  It  is  now  one 
involving  only  theoretical  risks.  These  bodies  are  sometimes  extremely  movable  and 
slip  about  within  the  joint  in  a  manner  to  almost  defy  removal  even  after  the  joint  cavity 
is  open.  If  such  a  body  can  be  felt  and  fixed  by  digital  pressure,  or  by  the  method  of 
"stockading"  suggested  by  Andrews  some  years  ago,  i.  e.,  fixation  by  forcing  sterilized 
pins  into  the  tissues  around  it  so  that  it  cannot  escape,  it  is  then  an  easy  matter  to  cut 
down  upon  it  and  remove  it.  Otherwise  incision  may  require  to  be  sufficiently  ample 
to  permit  insertion  of  a  finger  and  the  general  exploration  of  the  joint  before  it  is  en- 
countered. These  bodies  sometimes  exist  in  small  numbers,  antl  it  may  be  possible  to 
remove  several  through  a  single  opening.  If  the  joint  be  opened  and  explored  it  should 
be  done  thoroughly  in  order  that  nothing  may  escape.  After  removal  the  capsule 
is  clo.sed  with  buried  sutures,  the  balance  of  the  wound  closed  as  usual,  and  the  limb 
then  dressed  upon  a  splint  with  absolute  fixation  for  several  days,  in  order  to  ensure 
physiological  rest   (Fig.  209). 

ANKYLOSIS. 


Fig.  210 


The  term  ankylosis'}  implies  angular  deformity,  but  is  used  to  designate  partial  or  com- 
plete fixation  of  joints,  such  fixation  being  usually  accompanied  by  more  or  less  deformity 
or  displacement.  It  is  a  name  for  a  condition  and  not  for  a 
disease,  but  is  always  produced  by  the  latter  or  by  injury. 
The  term  itself  implies  nothing  as  to  the  nature,  extent,  or  ap- 
pearance of  the  exciting  cause.  The  actual  cause  may  have 
been  disease  of  the  joint,  of  the  tissues  around  it,  or  may 
have  been  the  result  of  injury  rather  than  of  infectious  or 
other  active  disease. 

For  convenience  we  speak  of  jihrous,  false,  or  pseudn-ankij- 
losis,  and  of  that  which  is  bony  or  acfiial.  A  more  accurate 
use  of  terms  would  lead  us  to  refer  to  the  former  as  con- 
tracture rather  than  true  ankylosis. 

Contractures  are  the  result  of  acute,  usually  septic  intra- 
articular and  peri-articular  processes,  where  muscle  spasm 
is  a  ])ronounced  factor  and  where  the  intensity  of  the  pro- 
cess has  more  or  less  weakened  the  joint  structures.  The 
profession  is  hardly  in  the  mood  to  accept  acute  rheumatism 
as  an  infectious  process.  If  true  or  not  the  acute  rheumatic 
affections  are  frequently  followed  by  fibrous  ankylosis  with 
contractures.  Disfigurements  of  this  kind  are  often  produced 
as  the  result  of  the  surface  lesions  of  severe  burns  or  ulcera- 
tions, followed  by  cicatricial  contraction  and  the  formation 
of  dense  bands  and  scar  tissue.  This  is  a  condition  which 
can  always  be  foreseen  and  which  should  be  guarded 
against  with  very  great  care.  (See  Treatment  of  Burns.) 
Contractures  also  occur  as  the  result  of  certain  diseases  of  the 
spinal  cord,  either  as  the  result  of  active  contraction  of  one  set 
of  muscles,  or  of  paralysis,  by  which  the  opposing  muscles 
are  deprived  of  resistance  and  thus  draw  the  limb  out  of 
shape. 

True  ankylosis  is  sometimes  fibrous,  sometimes  osseous,  and  occasionally  both  com- 
bined.    The  older  the  case  the  more  probable  is  actual  osseous  union  of  joint  surfaces. 


Ankylosis  of  hip  witli  con- 
tracture of  knee,  following 
post-scarlatinal  arthritis. 


404 


SURGICAL   AFFECT  loss  OF   THE   TISSUES 


Bony  iinkvlo.si.s  implies  a  .sharj)ly  tlestructivc  type  of  arthritis,  which  may  have  been 
oriirinally  of  jn'ocjenic,  <i;()norrlieal,  or  tuberculous  character,  or  else  indicates  a  series  of 
very  slow  ossific  and  calcific  chano;es,  such  as  are  connected  with  the  osteo-arthritis 
already  described.     Many  of  these  cases  are  to  be  referred  to  lesions  of  the  cord,  and  many 


Fig.  211 


Bony  ankylosis  of  knee.     (Ransohoff.) 


Bony  ankylosis  of  hip  with  deformity.     (Ransohoff.) 


of  them  are  of  polyarticular  character.  Fig.  195,  illustrating  one  of  the  cases  of  so-called 
"ossified  men"  under  the  writer's  observation,  will  jiortray  a  series  of  lesions  of  this 
kind,  most  of  the  vertebral  as  well  as  the  other  joints  being  involved  in  an  absolute  osseous 
union, 


AXKYLOSIS 


405 


When  a  joint  is  stifT  honv  ankylosis  may  ho  inforrcd.  So  lonp;  as  thoro  is  any  motion 
possible  it  is  essentially  ot"  the  (ihrous  type.  The  condition  is  one  easy  of  recognition, 
and  is  seen  in  all  degrees  of  completeness.  In  many  instances  joint  fi.xation  i.s  accom- 
panied by  adhesions  of  tendons  and  tendon  sheaths,  while  as  time  passes  all  the 
structnres  around  a  joint  thus  fixed  become  less  movable  and  more  stiffened.  Even 
the  j)atella  may  become  firmly  attached  to  the  bony  surface  upon  whicii  it  normally 
rests,  and  thus  interfere  with  motion  of  the  knee  almost  as  much  as  though  the  femur 
and  the  tibia  were  alone  involved.  Occasionally  one  of  the  acute  exanthems  is  followed 
by  c()ntra<'(ures  of  a  joint,  with  or  without  actual  joint  lesions,  by  which  when  neglected 
distressing  deformities  are  ])roduced;  such,  for  instance,  as  jmrtial  ilcxion  and  fixation  of 
the  knees,  or  such  stiffening  of  the  hijjs  as  to  |)revent  the  thighs  from  being  separated. 
While  in  such  cases  stiffening  cannot  always  be  prevented,  deformity  at  least  can  be  if 
suitable  measures  instituted  sufficiently  early. 

Figs.  211  and  212,  from  llansohoff",  illustrate  osseous  union  in  the  hi]»  and  the  knee, 
while  Fig.  213  illustrates  the  deformity  which  may  be  j)roduccd  by  contractures  and 
ankylosis  at  the  hip. 

The  following  tabular  presentation  of  the  types  of  ankylosis  will  perhaps  convey  the 
greatest  amount  of  information  in  small  sj)ace: 

f  f  Capsular 

Ti    •      *•     1  r  Tendinous 


Ankylosis, 
true  and  false 


Extracapsular -<  Tendovaginal 
I  (.  Mu.scular 

{Synovial 
Cartilaginous 
Osseous 


Murphy  has  prepared  the  following  table  of  the  types  of  arthritis  which  lead  to  some 
of  these  varieties,  and  which  may  be  classed  as  follows: 


f    {(i)     Primary  hematogenous  fibrous  arthritis 
{!>)     Dry  filirous  arthritis.     Non-traumatic 

(c)     Traumatic  fibrous  arthritis 

r 


/  With  fracture  into  joint 

tw 


Hematogenous 


Arthritis  -I 


((/)     Suppurative    \ 


ie) 
(/) 


r 


'ithout  fracture  (contusion) 
f  Crvptogenetic 
j       ^  f  Typhoid 

Metastatic  ]  Scarlatina 
I  {   f'yemia 

I  [  Gonorrhea 

[^  Traumatic 

f  Tuberculous 


Extension    -! 


Osteitis 


\  Osteomyelitic  (infective) 


Ossifying  arthritis  (primary 
Static  adhesive 


I  Peri-arthritis  (phlegmon) 
L  Panarthritis 


Treatment. — The  best  method  of  treatment  should  be  determined  by  the  original 
character  of  the  exciting  cause,  the  duration  of  the  condition,  the  amount  of  deformity 
present,  and  the  degree  of  joint  fixation.  That  which  will  be  possible  if  done  early  will 
be  useless  if  not  resorted  to  until  the  case  is  old  and  chronic.  In  every  acute  or  subacute 
condition  which  may  threaten  ankylosis  every  possible  precaution  should  be  taken  to 
prevent  it.  If  ankylosis  be  inevitable  it  should  occur  with  the  limb  in  the  most  suitable 
position.  At  the  elbow,  for  example,  this  will  be  the  right-angle  position;  at  the  knee, 
one  with  the  leg  almost  completely  extended.  In  the  lower  extremity  traction  with 
weight  and  pulley  will  serve  a  useful  purpose  in  many  instances,  either  to  overcome  a 
threatening  condition  or  to  improve  one  actually  existant.  INIechanical  measures  (i.  e., 
use  of  various  splints  or  forms  of  orthopedic  aj^paratus)  will  sometimes  be  of  great  use. 
These  may  be  arranged  for  the  purpose  of  providing  absolute  rest,  with  fixation  in  a 
desirable  position  rather  than  in  one  which  is  undesirable,  or  they  may  be  made  with 
such  devices  as  shall  permit  of  frequent  change  of  position. 

The  mildest  operative  measure  which  can  be  practised  in  these  cases  is  manipulation, 
either  gentle  and  frequent,  combined  with  massage,  or  more  violent  and  painful,  such 
as  requires  anesthesia  for  its  performance.  The  cjuestion  of  when  to  resort  to  these 
manipulations  is  one  calling  for  the  soundest  judgment,  as  on  one  side  the  surgeon  faces 
the  possibility  of  setting  up  a  renewed  and  more  or  less  acute  disturbance,  and  on  the 


406  SURGICAL  AFFECTIOXS  OF   THE   TISSUES 

other  of  seeing  a  joint  gradually  stiffen,  perhaps  in  a  bad  position.  There  is  also  a  third 
difficulty,  i.  r.,  the  necessity  for  continuing  motion  in  order  to  j)revent  the  re-formation 
of  adhesions,  and  this  in  spite  of  the  fact  that  it  may  he  intensely  painful  to  the  patient. 
Fortunately,  however,  the  use  of  nitrous  oxide  anesthesia  usually  j)ermits  this  to  be  done 
as  often  as  may  be  necessary  with  a  minimum  of  discomfort. 

Firm,  fibrous  ankylosis  will  be  attacked  with  great  hesitation  by  the  experienced 
surgeon.  Even  though  he  may  succeed  in  restoring  the  limb  to  a  better  position,  he 
may  feel  quite  positive  that  the  patient  cannot  undergo  the  pain  of  the  subsequent 
frequent  handling.  With  bony  ankyloses  he  may  feel  that  nothing  short  of  radical 
measures  will  suffice.  Here  it  is  rarely  a  question  of  restoring  motility  but  rather 
of  overcoming  deformity.  At  the  knee  a  wedge-shaped  portion  of  the  joint  may  be 
removed,  its  angle  corresponding  to  the  angle  of  deformity,  and  thas  a  crooked  leg 
may  be  restored  to  the  straight  position;  in  fact,  with  a  raised  heel  under  such  a  limb 
it  may  l)e  made  almost  as  useful  as  ever.  At  the  hip  one  may  do  a  subcutaneous  oste- 
otomy, dividing  the  femoral  neck  either  with  chisel  or  with  a  small  and  protected  saw,  and 
then  bringing  the  limb  down  into  the  normal  position  of  extension,  allowing  the  bone 
to  repair  itself,  and  effecting  improvement  only  in  position,  or,  by  constantly  moving  it, 
securing  a  false  joint;  or  a  more  formal  exsection  may  be  made  and  by  removing  the 
head  of  the  femur  and  clearing  out  the  acetabulum  a  degree  of  motion  may  be  estab- 
lished at  this  point.  At  the  wrist,  elbow,  and  shoulder-joint  resections  will  usually  give 
good  results  if  the  operation  be  performed  before  the  muscles  have  almost  disappeared 
by  atrophic  processes. 

Danger  attaches  to  the  performance  of  the  so-called  bloodless  operations,  in  that  there 
is  a  possibility  of  laceration  of  nerve  trunks  or  of  large  vessels  which  may  have  become 
fixed  in  the  condensed  tissues  and  be  torn  with  them.  There  is  more  danger  of  this 
perhaps  at  the  knee  than  in  other  joints,  and  ruptures  of  the  popliteal  vessels  and  nerves 
have  been  repeatedly  reported.  The  first  attempt  in  breaking  up  such  a  joint  should 
be  to  increase  the  degree  of  flexion.  If  by  efforts  in  this  direction  the  tissues  can  be 
first  released,  then  there  is  less  danger  of  their  ^^elding  when  extension  is  made.  Another 
danger  which  threatens  in  all  resistant  cases,  and  especially  in  elderly  people,  i?  fracture 
of  bones.  The  writer  has  seen  the  upper  end  of  the  tibia  as  well  as  the  neck  of  the 
humerus  vield  under  these  circumstances.  In  the  latter  event  one  should  endeavor  to 
prevent  bony  union,  and  thus  to  gain  a  false  joint  in  place  of  the  original. 

In  regard  to  the  nature  of  the  operative  attacks  upon  the  above  types,  the  following 
is  copied  from  ^Murphy:' 

(  1.  Tendon  elongation  (tendoplastjO- 

A.     Extracapsular  disease    -,  2.  Tendovaginitis  (exsection  of  sheath). 

(.  3.  Cicatrices  (removal). 

j5      y   ,  ,  f  1.  Adhesive  svnovitis  (exsection  of  capsule). 

li.      intracapsular        •      •    \  2.  Replacement  by  aponeurosis  or  muscle. 

f  1.  Disconnect  bones 

I  2.  Remove  neighboring  bony  processes  or  prom- 

I  inences. 

C.  Osseous      .      .      .      .    -j  3.  Liberate  soft  partr3. 

4.  Prevent  subsequent  bony  contact. 

I    5.  Interpose  tissue  to  form  hygroma  or  fibrous 
I,  surface, 

f    1.  Mandibular. 

D.  Joints    suitable     for    j    |  f^^^^^^^^ 
operation     .      .      .     \    ^    ^j^^^^ 

.5.  Knee. 

1.  Flap   formation  (skin    flap   with   fascia,    or 
muscular). 

2.  Exposure  of  ankylosed  area. 

3.  Osseous  separation. 

E.  Technique       ,      .      .    ^    4.  Transplantation  and  fixation  of  interposition 

flap. 

5.  Replacement  of  bone. 

6.  Fixation  of  parts. 

7.  Drainage. 
1.  Passive  motion 

F.  Subsequent  treatment   \    2.  Active  motion. 

3.  Forced  traction. 

1  Journal  American  Medical  Association,  May  20,  1905,  p.  1573. 


MA./oii'  (>i'i-:iiAr/(>.\s  ()\  JOISTS  407 

To  the  various  expedients  wliieli  may  he  adopteil  for  iiial^iiij^  stiil'eiied  joints  inon? 
nset'ul  may  he  f^iveii,  in  a  p'neral  way,  the  ti'rm  aiilirophi.^-li/.  A  variety  of  mechanical 
contrivances  hav(>  heen  resorted  to  in  the  past,  operators  hopinj;  to  he  ahle  to  secure, 
for  instance,  a  movahle  kne(>  instead  of  one  which  is  stifi'.  Artificial  joints,  made  of 
celluloid,  ivory,  etc.,  have  heen  used  for  experimental  jjurposes,  hut  while  occasionally 
they  have  given  good  results  in  animals,  they  have  rarely  heen  satisfactory  in  man. 
For  the  prevention  of  re-adhesion,  |)lates  of  celluloid,  thin  metal,  gutta-percha,  ruhher, 
etc.,  have  heen  used.  These  are  either  wraj)ped  around  a  hone  end  or  are  used  for  lining 
a  hone  cavity,  and  rai)idiy  accumulating  experience  is  showing  that  this  may  he  done 
with  great  henefit. 

Thoroughness  of  operative  work  is  one  of  the  important  contrihuting  agents  to  the 
securcment  of  wide  range  of  motion,  especially  in  coni|)lete  reuKnal  of  synovial  mem- 
hrane,  capsule,  and  ligaments.  Soft  parts  should  he  liherated  thoroughly.  Of  the 
materials  which  can  he  interposed  hetween  hone  ends  in  order  to  prevent  reunion,  mus- 
cular aponeurosis,  with  a  certain  amount  of  fatty  tissue,  makes  the  best  material  for 
interposition.  When  aponeurosis  cannot  be  secured,  then  muscle  should  be  tried,  with 
some  fat,  as  the  former  flattens  out  and  undergoes  structural  changes,  with  conversion 
into  fibrous  tissue. 

It  should  be  rej)resented  to  the  patient  as  a  legitimate  scientific  experiment,  and  in 
such  a  way  that  no  matter  what  may  happen  no  blame  can  be  attached  to  the  operator. 
In  general  it  may  always  be  stated  that  the  older  the  lesion  the  less  satisfactory  will  be 
any  measure  of  treatment  except  possibly  resection  and  arthroplasty. 


ARTHRODESIS. 

This  term  applies  to  the  intentional  production  of  ankylosis  in  a  joint  previously 
healthy  or  nearly  so,  with  the  intention  of  stiffening  a  useless  limb  and  thus  enhancing 
its  usefulness.  The  measure  applies  mainly  to  those  cases  of  infantile  paralysis,  with 
loss  of  control  of  the  knee  or  ankle,  or  both,  when  by  stiffening  the  limb  it  can  be  made 
to  serve  the  purpose  of  a  crutch.  It  is  the  last  resort  in  this  direction  when  there  is  no 
possibility  for  tendon  grafting.  Long  confinement  of  a  limb  in  a  fixed  dressing  will 
lead  to  considerable  stiffening  of  the  joint,  yet  a  joint  so  immobilized  lacks  that  firm- 
ness of  support  called  for  in  cases  above  mentioned.  Therefore  when  it  is  desired  to 
perform  arthrodesis  the  joint  is  usually  opened  and  more  or  less  of  its  articular  surface 
removed,  the  intent  being  to  produce  the  effect  in  the  shortest  time  and  in  the  best 
way.  It  can  be  better  attained  by  a  removal  of  articular  surfaces  with  the  saw  and  the 
apposition  of  fresh  bone  surfaces  to  each  other,  their  retention  being  ensured  either  by 
sutures  (tendon  or  wire)  or  accurate  fixation  in  plaster  of  Paris.  Under  these  circum- 
stances drainage  should  not  be  necessary,  and  limbs  can  be  completely  enclosed  in  a 
fixed  dressing. 

MAJOR  OPERATIONS  ON  JOINTS. 

Aside  from  arthrotomy  and  partial  or  complete  arthrectomy,  as  above  mentioned,  the 
latter,  including  removal  of  synovia  or  cartilage,  and  perhaps  curetting  of  bone  foci, 
the  formal  resections  or  excisions  of  joints  remain  to  be  considered.  The  latter  is  the 
preferable  term,  as  it  is  meant  to  include  removal  of  the  component  parts  that  enter  into 
the  construction  of  joints,  while  the  term  resection  implies  rather  the  removal  merely 
of  portions  of  bone. 

Joint  excisions  are  practised  especially  for  the  following  purposes :  (a)  To  atone  for  the 
result  of  old  unreduced  dislocations;  (b)  in  certain  compound  dislocations,  with  or  with- 
out fracture ;  (c)  in  certain  comminuted  fractures  where  there  is  no  prospect  of  recovery 
with  useful  joints ;  (d)  in  the  destructive  forms  of  acute  arthritis  where  the  entire  joint 
is  disorganizefl  and  the  bone  ends  carious;  (e)  in  tuberculous  arthritis  or  panarthritis, 
with  or  without  suppurative  com])lications;  (/)  in  occasional  instances  of  disabling 
osteo-arthritis;  (g)  for  relief  of  ankylosis,  either  for  improvement  of  position  (knee) 
or  restoration  of  motion;  (h)  occasionally  after  gunshot  injuries.  Excinom  required 
by  the  exigencies  of  traumatisms  should  be  prompt!  1/  done.  If  the  case  be  complicated 
with  septic  infection  the  prognosis  is  much  less  favorable.     For  convenience  of  descrip- 


408  SURGICAL   AFFECTIONS  OF   THE   TISSI'ES 

tion  excisions  may  be  classified  as  priinarij,  inter  median/,  aiul  .secoiidar//.  According 
to  the  joint  involved,  as  at  the  knee,  the  purpose  underlying  the  operation  is  to  effect 
an  absolutely  rigid  bony  ankylosis. 

The  development  and  perfection  of  the  general  method  of  joint  excisions  is  a  matter 
of  but  little  more  than  a  century.  Previous  to  that  time  amj)utation  was  almost  the  only 
resort  when  destruction  had  occurred.  The  most  j)romiiicnt  surgeons  in  the  early 
development  of  the  measure  were  Park,  of  Jjiverpool,  and  Moreau,  of  France.  During 
the  latter  part  of  the  past  century  Oilier,  of  Lyons,  greatly  imjiroved  the  technique  by 
demonstrating  the  importance  of  the  periosteum  and  by  introducing  the  so-called  .w/> 
pcrio.ifeal  methods.  This  is  of  great  value  in  mtinfeeted  cases.  It  is  a  mistake,  however, 
to  endeavor  to  save  periosteum  which  has  become  involved  in  the  tuberculous  process ; 
in  fact,  in  the  presence  of  tuberculous  disease  we  cannot  be  too  radical  in  the  removal 
of  all  affected  tissue. 

In  the  so-called  subperiosteal  method  the  operator  endeavors,  so  far  as  possil>le,  to 
preserve  the  periosteum  of  the  i)arts  exposed  to  attack,  and,  if  possible,  the  ca})sular 
ligament  as  well.  Thus  at  the  elbow  the  capsule,  //'  not  diseased  or  obliterated,  should 
be  preserved,  the  osseous  tissue  being  shelled  out  from  within,  so  far  as  possible.  The 
less,  then,  the  connections  between  the  capside  and  the  periosteum  are  disturbed  the 
better.  The  French  apply  to  this  method  the  term  "subcapsular  periosteal."  When 
the  bone  covering  can  be  preserved  new  bone  is  easily  formed  to  replace  that  which 
has  been  lost,  especially  during  adolescence,  while  the  preservation  of  the  capsule,  with 
its  ligamentous  connections,  affords  a  better  joint  cavity  than  will  the  substitute  which 
results  from  natural  processes.  Furthermore  the  surrounding  tendons  are  less  disturbed 
and  the  condition  remains  more  like  the  original.  Nevertheless  one  does  not  exsect 
healthy  joints,  and  the  method  is  not  always  easy  nor  even  possible  of  performance. 
It  will  suffice  to  say  that  it  should  be  adhered  to  only  as  far  as  circumstances  may  justify 
or  permit. 

Surgeons,  however,  have  not  been  satisfied  with  the  older  methods,  and  have  en- 
deavored to  still  further  enhance  motility  in  operated  joints.  (See  above — Arthro- 
plasty.) To  this  end  the  interposition  of  muscle,  fascia,  or  of  foreign  membrane  has 
been  suggested.  Thus,  after  removal  of  the  head  of  the  femur  a  strip  of  fascia  lata 
may  be  interposed  between  the  raw-bone  surface  and  the  cavity  of  the  acetabulum, 
being  fastened  there  by  catgut  sutures.  In  the  shoulder  a  similar  procedure  has  been 
carried  out,  utilizing  a  strip  of  deltoid  muscle.  At  the  elbow  a  piece  of  the  pronator 
radii  teres  may  be  detached  and  fixed  by  sutures  to  the  brachialis  anticus.  In  every 
case  the  methofl  should  be  adapted  to  the  demands  made,  the  intent  being  to  cover 
divided  bone  ends  with  tissue  which  will  prevent  osseous  union,  as  it  is  known  to  do  in 
many  cases  of  fracture  where  such  interposition  produces  non-union.  In  so  far  as  one 
attempts  here  to  imitate  conditions  which  are  considered  undesirable  in  certain  other 
traumatisms,  IVIurphy  has  done  more  than  any  other  American  surgeon,  both  in  the 
experimental  and  clinical  study  of  this  subject.      (See  above.) 

For  the  joints  below  the  hip  and  shoulder  the  bloodless  method  will  facilitate  operative 
work.  In  case  of  a  septic  joint,  however,  it  would  not  be  advisable  to  apply  the  elastic 
bandage  below  and  then  over  and  around  the  joint,  as  by  the  pressure  thus  made  some 
septic  material  may  be  forced  into  the  absorl>ents.  In  clean  cases  the  rubber  bandage 
is  a  great  advantage  to  the  operator.  It  has  this  objection,  however,  in  that  hemor- 
rhage which  does  not  occur  during  the  operation  has  to  be  checked  after  its  conclusion, 
and  I  have  often  thought  it  advisable  to  avoid  the  use  of  the  bandage  and  to  secure  vessels 
as  they  are  divided,  in  order  that  when  bleeding  has  once  ceased  there  be  no  fear  of  its 
recurrence  later. 

The  question  of  drainage  is  one  of  importance.  In  a  general  way  one  may  feel  that 
in  an  absolutely  clean  case  drainage  is  not  required,  save  possibly  a  small  opening  for 
escape  of  blood.  If  practised  at  all  it  should  be  thoroughly  done.  Drainage  tubes  are 
often  too  small  and  do  not  permit  the  escape  of  either  clotted  blood  or  debris  of  injured 
tissue. 

The  ajter-treatment  of  excisions  demands,  first  of  all,  phi/siological  rest  of  the  part 
involved,  especially  if,  as  at  the  knee,  sutures  or  other  expedients  for  maintaining  appo- 
sition have  been  inserted.  When  motion  is  sought  there  will  soon  come  a  time  when 
passive  motion  can  be  begun.  This  will  vary  with  the  size  of  the  joint  and  the  magnitude 
of  the  procedure.     Actual  rest  should  be  maintained  until  firm  wound  healing  has  been 


MAJOR  orh'lx'ATlO.ys  ox  JOIXTS  409 

secured.  Passive  motion  is  tlieii  heifiiii,  lo  l)e  praetisi'd  daily,  the  sensation  of  (lie 
patient  heiiifi;  the  guide  as  to  the  ranp-  of  tiie  inoveuieut  and  extent  of  niani))uhition. 
Thus,  after  exseetion  of  an  eihow  with  |)roui|)t  union  of  the  \Vf)und  passive  motion  shouhl 
he  he<:[un  in  ahout  two  weeks,  hut  it  sliouhl  not  he  he<fuu  for  a  month  if  the  joint  has 
been  thorou<:;hI\'  (hsorj^anized  and  the  cavity  is  still  dischar^in<f.  Motion  should  l)e 
begun  as  earlv  as  is  considered  feasible  in  order  to  guard  against  a  false  joint. 

The  remote  eouseiiuetiees  of  joint  e.rcisioii.s'  are  usually  very  satisfactory.  The  l)est 
results  are  obtained  in  the  young,  /.  e.,  those  whose  tissues  are  still  undergoing  natural 
changes  and  whose  bones  are  growing.  In  the  course  of  time,  by  condensation  of  sur- 
rounding tissues,  a  new  joint  capsule  is  formed,  its  interior  smoothed  oli",  apparently 
covered  with  endothelium  and  filled  with  a  sufficient  amount  of  fluid,  similar  to  that  of 
normal  joints,  to  serve  the  j)urpose;  in  this  way  a  new  joint  becomes  gradually  substi- 
tuted for  the  old,  which  serves  the  original  purpose,  in  a  surprising  and  gratifying  way. 
Even  in  those  of  advanced  years  a  satisfactory  result  is  often  obtained.  It  is  often 
necessary  to  alford  some  suj)jx)rt,  by  which  too  great  a  range  of  motion  may  be  avoided; 
thus  at  the  elbow  the  result  at  first  is  what  may  be  called  a  "flail-joint,"  which  permits 
much  undesirable  lateral  movement.  This  can  be  avoided  by  having  light  leather 
corsets  fitted  to  the  forearm  and  arm,  connected  by  two  lateral  hinged  braces.  This 
being  constantly  worn,  and  no  motion  permitted  which  is  not  an  imitation  of  the 
normal,  the  parts  in  time  adapt  themselves  to  the  purpose,  so  that  all  apparatus  can 
after  a  while  be  removed. 

Excisions,  like  amputations,  may  be  practised  and  the  general  methods  learned  on 
the  cadaver,  but  their  actual  performance  in  the  presence  of  extensive  disease  will  be 
found  to  be  a  different  procedure  from  that  learned  uj>on  the  dead  body.  For  reasonably 
representative  cases  typical  operations  can  be  devised,  with  explicit  directions.  It  is  not 
advisable  to  try  to  do  such  work  through  too  short  incisions.  A  long  incision  heals  as 
kindly  as  one  shorter  and  affords  more  room  for  operative  work.  The  incision  should 
be  so  ]ilanned  and  executed  as  to  afford  the  maximum  of  exposure  with  the  minimum 
of  damage  to  important  structures.  The  region  of  the  great  vessels  is  avoided  in  all 
the  classical  operations,  while  nerve  trunks,  if  exposed,  are  retracted  and  kept  out  of 
harm's  way.  After  the  knife  has  once  laid  open  the  joint  it  is  used  but  little  except  for 
the  division  of  resisting  structures,  e.  g.,  ligaments.  The  greater  part  of  the  work  is 
then  done  with  elevator.;,  or  periostomes  with  reasonably  sharp  edges  and  sufficiently 
broad  surface,  so  that  the  periosteum  can  be  divided  with  the  latter  and  separated 
with  the  former  to  the  necessary  extent.  Obviously  epiphyseal  junctions  should  be 
spared  whenever  possible,  especially  in  the  young.  To  remove  an  entire  epiphysis  is  to 
materially  impair  the  later  growth  of  the  limb.  In  some  of  the  most  serious  cases  it 
will  be  found  already  loosened  and  lying  as  a  sequestrum  in  the  joint  cavity.  In  this 
case  it  may  be  easily  lifted  out  of  place.  Tendons  should  never  be  divided  unless  abso- 
lutely necessary.  Incisions  in  their  neighborhood  should  be  so  planned  as  to  be  parallel 
with  their  direction  and  permit  their  displacement  without  division.  The  sharp  spoon 
should  be  employed  for  euretting  the  interior  of  a  joint  capsule  or  cleaning  out  a  bone 
focus  (erasion).  A  capsule  involved  in  tuberculous  disease  should  be  completely  extir- 
pated. Diseased  bone  ends  should  be  sufficiently  exposed  to  permit  of  the  use  of  an  ordi- 
nary saw  or  a  chain  or  wire  saw.^  Considerable  force  will  often  be  necessary  in  making 
bone  ends  accessible  for  this  purpose.  The  chisel  is  rarely  used  except  in  cases  of  bony 
ankylosis,  where  it  is  not  possible  to  force  bone  ends  through  the  opening  in  order  to 
attack  them  with  the  saw.  As  remarked  above,  clean  cases  may  be  closed  without  drain- 
age. Visible  vessels  should  be  secured,  and,  while  a  certain  amount  of  oozing  may  be 
expected,  if  the  part  be  enclosed  in  suitable  compressive  dressings  and  elevated,  it  need 
not  cause  alarm.  The  gentle  application  of  an  elastic  bandage  for  three  or  four  hours 
may  afford  additional  security.  It  should  not,  however,  be  allowed  long  to  remain. 
The  terminal  portion  of  the  limb  will  always  afford  an  indication  as  to  the  condition  of 
the  circulation.  Should  it  become  cyanotic  or  cold  the  dressing  should  be  renewed  and 
the  woimd  examined  promptly. 

Special  Incisions.  The  Shoulder. — A  longitudinal  incision  suffices  for  most  cases 
(Fig.  214).  This  may  be  made  posteriorly  between  the  fibers  of  the  deltoid  or  anteriorly 
and  externally  over  the  bicipital  groove.  It  is  better  to  separate  the  deltoid  fibers  than 
to  divide  them,  although  they  may  be  divided.     Should  the  straight  incision  afford 

1  Wyeth's  "exsector"  is  an  admirable  substitute,  especially  at  the  shoulder  and  hip. 


410 


SURGICAL  AFFECTIONS  OF   THE   TISSUES 


Fig.  214 


insufficient  room  another  incision  at  rif^ht  angles  will  afford  ample  access.  The  capsule, 
having  been  exposed,  is  opened,  the  wound  widely  separated  with  retractors,  the  arm 
rotated  throuo;h  a  wide  arc,  while  with  a  stout  knife  the  capsular  li<i^ament  and  the  various 
muscular  attachments  around  the  neck  of  the  bone  are  divi(l(>d.  The  greater  and  lesser 
tuberosities,  with   their  muscles   undivided,  should   be  retained,  when   circumstances 

permit.  The  head  of  the  bone,  being  freed,  is  dis- 
located and  forced  out  through  the  wound,  where  it 
may  be  seized  with  large  forceps  and  removed  with  a 
saw.  The  higher  the  bone  is  divided  the  better. 
Every  other  consideration,  however,  should  be  sacri- 
ficed to  removal  of  all  foci  of  disease.  The  capsule 
may  then  be  extirpated  and  the  glenoid  cavity  thor- 
oughly cleaned  out  with  a  sharp  spoon.  Should 
the  case  be  one  of  serious  infection  it  is  advisable 
to  make  a  posterior  o|xMiing,  even  through  the  del- 
toid, for  purposes  of  thorough  drainage.  The 
greater  part  of  the  first  incision  is  to  be  closed  with 
sutures,  the  arm  dressed  in  a  comfortable  position, 
with  the  elbow  at  a  right  angle,  and  the  patient 
allowed  to  be  up  and  around  as  soon  as  he  feels  in 
the  mood  for  it. 

The  Elbow. — Here  a  variety  of  methods  have  been 
advised,  and  the  extent  of  the  operation  must  depend, 
to  some  degree  at  least,  on  the  nature  and  extent 
of  the  condition  which  necessitates  it.  Partial  excisions  have  been  recommended,  though 
in  the  writer's  experience  incomplete  operations  often  give  less  satisfaction  than  those 
which  are  complete.  However,  when  it  is  a  question  of  removing  callus  or  displaced 
bone  fragments,  which,  after  fracture  into  the  joint,  impair  its  function,  then  partial 
resections  may  be  serviceable. 


Excision  of  the  shoulder:  A 
sion;  B,  supijlementary. 


,  regular  inci- 
(Ollier.) 


Fig.  215 


Fig.  216 


Fig.  217 


Excision  of  the  elbow- 
joint:  A,  von  Langen- 
beck;  B,  Oilier. 


I      :    \ 

!    !    1 


I  i  i 


Excision  of  the  elbow- 
joint:  A,  N^laton;  B,  C, 
Hueter. 


Osteoplastic  method:  A, 
by  external  incision;  B, 
von  Mosetig-Moorhof. 


The  essential  incision  is  a  long  posterior  one,  which  may  be  somewhat  modified  (Figs. 
215,  216  and  217).  It  is  essential  here  to  avoid  the  ulnar  nerve,  which  passes  between 
the  internal  epicondyle  and  the  olecranon,  and  the  vessels  and  nerves  in  front  of  the 
joint.  If  it  be  made  an  inviolable  rule  to  always  keep  cloxe  io  the  bone  both  of  these  (hmgers 
may  be  avoided.  Ligamentous  and  muscular  structures,  among  the  latter  the  anconeus, 
should  be  spared  as  much  as  possible.  After  separating  the  joint  surfaces  thoroughly, 
by  forced  flexion,  it  is  usually  easier  to  force  out  the  lower  end  of  the  humerus  and  first 
remove  it,  after  which  the  upper  ends  of  the  radius  and  ulna  are  exposed  and  removed. 


MAJOR  OPF.RATIOXS  O.V  JOISTS 


411 


Wlu'ii  tlu'iv  is  hoiiy  ankylosis  it  is  j)r('tVral)lc'  to  divide  tlu'  hones  ot"  tiic  lorearni  first. 
The  tendon  ot"  the  trieejxs  is  not  only  detaehed  from  the  olecranon,  hut  divided  hy  the 
first  loni^r  incision.  After  eoneludinjj  the  incision,  the  cajisule,  if  it  remains,  is  to  he  closed 
with  chromic  catfjut  sutures  and  the  end  of  the  triceps  tendon  or  some  of  its  periosteal 
attachment  united  to  the  |)eriosteuni  of  the  u|)per  end  of  the  ulna. 

The  arm  is  now  fixed  in  the  rii>lit-un(fie  ])osition  and  held  comfortahly  to  the  hody 
l)y  a  siiitahle  slini;. 

The  Wrist. —  It  is  rare  thai  in  disease  of  the  wrist-joint  this  is  found  to  he  hniited  to 
a  sinjile  hone  of  the  car|)us.  Should  an  .r-ray  examination  indicate  such  limitation 
then  the  focus  can  he  exj)osed  and  cleaned  l)y  an  incision  upon  the  dorsum  of  the 
wrist,  where  it  may  seem  hest  adapted  for  the  purpose.  Su])p\irative  and  tuherculous 
afi'ections  of  the  wrist  usually  necessitate  removal  of  the  carj)al  hones,  indudino^,  j)ossibly, 
the  lower  extremities  of  the  ulna  and  radius.  When  the  wrist-joint  is  involved  it  may  be 
sufficient  to  remove  th(>  latter  with  the  first  row  of  the  carpus. 

Fiij.  21 S  illustrates  the  incisions  to  he  recommended  for  wrist  resection,  of  which  the 
Langenbeck  line  is  to  he  ])referred.     Occasionally  two  lateral  incisions,  witli  throujrh 


]'i<i.  218 


Fig.  219 


Excision  of  the  wrist:  A,  Lister's  radial  incision;  B,  Lister's 
ulnar  incision;  C,  Oilier;  0,von  Langenbeck. 


Excision  of  the  hip:  .4,  Sayre;  B,  Oilier. 


drainage,  will  better  serve  the  purpose.  It  may  be  necessary  to  divide  the  short  radial 
extensor,  but  this  may  be  united  again  with  suture.  In  most  instances  it  is  possible  to 
retract  the  tendons  to  either  side  and  thus  clear  the  carpal  region.  By  hyperextension 
the  extensor  tendons  are  relaxed  and  more  room  is  thus  made.  The  incision  marked 
''A"  combined  whh  that  marked  "5"  in  Fig.  218,  affords  the  best  exposure  when  dis- 
ease is  extensive.  The  incision  along  the  inner  border  of  the  wrist  is  made  5  Cm.  above 
the  styloid  process  of  the  ulna,  and  between  the  latter  and  the  ulnar  flexor  down  to  the 
middle  of  the  last  metacarpal  hone.  Here  the  tendon  of  the  latter  muscle  should  be 
divided  at  its  insertion  and  lifted  out  of  its  groove  in  the  ulna.  The  collection  of  extensor 
tendons  is  then  separated  from  the  back  of  the  wrist  and  lifted  up,  it  being  usually 
necessary  to  divide  the  unciform  process  of  the  unciform  bone  with  forceps.  The  knife 
should  be  kept  from  the  palmar  surfaces  of  the  metacarpal  bones  in  order  to  avoid  injury 
to  the  deep  arch.  After  dividing  the  anterior  radiocarpal  ligament  the  carpus  is  extir- 
pated through  the  ulnar  incision.  The  ends  of  the  ulna  and  radius  are  now  easily 
accessible  for  removal  with  forceps  or  a  metacarpal  saw.  The  same  is  also  true  of  the 
proximal  ends  of  the  metacarpals.  After  spreading  the  hand  and  forearm  upon  a  flat 
splint  drainage  can  be  made  to  the  desired  extent  and  the  wound  closed. 


412  SURGICAL  AFFECTIONS  OF  THE  TISSUES 

So  far  as  tlie  Jirnid  and  fiucjers  are  concerned  little  resectinji^  need  he  done,  the  surgeon 
usually  confining  hinist'li"  to  tiie  removal  of  se((uestra  or  curetting  of  carious  l)one.  In 
cases  of  compound  comminuted  fracture  hone  fragments  may  he  removed;  only  in 
cases  of  lost  or  destroyed  phalanges  will  amputation  he  necessary. 

The  Hip. — In  its  structure  the  hij)-joint  is  one  of  the  simplest  in  the  hody.  Although 
it  lies  tlecply  it  is  easily  made  accessihle.  Fig.  219  illustrates  the  incisions  hy  which  the 
joint  is  attacked  for  the  purjwse  of  exsection.  If  necessary  either  extremity  of  the  incision 
can  be  extended  or  enlarged  hy  a  cross-cut.  When  the  joint  is  disintegrated  by  disease, 
especially  when  partially  dislocated,  the  parts  will  lend  themselves  to  an  easy  and  simple 
operation.  When,  however,  the  operation  is  done  for  ankylosis  or  for  disease,  hy  which 
great  thickening  and  fixation  have  heen  jiroduccd,  the  measure  may  become  difficult.  For 
ordinary  ])urposes  the  sim|)lest  m(>thod  is  to  drive  a  sharp-pointed,  strong-hladed  knife 
directly  down  uj)on  the  neck  of  the  lione  from  a  point  midway  between  the  great  tro- 
chanter and  the  crest  of  the  ilium;  then  keeping  the  knife-blade  in  contact  with  the  hone 
the  incision  is  carried  downward  over  the  trochanter  and  along  the  shaft  to  a  length 
making  it  sufficient  for  easy  exposure  of  the  hone  and  of  the  joint.  Nothing  is  gained 
in  these  cases  hy  trying  to  work  through  a  short  incision.  A  long  one  heals  as  readily 
and  makes  the  operation  more  simple.  It  is  as  easy  to  make  the  entire  incision  in  one 
cut  as  to  divide  the  muscles  layer  by  layer.  The  capsule  of  the  neck  of  the  femur  being 
exposed  by  a  wide  retraction  of  wound  margins,  it  is  necessary  next  to  divide  muscular 
attachments  to  the  great  trochanter  by  raising  the  periosteum  to  which  they  are  attached 
and  saving  both.  To  expose  these  insertions  the  femur  should  he  rotated  inward  and 
outward,  while  the  cai«ule  is  at  the  same  time  divided.  The  ligamentum  teres,  which 
offers  a  theoretical  obstacle,  usually  disappears  in  the  presence  of  any  active  disease  and 
is  scarcely  ever  encounteretl;  it  can  he  divided  with  curved  scissors.  Now  by  more  or 
less  powerful  effort,  including  flexion  and  atlduction  to  the  extreme  limit,  with  more  or 
less  rotation,  the  head  of  the  bone  is  forced  out  from  its  socket  and  through  the  wound. 
Whether  the  bone  should  he  decapitated  with  chain  saw,  metacarpal  saw,  or  by  the  ex- 
sector  of  Wyeth  will  dejiend  partly  upon  the  freedom  with  which  it  can  be  exposed  and 
on  the  equipment  of  the  operator.  It  may  be  advisable  to  divide  the  neck  with  a  chisel. 
The  trochanter  major  should  be  preserved  whenever  its  removal  is  not  made  imperative 
hy  the  progress  of  the  disease.  The  head  and  neck  of  the  bone  having  heen  removed, 
the  acetahulimi  is  now  more  or  less  easily  exposed,  especially  with  retractors,  and  it 
should  l)e  cleaned  with  a  sharp  spoon.  The  capsule  also  should  be  removed,  at  least 
when  the  operation  is  done  for  tuberculous  or  other  infectious  condition.  It  is  advisable 
to  irrigate,  then  to  wipe  dry  all  the  original  joint  surfaces  and  raw  hone,  and  finally  to 
cauterize  either  with  pure  carbolic  or  with  zinc  chloride,  which  should  be  washed  away 
with  the  irrigating  stream,  the  intent  being  to  close  the  mouths  of  all  the  absorbents  and 
prevent  absorption  from  fresh  exposure.  Sinuses  if  present  should  be  thoroughly 
excised,  scraped,  and  treated  in  the  same  way.  A  drainage  tube  is  usually  preferable 
to  the  use  of  gauze. 

The  above  is  the  method  usually  relied  upon  for  hip  exsection.  Other  methods  have 
been  devised,  especially  l^y  anterior  incision;  of  these  the  best  j^robably  is  that  of  Barker. 
The  cut  is  made  along  the  outer  border  of  the  anterior  surface  of  the  sartorius  and 
rectus,  and  through  it  the  femoral  neck  is  reached.  By  wide  retraction  the  anterior 
surface  of  the  joint  can  he  completely  exposed  and  o]:)ened,  and  through  this  opening 
the  neck  of  the  femur  can  be  divided  with  a  chain  saw  or  chisel,  before  removal  of  the 
head  from  th(>  acetabulum.  The  disadvantage  of  anterior  incision  is  that  pertaining  to 
drainage.  Nevertheless  this  can  be  obviated  with  cajiillary  drains.  Its  advantages  are 
that  splinting  and  protection  can  be  more  perfectly  effected,  with  less  necessity  for 
frequent  interference.  In  other  words  it  makes  the  subsequent  care  of  the  patient  easier. 
Many  English  surgeons  are  in  favor  of  it.  ( )llier  devised  a  so-called  osteoplastic  excision, 
made  through  a  curved  incision  with  a  downward  convexity,  the  top  of  the  great  trochanter 
being  exposed  and  divided  with  a  chisel  sufficiently  to  permit  of  its  being  turned  up  with 
the  flap,  and  then  being  reunited  to  the  main  part  of  the  hone  after  the  removal  of  the 
neck  and  head.  This  method  has  its  advantages  in  a  limited  number  of  cases,  hut  it 
has  not  become  popular  in  this  country.  It  would  seem  to  be  an  advantage  to  preserve 
the  trochanter,  although  some  surgeons  remove  it.  So  long,  however,  as  disease  is 
confined  to  the  head  and  neck  of  the  bone  it  is  unnecessary  to  remove  this  projection. 

The  after-care  of  a  hip  excision  is  not  an  easy  matter.     Most  surgeons  prefer  to  main- 


MA.fO/i'  OI'I'.RATIOSS  ()\   JOISTS 


\\:\ 


Fig.  220 


tain  tlir  liiiih  in  position  by  the  aid  of  traction,  witli  sufficient  \vci;;lit  U)  overcome  all 
niusek'  .sj)a.sni.  If  the  case  be  such  that  (Iressiiif^s  need  only  be  made  at  lonj;  intervals, 
then  it  matters  little,  but  in  a  septic  case  in  which  there  is  considerable  discharjife  the 
|)roblem  is  sometimes  a  serious  one.  Various  beds  or  suspension  splints  have  been 
devised,  consisting;  essentially  of  frames  with  cross-strips  of  stout  material,  iij)on  which 
the  patient  lies.  After  raisiiij;  the  frame  one  or  two  of  these  strips  are  relca-sed  and  tiie 
parts  exposed.  This  arran<;emi'nt  also  jx-rmits  of  the  easy  mana<;ement  of  a  bed-})an. 
In  yountj  children  a  wire  splint  with  a  fenestrum,  or  a  plaster-of-Paris  spica  or  breecjies 
with  larije  optMiinj;  cut  opposite  the  womid,  will  often  l)e  serviceal)le.  The  tendencv 
is  ratlier  toward  adduction,  and  this  should  be  overc(jnie.  Sometliin<;  will  depend  uijon 
whether  the  suro;eon  is  working  for  ankylosis  or  for  a  movable  joint.  In  the  former 
case  a  rijjid  dressing  should  be  employed  as  soon  as  the  condition  of  the  wound  permits. 
In  the  latter  passive  movement  should  be  begun  as  soon  as  the  wound  is  healed. 

While  the  operation  is  usually  performed  (juickly,  and  is  not  regarded  as  serious,  it 
nevertheless  has  a  considerable  mortality,  especially  in  the  young  and  the  aged,  because 
of  the  conditions  which  necessitate  it.  After  a  complete  ex.section,  even  by  the  most 
ideal  method  and  in  the  most  ideal  case,  the  limb  remains  somewhat  shortened.  This 
may  be  com|)ensated  by  raising  the  heel  of  the  shoe  worn  on  the  affected  side.  In  severe 
cases  it  may  be  necessary  to  supj)ly  even  two  or  three  inches  of  artificial  support  for  tliis 
j)urpose.     Unless  this  Ls  done  compensatory  spinal  curvature  will  ensue. 

The  Knee. — The  knee  is  generally  more  accessible  for  operation  than  the  elbow,  as 
the  important  structures  which  should  not  be  disturbed  lie  grouped  upon  its  posterior 
aspect.  Protection  for  one  of  these  is  protection  for  all,  and 
the  freedom  with  which  the  joint  may  be  opened  makes  it 
especially  easy  to  do  either  complete  or  partial  ojx'ration.  Here 
the  surgeon  should  endeavor  to  preserve  the  epiphyses,  especially 
in  children,  as  they  have  much  to  do  with  the  growth  and  length 
of  the  limb.  So  long  as  incision  is  confined  to  the  anterior 
aspect  of  the  joint  it  can  be  made  in  almost  any  manner.  The 
usual  method  is  that  represented  by  line  A  in  Fig.  220,  by 
which  a  horseshoe  flap  is  raised  and  the  joint  interior  exposed. 
Occasionally  the  direction  of  the  flap  is  reversed,  and  it  is  turned 
downward  rather  than  upward.  In  the  former  case  the  liga- 
mentura  patellae  is  divided;  in  the  latter,  the  tendo  patcllse. 
Whichever  way  the  flap  is  turned  it  is  made  to  include  the 
])atella,  although  this  bone  can  be  removed  at  any  time.  The 
lateral  ligaments  being  divided,  as  well  as  the  crucial,  and  the 
limb  completely  flexed,  exposure  of  the  joint  surfaces  is  made. 
It  is  now  possible  to  do  an  arthrectomy,  a  partial  exsection  or 
a  complete  one,  according  as  the  disease  is  more  or  less  exten- 
sive. In  the  complete  operation  the  articular  surfaces  of  the 
femur  and  of  the  tibia  are  usually  removed  with  an  amputating 
saw.  If  this  be  introduced  from  the  front  and  made  to  work 
its  way  backward  the  popliteal  vessels  should  be  amply  protected 
against  possible  injury.  Here  it  should  be  borne  in  mind  that  the  leg  is  not  constructed 
in  a  straight  line,  but  that  there  is  a  lateral  angle  at  the  knee,  as  the  femurs  diverge  as  they 
pass  upward,  and  this  angle  should  be  imitated  in  directing  the  saw  and  removing  the  bone 
end.  Again,  a  slight  bend  anteriorly  will  make  the  limb  more  useful  than  one  which 
is  absolutely  straight.  The  intent  thus  should  be  to  give  the  knee  at  a  slight  angle  ante- 
riorly and  interiorly,  and  the  saw  should  be  manipulated  with  great  care.  In  a  complete 
operation  the  patella  is  also  removed.  In  tuberculous  and  other  septic  disease  the 
capsule  should  be  completely  extirpated.  This  offers  no  difficulty,  save  at  the  posterior 
surface,  where  it  may  approach  closely  to  the  region  of  the  great  vessels. 

Various  modifications  have  been  practised  in  these  operations.  Some  open  the  joint 
by  straight  cross-incision  whh  division  of  the  patella,  the  latter  being  reunited  with  tendon 
or  wire  sutures.  Others  have  practised  a  more  complicated  H-shaped  incision,  the 
transverse  portion  being  carried  either  through  the  patella  or  just  below  it.  The  line 
marked  B  in  Fig.  220  was  suggested  by  Oilier.  It  is  questionable  whether  any  of  these 
methods  offer  any  advantages  over  the  one  first  described. 

After  exsection  it  is  desirable  to  maintain  the  bone  ends  in  an  accurate  position  if 


Excision  of  the  knee- 
joint:  .4,  semiluijar  inci- 
sion; B,  Ollier'.s  incision. 


414  SURGICAL   AFFECTIONS  OF   THE   TISSUES 

speedy  reunion  be  desired,  and  for  this  purpose  various  methods  are  in  vogue.  The  bones 
may  be  drilled  and  fastened  together  with  tendon  or  wire  sutures,  or  ivory  nails  may  be 
driven  in,  one  on  each  side,  directing  them  ol)liquely,  so  that  displacement  cannot  easily 
occur,  or  metal  nails  may  be  used  for  the  same  purpose.  Another  plan  is  to  insert  two 
long  metal  drills,  one  on  either  side,  which  perforate  the  skin  two  or  three  inches  above 
the  wound,  and  are  passed  downward  and  toward  the  other  side  so  as  to  fix  the  surfaces, 
as  it  were,  by  a  cross-forked  arrangement.  After  two  or  three  weeks  these  drills  may  be 
withdrawn.  Fixation  of  this  kind  is  advantageous,  for  when  complete  excision  has 
been  practised  the  surrounding  tissues  are  lax  and  the  parts  are  not  easily  held  in 
position  by  external  dressings  alone.  In  a  clean  case,  with  careful  hemostasis,  very 
little  drainage  will  be  required.  What  is  needed  can  be  provided  by  an  absorbable 
drain  passed  through  the  lower  portion  of  the  wound  on  either  side.  In  a  septic  case 
it  would  be  well  to  provide  for  ample  drainage  on  each  side. 

The  limb  may  be  dressed  upon  a  fenestrated  wire  or  gauze  splint,  which  is  easier 
when  frequent  change  of  dressing  can  be  foreseen,  or  it  may  be  immobilized  in  a 
plaster-of-Paris  splint. 

The  Ankle.^ — The  ankle  is  usually  reached  by  an  incision  on  either  side,  three  or  four 
inches  in  length,  extending  from  above  each  malleolus  downward  and  forward  on  to 
the  tarsus.  The  knife-blade  should  be  forced  to  the  bone,  so  as  to  divide  the  periosteum, 
which  is  subsequently  separated  and  lifted  by  an  elevator,  in  order  that  the  operation 
may  be  made  subperiosteally.  The  fibula  is  usually  first  divided,  with  a  chain  saw  or 
a  chisel,  an  inch  above  its  tip.  The  divided  fragment  is  wrenched  from  its  place  with 
forceps,  and  severed  from  the  ligaments  by  knife  or  scissors,  being  careful  not  to  injure 
the  external  lateral  ligament.  The  inner  incision  is  made  in  practically  the  same  way, 
the  periosteum  separated,  the  internal  lateral  ligament  divided,  and  the  end  of  the  tibia 
forced  through  the  incision  by  everting  the  foot.  Its  joint  end  may  be  removed  with  a 
saw,  dividing  on  the  same  level  and  plane  with  the  lower  end  of  the  fibula.  Through  the 
gap  thus  made  the  astragalus  may  be  either  removed  or  its  upper  surface  divided  with 
a  metacarpal  saw.  The  fresh  bone  surfaces  left  in  this  way  will  unite  and  ankylosis 
will  result,  unless  fibrous  or  muscular  tissue  be  interposed  to  favor  the  formation  of  a 
false  joint. 

As  in  other  operations  methods  may  be  varied  to  meet  the  exigencies  of  certain  cases. 
Longitudinal  incisions  may  be  placed  farther  forward  than  indicated  above,  as  is  shown 
in  Fig.  221,  which  illustrated  Konig's  method.  Here  the  bone  surfaces  are  divided 
with  broad  chisels.  A  transverse  incision  of  the  front  and  upper  part  of  the  ankle  may 
be  made,  through  which  the  tendons  are  exposed,  lifted  in  a  group  out  of  harm's  way,  and 
curetting  and  bone  sawing  performed.  Kocher  makes  a  semilunar  incision  from  the 
outer  border  of  the  tendo  Achillis  to  the  outer  border  of  the  extensor  tendons,  its  line 
passing  beneath  the  external  malleolus.  By  this  method  the  joint  is  opened  and  the 
peroneal  tendons  divided,  their  ends  being  reunited  after  the  completion  of  the  balance 
of  the  work.     This  method  is  usually  applicable  in  children. 

Am])le  drainage  is  recjuired  in  these  cases,  for  the  operation  is  seldom  performed  in 
the  absence  of  septic  complications.  The  foot  should  be  kej)t  in  proper  and  right- 
angled  position  by  metallic  splints,  or  by  plaster  of  Paris,  the  latter  preferable,  fenestra 
being  cut  in  order  to  make  access  to  the  wound. 

Excisions  of  the  Tarsus  and  Osteoplastic  Excision  of  the  Heel. — Removal  of  the  tarsal 
bones  is  confined  usually  to  cases  of  tuberculous  disease,  and  may  be  performed  by  a 
variety  of  methods.  Thus  the  tissues  of  the  sole  of  the  foot  may  be  divided  transversely 
by  an  incision  carried  from  the  tubercle  of  the  scaphoid  beneath  the  sole  and  across 
to  a  point  one  inch  behind  the  base  of  the  metatarsal.  Through  this,  access  can  be 
made  to  the  inferior  surface  of  the  tarsus.  Conversely  the  upper  portion  may  be  exposed 
by  a  similar  transverse  incision  across  the  dorsum  of  the  foot,  by  lateral  incisions,  or  by 
a  combination  of  both.  It  is  seldom  necessary  to  divide  the  tendons,  it  being  nearly 
always  possible  to  gather  them  into  a  group  and  lift  them  out,  while  the  bones  are 
attacked  with  a  sharp  spoon  or  a  chisel. 

Occasionally  the  calcis  becomes  involved  in  cancerous  or  tul)erculous  disease  and  it 
would  appear  that  removal  of  the  heel  proper  would  be  all  that  is  required.  To  meet 
these  indications  Wladimirov,  in  1871,  and  Mikulicz,  in  1880,  independently  devised 
a  method  by  which  the  ankle-joint  may  be  opened  and  as  much  of  the  heel  and  adjoining 
tarsus  as  necessary  removed,  the  foot  being  later  fixed  in  the  extreme  equinus  position. 


MAJOR  oriHi'ATloXS  (>.\   JOISTS 


415 


Fig.  221 


This  is  rct'crriMl  to  as  o.tfro plastic  r.rri.s-ion  or  atiipiitdtiou  of  the  heel.  Fig.  222  il 
tlu'  line  of  iiH'ision,  which  e.xtonds  from  the  tubercle  of  the  scaphoid  beneath 
to  a  j)oint  on  the  opposite  side, 
then  obliquely  upward  and  back- 
ward to  the  base  of  each  malleolus, 
and  then  transversely  and  pos- 
teriorly, thus  including  within  its 
line  the  region  of  the  heel.  These 
incisions  extend  to  the  bone,  the 
ankle-joint  is  opened  posteriorly, 
the  lateral  ligaments  divided,  the 
lower  extremities  of  the  tibia  and 
fibula  removed  with  a  saw,  the  as- 
tragalus and  calcis  separated  from 
their  attachments,  anil  the  jK)sterior 
articular  surfaces  of  the  scaphoid 
and  cul)oid  also  removed.  The 
lines  of  division  of  bone  are  indi- 
cated by  dotted  lines  in  Fig.  222. 
Thus  the  lower  ends  of  the  leg 
bones  are  brought  into  contact 
with  the  upper  end  of  the  divided 
tarsus  by  straightening  the  foot 
in  the  extreme  equinus  position 
and  maintaining  this  position  with 

wire  sutures  or  bone  or  metal  pins.  Konig's  incision  for  excision  of  the  ankle. 


lust rates 
the  heel 


Fig.  222 


Osteoplastic  excision  of  the  foot.    (Mikulicz.) 


_  The  cases  in  which  this  method  is  of  use  are  rare,  but  when  indicated  it  has  usually 
given  satisfactory  results.  It  is  a  substitute  for  amputation  of  the  leg,  and  it  is  often 
an  open  question  as  to  which  will  give  the  most  satisfactory  result.  It  has  probably 
not  been  practised  a  hundred  times. 


CHAPTER    XXXII. 

SURGICAL  DISEASES  OF  THE  OSSEOUS  SYSTEM. 

At  the  outset  of  a  study  of  surgical  diseases  of  the  osseous  system  it  is  necessary 
to  enijjhasizc  a  fact  which  students  anfl  young  practitioners  are  liable  to  forget, 
namely,  that  bone,  even  the  densest,  is  a  tissue,  and  that  as  such  it  is  liable  to  infection, 
supjjuration,  gangrene,  etc.,  just  as  is  any  other  tissue;  that  all  infectitms  processes  are 
identical  in  general  character,  their  gross  manifestations  varying  only  by  virtue  of  the 
peculiar  characteristics  of  the  tissue  in  which  the  infection  occurs.  Bone  is  vascular, 
and  even  that  exceedingly  hard  variety,  which  is  met  with  in  the  petrous  portion  of  the 
temporal,  or  the  ivory  exostosis,  has  sufficient  connection  with  the  vascular  system  to 
permit  of  its  proper  nutrition.  The  firmest  and  hardest  bone  will  bleed  when  divided 
or  injured,  and  any  tissue  which  will  thus  bleed  can  react  injuriously  to  various  irritants. 

All  bone-marrow  begins  as  red  marrow,  with  1  or  2  per  cent,  of  fat,  and  ends  l)y 
becoming  yellow,  with  00  or  70  per  cent,  of  fat,  and  whether  this  change  shall  take  place 
suddenly  or  rapidly  depends  upo.i  diverse  conditions.  Many  years  ago  it  was  claimed 
by  Bourgery  that  bone  is  simply  a  large  cavernous  arrangement  where  stagnation  of 
the  blood  current  favors  the  deposition  of  fat.  Fatty  alteration  progresses  from  per- 
iphery to  centre,  and  the  bones  of  the  hands  and  feet  undergo  fatty  alterations  before 
those  of  the  trunk  and  pelvis.  In  other  words,  the  truncal  skeleton  remains  as  "red 
bone"  longer  than  the  balance  of  the  osseous  system,  and  he  whose  sternum  has  become 
a  "yellow  bone"  should  have  reached  a  ripe  old  age.  In  long  bones  distal  extremities 
first  become  fatty.  Individual  peculiarities  seem  to  govern  these  changes.  Thus  the 
neck  of  the  femur  will  sometimes  be  fatty  and  frialjle  at  the  fortieth  year,  or  reasonably 
firm  and  still  red  at  the  eightieth.  This  fatty  condition  is  not  to  be  confounded  with 
true  osteoporosis  or  rarefaction  in  bone,  th(nigh  it  is  often  associated  with  it.  When 
the  two  c(jn(litions  are  combined  we  have  o-sfcoporosis  adiposa.  Into  this  condition 
immobilized  limbs  pass  more  easily  than  those  which  are  used.  Their  weeks  have 
been  equal  to  years  of  ordinary  inactivity.  Red  bone  seems  to  be  too  highly  vascular 
to  be  a  favorite  site  for  tubercle,  and  distinctly  yellow  bone  too  non-vascular.  Conse- 
quently bone  tuberculosis  is  less  often  seen  at  the  extremes  of  life.  White  bone,  as 
those  who  make  anatomical  preparations  call  it,  is  most  favorable  for  tuberculous 
infection  on  account  of  its  minimum  contents  of  blood  and  fat.  These  bones  come 
from  phthisical  subjects. 


ACUTE  OSTEOMYELITIS. 

This  condition  was  never  accurately  recognized  until  described  by  Chassaignac,  in 
1853,  and  even  he  missed  many  of  its  distinctive  features,  although  he  gave  to  it  a  most 
descri|)tive  name,  "typhus  of  the  limbs." 

Pathology. — The  disease  is  a  distinctly  infectious    process,    limited   sometimes    to 
the  bone-marrow  and  internal   |)ortion  of    the  l)one,  sometimes  a[)parently  involving 
every  particle  of  the  osseous  structure.     Its  onset  is  sudden,  its  manifestations  acute  and 
serious,  and  its  ravages,  when  n«)t  promptly  checked,  most  extensive.     The  following 
more  or  less  distinct  varieties  may  be  distinguished; 
The  staphylococcus ; 
The  streptococcus ; 
The  pneumococcus; 
The  tuberculous; 

Miscellaneous  infections,  including  the  colon  bacillus,  the  typhoid  bacillus,  etc. 
It  is  known  that   the  virulence  of  cocci  growing  under  pressure  is  thereby  much 
enhanced;  hence  the  extreme  rapidity  of  some  of  these  disease  processes  may  be  thereby 
better  explained. 
(416) 


PLATE  XXXV 


V     L 


i 


^£ 


i\ 


■.M^ 


Acute  Osteomyelitis,  showing  Purulent  Foci  and  Accompanying  Disturbances. 

(Kocher.) 


Acrri-:  osteomyki.itis  417 

The  iiicclianisiii  ot'  tlir  iiitVction  and  tlu-  lesions  produced  hy  tlie  orj^anisin  are  essen- 
tially similar,  and  may  he  (leseril)ed  tojjether.  These  consist  of  rapid  i/iroinhofdt, 
coagulation  ^rrro.v/.v,  and  .suppuration,  along  with  the  local  destruction  incident  liiereto, 
and  with  unliniiteil  j)()ssil)ilities  in  the  way  of  auto-intoxication  from  the  local  lesions 
and  from  the  disturbance  of  ihe  general  economy  and  interference  with  excretion. 
Every  severe  case  is  accomj)anied  hy  inoie  or  less  of  general  septic  intoxication,  j>re- 
sumahly  from  the  j)tomains  produced  hy  the  l)acteria,  while  in  many  instances,  particu- 
larly those  where  the  l)acteria  at  fault  seem  extremely  viru- 
lent, the  iiUoxicatiou  is  overwhelming  and  the  course  a 
rapidly  fatal  one.  Deatii  has  been  known  to  follow  within 
thirty-six  hours  after  the  first  symptom  of  an  acute  osteo- 
myelitis. For  the  average  case  three  more  or  less  distinct 
stages  can  usually  be  distinguished:  first,  a  period  of 
purulent  infiltration,  with  the  formation  of  local  foci  in  the         „    .•,.,.•       r  u 

r  '  ,  ,  1-1  p      ^  Typhoid  infection  of  bone; 

bone-marrow    and    speedy    secondary   involvement   or    the  focus  in  rib.    (Lexer.) 

j)eriosteum   and    synovial    membrane;   second,  a    [)eriod    of 

sequestration  or  formation  of  a  sequestratrum  inside  of  an  abscess  cavity;  third,  the  stacjc 
of  repair. 

First  Stage* — During  this  period  there  occurs  violent  inflammatory  infiltration,  localized 
areas  becoming  at  first  hyperemic,  then  infiltrated  with  hemorrhagic  exudate,  whose 
rapidity  of  j)roduction  will  indicate  the  intensity  of  the  infection.  Often  at  the  same  time 
are  found  enlargement  of  the  spleen  and  hemorrhagic  exudations  in  distant  serous  cavities, 
such  as  the  pleura  and  pericardium.  The  locally  infected  areas  of  bone-marrow  break 
down  into  collections  of  pus,  which  spread  either  toward  the  epiphyseal  line  or  else 
along  the  Haversian  canals  toward  the  periosteum,  which  becomes  both  infiltrated  and 
loosened.  The  loosening  is  particularly  marked  al)out  the  shafts  rather  than  the  joint 
ends,  while,  as  a  rule,  that  end  of  the  bone  toward  which  the  nutrient  artery  is  directed 
is  the  one  whose  epiphyses  are  first  loosened.  Nevertheless  about  the  knee  it  would  seem 
as  though  the  lower  end  of  the  femur  and  upper  end  of  the  tibia  are  the  particularly 
predisposed  localities. 

In  many  instances  obliteration  of  nutrient  vessels  and  thrombosis  are  early  features. 
The  area  of  separation  of  the  periosteum  is  usually  an  index  of  the  extent  of  deep 
destruction.  From  the  periosteum  the  infection  may  extend  toward  the  covering  of  the 
soft  parts,  in  which  case  there  may  be  a  parosteal  abscess,  or  it  may  perforate  toward 
the  joint  cavity,  leading  quickly  to  pyarthrosis  and  destruction  of  joint  structures.  It 
would  appear  in  children,  particularly,  that  the  epiphyseal  cartilage  often  forms  a 
barrier  to  the  advancement  of  the  lesion  in  the  direction  of  the  joint,  and  thus  it  happens 
that  we  have  acute  necrosis  of  the  shaft  of  a  long  bone,  with  perforation  through  the 
periosteum  at  both  of  its  ends.  In  adults  this  takes  place  less  often,  the  joint  ends  being 
often  primarily  involved.  Softening  and  separation  of  cartilages  are  usually  secondary 
to  the  other  processes.  It  is  possible  even  to  have  the  primary  infection  in  the  joint  end 
pro])er,  and  extension  therefrom  to  the  e])iphyses  permitting  of  epiphyseal  separation 
and  extrusion  of  this  fragment  as  a  sequestrum.  This  separation  occurs  in  many 
instances  rapidlv  and  before  the  attendant  is  aware  of  what  has  happened. 

Second  Sta^e. — The  second  stage  includes,  coincidently  with  the  occurrence  of  suppura- 
tion, the  proliferation  of  considerable  granulation  tissue,  by  which  more  or  less  protection 
is  afforded;  also,  when  time  is  afforded,  the  rapid  formation  of  new  bone,  whose  effect 
is  to  wall  off  the  scene  of  conflict  and  death  from  the  surrounding  tissue,  by  which  event 
prognosis,  so  far  as  the  patient's  life  is  concerned,  is  improved.  Intra-osseous  abscesses 
may  quickly  coalesce,  and  the  result  may  be  one  long  tubular  abscess  extending  through 
the  shaft.  At  other  times  both  bone-marrow  and  the  cancellous  tissue  are  bathed  in  pus, 
while  if  the  periosteum  have  been  totally  separated  the  consequence  will  be  a  sequestrum 
whose  dimensions  correspond  with  those  of  the  shaft.  When  periosteum  is  not  loosened 
the  necrosis  will  probablv  be  central  and  more  or  less  circumscribed.  (See  Plate 
XXXV.) 

Third  Stage. — The  third  stage  is  the  period  of  efforts  at  spontaneous  repair.  There 
is  a  natural  effort  toward  elimination  of  the  sequestrum  by  the  process  of  softening  or 
liquefaction  in  the  direction  of  least  resistance.  This  process  may  extend  over  months, 
when  surgical  relief  has  been  delayed,  and  may  be  accompanied  by  so  much  other  dis- 
turbance as  to  completely  ruin  a  bone  or  limb  for  further  use.  In  neglected  cases  several 
27 


418 


SURdlCAL   AFFECTIONS  OF   THE   TISSUES 


Fig.  224 


sinuses  may  lead  down  toward  the  central  seciuestriini.  On  the  other  hand,  once  this 
sequestrum  of  eliminated  an  extraordinary  amount  of  activity  is  usually  displayed  in 
the  dircctidii  of  repair  (Fijj.  224). 

Symptoms.  In  a  general  way  the  signs  and  symptoms  of  acute  infectious  lesions 
in  bone  are  strikingly  similar,  and  are  significant  when  construed  aright.  Patients 
complain  usually  first  of  r.rhausfion,  followed  by  pain,  which  may  become  agonizing. 
This  is  often  accompanied  by  an  introductory  chill  with  high  fever,  after  which  the 
general  character  of  the  disease  assumes  the  typhoid  asix-ct.  Evening  temperature 
may  rise  high  and  be  followed  by  some  morning  remission.     The  spleen  is  usually 

enlarged,  the  primse  via-  disturbed,  and 
often  we  have  to  do  with  a  fetid  diarrhea. 
In  the  young  the  sensorium  is  early  affected 
and  children  soon  become  delirious.  The 
pain,  at  first  vague,  quic-kly  focuses  in  the 
particular  bone  or  bones  most  involved,  and 
as  it  increases  in  intensity  there  is  a  signifi- 
cant tenderness.  Ordinarily  there  appear 
early  reddening  and  swelling  of  the  affected 
parts.  With  all  these  evidences  there  is 
also  a  characteristic  muscle  spasm,  by  which 
c-ertain  posture  signs  will  be  produced, 
varying  with  the  bone  involved.  Pain  is 
always  intensified  by  the  slightest  degree  of 
disturbance.  In  consequence  the  limbs  (for 
it  is  the  limbs  which  are  usually  involved) 
are  contracted,  and  every  effort  to  overcome 
the  contractures  is  followed  by  aggravated 
])ain.  The  more  acute  the  pain  the  more 
\ivi<l  the  external  evidences  of  inflammation 
and  the  edema  of  the  parts,  especially  below 
and  about  the  lesion.  Thus  it  may  happen 
that  within  forty-eight  hours  there  may  be 
swelling  and  edema  of  the  part  involved, 
which  should  be  regarded  as  pathogno- 
monic. 

A  little  later,  superadded  to  the  other 
signs  of  inflammation,  there  is  fluctuation 
if  parosteal  abscesses  have  formed,  or  pos- 
sibly the  evidences  of  epiphyseal  loosening 
or  complete  separation.  ^\  hen  the  disease 
is  primary  in  an  epiphysis  the  C'orresponding 
joint  will  be  early  involved,  and  the  joint 
symptoms  will  assume  the  type  of  an  acute 
purulent  synovitis,  but  with  more  ])ain.  It  is  probable  that  under  few  circumstances  is 
complaint  of  pain  more  serious  or  aggravating  than  in  cases  of  acute  osteomyelitis  of 
the  fulminating  type. 

So  far  only  local  symptoms  have  been  described.  To  these  there  should  be  added  the 
list  of  those  pertaining  to  thrombosis  and  metastatic  infection,  with  their  septic  and  dis- 
a.strous  consequences.  The  disease  is  frequently  so  acute  and  rajiid  that  even  within 
the  first  day  or  two  not  only  are  added  extensive  thrombosis  in  and  along  the  bones, 
whh  rapid  purulent  degeneration  and  thrombi,  but  soon  that  even  more  serious  general 
condition  to  which  these  lesions  so  easily  give  rise — i.  e.,  unmistakable  pyemia. 

The  general  symptoms  are  common  to  the  disease,  no  matter  what  bone  be  involved. 
Local  symptoms  will  change  in  accordance  with  their  location.  While  not  so  common, 
the  flat  bones,  like  the  pelvis,  cranium,  and  sternum,  may  be  involved  in  active  mani- 
festations of  this  disease.  The  same  is  true  even  of  the  vertebrse,  but,  as  a  rule,  it  is 
in  the  long  bones  of  the  extremities  that  its  ravages  are  most  frequently  .seen. 

Prognosis. — The  prognosis  depends  upon  the  early  recognition  of  the  disease  and 
prompt  surgical  relief.  There  is  perhaps  no  disease  less  amenable  to  purely  medicinal 
treatment,  and  if  bones  are  to  be  saved  in  their  entirety  earlv  and  free  incision  is  called 


Acute  necrosis  of  tibia,  with  formation  of  cloacse 
for  affording  opportunity  for  escape  of  sequestra. 
Illustrating  also  the  extensive  openings  which  necrot- 
omy may  necessitate.     (Lexer.) 


ACUTE  oS/'hOM)  KJJ'riS  4I9 

''or.  (4)iis('i|iic"ntly  wlu-ii  tlir  tasc  is  seen  latr  it  almost  iiivariiihly  eiituiis  necrosis, 
with  more  or  less  disturhunee  of  function,  or  possibly  such  a  serious  condition  as  to  call 
for  am|)utation.  The  fulminant  cases  when  not  early  rcco^niized  and  promptly  operated 
often  prove  fatal,  and  death  has  been  known  to  follow  within  thirty-six  hours  after  the 
onset  of  tiic  first  symptom,  the  fatal  r(>sult  beinji;  due  to  overwhelming;  se])tic  infection, 
with  thrombosis,  etc.     Almost  every  case,  however,  if  seen  sufficiently  early  can  be  saved. 

Complications. — The  complications  are  to  be  divided  into  the  constitutional 
and  liic  local.  The  fornu'r  refer  rather  to  the  spread  of  sej)tic  infection  and  its  more 
or  less  disastrous  and  remote  rava<2;es.  Metastatic  infections  may  produce  .serious  or 
fatal  complications,  while,  when  less  acute,  important  functions  may  suffer  a  serious 
impairment.  Among  the  local  sequels  are  to  be  considered  mainly  the  results  of  destruc- 
tion of  bone  tissue  and  neifjhborino;  joint  structures.  When  the  disea.se  occurs  in  young 
and  rapidly  growing  children  partial  or  comj)lete  arrest  of  development  in  the  bone 
involved  is  not  infre(|uent.  This  may  lead  to  inc(|ualitics  in  length  of  the  femora 
or  humeri.  It  may  lead  also  to  com])ensat()ry  hy})ertro{)hy  of  bone,  with  perhaps 
consi(l(M'able  distortion  during  subsequent  growth. 

.\u  entin^ly  distinct  consequence  of  osteomyelitis  is  hone  ahiccs.'i,  in  which  the  acuteness 
of  syuipioms  has  long  since  subsided,  but  in  which  a  distinct  local  focus  remains. 

Etiology. — The  disease  is  an  infection  from  the  beginning,  but  the  source  of  the 
infection  is  not  always  easy  to  trace.  Two  distinct  causes  seem  to  conspire  to  produce 
the  majority  of  these  bone  infections — microurr/ani.sms  of  more  than  ordinary  virulence, 
and  a  pn'di.tpo.sing  condition  of  the  .system,  due  sometimes  to  constitutional  weakness 
or  inherited  taint,  or  to  the  results  of  exposure  and  fatigue.  The  causes  of  sujjpuration 
have  been  discussed  in  Chapter  III.  It  is  a  fact,  however,  that  the  majority  of  cases 
occur  in  children  and  after  a  combination  of  exposure  and  fatigue — as,  for  instance, 
sitting  upon  the  ice  after  being  exhausted  by  skating — all  of  which  would  be  inoperative 
to  produce  an  infection  were  not  the  germs  at  hand  ready  to  assail  every  tissue  whose 
resistance  is  thus  temporarily  lowered. 

The  infection  may  occur  from  within  or  from  without — from  within  perhaps  through 
the  alimentary  canal  or  the  respiratory  tract,  probably  from  the  tonsils  and  the  pharynx. 
Infection  from  without  may  occur  through  an  abrasion  or  scratch,  a  blister  upon  the 
foot  made  by  an  ill-fitting  shoe  or  by  a  skate-strap.  These  cases  occur  generally  in 
the  young,  more  often  in  boys  than  in  girls,  probably  because  in  the  former  more  oppor- 
tunities for  infection  are  permitted.  Bone  infections,  however,  are  possible  even  in 
the  newborn,  in  which  case  the  infection  may  occur  through  the  pharynx  or  through 
the  umbilicus,  while  the  local  resistance  may  have  been  lowered  by  the  injury  due  to 
mechanical  delivery,  turning,  etc.     In  elderly  people  the  disease  is  almost  unknown. 

Diagnosis. — The  disease  for  which  this  is  most  commonly  mistaken  is  acute  rheu- 
matism. There  may  have  been  some  excuse  for  this  in  the  past  because  of  the  lack  of 
general  knowledge  of  bone  infections;  now  there  is  none.  The  majority  of  cases  of 
necrosis  following  osteomyelitis  which  have  come  under  the  writer's  observation  were 
the  result  of  errors  in  diagnosis. 

Rheiunatism  is  never  followed  by  suppuration  and  seldom  produces  a  septic  type  of 
disease;  its  painful  lesions  are  rarely  so  painful  as  those  due  to  osteomyelitis.  Lesions 
of  rheumatism  are  usually  multiple;  those  of  bone  infection  are  mostly  single.  The 
first  complaint  of  pain  in  the  latter  is  generally  along  the  shaft  of  a  bone  than  at  the  joint 
end,  while  this  is  not  true  of  rheumatism.  Moreover  in  acute  osteomyelitis  the  disease 
a.ssumes  from  the  outset  a  seriousness  which  is  seldom  approximated  by  acute  inflam- 
matory rheumatism. 

Treatment. — The  treatment  for  acute  osteomyelitis  is  essentially  surgical.  Ano- 
dynes may  be  necessary  for  relief  of  pain,  but  no  time  should  be  lost,  when  once  the 
diagnosis  is  made,  in  making  incisions  to  expose  the  bone  involved,  and  then  opening 
to  its  interior  to  relieve  tension  and  to  remove  septic  products.  The  incision  over  the 
femur  or  tibia,  for  instance,  may  be  ten  or  twelve  inches  in  length.  The  tissues  will 
invariably  be  found  edematous  or  infiltrated,  with  evidence  of  the  proximity  of  pus; 
the  periosteum  will  be  thickened  and  infected,  and  between  it  and  the  bone,  as  well  as 
outside  of  it,  there  may  be  collections  of  pus.  If  seen  late  the  characteristic  muscle 
appearances  already  described  may  be  noted.  The  periosteum  should  be  incised  to 
the  bone  throughout  the  length  of  the  incision,  and  then  an  ordinary  bone  drill  may  be 
used  to  perforate  the  bone  for  exploratory  purposes.     From  the  punctures  in  the  bone 


420 


SURGICAL   AFFECTIONS  OF   TUE   TISSUES 


Fig.  225 


thus  involved  will  exude  purulent  fluid,  often  sanious,  thus  indieating  the  condition 
within.  A  deep  "groove  or  channel  shoidd  now  he  cut,  openino;  into  the  marrow  cavity, 
in  which  numerous  foci  will  he  found,  or  in  which  all  distinctive  .structure  of  hone-marrov/ 
may  he  lost,  the  cavity  being  filled  with  ])u.s.  The  pus  cavity  should  be  scrajx'd  and 
disinfected  with  hydrogen  ])eroxide  and  cauterized  with  zinc  chloride  or  its  ecjuivalent, 
and  then  packed,  the  wound  being  left  open.  Even  this  may  not  be  sufficient,  but  if 
there  be  e])iphyseal  separation,  or  evidences  of  joint  infection,  the  neighboring  joints 
should  be  explored  under  aseptic  precautions;  if  pus  be  found  they  should  be  opened, 
Avashed  out,  and  drained.  Meanwhile  if  in  the  soft  tissues  exposed  by  the  incision  the 
parosteal  veins  are  found  filled  with  septic  thrombi,  they  should  be  opened  as  far  as 
exposed  and  their  contents  removed. 

These  operations  are  often  severe,  but  nothing  in  the  way  of  operative  treatment  can 
be  so  severe  nor  so  serious  as  the  disease  itself  when  left  unoperated;  the  rule  is  stringent 
that  everv  infected  tissue,  and  especially  every  infected  bone  interior,  should  be  exposed 
and  cleaned  out.  Only  in  this  way  can  lives  be  saved.  Moreover,  it  is  necessary  to 
carrv  out  this  treatment  in  the  fulminant  cases  as  early  as  possible;  and  errors  in  diagnosis 
by  which  it  may  be  postponed  until  metastatic  infection  or  grave  pulmonary  and  cardiac 
complications  have  set  in  are  unfortunate.  So  long  as  the  local  indications  are  as  above 
described,  surgical  treatment  is  desirable,  whether  the  systemic  complications  are  pro- 
nounced or  not.  The  immediate  effect  of  the  operation  having  passed  the  relief  thus 
afforded  will  often  be  so  pronounced  that  within  twenty-four  hours  patients  may  be 
out  of  danger. 

The  results  of  this  operation  are  a  wound  which  will  discharge  at  first  freely,  and  which 
so  soon  as  septic  material  is  out  of  the  way  will  begin  to  gran  ulate.     Ordinarily  no  attempt 

should  be  made  to  close  such  a  wound,  though  much 
may  be  done  to  favor  rapidity  of  granulation.  While 
some  antiseptic  dressing  is  always  employed,  it  will  be 
of  advantage  occasionally  to  change  the  character  of 
the  same,  and  to  alternate  betAveen  various  antisep- 
tics, the  effect  of  any  one  drug  being  apparently  lost 
after  it  has  been  used  for  some  time. 

There  are  some  cases  where  an  entire  diaphysis  or 
bone  shaft  will  be  found  separated  from  one  or  both 
epiphyseal  terminations,  lying  in  a  subperiosteal  ab- 
scess cavity,  bathed  in  pus,  and  dead  beyond  possibility 
of  repair.  This  is  lotal  necrosis  of  the  shaft  from  an 
acute  infectious  process,  and  is  to  be  treated  by  com- 
plete removal  of  all  dead  and  dying  tissue.  In  the 
case  of  the  forearm  or  leg  it  may  be  that  the  remaining 
bone,  when  only  one  is  involved,  as  is  usual,  will  be 
sufficient  to  maintain  the  integrity  of  the  limb  until 
new  bone  can  be  reproduced  within  the  periosteal  bed 
occupied  by  the  old  one.  INlore  or  less  complete  re- 
(jeneraiion  of  hone  is  possible,  particularly  in  the  young, 
and  in  connection  with  compensatory  hypertrophy  of 
the  parallel  bone  will  permit  the  restoration  of  the  leg 
to  partial  or  complete  usefulness.  On  the  other  hand, 
should  this  later  prove  a  complete  failure,  amputation 
and  substitution  of  an  artificial  limb  may  be  required. 
When  the  disease  has  involved  the  articular  side  of  an 
epiphyseal  line,  and  when  there  is  complete  epiphyseal 
separation  with  consecjuent  pijarthrosis,  the  probable 
consequence  will  be  necessity  for  a  complete  or  partial 
resection  of  the  joint  and  the  probability  of  subsequent  ankylosis.  Patients  may  find 
later  that  a  modern  artificial  limb  with  its  possibilities  will  be  preferable  to  such  a 
condition,  and  may  readily  consent  later  to  an  amputation  which  they  would  at  first 
refuse. 

Acute  Infectious  Periostitis. — This  is  an  infection  of  the  same  general  character 
and  type  as  the  osteomyelitis  just  described,  but  refers  to  those  cases  where  the  disease 
Apparently  is  confined  to  the  periosteum  and  the  outermost  layer  of  the  bone.     In  its 


Total  necrosis  of  humerus,  as  seen  by 
aid  of  the  cathode  rays.     (Lexer.) 


ACITK  OSTF.OMYKLITIS  421 

|)os.siI)ilitic'.s  for  Imrin  it  is  scarcvly  less  serious,  iiltliouj^li  in  its  tciKJcucy  to  spontaneous 
|)('rt'()ration  and  escape  of  j)us  it  is  less  likely  to  prove  fatal. 

Causes. — The  causes  an<l  the  fjeneral  clinical  manifestations  are  practically  identical. 
The  disea.se  is  |)erhaps  less  <;rave  in  its  acute  manifestations,  the  localization  of  pain 
more  exact,  with  ordinarily  less  tendency  to  joint  c()m|)licati()ns.  Local  tenderness  is 
excjuisite,  and  particularly  in  those  hones  which  lie  near  tlu-  surface — e.  g.,  the  tibia — 
ami  early  recoijnition  of  (luctuatinji;  areas  is  ea.sy.  It  may  he  localized  over  a  small 
area,  or  the  entire  periost(>um  of  the  shaft  may  he  involved;  in  which  case,  .so  .soon  as  pus 
forms  and  the  periosteum  is  .separated  from  the  hone,  there  is  jirohahility  of  acute  necrasLS 
of  the  shaft.  Here,  attain,  there  may  he  a  tendency  to  mistake  at  least  the  first  sio^ns  of 
the  di.sea.se  for  acute  rheumatism,  from  which  it  must  necessarily  be  early  differentiated 
as  ai>()vc. 

Treatment. — Here  also  there  is  the  same  necessity  for  immediate  intervention,  if  pos- 
sible before  |nis  be  formed,  in  order  that  there  may  be  little  or  no  periosteal  .se])aration  and 
encourajjement  to  necrosis.  Anesthesia  is  necessary,  with  prompt  incision,  the  u.se  of 
the  sharp  sjjoou,  and  disinfectinti;  agents:  no  attem])t  should  be  made  to  clo.se  the  wound, 
but  draina<]jc  should  be  favored  in  every  way.  The  intensity  of  the  pain  is  promjitly 
relieveil  and  the  whole  clinical  picture  immediately  chanjijed  by  such  a  procedure. 

The  ordinary  hone  felon  upon  a  terminal  phalanx  is  practically  an  expression  of  this 
type  of  disease,  and  experience  corroborates  the  wisdom  of  deep  and  early  incision,  even 
in  the  case  of  so  small  a  bone  entity  as  a  phalanx. 

Acute  Epiphysitis. — This  is  a  term  applied  rather  indiscriminately  to  a  form  of 
acute  csteomvelitis  involving  j)rimarily  and  especially  the  epiphyseal  lines,  or  to  a  con- 
dition of  hyperemia  and  neurovascular  excitement  at  epiphyseal  junctions  stop})ing 
short  of  suppuration,  but  giving  rise  to  intense  pain,  muscle  contraction,  joint  tenderness, 
etc.  It  is  often  .seen  at  the  upper  end  of  the  tibia.  Sympathetic  disturbance  may  extend 
even  to  serous  effusion  into  a  joint,  although  this  is  not  necessarily  the  case.  The  limbs 
are  early  drawn  up,  and  every  attempt  to  extend  them  simply  aggravates  the  distress. 
So  long  as  there  are  no  evidences  of  suppuration,  it  is  sufficient  in  these  ca.ses  to  apply 
a  sufficient  degree  of  traction  to  overcome  muscular  contracture  and  to  straighten  the 
limbs.  This  should  be  applied  first  under,  anesthesia,  and  the  patient  kept  under  ano- 
dynes for  a  few  hours  thereafter.  So  soon,  however,  as  the  muscles  are  tired  out  by 
the  steady  traction,  pain  subsides,  and  the  intensity  of  the  condition  may  be  thus  relieved 
within  forty-eight  hours  or  less.  It  would  be  well  to  continue  physiological  rest  and 
traction  as  long  as  there  remains  the  slightest  tenderness.  Should  evidences  of  suppu- 
ration at  any  time  supervene,  incision  and  evacuation  of  pus  and  exudate  should  be  prac- 
tised. Should  epiphysitis  occur  in  one  of  two  parallel  bones,  there  may  result  such 
failure  of  growth  of  that  bone  as  shall  cause  marked  deformity  in  the  attacked  hand  or 
foot.  In  some  of  these  cases,  should  operation  be  required  on  one  bone,  the  other  may 
be  shortened  at  the  time,  or  later,  by  exsection  of  a  portion  of  the  shaft,  or  even  of  the 
epiphyseal  junction. 

Periostitis  Albuminosa. — This  is  a  rare  manifestation  of  bone  disease,  only 
given  an  identity  of  its  own  since  ISGS,  wdien  Oilier  first  distinguished  it,  since  which  time 
it  has  been  the  subject  of  considerable  controversy.  The  name  refers  to  a  condition 
less  acute  than  the  infectious  periostitis  just  described,  almost  always  localized  in  a 
single  bone,  necessitating  incision  and  evacuation  of  a  fluid  which  is  gelatinous  or  mucoid 
in  appearance  rather  than  purulent.  It  is  because  of  the  peculiarity  of  the  subperiosteal 
collection  of  fluid  that  it  received  the  name  'periostitis  albuminosa,  and  it  was  not  generally 
regarded  until  recently  as  a  variety  of  the  infectious  form  of  periostitis.  It  is,  however, 
now  conceded  as  being  a  mitigated  form  of  infection,  in  which  the  products  of  exudation 
assume  the  serous  rather  than  the  purulent  type.  In  some  instances  it  appears  to  be 
the  tubercle  bacilli  which  are  at  fault.  At  all  events,  the  organisms  which  produce  the 
disease  are  more  or  less  virulent,  else  the  clinical  form  of  the  disease  would  be  less  serious 
than  it  really  is.  Cultures  made  from  these  subperiosteal  collections  have  in  almost  all 
recent  instances  revealed  the  presence  of  some  one  of  the  numerous  pyogenic  organisms. 
Quite  recently  Dor  has  described  a  polymorphic  microbe,  in  instances  of  this  kind, 
w'hich  he  has  called  the  Bacillus  cereus  citreus,  with  which  he  claims  to  have  been 
able  to  reproduce  the  disea.se  in  animals. 

Chronic  and  Latent  Osteomyelitis. — As  in  the  lungs,  however,  chronic  lesions 
are  met  with,  and  as  in  the  lungs,  again,  it  is  po.ssible  for  collections  of  microorganisms 


422 


SURGICAL  AFFECTIOXS  OF   THE   TISSUES 


Fin.  226 


:4- 


^ 


to  become  more  or  less  encapsulated  and  for  a  long  time  to  lie  latent  until  some  provoking 
cause  excites  them  again  into  activity.     In  this  way  are  to  l)e  explained  the  luunerous 

instances  of  recurring  abscesses  within  the  hone  necessi- 
tating repeated  operations,  often  at  long  intervals.     (See 
Plan-  XXXVI.) 
Possible  Consequences  of  Any  and  All  of  the 

Bone  Infections. — Bone  is  a  living  tissue,  calcified 
and  stiffened  by  inorganic  material  for  the  purpose  of 
giving  it  strength;  it  may  suffer  remotely  from  the  con- 
sequences of  local  infections,  the  same  as  other  tissue. 
Tluis  it  may  have  its  nutrition  impaired  so  as  to  pro- 
duce atrophi/ on  one  hand,  or  increased  so  as  to  lead  on 
the  other  to  hypcrtroplitj,  either  regular  or  irregular  in 
outline.  Again  in  its  texture  it  may  be  altered  to  a  wide 
extent  between  the  sponginess  or  porosity  on  one  side 
{osteoporosis),  or  to  the  density  attained  by  ivory  (osteo- 
sclerosis) on  the  other.  Similar  changes  are  also  noted 
in  cases  of  bone  tuberculosis,  which  is  to  be  considered 
by  itself.  The  densest  bone  has  sufficient  vitality  to  per- 
mit its  nutrition  and  life,  and  may  assume  dimensions 
much  larger  than  that  of  the  original,  and  a  hardness 
which  will  defy  the  best  steel  instrimients  should  it  be- 
come necessary  to  operate  upon  it.  The  other  extreme 
of  osteoporosis  includes  a  condition  where  the  bone  has 
barely  sufficient  inorganic  material  to  permit  it  to  retain 
its  shape  and  ordinary  proportions.  Such  bone  is  fra- 
gile in  the  extreme  and  scarcely  serviceable  as  a  sup- 
porting tissue.  The  principal  portion  of  its  bulk  is 
constituted  by  marrow  tissue,  which  makes  it  extremely 
vascular,  but  far  from  strong.  When  spongy  it  is  ordi- 
narily unserviceable  for  its  proper  function.  Aston- 
ishing pictures  of  osteosclerosis  and  osteoporosis  side 
bi]  side  are  present  in  many  instances  of  disease,  the 
latter  being  often  evidence  of  more  or  less  ossification  of 
new-formed  granulation  tissue.  This  is  often  a  happy 
combination,  bcause  the  bone,  which  has  been  sadly 
Aveakened  by  disappearance  of  its  calcareous  material  by  liquefaction  and  by  ab- 
sorption, is  reinforced  along  some  of  its  lines  by  a  pillar  of  osteosclerotic  tissue,  by 
means  of  which  it  still  functionates  as  a  more  or  less  useful  support   (Fig.  226). 

The  operating  surgeon  should  familiarize  himself  with  the  density  of  normal  bone  in 
various  locations,  as  in  many  operations  upon  the  deeper  bones  he  detects  healthy 
bone  rather  by  the  sense  of  touch  and  of  hearing,  and  the  resistance  which  it  offers  to  his 
instruments,  than  by  sense  of  sight. 


\^ 


Osteogenesis  au  1  osteosclerosis  in  slow 
infective  processes.  (Buffalo  Museum.) 


TUBERCULOSIS  OF  BONE. 


In  Chapter  IX,  on  Tuberculosis  in  general,  we  entered  into  considerable  detail  in 
regard  to  the  nature  of  tuberculous  lesions,  which  were  stated  to  be  essentially  the  same 
whether  occurring  in  hard  or  soft  tissue,  the  active  agent  being  the  now  well-known 
Bacillus  tuberculosis,  which,  finding  lodgement,  for  instance,  in  the  osseous  tissue,  acts  as 
a  specific  irritant,  and  so  provokes  the  production,  first,  of  atypical  tubercle,  and,  later, 
of  typical  granulation  tissue,  by  whose  ravages  the  distinctive  signs  of  bone  tuberculosis 
are  produced.  This  process,  then,  is  in  no  respect  different  in  bones  from  similar 
lesions  in  other  parts,  though  modified  to  a  slight  extent  pathologically,  to  a  greater  extent 
clinically,  by  the  dense  environement.  Nevertheless,  trifling  or  most  extensive  destruc- 
tion of  bone  substance  is  produced  by  this  tissue,  while  by  continuity  or  by  metastasis 
there  is  more  or  less  involvement  of  the  adjoining  textures,  either  parosteal  or  articular. 
It  is  by  granulation  tissue  that  so-called  caries  is  produced,  and  it  is  by  the  same  tissue 
that  distinct  portions  of  bone  are  sometimes  completely  segregated  from  their  vascular 


PLATE  XXXVI 


Tuberculous  Disease  cf  Hip-joint  and  Pelvis,  involving  the  Muscles  (rare). 

(Lannelongue.) 
0,  rarefying  ostitis  (/.  e.,  osteoporosis    ;  /,  fungus  granulation  tissue. 


TUBERCULOSIS  OF  BOSK  423 

surroundings  and  shut  oft"  from  nutrition,  so  tliat  tlicy  die  and  form  what  arc  known  as 
.sr(fur.s-frn.     A'rrro.sv.v  may  then  he  thr  ri'suit  of  tulM-rcnions  (hscasc. 

.So  lonif  as  the  j)rorc\s  is  active,  this  <ijramihition  tissue  tends  to  eniar<je  its  boundaries, 
and,  hke  pus,  to  spn^ad  in  the  dir(>ctiou  of  least  resistance.  When  pnxhiced  in  the 
shaft  of  a  lonj;  l)one  this  may  lead  to  itivolvcment  of  the  entire  siiaft,  or  there  mav  he 
h(iucfaction  and  absorption  of  dense  l)one  and  tlic  formation  of  a  sinus  from  the  marrow 
cavity  to  the  periosteum,  l)eneath  which  the  <franulation  tissue  will  s|)read,  and  throuj^h 
which  it  will  sooner  or  later  |)erf()rate,  to  resume  its  pro<i!;ress  toward  the  surface,  ci/iray.s 
III  the  direction  of  least  refii.s-tance.  In  this  j)roii;ress  tendon  slieatli.s  or  bursa'  may  be 
involved,  or  dense  aponeuroses  may  turn  the  graiuilation  column  aside,  causing  it  to 
|)erforate  toward  the  surface  at  some  remote  point;  while  it  may  spread  out  more  or  less 
lu-neath  the  skin  before  finally  causing  its  destruction.  Sooner  or  later,  if  uninterrupted 
by  treatment,  this  escape  will  occur,  and  then  we  have  the  condition  of  a  tuberculous 
ulcer  of  the  skin,  from  which  leads  down,  by  a  devious  jjath,  a  .s'm//.s-  toward  the  original 
focus. 

WluMi  this  original  focus  has  been  juxta-epi})hyseal  there  is  involvement  of  the 
epi])hyseal  cartilage  and  a  pathological  diastasis,  which  may  early  lead  to  spontaneous 
or  pathological  lu.vation.  Or,  again,  a  focus  having  once  originated  at  an  epiphy.seal 
extremity,  tends  usually  to  perforate  quickly  into  a  joint  cavity,  after  which  a  considerable 
length  of  time  is  usiudly  expended  in  filling  up  this  joint  cavity  with  exuberant  graiuda- 
lion  tissue.  This  is  the  material  so  often  found  in  tuberculous  joints,  and  is  well  charac- 
terized by  the  name  given  to  it  by  the  (xermans,  fungous  tissue,  they  calling  such  j(»int 
art'ections  funr/ou.'i  joint  inflamniafioiis.      (See   previous  cha})ter.) 

Seen  thus  in  joints,  after  it  has  been  long  exj)osed  to  friction  and  to  more  or  le.ss 
pressure,  it  may  have  lost  some  of  its  original  luxuriant  features.  It  is  best  seen  when 
it  is  freshest  and  has  been  exposed  to  least  disturbance.  Under  the.se  circumstances 
it  is  vascular,  dark  red  in  appi-arance,  friable,  and  easily  removed  from  the  tissue  upon 
which  it  has  grown.  Ordinarily  it  is  infectious,  and  by  its  inoculation  into  animals 
is  capable  of  reproducing  the  disease. 

Pathology. — The  pathology  of  tuberculosis  of  bone  may  then  be  virtually  summed 
uj)  in  saying  that  it  consists  of  the  ravages  produced  by  the  presence  of  this  granulation 
tissue,  with  the  irritative  hyperplasia  of  surrounding  tissues  which  its  ]>resence  always 
excites,  even  though  they  be  not  actively  infected.  This  is  the  explanation  for  tlie 
majority  of  cases  of  caries,  of  tumor  alhus,  of  Pott's  disease,  of  spina  ir/;to.s'a,  and  of  the 
condition  which  has  been  knowii  under  many  other  names. 

Varieties.  Acute  Miliary  Tuberculosis  of  Bone. — This  corresponds  to  a  similar  invasion 
of  the  lungs.  It  might  be  fittingly  described  as  an  acute  tuberculous  jorm  of  osteomye- 
litis. It  may  run  its  destructive  course  within  a  short  time  and  cause  such  involvement 
of  structures  as  to  necessitate  amputation  of  a  limb,  or  it  may  appear  in  the  truncal  skele- 
ton as  a  ))rimarv  disease,  spreading  rajiidly  therefrom  and  involving  the  viscera  or  the 
cerebrospinal  membranes,  and  causing  an  early  death,  perhaps  within  a  few  weeks 
after  its  onset.  This  condition  has  been  more  prevalent  than  is  generally  understood, 
and  has  not  even  yet  received  the  attention  it  deserves.  It  is  less  painful  than  the  pyo- 
genic forms  of  osteomyelitis,  and  may  assume  less  of  the  septic  and  more  of  the  typhoid 
or  meningeal  type  of  disease.  The  pain  also  may  be  less  severe,  though  reflex  symptoms, 
especially  muscle  spasm,  wall  be  an  early  and  marked  feature  of  these  cases.  When 
a  limb  is  involved  the  case  may  not  be  hopeless;  but  when  involving  the  craniinn,  spine, 
or  trunk  it  is  fatal,  and  little  can  be  accomplished  by  treatment.  The  operative  treat- 
ment for  parts  which  are  accessible  is  given  under  Acute  Osteomyelitis. 

Chronic  Tuberculous  Osteomyelitis. — This  is  the  ordinary  ftjrm  of  the  disease,  and  is 
exceedingly  common.  In  some  sections  it  constitutes  nearly  one-third  of  the  diseases 
necessitating  surgical  treatment  in  clinics  and  hospitals.  This  is  particularly  so  in  the 
thickly  .settled  portions  of  the  European  continent.  In  Buft'alo  it  constitutes  from  15 
to  20  per  cent,  of  cases  found  in  my  wards  and  in  my  clinic.  The  proportion  some  years 
lias  been  larger. 

Symptoms. — The  essential  symptoms  of  bone  tuberculosis  are  muscle  atrophy, 
muscle  spasm  and  paiji,  direct  or  referred,  and  upon  the  existence  of  the.se,  coupled 
with  local  tenderness  and  local  swelling,  a  diagnosis  can  almost  always  he  made.  Muscle 
atrophy  is  distinct,  and  is  not  alone  that  of  disuse,  but  is  a  distinctive  evidence  of  the 
tuberculous  process.     It  involves  the  parts  ab(;ve  and  below  the  lesions. 


424 


SURGICAL   AFFECT  loss  OF   THE   TISSUES 


Muscle  spasm  is  never  lacking,  hut  is  most  noti('eal)le  about  the  spine  and  tiie  joints 
of  the  extremities.  In  Pott's  disease,  for  instance,  the  condition  causes  a  stiffening  of 
the  back  and  an  inflexil)iHty  of  the  s])ine.  About  the  joints  it  leads  gradually  to  /i.cation, 
usually  in  the  condition  of  more  or  less  flexion,  the  flexor  muscles  being  ordinarily 
stronger  than  the  extensors  in  all  parts  of  the  l)ody.  Thus  we  see  the  knee  and  the 
elbow  drawn  up,  and  most  other  joints  in  a  condition  of  flexion  so  far  as  it  may  be 
})ermitt('d. 

It  is  characteristic  also  that  invsclc  spasm  is  frequently  exaggerated,  usually  in  a  reflex 
way,  by  which  pain  is  always  augmented.  These  sudden  but  brief  contractures  occur 
more  often  during  sleep  than  during  the  waking  hours,  and  give  rise  to  the  so-called 
starling  pains,  usually  nocturnal,  which  are  noted  in  nearly  every  case  of  this  kind. 

The  pain  is  in  large  measure  the  result  of  contracted  muscles  pulling  tender  joint 
surfaces  together,  and  is  consequently    augmented    during    the    muscle    spasms  just 


Fig  227 


Fig.  228 


-^■%:- 


Tuberculous  disease  of  the  hip. 
(Buffalo  Museum.) 


'*        *^ 


Healed  tuberculosis  of  the  spine. 
(Buffalo  Museum.) 


described  to  an  extent  causing  the  patient  to  cry  out  even  during  sleep.  There  is  also 
usually  a  more  or  less  deep-seated  and  constant  pain  or  soreness,  manifested  in  increasing 
degree  as  the  lesion  advances.  These  j)ains  are  also  often  referrccl,  lesions  in  the  upper 
ends  of  long  bones  usually  giving  rise  to  pain  which  patients  refer  to  the  lower  ends. 
In  hip-joint  disease  pain  is  often  referred  to  the  knee,  and  in  Pott's  disea.se  to  the  anterior 
}>art  of  the  trunk.  Slight  but  slowly  increasing  disturbance  of  function  of  a  joint  inaugu- 
rated by  trifling  muscle  spasm,  with  comjjlaint  of  aching  ])ain,  is  signiflcant  and  needs 
careful  examination,  it  being  a  mistake  to  anesthetize  patients  for  this  purpose,  as  by 
the  anesthetic  the  pathognomonic  muscle  spasm  is  abolished  and  mistakes  in  diagnosis 
favored. 

It  will  be  .seen  that  the.se  features  are  also  met  with  in  tuberculous-joint  di.sease,  the 
fact  being  the  conditions  are  not  onlv  allied  but  often  as.sociated. 


BONE  ABSCESS  425 

Treatment.  'I'lu-  trcatinciit  of  tultcrculosis  of  hone  is  constitutional  and  local. 
'I'lic  lornuT  consists  in  the  best  possible  liyijjicnc  anil  in  tliosi'  measures  which  are  everv- 
where  reeotijnized  as  helj)tul  in  similar  conditions.  I  believe  in  the  internal  use  of 
benzosol,  or  its  ecjuivalents,  in  do.ses  sufficiently  \iiv\ry  to  influence  the  ti.ssues.  In  addition 
the  tonics  and  evacuants  should  be  judiciously  used.  Hut  it  is  mainly  with  local  treat- 
ment that  we  shall  here  have  to  deal. 

The  local  trnitiiinit  may  be  divided  into  the  non-oprratirc  and  the  oprralivr.  The 
former  consists  in  enforcin<f  the  <reneral  j)rinci])les  of  physioloirical  rest,  which  is  done 
partly  by  orthoprdtr  (ipixtnifii-s  proper  an<l  partly  by  the  <fencral  princi|)les  of  tnidlon, 
and  is  resorted  to  mainly  in  a  class  of  cases  treated  of  under  ( )rt!io|)e(lic  Sur<i;ery,  the  best 
methods  for  the  purpose,  a|)|)aratus,  etc.,  beinjjf  found  in  tlu^  next  chapter. 

.\side  from  this  a  hopeful  metiiod  has  been  that  suggested  by  Bier,  consisting  of 
making  an  artifrial  clironic  coiKjestion,  it  having  been  hnig  known  that  tubercles  do  not 
thrive  when  bathed  in  much  blood.  The  congestion  is  secured  by  wearing  an  elastic 
bandage  above  the  point  involved,  elastic  constriction  being  made  to  a  degree  as  great 
as  may  be  comfortably  borne.  The  result  is  venous  congestion,  j)ossibly  edema  of  the 
parts  below,  which  to  be  made  eft'ective  should  be  carried  nearly  to  the  tolerable 
extreme.  Constriction  may  be  at  first  enforced  for  only  a  short  time,  l)Ut  can  be  later 
borne  for  longer  periods,  until  a  time  is  reached  when  the  patient  can  wear  a  bandage 
almost  continuously.     Marked  improvement  in  many  cases  follows  this  method. 

TJic  operative  treatmrnt  consists  in  ignipuncturr,  cureftage,  or  formal  extirpation.  Igni- 
puncfurc  is  the  insertion  into  the  bone  focus  of  the  glowing  point  of  the  thermocautery. 
It  should  be  practised  under  an  anesthetic,  and  when  the  bone  is  superficial  the  cautery 
should  be  plunged  through  the  skin,  making  it  burn  its  way  into  the  depth  of  the  bone. 
This  is  not  difficult  when  the  cancellous  tissue  is  that  at  fault.  If  the  bone  be  deep  an 
incision  may  be  made  down  to  it,  after  which  the  cautery  is  applied  as  above.  The 
result  in  almost  every  instance  is  relief  from  pain. 

This  effect  seems  to  be  brought  about  partly  by  relief  of  tension,  partly  by  destruction 
of  diseased  tissue,  and  by  the  acute  congestion  which  is  the  result  of  vigorous  counter- 
irritation.  It  need  occasion  no  fear  nor  difficulty,  and  is  applicable  to  all  accessible 
bones.  It  must  not  be  expected  to  cure  every  case,  but  is  a  measure  which  may  be 
confidently  expected  to  relieve  pain  and  to  do  good. 

The  raxlical  form  of  treatment  is  necessary  when  it  can  be  determined  that  the  carious 
process  is  advancing  or  that  pus  or  caseated  deposits  are  present.  This  is  made  known 
in  various  ways ;  but  when  reasonably  sure  of  their  presence  it  is  best  to  begin  the  opera- 
tion as  an  exploration,  going  as  far  as  the  findings  may  justify.  This  may  include 
scraping  out  of  a  small  focus,  or  it  may  entail  removal  of  a  large  portion  of  a  bone  or 
resection  of  a  joint,  or  even  amputation,  according  to  the  severity  of  the  deep  lesion. 
It  is  best  to  do  whatever  may  be  necessary,  and  to  do  it  all  at  once.  The  operator  should 
not  rest  content  v>'ith  mere  operative  attack,  but  should  carefully  disinfect  the  entire 
tract,  cutting  away  or  removing  with  the  spoon  the  sinus  wall  and  fungous  tissue, 
which  he  should  follow  wherever  it  may  lead,  disinfecting  freely  with  hydrogen  peroxide 
or  caustic  pyrozone,  and  then  using  an  active  caustic,  like  zinc  chloride  or  the  actual 
cautery,  unless  caustic  pyrozone  has  already  been  used.  In  this  way  material  may  l)e 
destroyed  which  has  escaped  the  instruments  used,  and  absorbents  are  eared  or  closed 
and  protection  afforded.  My  personal  preference  is  for  a  packing  made  of  bismuth 
subiodide  gauze,  soaked  in  a  mixture  of  balsam  of  Peru  containing  10  per  cent,  of 
gnaiacol,  which  I  find  more  advantageous  than  anything  I  have  used.  There  should  be 
added  to  these  measures,  however,  whatever  may  be  necessary  in  the  way  of  after- 
treatment,  both  local  and  constitutional,  and  the  surgeon  should  be  prepared  to  operate 
once  or  twice  again  should  latent  foci  subsequently  manifest  themselves  or  should  there 
be  recrudescence  of  the  active  disease. 

BONE  ABSCESS. 

Bone  abscess  is  a  term  applied  to  deep  and  circnmscrihed  collections  of  pits  icithin 
the  bone,  mainly  within  the  shafts  of  long  bones.  They  are  due  either  to  the  acute 
ravages  of  pyogenic  cocci  or  to  the  slower  lesions  produced  by  the  tubercle  bacillus. 
They  are  frequently  evidences  of  return  of  disease  in  its  acute  type  after  a  long  period 
of  latency.     The  nianifestations  are  usually  localized,  in  this  resi^ect  differing  from  those 


426 


SURGICAL   AFFECTIONS  OF  THE  TISSUES 


of  acute  osteomyelitis.  The  jmiii  is  (l(>e|)-seate(l  aiul  boring,  while  there  is  local  tender- 
ness, often  with  consitlerahle  enlargement  of  the  overlying  bone.  The  lesion  occurs 
more  often  in  the  tibia  than  in  all  of  the  other  bones  together — at  least  under  those 
clinical  conditions  which  entitle  it  to  be  called  bone  abscess.  The  pain  is  fre(iuently 
??of'/((,"//a/ or  osteoscopic,  and  patients  may  endure  it  for  weeks  or  months  before  seeking 
relief. 

'^i^'hc  surgeon  may  always  expect  to  find  a  layer  of  condensed,  sometimes  extremely 
hard  l)<)ne  around  these  local  foci,  and  it  is  due  to  this  that  they  do  not  either  jx'riorate 
or  diti'usi'  and  cause  extensive  trouble. 

Treatment. — Treatment  is  always  operative;  it  should  consist  in  anesthesia,  exj)osure 
of  the  bone,  effective  exploration  by  means  of  the  bone  drill,  as  the  hypodermic  needle 
would  be  used  for  exploration  in  the  soft  parts,  and  then  the  free  use  of  the  bone  chisel 
or  other  instruments  by  which  the  area  may  be  widely  exposed.  The  density  and  firm- 
ness of  the  bone  under  these  conditions  will  sometimes  almost  defy  the  best-tempered 
instrimients.  Care  should  be  taken  to  make  the  external  opening  nearly  the  size  of 
the  deej^  focus,  in  order  that  the  siu'face  may  not  heal  too  readily  and  before  the  deeper 
part  is  filled.  The  same  directions  with  regard  to  cauterization  and  packing  the  cavity 
obtain  as  given  before. 

SYPHILIS    OF   BONE. 

Syphilis  of  bone  may  assume  the  type  of  gummatous  involvement  of  the  periosteum 
or  of  the  hone  itself  or  of  syphilitic  caries  and  necrosis.     The  former  appears  usually 


Fig.  229 


Fig.  230 


Syphilitic  gummas  of  head  and  face.     (After  Jullien.) 


Syphilitic  ostitis  and  osteosclerosis. 


as  a  distinct  tumor,  ordinarily  tender  and  exceedingly  painful,  especially  at  night,  it 
being  characteristic  of  almost  all  cases  of  bone  syphilis  that  the  pain,  however  great  during 
the  day,  is  exaggerated  at  night.  The  true  syphilitic  gumma,  or  syphiloma,  of  bone 
is  but  little  different  from  gumma  in  other  tissues,  which  may  become  secondarily  in- 
fected and  then  suppurate  with  the  formation  of  sinuses,  etc.  Suppuration,  however, 
is  rare.  Central  gumma,  like  central  osteosarcoma,  is  possible,  and  may  lead  to  expan- 
sion of  the  surrounding  bone.  Syphilitic  7iecrosis,  so  far  as  the  bone  lesion  is  concerned, 
scarcely  differs  from  the  other  varieties.  It  is,  however,  almost  always  of  the  slow  form, 
and  involves  more  often  the  flat  than  the  long  bones.  It  is  esjiecially  seen  in  the 
cranium  and  the  sternum.     Syphilis  of  bone  is  often  mistaken  for  rheumatism  or  pseudo- 


CARIES 


427 


i-|icuiiiatisiii  l)cc;iiis(>  ol"  (he  (Iccp-scatcd  and  soiiicwliat  indolent  pain.  Syphilitic  (lisca.se 
of  lK)nt'  |)('rniits  occasional  spontaneous  rractuiv,  the  bone  afi'ected  with  this  disease 
heinij  always  more  Triable  than  natural.  There  is  also  aiiotlu;r  form  of  bone  syj)hilis 
— namely,  the  /inrdifari/.  It  leads  either  to  bone  rnlarr/rinrnt  or  to  carie,<i  and  necrosis, 
the  latter  usually  ui)<)n  the  cranivmi,  where  extensive  ulceration  and  sequestrum  forma- 
tion may  be  observed,  even  the  diu'a  beinjij  exposed  by  breaking  down  of  the  funfi;ous 
tissui'. 

Hereditary  bone  syphilis  is  also  characterized  by  osteophytic  formation,  by  the  sub- 
stitution of  ijclatinous  for  sponi:;y  bone  tissue  in  the  neiijjhborhood  of  c|)iplivscs,  and  by 
early  and  easy  epiphyseal  separations.  It  is  characterized  also  by  irrcffularity  of  ossifi- 
cation of  cai'tilajfc  and  consetiuent  deformity  of  bone  ends,  especially  about  the  phalan<jes 
and  the  metacar[)al  and  metatarsal  bones.  In  almost  every  case  where  doubt  would 
in  other  respects  arise  the  other  evidences  of  congenital  or  acquired  syphilis  are  so  plain 
as  scarcely  to  permit  uncertainty  (Fig.  230). 

The  possthic  comJ>i nation  of  sijphilis  ami  tuherrulosis  in  the  same  subject  may  occur, 
the  lesions  partaking  of  one  or  the  other  character  according  as  the  tuberculous  or 
syphilitic  taint  may  j)redominate. 

There  is  urgent  necessity  in  all  cases  of  syphilis  in  bone,  whether  operated  on  or  not, 
for  the  coinhination  of  suifnble  Intcrnnl  Irratincnt  with  surgical  intervention.  Only  by 
this  combination  can  the  efforts  of  the  surgeon  be  crowned  with  success.  In  failure  to 
appreciate  this  fact  operation  often  seems  to  be  almost  futile. 


CARIES. 


Fig.  231 


f : 


Caries  is  a  term  applied  to  infiltration,  and  substitution  in  healthy  bone  of  granu- 
lation tissue,  which  has  been  in  use  for  many  centuries,  from  a  time  long  before  the 
pathology  of  the  condition  was  understood.  Caries  never 
occurs  except  in  the  presence  of  a  specific  irritant,  which,  in 
general,  is  tuberculous  and  sometimes  syphilitic  in  char- 
acter. The  pure  type  of  caries  is  connected  entirely  with  the 
formation  of  granulation  tissue,  and  the  slow  ravages  con- 
nected with  its  presence  in  and  substitution  for  the  original 
bone.  As  long  as  septic  infection  (pyogenic)  is  avoided  it  as- 
sumes the  dry  type,  as  it  used  to  be  known,  called  by  the  older 
writers  caries  sicca.  When  the  fungous  tissue  is  invaded  by 
putrefactive  or  pyogenic  organisms  suppuration  takes  place, 
and  then  occur  the  moist  forms  of  caries,  the  caries  humida 
of  our  forefathers,  connected  with  the  presence  of  pus.  When 
closed  areas  of  bone,  small  or  large,  being  thus  shut  off 
from  nourishment,  die  as  the  result  of  its  presence  the  com- 
plicated condition  used  to  be  known  as  caries  necrotica.  Oc- 
curring under  any  circumstances,  caries  is  a  result  and  not  a 
cause,  and  is  to  be  dealt  with  accordingly. 

Peculiar  alterations  and  markings  in  bone  are  the  conse- 
quence of  carious  changes,  and  bones  are  given  a  fantastic 
and  peculiar  appearance  in  consequence.  The  surface  is 
almost  always  irregular,  tunnels  or  canals  are  formed,  and  the 
bone  is  often  honeycombed,  as  it  were,  by  the  excavations  just 
made.  Along  with  the  process  of  osteoporosis  and  disappear- 
ance of  bone  at  one  point  may  be  seen  osteosclerosis  in  an 
adjoining  area,  and  the  bone,  which  is  apparently  much 
weakened  by  the  destructive  process,  is  strengthened  in  a 
compensatory  way  by  the  artificial  density  of  the  tissue  un- 
dest  roved. 

The  clinical  evidences  of  caries  are  those  of  joint  and  bone 
tuberculosis  or  syphilis,  which  have  been  already  discussed, 
and  its  operative  treatment  consists  always  in  surgical  attack  with  bone  chisel  and  sharp 
spoon,  according  to  the  rules  already  laid  down.  The  bone  which  is  completely  carious 
calls  for  e.vtirpation—i.  e.,  usually  "amputation.     In  the  carpus  and  tarsus  resection  will 


Caries  of  lower   end  of  femur. 
(Bufifalo  Clinic.) 


428  SURGIC.iL  AFFECTIOXS  OF  TIIF  TISSUES 

often  suffice,  and  also  when  the  disease  is  limited  to  joint  ends.  Occurring  in  the  {X'lvLs, 
ribs,  sternum,  or  cranium,  more  or  less  extensive  resecfion.s  of  flat  bones  are  necessary,  in 
the  latter  j)lace  leading  to  exposure  of  the  dura  (of  which  one  need  have  no  fear).  The 
same  rules  with  regard  to  cleansing  and  packing  the  wound  should  be  observed  as  in 
operation  on  tuberculoas  bones. 


NECROSIS  OF  BONES. 

Necrosis  corresponds  to  gangrene  of  soft  parts,  and  the  term,  when  used  by  itself, 
is  limited  to  death  of  bone  tissue.  Necrosis  by  itself  is  a  distinct  disease,  but  indicates 
the  terminati(jn  of  some  preceding  disease  process.     It  may  be  considered  as: 

1.  Traumatic; 

2.  Pathological — i.  e.,  the  result  of  disease;  or 

.3.  Toxic,  due  to  the  presence  of  specific  poisons  in  the  system. 

1.  Traumatic  Necrosis. — Traumatic  necrosis  is  due  to  the  discontinuance  of  the 
blood  supply  by  accident  or  by  separation  of  the  whole  or  a  part  of  a  bone  in  the  same  way. 
Thus  in  consequence  of  multiple  fractures  fragments  occasionally  die  and  require  removal. 
The  same  result  has  been  ascribed  to  traumatic  or  non-traumatic  embolism  of  the  principal 
nutrient  artery  of  a  bone,  but  the  possibility  of  this  condition  is  doubtful,  bone  being  too 
well  supplied  by  its  surrounding  periosteum.  Necrosis  in  connection  with  fracture  is 
rare  except  in  compound  fractures,  and,  when  a  detached  fragment  can  be  seen,  may 
be  anticipat('(l  by  removal  of  the  same. 

2.  The  PatHological  Form. — The  pathological  form  is  due  to  the  preexistence 
either  of  tuberculosis,  syphilids,  or  an  acute  infection,  such  as  osteomyelitis.  It  may  also 
be  the  result  of  acute  infectious  periostitis,  where  the  periosteum  is  completely  loosened 
from  the  shaft  of  a  long  bone.  These  conditions  are  connected  either  with  the  slow 
ravages  produced  by  granulation  tissue,  or  with  the  acute  septic  processes  by  which 
infected  exudates  shut  off  large  areas  from  sufficient  blood  supply,  or  by  which  in 
consequence  of  septic  thrombosis  a  similar  condition  results.  In  consequence  there 
may  be  met  bone  dying  in  small  visible  particles,  or  the  entire  shaft  of  a  long  bone  or 
several  smaller  ones  may  be  involved  in  the  destructive  processes. 

The  portion  which  dies  is  known  as  the  sequestrum,  which  may  assume  irregular  and 
unusual  shapes,  varying  entirely  with  the  area  involved.  The  general  character  and 
size  of  a  sequestrum  will  depend  upon  the  nature  of  the  cause.  In  acute  osteomyelitis 
it  is  either  a  bone  shaft  or  an  epiphysis  which  thus  suddenly  dies.  In  the  slower  processes 
the  fragments  may  be  of  almost  any  imaginable  size  and  form — irregular  with  jagged 
ends,  or  long,  extending  completely  through  a  bone,  either  from  end  to  end  or  from  side 
to  side. 

.3.  The  Toxic  Forms  of  Necrosis. — The  toxic  forms  of  necrosis  are  due  mainly 
to  two  substances  used  in  the  arts — -mercury  and  phosphorus — whose  use  seems  to  be 
inseparable  from  the  manufacture  of  many  modern  industrial  products. 

Mercurial  necrosis  may  come  either  from  the  volatilization  of  the  metal  in  factories 
where  mirrors  are  made  or  from  refineries  where  amalgam  is  distilled.  It  also  occurs 
from  the  internal  use  of  the  drug.  Its  effects  are  seen  more  frecjuently  in  the  alveolar 
portion  of  the  lower  and  upper  jaw  than  elsewhere.  It  is  through  some  unknown 
peculiarity  that  the  jaws  are  the  bones  commonly  involved  in  both  of  these  forms. 

Plwsphorus  necrosis,  on  the  other  hand,  manifests  itself  alracxst  entirely  in  the  lower 
jaw,  and  occurs  usually  among  the  young,  in  factories  where  matches  are  made. 
It  is  due  to  the  vapors  of  phosphorus,  which  cause  a  form  of  nearly  distinct  maxillary 
necrosis — a  fact  which  has  been  so  widely  recognized  as  to  lead  to  State  legislation  pre- 
venting the  employment  of  the  young  in  such  work. 

Phosphorus  necrosis  begins  as  a  periostitis  with  the  production  of  osteoph^ies,  and 
is  com])lcted  as  a  nearly  total  necrosis  of  the  entire  bone. 

Treatment  of  the  Toxic  Forms — The  preventive  treatment  should  consist  of  super- 
vision of  the  teeth,  the  u.se  of  alkaline  mouth-washes,  inhalation  of  terebinthinate  vapors, 
which  neutralize  those  of  phosphorus,  and  the  ventilation  of  establishments  devoted 
to  match-making.  The  curative  treatment  consists  of  buccal  antisepsis,  opening  of 
abscesses,  and  the  removal  of  diseased  bone,  especially  of  dead  bone,  upon  the  first 
provocation.     The  occurrence  of  fistulas  should  always  be  regarded  as  pathognomonic 


PLATE  XXXVn 


Necrosis  of  Shaft  of  Femur  with  Sequestra.      (Life  size.) 


M'JCROS/S  OF   liOXh'S 


429 


of  (liscasfd  hone.  In  ;i}i;^rav;i(i'(l  cuscs,  sucli  as  arc  rarely  if  ever  seen  since  lej^islalion 
has  been  hrou^lit  to  l)ear  npon  the  suhjeet,  practically  complete  necrosis  of  the  lower 
jaw,  (Mtlier  fn  iikis.sc  or  in  portions,  was  far  from  imknown,  and  the  [)ossil)ility  of 
r(>ijeiuM-ati(»ii  of  the  hone  was  for  a  loiifi;  time  discrechted,  until  the  late  James  R.  Wood, 
of  New  \ Ork.exhihited  a  s|)c<Mnien,  hoth  at  home  and  abroad,  which  proved  its  possibility. 
Since  then  we  have  learned  that  it  is  possible  for  bone  thus  to  rcii;eneratc,  the  cause  of 
the  (lislurbance  lKivin<i;  l)ccn   removed. 

Sequestrum  Formation.— 'I'o  the  portion  of  l)on(>  which  dies  is  (fiven  the  name 
.sr(iiir.s-friini,  while  multi|)le  se(|uestra  are  by  no  means  uncommon.  The  se(|uestruni  is 
white  and  ivory-like  in  hardness  wlien  it  consists  of  original  compact  struc-ture.  It 
is  rare  to  find  a  distinct  secjucstrum  of  sponji^y  tissue,  as  this  yields  so  readily  to  the 
presence  of  granulation  tissue  and  of  j)yogenic  infection.  A  sequestrum  may  include 
an  entire  bone  shaft,  or  epiphysis,  or  only  a  small  fragment.  A  |)ortion  of  the  bone 
having  lost  its  vitality  becomes  a  foreign  body  which  the  surrovmding  tissues  endeavor 
to  extrud(>  or  to  wall  ofl"  and  surround.  The  extrusive  effort  is  the  one  which  is  usually 
seen.  This  is  done  by  the  continued  presence  of  granulation  tissue,  which  gradually 
perforates  the  surrounding  bone  at  ])laces  of  least  resistance,  the  result  being  the  slow 
formation  of  a  sinus  or  several  sinuses,  ultimately  connecting  with  the  stirface,  and  in 
which  in  nt>gleeted  cases  the  dead  fragment  of  bone  can  be  seen  or  felt,  or  from  which 
it  can  l)e  withdrawn  almost  without  operation.     While  this  weakening  of  bone  is  going 


Fig.  232 


Phosphorus  necrosis  of  the  lower  jaw.     (Musee  Dupuytren.) 

on  in  certain  portions  a  corresponding  strengthening  process  is  also  being  put  into  effect; 
and  the  result  is  a  quantity  of  new  bone,  which  is  often  wrapped  around  the  seques- 
trinn  and  is  simply  the  effort  to  atone  for  its  pathological  weakness  and  to  strengthen  it. 
This  new  osseous  tissue  which  so  often  surrounds  the  sequestriun  is  called  the  invohi- 
crum,  and  in  many  instances  it  is  necessary  to  remove  more  or  less  of  the  involucrum 
before  the  sequestrum  can  be  lifted  out  of  its  bed  or  removed.     (See  Plate  XXXVII.) 

The  whole  necrotic  process  is  intelligible  if  read  aright  as  an  endeavor  on  the  part  of 
Nature  to  get  rid  of  dead  and  irritating  material.  When  this  effort  is  properly  interpreted 
the  natural  efi'orts  can  be  seconded  by  the  interference  of  the  surgeon  at  a  time  when 
disturl)ance  is  limited  to  the  minimum  and  before  external  sinuses  have  had  ()pj)ortunity 
to  form.  ( )n  the  other  hand,  ignorance  and  neglect  may  lead  to  the  extreme  condition, 
and  most  fantastic  arrangements  of  sequestra  and  involucra  are  seen  in  all  pathological 
museums,  some  of  which  seem  to  partake  almost  of  the  perplexities  of  Chinese  puzzles. 
The  ex])lanation,  however,  is  always  as  above  afforded.     (See  Figs.  233,  234  and  235.) 

Treatment.— The  treatment  should  be  surgical,  and  consist  in  removal  of  the 
dead  portions  and  restoration  of  the  parts  to  a  condition  favoring  rapid  regeneration. 
It  should  always  be  radical,  but  is  sometimes  made  difficult  by  the  inaccessibility  of  the 
fragment  or  by  the  density  of  the  involucrum  and  the  necessity  for  large  external  open- 
ings in  order  to  remove  the  sequestrum. 

Large  and  powerful  forceps  and  strong  and  well-tempered  bone  chisels  are  usually 


430 


SURGICAL   AFFECTIONS  OF   THE   TISSUES 


necessary,  while,  after  making  the  necessary  openino;  for  removal  of  the  secpiestrum, 
the  sharp  sjmon  sh(nild  be  used  thoroughly  to  scrape  away  all  the  lining  material  of 
cavities  in  which  fragments  have  been  lying  or  all  fungous  tissue  which  may  fill  sinus 
tracks.  It  will  be  well  after  this  to  thoroughly  cauterize  the  wall  of  the  cavity,  after 
which  it  is  to  be  packed. 

The  packing  of  old  bone  cavities  is  of  importance,  and  operators  should  appreciate 
the  reason  for  so  treating  them.  The  packing  is  essentially  a  foreign  material  which 
the  tissues  will  naturally  endeavor  to  extrude  as  they  did  the  sequestrum.  The  method  of 
extrusion  is  by  filling  uj)  beneath  and  around  it  with  granulation  tissue,  which  later  may 
ossify.  The  packing  is  therefore  a  constant  provocation  to  the  formation  of  this  tissue, 
which  is  now  desirable,  and  is  used  mainly  for  this  purpose.  It  is  antiseptic  material, 
and  will  serve  to  prevent  decomposition  of  the  pyoid  material   which  would  otherwise 


Fig.  233 


Fig.  234 


Fig.  23.5 


Central  necro.sis  of  the 
tibia,  long  central  -seques- 
trum. 


Sequestrum  in.side  of  a  core 
of  new-bone  tissue,  arranged 
much  like  a  puzzle. 


Necrosis  of  tibia,  showing  sequestra 
after  removal.  (All  three  specimens 
from  the  Buffalo  Museum.) 


fill  such  a  cavity  as  the  result  of  waste — ^Nature's  effort  at  formative  material  gone  to 
waste.  A  number  of  years  ago  Gunn  suggested  the  use  of  wax  for  this  purpose,  wax 
being  plastic  and  incapable  of  absorption.  A  piece  of  white  wax  was  heated  in  hot  water, 
molded  with  the  fingers  to  fit  the  cavity,  where  it  served  the  purpose  of  a  packing,  and 
Avas  reduced  in  size  with  each  dressing,  as  was  necessary  to  permit  it  still  to  remain. 
It  is  not  now  used  as  much  as  it  deserves  to  be.     (See  p.  431.) 

In  favorable  cases  it  may  be  possible  to  so  thoroughly  cleanse  the  bone  cavity  without 
the  use  of  caustics  as  to  justify  the  attem])t,  after  rigid  asepsis,  of  allowing  it  to  fill  with 
blood,  which  will  coagulate  and  organize  into  connective  tissue.  When  this  eftect  is 
desired  the  wound  should  be  covered  with  green  silk  protective,  over  which  the  other 
dressing  may  be  snugly  applied.  This  healing  by  the  aseptic  blood  clot  is  the  ideal  method 
when  possible. 


fili.im;  of  lio.M-i  c.wiTHis  431 

The  cxtciil  to  wliicli  r{'<;ciuM'ati()ii  of  l)oiio  is  possible  is  often  aniaziiifj,  especially  in 
the  y()llIl^^  'rims  after  removal  of  the  entire  shaft  of  a  tibia  there  may  result,  in  time, 
not  a  complete  restoration  to  former  inte^nily,  but,  in  addition,  the  formation  of  so  nmch 
new  osseous  material  as  to  restore  a  tj;reat  <le<fri'e  of  strenijth.  and  which  shall,  with  the 
compensatorily  hypertr<)phi(>d  fibula,  make  the  le<f  as  useful  as  ever.  In  the  thi<i^h, 
however,  complete  necrosis  of  the  fennu'  means  amputation,  as  it  will  also  in  the  arm 
unless  the  necrotic  portion  is  but  a  small  j)roportion  of  the  len<itli  of  the  humerus.  The 
treatment  of  necrosis  of  the  skull,  or,  in  fact,  of  any  bone  in  the  body  which  is  accessible, 
is  based  practically  on  the  i)rinciples  already  laid  down. 


BONE  TRANSPLANTATION  AND  TRANSFERENCE. 

In  the  effort  to  atone  for  extensive  loss  of  bone  many  experiments  have  been  tried, 
first  on  animals  and  afterward  on  men,  success  with  the  former  having  lent  much  pros- 
pect to  the  latter.  It  has  been  learned,  for  instance,  that  portions  of  livinji;  bone  can  be 
removed  from  some  of  the  lower  animals  and  transferred  into  a  bed  of  more  or  less  healthy 
sterile  human  tissues,  often  with  the  result  that  a  fragment  thus  transplanted  becomes 
vitalized  and  incorporated,  and  serves  the  purpose  for  which  it  was  intended;  still  these 
efi'orts  do  not  in  all  instances  succeed.  However,  experience  has  led  to  the  effort  to  utilize 
some  portion  of  the  ])atient's  own  osseous  system.  This  becomes  more  easily  possible 
in  the  case  of  tlie  forearm  or  leg  where,  especially  in  the  latter,  a  small  or  less  important 
bone  can  be  utilized  to  take  the  place  of  the  greater.  Thus,  when  the  entire  shaft  of 
the  tibia  has  been  removed  for  necrosis  resulting  from  acute  osteomyelitis,  the  fibula 
has  been  sawed  across,  opposite  the  site  of  the  ends  of  the  lacking  tibial  shaft,  and  trans- 
planted into  the  trough-shaped  depression,  thus  making  it  functionate  for  the  lost  tibia. 
Huntington  has  recently  reported  a  case  in  which  not  only  was  this  done,  but  later  the 
upper  and  lower  ends  of  the  fibula  attached  to  the  tibia,  with  good  bony  union  and  with 
an  almost  perfect  functional  result.  This  will  illustrate  what  elsewhere  may  be  done  in 
this  direction. 

FILLING  OF  BONE  CAVITIES. 

Our  methods  for  removal  of  sequestra  and  cleaning  out  of  infected  bone  cavities  are 
now  simplified  and  made  safe.  The  difficulty  which  is  still  universal  is  to  secure  a 
rapid  filling  or  closure  of  these  cavities.  If  we  could  be  certain  of  cleaning  out  every 
particle  of  infected  tissue  and  the  removal  of  every  germ  which  might  excite  putrefaction, 
then  we  might  resort  to  Schede's  plan  and  allow  even  a  large  cavity  to  fill  with  blood  clot 
and  await  its  organization,  but  no  complicated  and  infected  cavity  in  such  tissue  as 
bone-marrow  can  ever  be  so  treated  to  a  theoretical  degree  of  perfection.  Therefore 
disappointment  often  follows  this  attempt.  Senn  endeavored  to  improve  upon  the  ])lan 
by  the  insertion  of  chi])s  of  decalcified  bone,  but  this  method  is  open  to  the  same 
objection.  Dentists  have  the  advantage  of  surgeons  because  they  deal  with  small 
cavities,  and  in  tissues  which  can  usually  be  thoroughly  sterilized.  Other  things  being 
equal,  the  methods  to  which  they  resort  could,  with  advantage,  be  imitated  by  surgeons. 
In  1903,  INIosetig-Moorhof  suggested  a  mass  containing  iodoform  60  parts,  spermaceti 
40  parts,  and  oil  of  sesame  40  parts.  When  this  mixture  is  slowly  heated  to  100°  C.  and 
allowed  to  cool,  there  remains  a  soft  material  which,  when  desired  for  use,  is  melted, 
being  constantly  stirred  to  keep  the  iodoform  pn)])erly  suspended,  while  it  is  poured  into 
the  cavity,  where  it  immediately  solidifies.  It  is  claimed  that  its  physical  j^roperties 
permit  of  its  gradual  absorption  and  rejilacement  by  granulation,  and  finally  by  new 
bone,  as  has  been  shown  by  a  series  of  skiagrams.  A  cavity  in  which  this  preparation  is 
used  should  be  prepared  as  dentists  prepare  theirs.  It  is  successful  in  proportion  to 
the  absolute  disinfection  of  the  same.  For  this  purpose  wide  opening  and  ready  access 
are  necessary  in  order  to  dry  and  cleanse.  Should  oozing  be  persistent  strands  of  catgut 
may  permit  of  escape  of  the  blood  which  enters  the  cavity.  It  would  probably  be  best 
to  use  the  elastic  bandage  and  bloodless  method,  and  to  protect  for  a  few  moments  the 
solidifying  mass  l)efore  allowing  the  blood  to  return  to  the  limb.  The  originator  uses, 
in  his"  own  clinic,  a  hot-air  blast.  The  air  is  heated  by  an  electric  contrivance,  and 
both  dries  and  disinfects  the  cavitv.     After  the  cavity  is  thus  filled  the  tissues  are  closed 


432  SURGICAL  AFFECTIONS  OF   THE   TISSUES 

over  it  and  a  sterile  dressiiiij  aj)j)lie(l.  It  is  serviceable  in  ehronie  cases  and  after  thorough 
work.  In  acute  osteomyelitis  it  is  scarcely  to  be  thought  of  because  of  the  acute  character 
of  the  infection. 

OTHER  PARASITIC  AFFECTIONS  OF  BONES. 

These  are  mainly  of  two  varieties — hydatid  disease  and  actinomycosis. 

Hydatid  Disease  of  Bone. — Hydatid  disease  of  bone  consists  in  the  development 
of  hvdatid  cysts,  whicli  may  l)e  either  of  primary  or  secondary  origin.  Almost  all  the 
bones  of  the  skeleton  are  liable  to  cyst  formation,  except  the  short  bones  of  the  carpus, 
tarsus,  and  digits.  In  the  long  bones  they  occur  most  frecpiently  in  the  region  of  the 
epiphyses.  The  particular  vascularity  of  this  region  is  the  main  factor  in  their  location 
at  this  point.  The  cysts  may  be  unilocular  or  multilocular,  and  around  them  may  be  a 
thin  or  a  large  area  of  infiltration.  In  other  words,  their  boundaries  may  be  abrupt 
or  not.  Their  volume  is  exceedingly  variable,  unilocular  cysts  sometimes  attaining 
considerable  size  and  distending  the  bone  beyond  its  normal  proportions.  (See  Chapter 
XXVI  for  further  reference  to  the  pathology  of  hydatid  cysts.) 

Treatment. — The  treatment  is  purely  operative.  The  contents  of  the  cysts  should  be 
evacuated  and  its  walls  radically  destroyed  by  caustic,  spoon,  etc.  All  sequestra  should 
be  removed;  in  the  limbs  amputation,  is  sometimes  necessitated  by  the  extent  of  the  affec- 
tion. 

Actinomycosis. — The  general  character  of  this  parasitic  disease  has  already  been 
considered.     (See  Chapter  VIII.) 

The  peculiar  fungus  may  be  found  in  the  periosteum,  in  the  compact  outer  layers  of 
the  bone,  or  within  its  more  spongy  depths.  When  the  lesion  is  sufficiently  large  to  be 
recognizable  to  the  naked  eye  it  assumes,  for  all  practical  purposes,  the  appearance  of 
caries,  like  that  due  to  tuberculous  or  leprous  diseases,  while  in  the  pus  or  debris  dis- 
charged from  the  same  or  contained  within  the  invaded  bones  the  characteristic  yellow, 
cheesy,  or  calcareous  particles  will  always  be  recognized.  In  this  disease  there  never 
seems  to  be  the  slightest  tendency  to  encapsulation  nor  to  protect  against  further  spreading 
by  any  process  of  repair.  The  diseased  area  constantly  enlarges  its  dimensions,  involving 
everything  as  it  spreads,  it  being  limited  by  no  membrane  or  tissue  of  the  body. 
Occurring  in  the  bones,  it  is  usually  a  secondary  or  metastatic  infection,  and  may  be 
found  in  any  part  of  the  body. 

The  symptoms  will  be  those  of  osteoperiostitis,  first  occurring  frequently  in  the  jaws, 
as  it  nearly  always  does  in  cattle,  and  often  in  man ;  this  is  accompanied  by  loosening 
of  the  teeth  and  involvement  of  the  submaxillary  tissues.  The  course  of  the  disease  is 
slow,  with  little  or  no  tendency  toward  spontaneous  recovery. 

TROPHONEUROTIC   DISEASES   OF   THE   BONES. 

Under  this  heading  it  is  proposed  to  group  a  number  of  diseases  whose  clinical  manifes- 
tations are  distinct  or  classic,  but  whose  underlying  causes  are  more  or  less  obscure. 

Achondroplasia. — This  is  a  lesion  of  intra-uterine  life  which  includes  a  softening 
of  primary  cartilaginous  structures  and  curvature  or  malformation  of  the  bones  which 
should  be  formed  from  them.  It  belongs  to  that  period  of  fetal  life  between  the  third 
and  sixth  months.  It  is  sometimes  referred  to  as  inira-uterine  rickets.  Under  this  name 
it  was  first  descrilx'd  by  Miiller,  in  1800,  and  since  then  under  various  names,  most  com- 
monly as  fetal  rickets.  It  aj^pears  that  in  this  disease  the  fetal  cartilage  contains  mucus 
abnormally  collected,  quite  generally,  in  minute  cavities  or  cells  just  at  its  borders. 
The  chondrol)lasts  and  osteoblasts  are  not  regularly  dispersed,  and  the  development 
of  the  growing  bone  is  thereby  much  interfered  with.  The  periosteum  appears  to  have 
nothing  to  do  with  this  condition.  In  consequence  the  cartilage  does  not  do  its  proper 
duty.  The  long  bones  fail  to  attain  their  proper  proportionate  length,  but  become 
thicker  than  normal,  the  periosteum  being  unaltered.  On  the  other  hand,  those  bones 
into  whose  formation  cartilage  enters  but  slightly,  such  as  the  clavicle  and  the  ribs, 
retain  their  normal  proportions — the  consequence  is  a  peculiar  malformation  and  dis- 
proportion of  the  whole  skeleton  (Fig.  230). 

These  deformities  are  symmetrical,  and  pertain  mosdy  to  the  bones  at  the  base  of 


TUOI'llOSHVIioriC   DISEASES  OF    'I'll hi   liO.M'JS 


433 


tlu'  skull  and  (o  the  loiiff  hones  of  the  liiuhs;  tlicrcrorc  the  distiiiclivc  a|)()caraiK'C 
may  he  rci-ofjiiizcd  even  at  the  hirth  of  (lie  child.  The  iicad  is  disi)ro|)ortioiiati-ly  large, 
the  spinal  cohnnn  short,  the  hinihar  curvature  exa<^f]jerated,  all  of  which  is  ratiier  the 
reverse  of  tiie  ordinary  rachitic  manifestations.     The  disease  is  not  connnon  (Fig.  237). 


Fig.  236 


Fi<;.  237 


Achondroplasic  skeleton.      (Porak.) 


Achondroplasia.     (Lugeol.) 

Prognosis. — The  prognosis  is  unfavor- 
able, because  it  seems  impossible  to  undo 
the  faults  of  the  intra-uterine  condition. 
The  disease,  however,  is  not  incompati- 
ble with  a  long  life. 

Rachitis. — This  also  is  a  constitutional 
condition,  and  has  been  described  in 
Chapter  XIII.  So  far  as  the  manifesta- 
tions in  the  bones  are  concerned  it  is 
a  constitutional  dystrophy  caused  by 
improper  deposition  of  calcareous  mate- 
rial in  the  softened  and  somewhat  per- 
verted fetal  cartilages.  It  is  a  condition, 
however,  pertaining  rather  to  postnatal 
life,  and  while  inconspicuous  at  birth 
becomes  more  and  more  marked  as  the  child  develops.  It  is  essentially  a  disease  of  mal- 
nutrition, and  consequently  may  be  seen  in  all  walks  of  life,  as  well  in  the  bottle-fed 
babies  of  the  wealthy  as  in  the  best-nourished  children  of  the  poor.  The  subject 
should  be  studied  also  in  connection  with  the  facts  set  forth  in  the  chapter  on  the 
Status  Lymphaticus,  which  bear  on  the  relation  of  the  ductless  glands  to  tissue  growth, 
and  especially  to  rickets.  The  lesions  are  widely  distributed.  The  disease  is  divided 
by  some  writers  into  three  periods:  (a)  Rarefaction  of  bone  tissue;  (h)  softening  of 
same;  (c)  re-ossification. 

The  first  stage  is  the  intra-uterine  part;  the  second  and  third  stages  are  postnatal. 
To  fetal  rarefaction  have  been  attributed  intra-uterine  fractures,  even  by  Hippocrates. 
The  general  dyscrasia  and  visceral  alterations  of  rachitis  interest  us  here  less  than 
deformities  of  the  various  bones.  The  head  is  disproportionately  large,  the  vertex 
flattened,  the  frontal  and  parietal  eminences  pronounced;  the  anterior  fontanelle  closes 
very  late.  To  the  atrophic  alterations  of  the  head  have  been  given  the  name  cranio- 
tabes.  The  face  is  disproportionately  small,  the  lower  jaw  assuming  a  polygonal  shape. 
The  palatal  vault  is  of  the  Gothic  type,  dentition  irregular  and  retarded.  In  the  thorax 
the  clavicular  curves  are  exaggerated,  by  which  the  bones  are  shortened  and  the  shoulders 
made  narrow.  The  costochondral  junctions  are  enlarged,  the  result  being  the  so-called 
28 


434 


SURGICAL   AFFECTIONS  OF   THE   TISSUES 


rachitic  rosary.  The  stermiin  projects  and  giw^  the  |)C(uliar  a])pcarance  known  as 
'pigeon-lyrea.st.  The  pelvis  is  often  deformed,  and  fre(|uently  distorted  to  such  an  extent 
as  in  after  years  to  make  normal  delivery  im{)ossible.  The  s))inal  column  may  either  be 
distorted  early  or  is  likely  to  underrjo  alterations  of  curvature,  due  to  the  combined  results 
of  ])ressure  and  traction  upon  softened  vertebne.  The  joint  ends  of  the  lono;  bones  are 
enlarijcd  or  clubbcfj,  this  beintj  true  even  of  the  ))halan(;es.  Joint  movements  are  often 
accomjmnied  by  crepitation,  '^fhe  axes  of  the  lonj;  bones  are  distorted,  and  more  or 
less  marked  deviations  and  curvatures  result,  giving  rise  to  such  deformities  as  knock- 
kiicc,  bow-leg,  etc.      (See  pp.  161  and  162.) 

Osteomalacia. — As  rickets  is  essentially  a  disease  of  early  childhood,  osteomalacia 
is  practically  confined  to  adults.  The  name  implies  a  peculiar  .wffening  of  the  bones, 
by  which  their  resistance  and  rigidity  are  weakened  and  deformity  permitted.  The 
disease  is  common  to  man  and  to  animals  in  confinement,  and  is  frequently  noted  among 
wild  animals  dying  in  zoological  gardens.  It  comuKMily  occurs  in  pregnant  women, 
Avhere  it  would  ap])car  as  if  the  mineral  elements  needed  for  the  growing  fetus  were 
abstracted  from  the  mother's  bones  rather  than  from  the  food  ingested.  It  is  brought 
about  also  by  starvation,  possibly  by  lactation,  especially  among  those  who  nurse  their 
children  for  unusual  periods. 

Fii;.  238 


Osteomalacia:  celebrated  case  of  Moraud,  1753.     (Skeleton  now  in  Musee  Dupuytren.) 

Spontaneous  fractures,  especially  of  the  long  bones,  are  frequent.  These  may  refuse 
to  unite  properly  and  false  joints  may  result.  The  urine  will  under  these  circumstances 
contain  an  excess  of  mineral  salts,  carbonates,  phosphates,  and  oxalates,  and  when  these 
are  discovered  in  the  urine  of  those  suffering  from  fractures  it  should  always  be  a  warning 
to  administer  calcium  salts  and  mineral  acids,  preferably  phosphoric,  internally,  and  to 
carefully  watch  the  excretions.  The  progress  of  the  disease  is  slow,  yet  steady,  and 
often  not  easily  checked,  if  at  all  affected,  by  mineral  acids.  Occurring  in  pregnant 
women,  it  may  be  checked  after  delivery,  especially  if  the  child  be  not  allowed  to  nurse 
from  the  mother.  In  some  instances  it  occurs  with  each  successive  confinement  in  the 
same  patient,  and  makes  distinct  advance  with  each  fresh  attack. 

Prognosis. — The  prognosis  is  therefore  unfavorable,  least  so  in  puerperal  cases. 

An  infantile  form,  as  well  as  a  fetal  form,  have  been  noted,  but  it  is  doubtful  whether 
these  forms  really  come  under  the  same  category,  and  whether  they  are  not  manifesta- 
tions of  rickets.  A  senile  form  has  also  been  described  which  affects  most  frequently 
the  sternum  and  thorax,  which  is  characterized  by  excess  of  nervous  excitability  and  by 
bone  pains,  as  well  as  by  liability  to  multiple  fracture  upon  the  slightest  provocation. 
This  form,  however,  difTers  but  little  from  the  osteoporosis  of  advanced  years,  and 


Tli(H'll().\KrU(>TJC  J)1SK.\SKS  OF    THE   liOSEH 


435 


scarcely  deserves  distinct  consideration.  Certain  writers  Imve  also  mentioned  a  .sijmp- 
tomatic  jonii — cancer,  syphilis,  scurvy,  etc  which,  however,  is  unnecessary,  since  the 
fractures  occurrin*;  in  cases  of  cancer  or  sy|)hilis  arc  due  to  secondary  lesions  of  the  same 
character,  while  those  occurrinif  durin<;  scurvy  are  simply  an  e.\|)ression  of  starvation 
and  weakcnin<,f,  even  of  the  l)ones.  Cases  of  cancer,  for  instance,  where  hones  have 
broken  without  heinii;  previously  weakened  by  secondary  fijrowths,  are  exceedinfjlv  rare. 

Under  the  name  of  o.s7ror/r//r.vAv  inijxTJcrin  has  hecii  described  the  "fra^ilitas  ossium" 
of  certain  writers.  The  condition  has  also  been  known  as  congenital  fetal  rickets. 
These  eases  may  usually  be  recognized  in  infancy,  in  that  the  extremities  are  more  or 
less  bent  and  deformed,  and  the  bones  very  frajjile.  Sometimes  intra-uterine  fractures 
occur,  which  may  be  recent  or  old,  and  united  with  more  or  less  callus  and  deformity. 
The  spinal  column  will  be  soft  and  friable,  with  marked  divisions,  and  the  ribs  are  often 
fractured.  The  clavicle  shows  lesions  of  this  kind  more  frequently  than  any  other  single 
bone.  Bones  so  afl'ected  will  be  found  extremely  fra<rile  and  delicate,  and  sometimes  so 
thin  that  they  may  be  crushed  between  the  fingers.  They  are  defective  in  every  respect 
of  structure.  But  these  changes  pertain  mostly  to  the  shafts  of  the  long  lujiies,  and  do 
not  concern  the  cartilages.  They  are  to  be  distinguished  from  chondrodystrof)hia 
fetalis,  in  which  the  extremities  are  shortened,  the  skin  thickened,  and  the  subcutaneous 
tissues  extremely  fatty  or  edematous.' 

The  condition  is  to  be  distinguished  from  rickets,  as  there  is  no  enlargement  of  rib 
ends  or  e])iphyses  and  no  distiu'bances  of  the  alimentary  or  nervous  systems.  Osteo- 
malacia usually  occurs  after  puberty.  Hereditary  syjihilis,  in  very  rare  instances,  is  a 
factor,  but  should  give  additional  evidences  in  other  parts  of  the  body.  At  present 
there  is  no  satisfactory  exj^lanation  as  to  the  cause  of  the  condition. 

Treatment. — The  treatment  for  all  these  conditions  should  be  removal  of  the  cause  if 
discoverable  and  the  administration  of  calcium  salts  in  accessible  shape,  as  in  cases  of 
rickets,  combined  with  thymus  or  pituitary  extract. 

Osteopsathyrosis,  or  "Fragility  of  Bones.— This  is  a  condition  distinct  from 
osteomalacia  and  is  due  to  trophic  nerve  disturbance.  The  condition  seems  to  be  heredi- 
tary, often  extending  through  several  genera- 
tions. It  is  characterized  by  fracture  of  long 
bones  upon  the  slightest  provocation,  and  is 
common  to  all  ages.  ^Yhile  apparently  congen- 
ital in  origin,  it  persists  often  throughout  life, 
no  impression  being  made  upon  the  condition 
by  medication.  It  is  not  characterized  by  dis- 
tinctive histological  changes,  and  all  theories 
heretofore  advanced  toward  its  cause  are  dis- 
ajipointing.  It  is  seen,  at  least  in  this  coun- 
try, most  often  in  paretics  and  inmaics  of 
insane  asylums.  The  ease  with  which  the 
bones  of  such  ]:)atients  are  broken  has  given  rise 
to  repeated  charges  of  violence  or  homicide. 
From  one  case  in  which  this  charge  was  made  I 
secured  specimens  of  the  ribs,  which  w'ere  so 
fragile  that  they  could  be  crumbled  between 
the  fingers.  Such  patients  might  easily  sustain 
serious  fractures  when  undergoing  necessary 
restraint,  even  of  the  gentlest  nature.  Alle- 
gations of  undue  violence  are  frequently  made 
in  these  cases,  which,  especially  in  asylums, 
may  be  most  unjust  and  difficult  to  prove  or 
disprove. 

The  relationship  of  osteomalacia  to  exoph- 
thalmic goitre  furnishes  another  illustration  of 
the  peculiar  and  mysterious  influences  which 
the  thyroid  exercises  upon  nutrition.  The  con- 
ditions have  a  similar  geographical  distribu- 
tion, as  well  as  being  coincidental  in  the  same  individual.  Honicke,  who  has  recently 
studied  the  subject,  believes  the  bone  condition  to  be  an  expression  of  thyroidal  dis- 


FiG.  239 


^ 


Osteopsathyrosis.     (Blanchard's  case.) 


436  SURGICAL  AFFECTIONS  OF   THE   TISSUES 

order,  the  more  so  in  tliat  eastration  does  not  remedy  the  disease,  thus  proving  that  the 
genital  glands  are  not  at  fault. 

The  peeuliar  relationshij)  between  the  bone  and  the  thyroid  in  these  eases  is  probably 
one  of  disturbanee  of  the  elaboration  of  the  pliosphorus  compounds  which  are 
necessary  for  the  proper  development  of  bone,  these  compounds  being  excreted  rather 
than  utilized. 

Osteopsathyrosis  of  this  congenital  type  is  perhaps  best  illustrated  by  a  case  reported 
by  Blanchard,^  of  Chicago,  in  the  case  of  a  woman  twenty-seven  years  of  age  at  the  time 
of  his  report,  who  up  to  that  time  had  sustained  over  one  hundred  fractures.  In  her 
case  it  was  sufficient  to  merely  gently  slide  from  the  sofa  to  the  floor  to  break  some  bone. 
Treatment  in  her  case  had  been  of  no  avail.      (See  Fig.  239.) 

Senile  Fragility  of  Bones, — This  means  weakening  of  the  bones  wdiich  is  incident  to 
advanced  age  in  either  sex,  due  to  and  comprised  under  the  term  osteoporosis.  Added 
to  this,  in  certain  places  is  a  positive  change  in  shape,  also  characterizing  the  senile 
condition — c.  g.,  the  neck  of  the  femur.  Under  these  circumstances  bones  will  break 
with  a  minimum  of  violence  and  without  invoking  any  theory  of  osteomalacia,  osteo- 
psathyrosis, or  the  like.  As  bone  disappears  under  these  circumstances  fat  usually 
takes  its  place,  so  that  while  the  volume  of  the  bone  may  not  be  particularly 
diminished,  its  weight  and  density  are  materially  altered.  (See  introductory  remarks 
to  this  chapter.) 

Atrophic  Elongation. — This  is  a  term  first  applied  by  Oilier,  and  refers  to  a 
distinct  type  of  alteration  in  long  bones  by  which  their  actual  volume  is  relatively  dimin- 
ished, although  they  increase  in  lengih.  It  is  produced  largely  by  lack  of  pressure,  and 
is  seen  in  many  amputated  stumps,  in  which  it  has  much  to  do  with  the  conicity  of  the 
same.  It  is  seen  in  certain  cases  of  typhoid  fever  or  in  forced  confinement  of  the  young 
in  bed,  where  the  bones  appear  to  grow  at  a  much  more  rapid  rate  than  normal.  It 
may  also  be  due  to  unequal  amounts,  or  defects,  of  nutritive  supply,  especially  that 
furnished  by  the  periosteum,  and  in  certain  other  cases  seems  to  be  a  purely  reflex  or 
trophoneurotic  change  which  is  always  inexplicable.  Freqviently  accom])anying  it  is 
muscular  wasting,  which  is  to  be  explained  rather  by  reflex  action  through  the  cord, 
produced  perhaps  through  the  mechanism  of  the  terminal  filaments  of  the  articular 
nerves. 

Ostitis  Deformans. — Ostitis  deformans  is  often  called  Paget' s  disease  of  the  hones, 
and  is  a  condition  found  alike  in  long  and  flat  bones,  the  osseous  tissue  being  condensed 
in  texture  and  increased  in  amount,  or  at  other  times  the  osseous  tissue  becoming  quite 
porous  and  the  spongy  tissue  rarefied  without  alteration  in  the  marrow.  It  is  due  to 
the  unknown  causes  which  may  be  summed  up  in  the  expression  trophoneurotic,  a 
'painful  and  a  pahiless  form  having  been  described,  the  former  the  more  frequent.  It 
produces  deformities,  disfigurements,  and  hypertrophies  of  the  long  bones.  It  is  dis- 
tinguished from  arthritis  deformans,  described  in  the  previous  chapter,  which  is  a 
distinct  malady. 

In  the  skull  it  is  usually  the  face  bones  which  are  most  involved,  although  the  disease 
often  commences  in  the  cranial  bones.  The  skull  proper  may  be  thickened  even  to 
3  Cm.  The  thorax  becomes  globular  or  cubic  in  form,  the  arms  are  relatively  too  long, 
and  there  is  usually  dorsal  kyphosis;  the  pelvis  is  thickened  and  distorted;  the  ribs  are 
augmented  in  size  and  the  femora  irregularly  curved;  the  patellfe  enlarged;  the  tibiae 
more  massive  and  their  curves  exaggerated.  The  disease  is  essentially  symmetrical, 
commonly  commencing  in  the  cranium  and  radius.  Fractures  are  rare,  because  the 
bones  become  stronger  rather  than  weaker. 

In  many  instances  these  changes  are  accompanied  by  severe  pains,  which  may  be 
exaggerated  by  pressure.  The  malady  is  usually  regarded  as  rheumatism,  but  it  may 
be  said  that  even  were  accurate  diagnosis  made  early  it  would  scarcely  avail  in  treatment, 
since  there  is  none  for  it.  It  may  require  to  be  distinguished  from  hereditary  syphilis, 
in  which  the  tibise  have  more  of  the  saber  shape;  from  acromegah/  or  leontiasis,  which 
begin  in  the  bones  of  the  face  and  involve  tlie  cranium  only  secondarily. 

Osteoarthropathie  Hypertrophiante  Pneumique. — Under  this  title,  which  has 

no  exact  equivalent  in  English,  was  described,  in  1890,  by  Marie,  a  peculiar  affection, 
often  wrongly  spoken  of  in  this  country  as  Marie's  disease.     This  is  in  large  part  a 

*  Trans.  Amer.  Orthopedic  Assoc. 


TUOI'llONFAJROTlr  D/SKASKS  OF  THE  HON  EH 


437 


pulinoiiiirv  allVclion  accoiiipaiiicd  l)y  (•iil:iiii;('iiiciit  of  tlu-  cxtrciiiitics.  'I'iicre  is  reason 
to  l)('lii"V(>  (hat  tluM-(>  aiv  j)ivst'nt  inicroorjranisnis,  <>;iviiiif  rise  to  i)ro(liic'ts  that  are  absorbed 
into  the  ifcncral  c-ireulation,  the  resuU  of  whose  presence  is  an  irritative  liyj)ertrophy  of 
certain  j)arts,  j)articuhirly  the  joints  and  ends  of  the  finjijers,  the  elbow-,  shoulder-,  and 
knee-joints,  and  often  the  wrist  There  is  also  onhnarily  dorsoluinbar  kyphosis,  which 
in  acronu'ifaly  is  usually  cervicodorsal.  The  cranium  remains  intact;  the  borders  of 
till"  jaw  arc  sometimes  involved. 

Acromegaly. — Acromejialy  is  so  named  from  its  tendency  to  increase  the  volume 
of  the  bone  extremities  or  apices.  The  first  case  of  this  disease  was  published  by  Marie 
in  ISS").  It  is  characterized  by  prof^ressive  increase  in  wei<:;lit,  by  enlar<ijement  of  all 
the  extremities,  bones  and  soft  tissues  alike;  but  the  most  characteristic  involvement 
is  that  of  the  lower  jaw,  tiie  upper  jaw  beino;  little  if  at  all  affected.  The  lower  jaw 
assumes  enormous  size  and  ])rojects  so  that  its  teeth  are  far  in  front  of  those  of  the 
upper.     The  supra-orbital  ri<lp;es  enlar<;e,  as  do  also  the  sternal  ends  of  the  clavicles  and 


J'k;.  LMO 


Fu;.  241 


P 


i 


Osteoarthropathy.     (Marie.) 


Acromegaly.     (Original.) 


costal  cartilages.  As  the  disease  progresses  the  ribs  are  widened  and  the  scapulae 
enlarged,  the  vertebrae  and  the  intervertebral  cartilages  thickened  and  fused  together, 
causing  usually  cervicodorsal  kyphosis.  The  long  bones  of  the  limbs  suffer  later, 
especially  at  the  lowermost  joint  ends — i.  e.,  hands  and  feet.  The  viscera  are  rarely 
affected,  but  there  is  a  peculiar  and  characteristic  enlargement,  usually  of  the  thyroid 
and  pituitary  bodies.  The  lower  cervical  ganglion  of  the  sympathetic  is  also  sclerosed; 
the  mucous  membrane  of  the  nose  is  usually  hypertrophied;  the  uvula  is  enlarged  and 
the  larynx  often  participates  in  the  changes.  Acromegaly  is  essentially  symmetrical, 
and  for  each  change  upon  one  side  of  the  body  is  noticed  a  correspon<ling  alteration 
upon  the  other.  Particular  features  are  observed  in  individual  cases,  but  the  above 
are  practically  common  to  all. 


438 


SURGICAL   AFFECTIOXS  OF  THE  TISSUES 


Fic.  242 


The  underlying  jiatliolo^ical  condition  is  as  yet  undetermined,  though  most  indica- 
tions point  to  hi(e  alterations  alonp;  the  original  rraiiiopliari/iu/cal  tract  of  the  young 

enihryo,  whose  remains  are  best  known 
in  the  ])ituitarv  body  and  the  thyroid. 
On  this  account  there  is  reason  for  try- 
ing the  treatment  by  extract  of  the  pitui- 
tary body,  or  even  of  the  thyroid.  The 
greatest  com]>laint  usually  is  of  headache, 
which  is  difficult  of  relief.  The  disease  is 
steady,  progressive,  unaffected  by  treat- 
ment, and  the  prognosis  bad,  tliough  its 
course  is  slow. 

Leontiasis. — A  dill'use  bilateral,  sym- 
metrical hy])ertro])hy  of  the  bones  of  the 
face  and  later  of  the  cranium,  described 
first  by  Virchow,  the  real  origin  appear- 
ing to  be  in  the  superior  maxilhe,  the  re- 
sult being  a  peculiar  leonine  appearance 
of  the  face,  hence  the  name  given  to 
the  disease.  There  is  no  distinct  tumor 
formation  in  the  bone,  but  rather  the 
entire  structure  of  the  bones  involved  is 
affected.  As  it  advances  function  of  the 
parts  is  interfered  with,  mastication  be- 
comes impossible,  headache  and  pain 
are  constant.  The  special  senses  are  disturbed  because  of  involvement  of  their 
nerves,  and  patients  die  usually  from  inanition,  because  no  longer  able  to  chew  and 
swallow  food.  It  is  distinguished  from  Paget's  disease,  because  it  shows  no  tendency 
to  involve  the  rest  of  the  skeleton;  from  acromegaly,  in  which  the  general  shape  of  the 
jaw  is  preserved,  though  its  dimensions  are  magnified;  from  tumors  of  the  jaw  or  face, 
because  of  its  synunetrical  enlargement.  Its  pathogeny  is  as  obscure  as  that  of  the  other 
bone  affections  mentioned  in  this  list,  and  its  treatment  as  unsatisfactory. 


Leontiasis:  skull   of  a  Chinese  woman. 
Museum,  No.  10,020.) 


(U.  S.  A. 


TUMORS  OF  BONE. 

As  between  the  various  hypertrophic  conditions  of  the  bones  above  noted  should  be 
distinguished  the  true  neoj^lasms,  which  answer  all  the  requirements  of  the  definition 
given  in  Chapter  XXVI.  There  are  few  of  the  true  tumors  which  may  not  be  met  with 
in  bone,  including  the  periosteum. 

Fig.  2 13 


Multiple  enchondromas  of  fingers. 


Fibromas. — Fibromas  may  spring  from  the  periosteum,  especially  about  the 
jaws  and  from  the  base  of  the  skull,  from  which  latter  place  they  may  j)roject  into  the 
nasojjharynx  and  interfere  with  the  welfare  of  the  patient.  Some  of  these  tumors  are 
soft  and  succulent,  as  well  as  extremely  vascular,  and  I  have  seen  d(>ath  occur  upon  the 
table  in  an  endeavor  to  remove  a  growth  of  this  kind,  hemorrhage  being  uncontrollable. 


TUMORS  OF  BONE 
FiQ.  244 


439 


Multiple  ecchondroses  and  exostoses.       Skeleton  in  tlie  museum  at  Lyons.     (Poncet,) 

Fig.  245 


.\Iulti|)le  etihcin(li\.ses  and  e\o-t<)«es       (Lexer.) 


440 


SURGICAL  AFFECTIONS  OF   THE   TISSUES 


Cartilaginous  Tumors.-  rartila<>iii()us  tumors,  as  stated  in  Chapter  XXVI,  are 
not  often  found  outside  of  the  hony  skeleton.  They  may  spring  from  eartilag'inous 
extremities  of  growing  bones,  from  e{)iphyseal  cartilages,  or  from  the  interior  of  long 


Fig.  24G 


Cancellous  osteomas  springing  from  the  fliploe.    (Muscle  Dupuytren.) 

and  short  bones,  where  their  origin  is  probably  due  to  inclusion  of  cartilaginous  elements, 
as  com]:)rehended  in  Cohnheim's  theory.  In  young  children  they  are  often  multiple  and 
involve  various  parts  of  the  body.     Occurring  in  adults  they  are  less  often  multiple,  but 


Fig.  247 


Fig.  248 


Sarcoma  of  femur.     (Buffalo  Clinic.) 


\ 
Fungating  osteosarcoma  of  cranium.     (Pemberton.) 


may  attain  considerable  size.  (See  Fig.  243.)  They  are  found  usually  about  the  ribs, 
sternum,  pelvis,  and  femora.  If  the  entire  structure  of  a  given  bone  be  involved  in  a 
growth  of  this  kind,  its  eradication — that  is,  am])utation — will  probably  be  necessary. 


TUMORS  OF  HOXE 


441 


J> 


a/ 


Whrn  otluTwisc,  coiiii)]!'!!"  n'iii()\;il  willi  carctul  caiitcrizatioii  ol'  the  base  ol"  (he  ifrowtli 
or  .surface  iroiii  wliicli  il  sprang  will  usually  Ih'  sufHcicnt.  'rhesr  cartilaginous  tumors 
tend  on  one  hand  to  nuicoid  soi'tminji;  and  cystic  formation,  and  on  the  other  to 
caleiKcation  or  ossification,  hy  which  tlie  orif];inal  cartilaijinous  charact  r  of  the  growth 
may  I)e  concealed. 

Osteomas .--( )steonias  are  hy  some  writers  made  to  include  f.roftfo.srs  and  Injprr- 
o.sVo.sv'.v.  In  accordance  with  the  .system  followed  in  this  work  only  those  growths  are 
considered  as  tumors  which  are  of  no  physiological 
usefulness,  and  it  is  preferable  to  maintain  a  dis- 
tinction between  osteomas  and  theexostostvs  or  bone 
hypertrophies,  which  pertain  either  to  evolutionary 
relics  or  to  con.stitutional  affections. 

There  is,  however,  a  peculiar  form  of  exostosis 
which  becomes  covered  by  an  adventitious  l)ursa, 
who.se  walls  become  in  time  quite  thick,  which  is 
called  r.ro.v/o.s'/.v  Jmrsain.  In  the  cavity  of  this  biu'sa 
may  frequently  be  found  rice-grain  ov  other  fibrin- 
ous concretions.  This  lesion  is  common  in  the 
neighborhood  of  joints,  and  the  new^  bursa  fre- 
quentlv  connuunicates  with  the  joint  cavitv  (Fig. 
24<)).   ' 

Myxomas. — Myxomas  are  rare  in  l)one,  and 
are  .seen  usually  only  as  degenerated  forms  of  car- 
tilaginous bony  or  malignant  growths.  They  lead 
to  cystic  degeneration.  A  primary  growth  of  this 
kind  has  for  its  origin  the  bone-marrow. 

Sarcoma. — As  already  described,  sarcoma  of 
bone  should  not  be  confused  with  osteosarcoma. 
(See  Sarcoma.)  The  former  refers  to  sarcoma 
springing  from  the  true  osseous  tissue  or  perios- 
teum. When  central  the  bony  walls  are  expanded 
and  form  a  shell.  Osteosarcoma  refers  to  a  tumor 
springing  from  the  original  connective  tissue  which 
holds  the  bony  elements  together,  and  contains 
osseous  tissue  scattered  through  it.  Sarcoma 
occurs  usually  in  the  long  bones,  although  none  are  exempt;  mostly  single,  it  never- 
theless may  be  multiple.  It  occurs  frequently  in  the  young,  is  seen  even  at  birth, 
and  in  these  instances  is  supposed  to  take  its  origin  usually  from  epiphyseal  struc- 
tures. No  period  of  life  is,  however,  exempt.  Tumors  attain  sometimes  enormous 
size.  ]\Iarsh  has  recently  described  such  a  tumor  weighing  thirty-three  pounds.  ]\Iicro- 
scopically  these  tumors  may  assume  any  of  the  varieties,  endothelioma,  angiosarcoma, 
etc.,  those  of  the  most  rapid  growth  being  found  rather  of  the  round-cell  type,  while 
those  of  slow  growth  are  usually  myeloid  or  contain  giant  cells. 

Sarcomas  frequently  arise  from  the  periosteum.  Commencing  in  the  interior  of  a 
bone,  they  develop  for  the  most  part  very  slowly,  and  expand  the  bone  more  or  less 
symmetrically,  in  distinction  to  those  growths  of  external  origin  which  are  in  evidence 
on  one  or  another  aspect  of  the  bone  involved  (Figs.  247  and  248). 

Sarcoma  not  infrequently  has  its  origin  from  the  callus  of  a  delayed  bone  union,  ami 
I  have  had  repeatedly  to  amputate  for  this  sequel  of  fracture.     (See  Fig.  252.) 

As  the  disease  advances  there  is  incresae  of  pain,  usually  with  increasing  cachexia, 
Avhile  augmentation  in  size  of  such  a  tumor  may  make  a  limb  not  only  useless,  but  the 
source  of  greatest  annoyance  and  difficulty  in  management  of  the  case. 

Treatment. — There  is  but  one  treatment  in  cases  which  will  permit  it — amputation 
of  limbs,  extirpation  of  tumors  from  certain  bones,  or  excision  of  entire  bones.  Thus 
for  sarcoma  of  the  scapula  we  extirpate  the  entire  bone;  for  sarcoma  of  the  skull  w'e 
make  extensive  resections  of  the  same,  removing  the  underlying  dura  wdien  involved; 
for  sarcoma  of  the  lower  or  upper  jaw  we  remove  it  in  whole  or  in  part.  Sarcoma 
of  the  spine  is  inoperable,  that  of  the  pelvis  almo.st  equally  so.  In  absolutely 
inoperable  cases  treatment  by  the  toxins  of  erysipelas  may  be  tested.  In  all  cases  w^here 
pain  is  severe  opiates  should   be  administered,  which  under  these  circumstances  are 


Exostosis  bursata.      (Orlow.) 


442 


SURGICAL  AFFECTIOXS  OF   THE   TISSUES 


anodyne,  stimulant,  and  almost  nutritive.  Patients  in  this  condition  should  not  be 
allowed  to  suffer,  and  oi)ium  in  assimilable  form  should  always  be  administered  to  any 
amount    necessary. 


Fig.  250 


Fig.  251 


Sarcoma  of  periosteum  of  humerus.     (Pemberton.) 


Bone  cyst  of  tibia.      (Buffalo  Clinic.) 


Myeloma  (Kahler'S  Disease).— Collins^  reports  the  tenth  recorded  case  in  this 
country.  The  disease  was  first  descril)ed  by  Bence  Jones  in  connection  with  a 
peculiar  proteid  found  in  the  urine.  It  is  characterized  l)y  changes  in  the  bones, 
with  pain  in  the  chest,  back,  and  loins.  In  the  urine  albuiuo.se  appears,  which  seems 
to  be  pathognomonic  wlien  taken  in  connection  with  such  symptoms  as  tho.se  above. 
(.)n  sectifju  numerous  small  tumors  are  .seen  in  the  bones.  The  disease  has  hitherto 
been  regarrled  as  an  expression  of  osteomalacia.  All  the  bones  of  the  skeleton  may 
be  involved  without  any  tendency  to  metastasis  in  other  tissues.  On  minute  exami- 
nation the  myelomatous  tumors  met  with  seem  to  be  found  alike  in  the  bone  substance 
and  the  marrow,  and  to  be  cell  proliferations  of  myeloid  tissue.  The  matter  is  still 
left  somewhat  in  doubt  as  to  what  should  be  meant  by  the  term  mijeloma,  this  being  a 
feature  to  be  cleared  up  later.  It  is  seen  more  often  in  males  than  in  females,  and  in 
the  later  part  of  life.  Aside  from  con.stant  malaise,  with  pain  in  the  back  and  side, 
there  occur  progressive  weakness,  with  anemia,  and  such  fiiu^l  softening  and  fragility 
of  bones  as  to  lead  to  spontaneous  fractures,  or  to  the  projection  of  tumors,  which  may 

>  Medical    Hecord,  .\pril  29,   1905. 


TrMORS  OF   ]i()\'E 


hv  esptH-iallv  noted  about  tlu'  ribs,  witli  (Icforiiiil  y  of  I  lie  vcrl.'bra'.  (hi  close 
the  urine  will  he  found  turhid  and  alhuniose  is  detected.  'Hie  disease  is  usuall 
as  hoi>eless;  there  is  no  infonnatioii  retjardino;  its  successful  treatUK-nt. 


443 

inspection 
y  regarded 


Sarcoma  developing  in  callus.     (Haberen.) 


CHAPTER   XXXIII. 

DEFORMITIES  DUE  TO  CONGENITAL  DEFECTS  OR  ACQUIRED  DIS- 
EASES OF  THE  LOCOMOTOR  APPARATUS;  ORTHOPEDICS. 

In  previous  chaj^ters  have  been  considered  the  various  morbid  conditions  of  bones, 
joints,  muscles,  and  tissues  which  help  to  form  the  locomotor  apparatus  of  the  body. 
It  would  seem  then  cpiite  proper  in  this  place  to  insert  the  chaj)ter  usually  relej^ated  to 
the  end  of  text-books  on  surgery  where  it  stands  by  itself,  i.  e.,  the  chapter  on  Ortho- 
pedics. As  a  subject  orthopedics  deals  with  the  causation  and  the  treatment  of  deformity, 
whether  inherited  or  caused  by  disease.  The  term  is  used  in  a  more  or  less  elastic  sense, 
and  is  made  by  some  to  cover  a  larger  field  than  others  would  accord  it.  The  subject 
divides  itself  into  two  parts: 

*  1.  The  consideration  of  deformities  produced  by   tulierculous  or  other  infectious 
disease,  and 

2.  Non-carious,  congenital,  and  acquired  deformities. 

Tuberculous  lesions  do  not  differ  in  jiathology  or  other  respects  from  the  tubercu- 
lous diseases  of  bones  and  joints  described  in  earlier  chapters  of  this  work.  Inasmuch, 
however,  as  some  of  them  form  distinct  and  clinical  types  of  deformity  they  assume 
an  importance  which  justifies  reasonable  consideration  by  themselves.  Of  these  we 
shall  consider  spinal  caries,  sacro-iliae  disease,  hip  disease,  and  tumor  albus. 

SPINAL  CARIES,  SPONDYLITIS,  KYPHOSIS,  POTT'S  DISEASE. 

These  various  terms  have  reference  to  deformities  of  the  spine  of  similar  type,  but 
with  considerable  variations,  produced  by  caries  (tubercidosis)  of  the  vertebral  column. 
Where  osseous  structures  are  separated  by  cartilaginous  or  more  or  less  complete  joint 
cavities  the  primary  focus  may  form  within  the  spongy  structures  of  the  vertebral  bodies 
or  in  the  softer  tissues  of  the  intervertebral  joints.  In  other  words,  it  is  caries  of  the 
ordinary  type  which  assumes  special  significance  only  because  of  the  accident  of  its  loca- 
tion. The  entire  vertebral  column  should  be  regarded  as  the  main  support  of  the  body, 
while  to  it  is  due  the  maintenance  of  the  erect  position  which  raises  man  above  the 
animal.  When  diseased  and  softened  it  yields  to  pressure,  the  result  being  exagger- 
ation or  distortion  of  its  natural  curves.  As  the  instinctive  tendency  of  the  human 
being  is  to  maintain  the  head  in  the  line  of  the  centre  of  gravity  above  the  pelvis,  any 
marked  degree  of  curvature  in  one  direction  brings  about,  i)y  natural  causes,  a  compen- 
satory curve  in  its  opjjosite  direction.  A  well-marked  case  of  kyphosis,  then,  is  char- 
acterized by  more  than  one  exaggerated  curvature  or  protuberance,  one  being  due  to 
disease,  the  other  to  compensation. 

While  there  may  be  several  foci  of  active  tuberculous  disease,  even  in  one  vertebra, 
there  may  be  found  pronounced  forms  of  angular  curvature  as  the  result  of  destruction 
occurring  in  but  one  or  two  of  them.  The  carious  process  once  begun  may  be  checked 
at  any  point  in  its  course,  or  it  may  proceed  to  complete  softening  and  destruction,  with 
formation  of  cold  abscess.  The  tuberculous  process  once  begun  spares  no  tissue,  and 
thus  bone  and  intervertebral  cartilage  melt  and  disappear  in  the  same  manner.  There 
may  be  a  possible  danger  from  spreading  of  tuberculous  disease  to  the  spinal  meninges 
or  to  the  cord,  or  of  its  being  generalized.  In  the  former  case  there  is  pachymeningitis 
and  myelitis  with  paralysis;  in  the  latter  case  it  causes  more  or  less  rapid,  acute  general 
tuberculosis.  Paralysis  is  more  often  induced,  however,  by  actual  compression  than  by 
mere  tuberculous  involvement,  although  the  disease  products  which  cause  this  pressure 
are  likely  to  come  from  a  caseous  pachymeningitis. 

The  disease  is  most  common  in  childhood,  about  80  per  cent,  of  cases  occurring 
before  puberty.  Of  the  three  regions  of  the  spine  the  thoracic  is  the  one  most  often 
( 444  ) 


SI'IXAL   CARlh'S,  SPOS DV LITIS,  KYI'JIOSIS,   I'OTT'S  DISI-ASI-J  445 

involwd,  lU'Xt  till'  luinhar,  and  lastly  tlic  (•(M-vicul.  'I'lic  most  (•oiniiioii  site  of  all  is  in 
the  lower  (lorsai  refi;ion.  Deformity  oiiee  estuhlislied  as  the  result  of  this  disease  cannot 
he  expected  to  spontaneously  disai)pear. 

Causes. — Sli<^ht  injuries  occurrini;  in  those  of  tuberculous  diathesis,  hy  wliicli 
there  is  j)roduce(l  a  focus  of  least  resistance,  or  secondary  infections  followinir  n|»()n 
such  conditions  as  scarlatina  and  typhoid,  constitute  the  most  frecjuent  rec()<;nizal)Ie 
causes.  There  can  usually  he  obtained  a  history  of  some  injury  in  about  half  of  the 
cases.     The  disease  once  established  may  assume  either  an  acut(>  or  chronic  type. 

Symptoms. — As  indicated  when  discussing  caries  in  joints  the  principal  siirns  and 
symptoms  are  pain,  muscle  s})asm,  muscle  atrophy,  tenderness,  deformity,  and  ini])air- 
ment  of  func-tion.  These  are  all  present  in  Pott's  disease,  to  which  they  give  that 
distinct  clinical  picture  which  Pott  so  graphically  described  about  a  century  ago. 

Pain. — Pain  is  rarely  absent.  It  may  be  misleading,  but  is  usually  referred  to  the 
terminal  distribution  of  the  intercostal  nerves,  and  thus  may  be  complained  of  in  the 
chest,  the  abdomen,  or  the  legs.  Many  a  "stomach-ache"  in  children  is  of  this  character 
and  origin,  and  a  com])laint  of  frequent  "growing  pains"  should  be  carefully  investigated. 
Even  in  sleej)  these  ])ains  are  characteristic,  and  have  been  previously  descril)e(l  as 
"starting  pains."  Children  cry  out  with  them  in  the  night.  They  tire  easily  and  tend 
to  seek  rest  instinctively.  Pain  is  always  aggravated  by  excessive  pressure  upon  the 
upper  spine  or  by  jars,  such  as  may  be  received  in  jumping.  It  is  not  necessarily  con- 
stant. Vertebral  tenderness  may  sometimes  be  detected  by  pressing  upon  the  ribs. 
This  will  especially  aggravate  symptoms  when  respiration  is  of  a  groaning  character  or 
when  there  is  any  expression  of  dyspnea.  There  may  be  vomiting  or  dysuria.  A  sudden 
increase  of  these  painful  features  means  a  fresh  focus  of  infection,  impending  abscess, 
or  a  danger  of  paralysis. 

Muscle  Spasm. — It  is  by  muscle  spasm  that  we  account  for  the  attitudes  and  postures 
of  Pott's  disease.  It  is  a  constant  feature,  but  will  vary  in  its  expressions  with  the 
location  of  the  disease.  In  caries  of  the  cervical  spine  the  chin  is  raised,  the  head  is 
balanced  somewhat  backward,  while  the  lower  spine  is  straightened  and  given  a  back- 
ward curve.  In  the  stooping  posture  the  head  is  supported  by  the  patient's  hands  in 
the  instinctive  eflFort  to  protect  it.  In  caries  of  the  mid-dorsal  region  there  is  elevation 
of  the  shoulder,  with  marked  tendency  to  support  the  weight  of  the  upper  part  of  the 
body  by  placing  the  hands  upon  the  knees  or  thighs.  Lumbar  caries  often  produces 
perceptible  backward  curve  in  the  lower  portion  of  the  spine. 

In  all  cases  there  are  stiffness  and  rigidity  of  the  spine,  and  patients  resort  to  all  sorts 
of  instinctive  expedients  to  avoid  motion  in  the  affected  area.  When  that  part  of  the 
spine  which  is  in  relation  with  the  psoas  muscle  is  involved  there  is  more  or  less  psoas 
contraction,  with  characteristic  flexor  deformity  at  the  hip,  which  is  usually  bilateral. 
This  will  give  a  peculiarity  to  the  gait  and  cause  it  to  be  not  only  stiff  in  appearance, 
but  it  will  be  seen  that  the  patient  walks  more  upon  the  toes  and  wdth  slightly  bent  knees, 
which  are  thus  made  to  act  as  springs.  An  attitude  assumed  in  stooping  or  in  the  effort  to 
lean  over  as  if  to  pick  up  an  object  from  the  floor  is  characteristic;  the  spine  will  not  be 
curved  forward  and  the  patient  will  not  stoop  as  usual  for  the  purpose,  but  the  spine 
wall  be  more  or  less  erect  and  stiff  and  lowered  to  the  floor  by  flexing  both  knees 
and  hips  until  the  squatting  position  is  assumed.  In  rising  the  same  effort  will  be 
made  to  protect  the  spine  from  any  motion  between  its  component  parts.  (See  Figs.  253 
and  254.) 

During  sleep  this  muscle  stiffness  becomes  even  more  pronounced,  so  that  in  the 
morning  patients  are  "stiffer"  than  later  in  the  day.  The  existence  of  muscle  spasm 
can  often  be  detected  by  palpation  of  the  spinal  "lesion.  Some  lateral  deviation  or 
asymmetry  of  signs  may  often  be  noted,  according  as  the  muscles  of  one  side  are  more 
pronouncedly  influenced  by  the  location  of  the  disease  focus,  and  it  is  the  more  common 
in  proportion  to  the  greater  severity  of  the  case. 

The  confinement  caused  by  the"  disease  will  naturally  be  followed  by  more  or  less 
atrophy  of  the  body  muscles,  but,  in  addition  to  that,  those  immediately  involved  about 
the  centre  of  the  disease  undergo  an  atrophy  due  to  it  and  often  apparent  on  inspection. 

Tenderness.— In  numerous  distinctive  ways  the  patient  constantly  evinces  tenderness 
and  makes  invariable  efforts  to  protect  against  movement  or  even  jar.  Tenderness 
can  also  be  evoked  by  pressure  upon  the  head  or  shoulders,  which  will  cause  severe  pain, 
or  by  causing  the  patient  to  jump  down  a  step  or  to  rise  upon  the  toes  and  then  come 


446 


SURGICAL   AFFECTIOXS  OF   TIIF   TfSSUFS 


down  abruptly  upon  the  ht-t'l.     Pressure  upon  the  spines  of   the  affeeted  vertebrae  or 
u|)oii  the  ribs  which  connect  with  them  will  also  cause  complaint  of  })ain. 

Defonnity. — This  is  the  most  strikinf]^  objective  feature  of  well-marked  Pott's  disease. 
It  is  practically  a  backward  ])rojection  known  as  kyphosis,  the  vertebra  first  affected 
bein^  usually  the  first  to  yield,  the  others  following  or  chantjin^  in  shai)e  as  the  disease 
spreads  or  as  the  growth  of  the  individual  permits  accommodation  and  necessitates 
rearrangement.  The  more  acute  the  disease  the  sharper  the  projection.  Old  and 
mild  cases  cause  an  abrupt  curvature  rather  than  a  protuberance. 


Ik;.  253 


Fig.  254 


Typical  postures  of  the  ppinal  muscle  spasm  of  spondylitis.     CBryant.') 

It  is  well  to  keep  a  record  of  the  deformity  in  cases  under  treatment.  This  may  be 
grapliically  preserved  by  putting  the  patient  flat  upon  the  abdomen  upon  a  straight  sur- 
face and  bending  a  strip  of  lead  so  that  it  shall  fit  the  contour  of  the  spinous  processes. 
After  it  has  been  made  to  fit  it  may  be  removed  and  a  tracing  of  the  curve  made  upon  a 
sheet  of  paper.  Comparison  of  tracings  thus  made  at  intervals  will  afford  a  graphic 
record  of  the  progress  of  the  disease  or  of  the  improvement  made.  Kyphotic  deformities 
lead  to  a  shortening  of  the  spine,  so  that  growth  is  stunted  and  patients  become  dwarfed 
in  ap])earance.  Secondary  curvatures  are  produced  al)ove  and  below  the  primary 
projection.  Gradually  as  the  shape  of  the  vertebral  bodies  anfl  of  the  entire  spinal  column 
changes  the  ribs  are  pressed  more  or  less  together,  often  Ix'ing  made  to  overlap,  the 
shape  of  the  chest  undergoes  alterations,  the  sternum  sometimes  being  depressed  and 
sometimes  protruded,  giving  the  chest,  in  the  latter  case,  the  so-called  "pigeon-breast" 
appearance. 

Loss  of  Function. — There  are  but  few  disorders  which  ])roduce  more  pronounced  and 
widespread  accompaniments  than  spinal  caries.  As  change  in  the  shape  of  the  spine 
occurs  and  assumes  a  marked  type  we  see  changes  occurring  through  the  body,  not  only 
in  the  direction  of  anemia  with  general  impairment  of  function,  mental  irritaVjility,  and 
cachexia,  but  there  occur  trophic  alterations  as  well.  The  shape  of  the  face  changes, 
the  expression  assumed  is  one  of  anxiety,  and  the  features  become  less  mobile. 

Complications  and  Sequels. — Tuberculous  meningitis,  cerebral  or  spinal,  is  the 
most  dangcnnis  and  acute  condition,  while  other  tuberculous  complications  may  occur 
in  various  regions  of  the  body.  In  fatal  cases  meningitis,  in  consequence  of  acute  or 
mixed  septic  and  terminal  infection,  furnishes  the  explanation  for  the  great  majority. 
Paralysis  is  not  infrec{uent  as  a  sequel,  assiuning  the  type  of  paraplegia  and  developing 
slowly.  ]Motion  is  first  impaired  and  a  consideraljle  interval  may  elapse  before  sensation 
is  affected.  ]Motor  impairment  varies  from  mere  mild  paresis  to  complete  paralysis, 
beginning  as  fatigue,  loss  of  strength,  and  inability  to  stand.  Unless  the  disease  be 
located  in  the  lumbar  region  the  reflexes  are  exaggerated  and  muscle  spasm  is  easily 
provoked  or  occurs  without  perceptible  cause.  As  above  noted  the  muscles  become 
atrcjphicfl,  and  when  the  corrl  is  seriously  compromised  are  rigid  in  chronic  spasm. 
The  rectum  and  the  bladder  suffer  finally,  especially  in  disease  of  the  lower  segments. 
Occasionally  in  cases  of  high  d(jrsal   disease  the  arms  will  suffer  more  or  less  motor 


SPIXAL   CMill'.S,   Sl'O.M))  IJT/S,    lOriloSlS,    I'OTT  S    1)1  Sl-'.ASF.  .|.j7 

iiii]);iiriiicii(.  Sensory  parjilysis  Ix-o-iiis  usually  jis  |)arfstlicsia.  In  nicrcly  bedridden  hut 
not  actually  [)araly/A><l  individuals  the  reflexes  should  he  normal.  ( )!'  the  niusele  ron- 
tnictures,  those  of  the  psoas  are  the  most  eonmiou  and  distinctive.  l*aralysis  follows 
rather  than  preeedes  tleformity,  and  is  noted  in  |)erha|)s  20  j)er  eent.  of  advanced  cases. 
It  should  rarely  occur  if  effectual  treatment  has  been  begun. 

Abscess.  Abscess  is  usually  of  the  "cold"  type.  Its  general  character  has  been 
previously  described.  It  may  be  of  the  pun>ly  tuberculous  type,  but  is  not  infreciucntiv 
the  result  of  a  secondary  pyogenic  infection.  It  is  a  eonse(|uence  of  neglect,  but  cami<)t 
always  be  prevented.  Signs,  both  local  and  general,  of  the  ])rcsenc(>  of  j)us  or  of  pyoid 
are  noti-d  here,  as  under  other  circumstances.  There  is  exaggeration  of  local  tenderness, 
with  development  of  tumor,  which  fluctuates  as  it  a|)proa(lK\s  the  surface.  (leneral 
sejitic  features,  projiortional  to  the  activity  of  tlie  process  and  its  location,  accompany 
the  local  indications.     Sometimes  it  occurs  insidiously  and  with  but  few  evidences. 

Pus  travels  here  in  the  direction  of  least  resistance.  The  fascial  ])lanes  of  the  bodv 
are  mostly  so  placed  as  to  protect  important  body  cavities,  consc(|uently  pus  will  travel 
usually  around  them  and  toward  the  surface,  burrowing  long  distances,  for  instance, 
from  the  lower  dorsal  region  to  the  groin  along  the  ])soas  nuiscle.  Cervical  abscesses 
usually  sjM-ead  anteriorly  toward  the  })harynx  (post])haryngeal)  and  dee))ly  into  the 
thorax  (mediastinal);  they  may  open  into  the  trachea  or  esophagus  or  externally  through 
an  intercostal  space;  or  they  may  burrow  laterally,  opening  behind  the  sternomastoid 
muscle.  Dorsal  abscesses  usually  travel  posteriorly,  o[)ening  not  far  from  the  spine,  or 
they  burrow  downward  and  forw^ard  along  the  psoas  so  as  to  appear  beneath  Poupart's 
ligament.  Lumbar  abscesses  escape  through  the  psoas  sheath  as  psoas  abscesses,  so 
called,  or  between  the  fasciae  of  the  spinal  muscles  and  those  of  the  abdomen  to  ap}x>ar 
upon  the  side;  they  may  extend  downward  beneath  the  iliacus,  escaping  over  the  brim 
and  into  the  pelvis  and  then  out  through  the  saerosciatic  notch.  Of  all  these  the  psoas 
abscess,  opening  in  the  groin,  is  the  most  common.  Tliis  will  in  time  destroy  the  muscle 
fibers  of  the  psoas,  but  it  leaves  the  vessels  and  nerves  intact,  whose  sheaths  are  much 
more  resistant,  and  which  can  be  found  passing  through  such  a  cavity  like  cords  through 
a  chamber.  This  form  of  cold  abscess,  with  its  consequent  bulging  and  final  escape  in 
the  groin,  has  been  mistaken  for  hernia  as  well  as  for  abscess  due  to  perinephritis  and 
appendicitis.  The  most  serious  mistake  would  be  to  take  it  for  a  femoral  hernia.  The 
customary  routes  of  all  these  collections  of  pyoid  have  been  thus  indicated.  Neverthe- 
less abscesses  may  burrow  and  appear  almost  anywhere.  They  will  give  rise  to  varying 
and  to  superadded  symptoms,  according  to  their  location.  For  example,  retropharyngeal 
abscess  may  seriously  threaten  respiration  by  pressure  upon  the  upper  air  passages, 
while  a  collection  of  pus  in  the  mediastinum  might  cause  serious  respiratory  difficulty 
of  another  character. 

Cold  abscesses  of  spinal  origin  may  remain  stationary,  the  fiuid  portion  of  the  pyoid 
material  may  even  absorb,  while  the  balance  undergoes  more  or  less  degeneration  and 
conversion  into  inert  material,  or  they  may  slowly  or  rapidly  increase  in  size.  The 
best  that  can  be  hoped  in  such  cases  is  absorption,  with  encapsulation  of  the  solid  residue. 
Even  this  may  be  a  source  of  danger,  as  it  is  a  focus  of  lessened  resistance,  in  or  about 
which  subsequent  trouble  may  result.  Those  abscesses  which  seem  to  remain  sta- 
tionary would  best  be  let  alone,  hoping  for  subsidence  imder  good  treatment.  Those 
which  open  spontaneously  leave  tuberculous  fistulas  behind  them,  which  may  possibly 
close  in  time,  but  which  lead  often  to  subsequent  acute  infection,  and  which  are  the 
hete  noir  of  surgeons,  for  it  is  often  impossible  to  heal  them.  The  best  that  can  be  done 
in  such  instances  is  to  wash  them  out,  keep  them  clean,  and  guard  them  from  infection 
from  without.  It  is  often  possible  to  pass  a  tube  along  the  sinus  and  through  this  to 
irrigate  with  a  solution  of  iodine,  of  formalin,  or  of  any  other  antiseptic  which  may  be 
preferred.  If  anything  be  done  with  them  in  the  operative  way  it  should  be  as  radical 
as  possible,  seeking  the  original  lesion,  thoroughly  curetting  its  site  and  the  whole  interior 
of  the  cavity,  and  making  ample  opening  so  as  to  provide  for  eflfective  drainage. 

Reiropharyngeal  abscesses  usually  necessitate  evacuation  because  of  the  obstruction 
which  they  cause  within  the  pharynx.  Lumbar  and  psoas  abscesses  may  be  let  alone- 
When  this  is  not  practicable,  then  choice  should  be  made  between  simple  aspiration, 
aspiration  with  washing  or  injection  of  some  antiseptic  fluid,  and  free  opening  with 
radical  treatment.  In  these  cases  we  are  to  be  guided  by  the  peculiar  features  and 
surroundings  of  each,  and  by  our  own  facilities  for  such  work  and  for  subsequent  care  of 


448  SURGICAL   AFFECTIONS  OF   THE   TISSUES 

the  case.  An  abscess  which  will  soon  rupture  should  be  opened  and  counterdrained; 
but  in  one  where  this  is  not  impending,  and  where  home  features  are  such  that  the 
patient  can  receive  no  adequate  or  prolonged  care,  it  would  be  wiser  to  abstain. 
Under  the  best  of  circumstances  in  these  cases  it  is  always  a  difficult  problem  to  decide. 
Even  aspiration  leaves  at  least  a  needle  track  to  be  subsequently  infected,  while  the 
contents  may  be  too  thick  to  flow  through  a  small  trocar.  Aspiration  with  thorough 
washing  out  and  then  with  injection  of  emulsions  of  iodoform  or  of  other  irritating 
antiseptics  have  found  favor  with  only  a  part  of  the  profession.  If  any  radical  measure 
is  to  be  adopted  the  greatest  care  should  be  given  to  carry  out  the  principles  expressed 
in  the  general  consideration  of  cold  abscesses.     (See  p.  114.) 

Diagnosis. — Intelligent  comprehension  of  signs  and  symptoms  should  enable  one 
to  make  a  diagnosis  in  most  cases.  Nevertheless  the  surgeon  is  occasionally  in  doubt  and 
has  to  distinguish,  for  example,  as  between  Pott's  disease  and  sprain,  lateral  curvature, 
hysterical  spine,  cancer,  cord  tumors,  rheimiatic  arthritis,  rickets,  syphilis,  actinomycosis, 
hydatid  disease,  acute  osteomyelitis,  /.  e.,  non-tuberculous  diseases,  and  certain  abdom- 
inal affections  followed  by  suppuration,  such,  for  example,  as  peri-appendicular  abscess. 
JNIoreover,  spondylitis  may  be  simulated  in  the  course  or  as  a  complication  of  typhoid, 
scarlatina,  gonorrhea,  and  other  acute  infections.  Psoas  abscess  should  be  distinguished 
from  perinephritic  abscess  as  well  as  from  acute  appendicitis,  which  often  causes  psoas 
contraction,  especially  when  the  appendix  is  posteriorly  placed  and  left  in  contact  with 
that  muscle.  We  may  also  have  to  distinguish  this  condition  from  sacro-iliac  disease 
and  from  ordinary  hip  disease. 

Prognosis. — In  some  degree  prognosis  depends  on  what  is  meant  by  a  cure.  Abso- 
lute cure,  with  restoration  to  the  original  condition,  is  exceedingly  rare.  Arrest  of 
disease,  with  improvement  of  deformity,  is  possible  in  cases  seen  early.  Even  con- 
siderable motion  may  be  restored  under  suitable  treatment.  In  late  cases  hectic,  amyloid 
degeneration,  and  dissemination  of  the  disease  make  the  outlook  very  discouraging. 
At  best  its  relief  is  slow  and  in  time  it  is  always  chronic,  no  matter  how  rapid  the  onset, 
except  in  those  instances  where  dissemination  occurs  early  and  rapidly,  in  which  case 
there  is  little  or  no  hope.  In  ordinary  cases  there  is  a  certain  tendency  to  spontaneous 
recovery,  but  not  without  deformity  and  impairment  of  function,  while  obviously  the 
occurrence  of  abscess  prolongs  a  case  to  a  considerable  degree. 

Treatment. — Those  general  measures  so  necessary  for  the  treatment  of  any  tuber- 
culous lesion,  namely,  hypernutrition,  fresh  air,  and  general  constitutional  measures, 
are  needed  here  as  in  any  other  such  disease.  Physiological  rest,  i.  c,  absolute  rest 
in  a  bed  without  springs,  the  patient  lying  flat  on  the  back  or  on  the  face,  and  not  on 
the  side,  and  lying  quietly,  constitutes  the  best  part  of  local  treatment.  In  the  case  of 
children  it  is  best  to  have  a  gaspipe  frame,  across  which  cloth  may  be  stretched,  on  which 
a  fretful  child  can  be  secured  by  straps  across  the  shoulders,  pehis,  and  knees.  This 
frame  may  be  laid  upon  the  bed  and  lifted  from  it  while  a  cross-piece  is  removed  for  toilet 
purposes,  or  a  suitable  opening  may  be  left  if  a  single  piece  of  cloth  be  stretched  across  it. 
If  the  patient  can  be  made  to  submit  to  this  repose,  then  a  pad  may  be  placed  under  the 
projection.  After  a  sufficient  length  of  time,  with  the  desired  improvement,  a  plaster 
shield  may  be  molded  to  the  back,  with  the  patient  Inng  upon  his  face;  and  then,  after 
removing  and  suital)ly  trimming  and  lining  this  mold,  the  patient  can  be  returned  in 
it  to  the  previous  position  in  bed,  from  which  he  may  gradually  be  raised.  This  is  the 
best  method  to  follow  in  acute  or  severe  cases,  or  when  the  disease  is  higher  up  in  the 
spine.  It  will  also  best  serve  the  purpose  when  the  case  is  complicated  by  abscess.  To 
it  may  be  added,  if  necessary,  traction  upon  the  head  (Fig.  255). 

Treatment  by  Apparatus. — The  simplest  of  all  apparatus  is  the  plaster  jacket,  or  corset, 
which  was  brought  into  favor  in  this  country  by  Sayre,  although  not  invented  by  him. 
It  is  usually  applied  in  suspension,  i.  e.,  with  the  patient  in  the  erect  position  beneath 
the  frame,  from  which  hangs  a  support  by  which  firm  traction  can  be  made,  both  upon 
the  head  and  the  arms  or  the  shoulders.  The  intent  of  such  a  jacket  is  to  apply  it  with 
the  patient  so  stretched  out  that  a  certain  degree  of  the  projection  will  at  least  be  elimi- 
nated and  the  back  made  more  nearly  straight  than  it  otherwise  woukl  be.  In  cases 
where  this  is  impossible  it  at  least  affords  better  expansion  of  the  thorax  and  supports 
the  ribs  in  better  relation  to  the  spine,  affording  more  chest  room.  The  plaster  is  not 
applied  next  to  the  skin,  but  a  thin  undershirt  or  its  equivalent  of  woven  materials 
should  be  applied,  care  being  taken  to  see  that  it  fits  snugly  and  b  not  allowed  to  fold 


SPIXAL   CARIES,  SPONDY LITIS,   K)  I'/HISIS,   I'OTTS   DISEASE 


449 


in  ridges.  After  the  |)alieiit  is  conipietely  suspeiuied  to  a  degree  where  diseoinfort 
begins,  then  a  small  "stomaeh  pad"  is  slipjx^d  beneath  the  under-jaeket,  in  front,  in 
onler  that  more  room  may  be  given  for  enlargement  of  the  abdomen  after  a  full  nu-ai. 
Finally  with  the  first  turns  of  the  ])laster  a  strip  of  tin  or  a  e<juple  of  strips  of  nunstened 
pastei)oard  should  be  applied  directly  over  the  middle  line  in  front  and  incorporated 


I'iG.  :.'55 


Child  in  bed-frame,  with  head  traction.      (Lovett.) 

in  the  successive  turns  of  bandage,  in  order  that  there  may  be  material  there  which  may 
be  cut  down  in  removing  the  jacket.  Small  pads  should  be  placed  over  the  iliac  crests 
and  over  the  protrusion  if  it  be  at  all  marked  or  tender.  Now  by  the  use  of  a  series  of 
bandages  of  gauze,   in  which  reliable  plaster  of  Paris 

has  been  incorporated,  the  entire  trunk  is  enclosed  F""'-  256 

within  a  corset,  which  will  quickly  harden  as  the 
plaster  becomes  firm.  It  should  extend  well  down 
over  the  pelvis  and  nearly  to  the  trochanters,  since 
from  this  portion  it  takes  its  fixed  support.  It  should 
then  be  extended  as  high  as  can  be  permitted  under 
the  arms  and  higher  yet  over  the  chest  and  back. 
Enough  material  should  be  used  along  •with  the  plaster- 
of-Paris  cream,  as  the  former  is  applied,  to  ensure 
sufficient  firmness  and  strength.  If  the  plaster  be  re- 
liable it  will  not  be  necessary  to  keep  the  patient  sus- 
pended more  than  a  few  moments  after  the  com- 
pletion of  the  jacket.  The  finishing  touches  may 
be  given  it  after  he  has  been  taken  from  the  frame 
and  placed  again  upon  a  soft  surface. 

Another  method  of  application  Ls  to  have  the  patient 
recumbent  and  properly  supported,  and  this  is  particu- 
larly necessary  in  acute  cases,  where  suspension  is 
likely  to  cause  faintne.ss  or  unpleasant  symptoms.  In 
this  attitude  the  spine  is  really  put  in  better  position. 
The  method  is  not  at  all  available  in  those  few  cases 
of  lateral  curvature  which  demand  jackets  (Fig.  256) . 

Substitutes  for  these  jackets  are  made  of  various 
materials,  such  as  leather,  raw^hide,  aluminum,  thin 
strips  of  veneering,  celluloid,  paper,  glue,  etc.  These 
have  to  be  constructed  over  a  mold  which  is  taken  from  a  plaster  jacket.  When  the 
disease  extends  above  the  level  of  the  fifth  dorsal  vertebra  there  should  be  incorporated 
wnthin  the  jacket  a  support  for  the  head,  known  since  Sayre's  time  as  a  "  jurv-mast." 
This  consists  of  a  metal  upright,  with  cross-pieces,  which  are  incorporated  with  the 
29 


Jury-mast   for   high  dorsal   and  cervical 
caries.     (Lovett.) 


450 


SURGICAL   AFFECTIOXS  OF   THE   TISSUES 


jacket  and  which  is  curved  uj)  l)ehind  and  over  the  head  and  made  to  carry  the 
frame  from  which  the  leather  straps  and  supports  pass  beneath  the  occiput  and  the 
chin,  and  thus  give  to  the  head  a  certain  amount  of  fixation.  The  support  is  so 
arranged  as  to  {permit  of  shding  and  of  sufficient  exjjansion  so  that  traction  upon  the  head 
can  he  made  effective. 

Fig.  2,5o  shows  the  appHcation  of  traction  to  the  head,  while  Fig.  256  illustrates  one 
form  of  apparatus  by  which  the  jury-mast  is  made  effective  in  producing  traction  on 
the  head  in  the  upright  position.  Figs.  257  and  25S  show  a  convenient  frame  and 
method  for  making  plaster-of-Paris  corsets  with  the  patient  in  the  recumbent  position. 
Figs.  25U  and  2G0  show  another  form  of  apparatus  intended  for  the  same  purpose. 

Fig.  257 


Frame  for  application  of  plaster  jackets  in  recumbent  position.      (Lovett.) 

The  variety  of  apparatus  which  has  been  devised  for  the  maintenance  of  rigidity  and 
correction  of  deformity,  and,  in  suitable  cases,  traction  upon  the  head,  is  to  be  measured 
almost  by  the  number  of  orthojKHlic  specialists,  nearly  every  surgeon  inclining  to  some 
device  or  at  least  modification  of  his  own.  Judson  probably  has  formulated  the  best 
rule  covering  the  entire  matter  when  he  says:  "The  apparatus  may  be  considered  as 
having  reached  the  limit  of  its  efficiency  if  it  makes  the  greatest  possible  pressure  upon 
the  projection  compatible  with  the  comfort  and  integrity  of  the  skin.  It  is  essential  that 
the  brace  is  efficient;  second,  that  it  is  one  that  can  be  constantly  worn,  if  necessary, 
or  can  be  easily  detached  from  the  body  if  not  to  l>e  worn  at  night."  Certain  ambulant 
cases  can  be  treated  l>y  an  effective  brace  through  the  day,  and  rest  at  night  upon  a 
reasonably  hard  mattress,  with  traction  upon  the  head.  Concerning  the  multitude 
of  these  special  aids  to  treatment  it  hardly  seems  worth  while  to  go  into  any  elaborate 

Fig.  258 


Application  of  a  plaster  jacket  in  the  recumbent  position.     (Lovett.) 

description  in  this  place,  inasmuch  as  one  who  is  incompetent  to  judge  as  to  what  is 
best  should  not  retain  the  management  of  such  a  case,  while  one  who  is  really  comj>etent 
will  probably  desire  to  make  his  own  selection,  and  the  writer's  recommendation  would 
count  for  but  little.  Every  ca.se  must  be  a  law  to  itself,  and  every  special  brace  must 
be  constructed  especially  for  the  individual  for  whom  it  is  meant;  otherwi.se  it  lo.ses  all  its 
serviceability. 

Forcible  Reduction. — The  feasibility  and  propriety  of  forcibly  reducing  the  deformities 
due  to  spinal  caries  was  first  suggested  by  Chipault,  of  Paris,  who  suggested  wiring 
the  spinous  processes  of  the  affected  vertebra,  and  then,  by  Calot,  who,  in  ISOfi,  described 
a  method  of  forcible  reduction  under  an  anesthetic.  The  first  to  actually  wire  the  spine 
under  the.se  circumstances  was  Hadra,  of  Texas,  who  had  actually  done  the  operation 
four  years  before  Chipault.     The  method  has  probably  less  to  commend  it  in  actual 


Sl'IXAL   CAL'Ih'S,   SI'OS l)Y LITI S,   lOl'IfOSI.H.   POTT'S  DlSh'ASI'J 


451 


pniftitr  (liaii  ill  theory,  tiiul,  Jittriutivc  as  it  may  In-  in  rrspoct  to  time  and  coinplctoncss 
of  rcdiu-tioii,  it  is  oftt'ii  followed  by  serious  aceidents,  sueh  as  heniorriiafije,  rupture  of 
abseess,  fracture  of  the  sj)ine,  etc.  Bradford,  in  1S99,  collected  (ilO  cases  performed 
by  20  different  o|)erators,  with  a  record  of  21  immediate  deaths  from  local  trauma  and 
15  cases  in  which  there  were  at  least  alarniiiijf  iinniediate  symptoms.  Of  221)  of  these 
cases  complete  corn^ction  was  eifected  in  1  I*.),  incomplete  in  94,  while  no  ^nh\  whatever 
was  made  in  1().  Of  results  rcj)ort(Ml  later,  (iO  showed  some  fjain,  there  was  no  relapse 
in  17,  while  41)  showed  more  or  less  return  of  deformity.  The  claim  has  been  made  that 
the  more  or  less  wide  jjaps  or  bony  defects  which  may  result  from  forcible  manipulation 
are  filled  in  by  new  bone,  but  there  do  not  seem  to  be  any  observations  to  c<jnfirm  this 
statement.  The  amount  of  force  which  must  be  employed  is  a  matter  for  the  finest 
discrimination.     The   method   includes  comj)lete   anesthesia,   traction   U[)on   the  spine 


Fig.  259 


Fig.  260 


Anteroposterior  support:  back  view. 
(Lovett.) 


Anteroposterior  support  with  head-ring  for 
high  dorsal  caries:  side  view.     (Lovett.) 


in  each  direction  from  the  location  of  the  deformity,  and  direct  pressure  force  applied 
to  the  protection  itself,  as  by  a  sling  passed  around  the  body  and  just  beneath  the  projec- 
tion, which  can  be  used  as  a  fulcrum  upon  which  the  rest  of  the  spine  can  be  applied 
as  a  double  lever,  with  the  application,  at  first,  of  gentle  force,  and,  finally,  sufficient  to 
either  satisfy  the  operator  that  he  should  go  no  farther  or  that  the  desired  eft'ect  has  been 
obtained.  Immediately  after  completion  of  the  maneuver  a  snugly  fitting  plaster  jacket 
should  be  applied  and  the  patient  kept  absolutely  at  rest  in  bed. 

The  method  seems  most  applicable  in  the  presence  of  paralysis,  even  of  long  standing, 
and  this  feature  has  often  been  relieved. 

Psoas  contraction  is  best  treated  by  traction,  with  the  patient  in  bed,  and  with  the  maxi- 
mum of  weight  and  power  applied  which  can  be  tolerated  by  the  individual.  If  this 
seem  impracticable,  then  the  patient  should  be  anesthetized  and  force  applied  until  it  is 
evident  that  more  harm  than  good  results.  Should  this  harm  appear,  then  open  division 
of  the  tissues  may  be  practised.  Finally,  as  a  last  resort,  in  intractable  cases,  a  sub- 
trochanteric osteotomy  may  be  made. 


452  SURGICAL  AFFECTIONS  OF  THE  TISSUES 

Pressure  'paralysis  necessitates  operative  relief.  This  may  Vje  practised  late  and  should 
consist  of  a  laminectomy  and  exposure  of  the  area  coni[)romised  bv  bone  pressure  or 
that  produced  by  })achymeningitis.  The  operation  is  done  in  the  same  way  as  for  frac- 
ture, and  will  be  described  in  the  cha{)ter  on  Surfrery  of  the  Spine. 

Finally  of  all  cases  of  Pott's  disease  it  may  be  said  that  each  should  be  studied  by  itself, 
and  for  each  a  suitable  method  or  apparatus  devised,  rather  than  to  endeavor  to  apj)ly 
indiscriminately  unchangeable  methods  or  forms  of  apparatus.  Every  apparatus  has 
its  disadvantages  as  well  as  its  benefits.  The  more  acute  the  case  the  more  is  absolute 
rest  in  bed,  with  traction,  demanded.  This  is  particularly  true  of  disease  in  the  upper 
spine.  On  the  other  hand,  the  more  chronic  and  the  lower  the  disease  the  easier  it  is 
to  handle,  and  with  such  simple  expedients  as  plaster  corsets.  When  the  sacral  region 
is  rigid,  however,  recumbency  is  usually  necessary,  because  of  the  difficulty  in  securing 
aderpiate  fixation  within  any  apparatus  that  can  be  worn.  The  necessity  for  general 
constitutional,  dietetic,  and  climatic  treatment  should  never  be  forgotten,  and  the  danger 
of  possible  acute  dissemination  kept  ever  in  mind.  This  is  particularly  imminent  when 
too  much  freedom  is  allowed.  Time,  patience,  and  discernment  are  the  dominating 
factors  beyond  the  general  principles  already  inculcated. 


SACRO-ILIAC  DISEASE. 

Under  this  name  is  included  a  tuberculous  condition  of  the  bony  tissues  on  either 
side  of  the  sacro-iliac  synchondrosis,  or  of  the  cartilage  itself,  similar  to  that  which 
produces  the  special  caries  described  above.  It  is  an  uncommon  expression  of  tuber- 
culous disease  occurring  often  in  the  young,  identical  in  pathology  with  other  tuberculous 
bone  lesions,  and  giving  rise  to  peculiar  symptoms,  mainly  because  of  its  location. 
Early  in  the  course  of  the  disease  these  may  consist  of  mild  discomfort  in  the  lower 
abdomen,  irritability  of  the  bladder  and  bowels,  disinclination  for  exercise,  while,  as 
the  disease  becomes  more  pronounced,  there  will  be  actual  pain,  intensified  by  standing, 
relieved  by  lying  down,  often  severe  at  night,  usually  referred  along  the  course  of  the 
sciatics.  A  most  significant  symptom  is  the  tenderness  and  complaint  produced  by  firm 
pressure  made  upon  both  sides  of  the  pelvis,  thus  forcing  tender  surfaces  against  each 
other.  In  the  later  stages  of  the  disease  abscess  may  develop  and  present  either 
externally  in  the  lumbar  region  or  internally,  breaking  into  the  pelvis  and  appearing 
perhaps  in  the  groin  or  close  to  the  perineum.  The  disease  is  usually  unilateral,  and 
will  cause  characteristic  limping  and  aggravated  pain  upon  standing  on  the  limb  of  the 
affected  side.  Naturally  this  limb  will  be  spared  in  every  possible  way.  It  is  likely 
to  be  mistaken  for  sciatica  or  lumbago,  in  neither  of  wliich  diseases  is  there  any 
tenderness  at  the  sacro-iliac  joint  such  as  can  be  evoked  by  pressure  from  the  sides  of  the 

Eelvis.     It  also  has  to  be  distinguished  from  hip  disease  by  the  fact  that  motions  at  the 
ip  are  not  interfered  with,  and  from  Pott's  disease  of  the  lower  spine,  which  usually 
causes  prominence  of  the  spinal  processes  and  local  tenflerness  in  a  different  region. 

The  surfaces  and  tissues  involved  are  extensive  and  the  disease  is  always  serious. 
It  is  one  of  the  most  chronic  of  all  such  affections,  and  too  often  tends  to  suppuration, 
with  its  slow  but  inevitable  consequences,  or  to  dissemination.  Thus  of  38  cases  with 
abscess  reported  by  Van  Hook  only  3  recovered. 

Treatment. — Treatment  should  consist  of  absolute  rest,  with  traction,  so  long  as 
the  symptoms  are  active,  and  avoidance  of  all  irritation  when  patients  rise  from  bed. 
Abscess  due  to  sacro-iliac  disease  should  be  radically  attacked,  especially  if  this  can  be 
done  early.  Intrapelvic  pus  collections  may  require  trephining  of  the  pelvic  walls  or 
resection  of  some  portion  of  the  ilium,  by  which  complete  evacuation  may  be  made  and 
drainage  be  amply  provided.  When  the  joint  itself  is  thoroughly  broken  down  the 
case  will  have  a  hopeless  aspect. 


CARIES  OF  THE  HIP. 

Hip-joint  disease,  or,  as  it  is  often  called,  coxitis  or  morbus  coxae,  is  worthy  of  special 
consideration  on  account  of  its  frequency,  its  importance,  and  the  deformities  which 
result  from  its  existence.     The  most  frequent  site  of  the  disease,  which  is  of  the  usual 


CARIES  OF   THE  JfJP  453 

ty|)('  of  tuhtTculoiis  ostitis  or  osteomyelitis,  is  on  tlic  femoral  side  of  the  joint,  usually 
in  or  near  the  lu-ad  of  the  hone.  In  a  small  |)ro|)()rtioM  of  eases  the  first  lesions  ap|)ear 
upon  the  aeetal)ular  aspect  of  the  joint,  while  in  some  eases  the  primary  tulMrcuJous 
lesion  is  of  the  type  of  a  tuberculous  synovitis.  (See  chapters  on  Bones  and  .Joints.) 
In  addition  to  those  chaii<;es  already  deserihed  in  previous  cha])ters  there  occur  certain 
distinctive  alterations  al)out  the  hip-joint  which  are  wortiiy  of  note.  On  the  jx-lvic  side 
the  mar<;ins  of  the  acetahuliun  occasionally  become  softent'd,  and  naturallv  yieldinj^ 
in  the  direction  of  pressure  as  the  result  of  muscle  j)ull  ujjon  the  th'i^U  toward  the  {M-lvis, 
cause,  first,  an  eloiifrationof  the  ori<jinally  merely  circular  cavity,  and,  finally,  considerable! 
shiftinii;  of  position,  often  n^ferred  to  as  migrafion  of  flir  arriahulum.  'riius  the  head 
of  the  bone  may  be  found  in  a  socket  thus  formed  on  a  level  one  inch  hifrher  than  on 
the  well  side.  So  also  perforation  of  the  acetabulum  may  occur,  with  perhai)s  final 
escape  of  the  head  of  the  bone  into  the  pelvic  cavity.  ( )n  the  other  hand,  similar  changes 
produce  decapitation  or  marked  alterations  of  shape  in  the  head  and  neck  of  the  femur. 
S3nnptomS. — When  the  .symj)toms  and  sii^ns  of  tuberculous  disease  in  this  location 
are  studied  in  accordance  with  what  has  already  been  stated  in  fjeneral  about  caries  of 
the  joint  ends  of  the  long  bones,  we  have  among  the  most  significant  features: 

1.  Pain. — This  is  referred  most  commonly  to  the  knee  because  of  the  relations  of 
the  obturator  nerve  to  the  hip-joint  and  to  the  region  of  the  knee.  Pain  may  also  be 
radiated  in  other  directions,  but  the  complaints  made  of  pain  in  the  knee  are  classical. 
Pain  is  not,  however,  a  pathognomonic  feature  and  may  be  almost  wanting,  but  the 
evidences  of  tenderness,  if  not  of  pain,  are  invariably  seen  in  the  unconscious  j)r()tection 
of  the  joint  afforded  by  muscle  spasm.  It  is  perhaps  in  hip-joint  disease  that  night  pains 
and  cries  are  most  freciuently  heard. 

2.  Muscle  Spasm. — Fixation  of  the  affected  joint  is  always  noted.  It  begins  as  a  limi- 
tation of  motion,  naturally  first  noticed  in  the  extremes  of  rotation,  flexion,  and  exten- 
sion, and  is  perhaps  the  most  important  early  sign  of  the  disease.  It  furnishes  the 
explanation  for  the  subsequent  postural  features,  as  well  as  an  index  regarding  the 
gravity  and  extent  of  the  morbid  process.  It  may  be  seen  even  in  the  lower  spinal 
muscles,  where  it  is  detected  by  laying  the  patient  upon  the  face,  lifting  first  one  leg  and 
then  the  other,  noting  the  freedom  of  hyperextension ;  in  fact,  this  spinal  muscular 
involvement  is  sometimes  so  marked  as  to  give  rise  to  the  suspicion  of  low  Pott's  disease, 
from  which  it  is  to  be  distinguished  by  the  fact  that  the  spasm  affects  one  side  rather 
than  both. 

3.  Muscle  Atrophy. — This  involves  in  time  all  the  muscles  concerned  about  the  hip. 
It  begins  early,  but  may  not  be  very  pronounced  until  quite  late.  It  can  usually  be 
determined  by  measurement  if  not  apparent  upon  inspection  and  palpation.  There 
w^ll  also  be  noted  more  or  less  obliteration  of  the  gluteal  crease  or  fold. 

The  three  cardinal  features — pain,  spasm,  and  atrophy— having  lieen  thus  considered, 
w^e  can  better  appreciate  the  characteristic  gait  and  postures  peculiar  to  this  disease. 
Limping  is  an  early  feature,  sometimes  insidious  at  first,  sometimes  abrupt.  Patients 
will  avoid  coming  down  quickly  upon  the  heel,  while  they  walk  with  the  knee  slightly 
flexed,  in  order  to  give  more  spring.  Stiffness  is  most  apparent  on  rising  from  bed  in 
the  morning,  while  the  limp  is  more  pronounced  at  night,  and  it  is  at  this  stage  especially 
that  night  cries  are  most  frequent.  To  mere  limping  succeeds  actual  lameness  with 
more  constant  pain.  INIuscle  spasm  now  leads  to  malpositions,  no  one  of  which  is 
necessarily  first  to  appear,  and  any  of  w^hich  may  occur  with  others  in  various  combina- 
tions, although  flexion  and  adduction  are  usually  the  first  to  be  seen,  the  patient  uncon- 
sciously assuming  that  position  which  happens  to  give  him  most  relief. 

It  is  important  to  realize  that  a  marked  degree  of  adduction  will  cause  apparent  short- 
ening, and  of  abduction  apparent  lengthening,  and  it  is  very  important  to  demonstrate 
that  these  variations  in  length  are  apparent  and  not  actual.  This  is  to  be  done  by  placing 
the  patient  upon  a  hard  surface  with  the  pelvis  at  right  angles  to  the  spine  and  the 
limbs  in  absolutely  symmetrical  position.  If  there  be  adduction  it  may  mean  that  the 
limbs  should  be  crossed ;  while  if  there  is  abduction  the  healthy  limb  should  be  abducted 
to  the  same  degree  as  the  one  affected.  Careful  measurement  will  show  that  the  differ- 
ences are  apparent  rather  than  real.  The  same  care  is  needed  in  regard  to  rotation, 
and  particularly  in  regard  to  psoas  contraction  which  leads  to  flexion.  One  of  the  most 
characteristic  evidences  of  hip-joint  disease  is  flexion  of  the  thigh,  which,  when  the 
thigh  is  brought  down  to  the  proper  level,  will  cause  an  arching  upward  of  the  lumbo- 


454  SURGICAL  AFFECTIONS  OF  THE  TISSUES 

sacral  region.  By  this  time  also  will  he  found  well-marked  limitations  of  motion  in 
every  direction.  All  of  these  features  should  be  ascertained  without  an  anesthetic,  as 
they  dei)end  upon  nuiscle  spasm,  which  anesthesia  would  sulxlue.  It  is  somewhat 
difficult  with  intractable  youn<>-  children  to  make  a  thorough  examination  of  this  kind, 
but  a  second  or  third  effort  will  usually  succeed  when  the  first  has  failed. 

Peri-articular  symptoms  affording  corroboration  are  found  in  thickening  of  the  tissues 
about  the  joint,  especially  enlargement  of  the  upper  end  of  the  femur,  or  increase  in 
thickness  of  the  ]xdvis,  which  may  perhaps  be  felt  from  the  outside  or  be  detected  by  rectal 
examination.  There  is  usually  involvement  of  the  inguinal  lymjjh  nodes,  and  there  is 
fre({uently  ])rominence  of  the  superficial  veins,  due  to  infiltration  of  the  deeper  tissues 
and  obstruction  to  the  return  circulation.     A  good  skiagram  will  also  render  much  aid. 

As  the  disease  progresses  there  will  apjiear  evidences  of  deep  suppuration,  as  abscess 
is  frequent  in  the  advanced  stages.  This  may  be  peri-articular  or  may  connect  with 
the  joint.  It  may  cause  separation  of  the  epiphyses  of  the  femoral  neck  and  complete 
loosening  of  the  head  of  the  femur,  which  will  then  become  a  foreign  body  in  a  joint 
cavity  probably  filled  with  pus.  Perforation  of  the  acetabulum  may  also  occur.  Much 
of  this  abscess  formation  goes  on  insidiously  and  without  marked  increase  of  symptoms. 
There  is  no  fixed  date  when  pus  may  begin  to  form.  It  may  occur  relatively  early  or  late. 
It  is  possible  for  small  amounts  of  pus  to  absorb  in  whole  or  in  part,  or  to  leave  a  residue 
more  or  less  encapsulated,  which  will  frequently  lead  later  to  a  secondary  abscess,  the 
latter  tending  to  burrow  along  between  the  fascial  planes  or  muscle  sheaths  and  appear 
at  some  distance  from  its  origin.  Pelvic  abscesses  result  from  ])erforation  of  the 
acetabulum  and  may  break  internally  or  externally.  Nearly  all  of  these  collections  are  of 
the  cold  type,  and  after  a  long  time,  if  they  have  opened,  may  cease  to  discharge  charac- 
teristic pus  or  even  pyoid,  and  simply  give  vent  to  a  watery  seropus.  Pus  left  to  itself 
usually  escapes  anteriorly  to  the  tensor  vaginse  femoris,  but  it  may  travel  in  any  direction. 

The  deformities  and  possibilities  which  may  result  from  the  advanced  stage  of  hip 
disease  are  striking.  Persistent  muscle  sjoasm  leads  to  more  and  more  flexure  of  the 
thigh,  with  abduction  or  adduction,  as  the  case  may  be,  while  later  the  leg  is  drawn 
up  so  that  the  knee  may  almost  touch  the  abdomen.  As  the  bony  portions  of  the  joint 
change  their  shape  there  occur  actual  shortening  and  final  dislocation, while  all  the 
adjoining  parts  show  the  effect  of  muscle  atrophy  and  perverted  nutrition.  In  addition 
to  this  the  region  of  the  hip  may  be  riddled  with  abscesses  or  with  sinuses,  and  the 
condition  in  every  respect  made  extremely  distressing. 

While  the  disease  is  generally  confined  to  one  side,  it  may  occur  in  both  hip-joints, 
in  which  it,  however,  very  rarely  begins  simultaneously.  Existence  of  tlouble  joint 
disease  of  this  character  makes  the  case  more  than  usually  troublesome  and  complicates 
it  seriously  in  every  respect.  The  writer  has  been  compelled  to  make  double  simultane- 
ous resection  of  t)oth  hips. 

Diagnosis. — This  has  usually  to  be  made  from  congenital  tlislocation,  hysterical 
joint,  infantile  paralysis,  non-tuberculous  disease — such  as  synovitis,  bursitis,  etc. — 
acute  osteomyelitis  of  the  upper  end  of  the  femur.  Pott's  disease  in  the  lumbar  region, 
and  sacro-iliac  disease,  as  well  as  from  perinephritic  abscess  and  ajjpendicitis. 

Prognosis. — Ilip-joint  disease  usually  tends  toward  recovery,  but  generally  with 
more  or  less  deformity.  When  the  circumstances  are  not  favorable,  ankylosis,  with  or 
without  deformity,  is  inevitable,  while  abscesses,  with  persistent  fistulne,  are  not  uncom- 
mon, and  one  may  in  extreme  cases  witness  death  from  general  tuberculous  dissemina- 
tion or  from  the  consequences  of  hectic,  with  amyloid  degeneration,  or  from  acute  septic 
infection. 

One  may  naturally  ask  what  may  be  considered  as  constituting  recovery.  In  cases 
of  this  kind  an  aljsolute  cessation  of  all  symptoms  and  indications  of  the  disease,  with  a 
minimum  of  deformity  and  of  limitation  of  motion,  are  the  nearest  approach  to  ideal 
recovery  that  can  be  expected  to  secure.  In  favorable  cases,  seen  early  and  properly 
treated  for  a  sufficient  time,  there  may  be  achieved  almost  a  restitution  ad  intcgram,  but 
such  an  ideal  is  seldom  attained ;  otherwise  there  is  nearly  always  more  or  less  limitation 
of  motion,  with  very  frequent  pseudo-ankylosis  or  actual  ankylosis.  Even  this  is  favor- 
able and  most  anything  may  be  considered  so  which  falls  short  of  actual  suppuration. 

Treatment. — The  essential  in  the  early  treatment  of  hip  disease  is  imeiion,  so 
applied  and  regulated  as  to  be  effective.  It  should  not  be  thought  that  by  such  traction 
as  can  be  tolerated  joint  surfaces  are  actually  pulled  apart.     What  it  really  accomplishes 


CARIES  OF  Till-:  nil'  455 

is  to  tiro  out  muscles  wliich  jirc  iu  ;i  condition  of  clonic  spasm,  overcoming];  tlicrchy  the 
deformity  wliicli  tliey  product*  and  thus  permittin<^  a  reduction  of  their  activity  and  of 
tlu>  harm  which  they  have  done.  To  do  even  this  rc(|uires  a  considerahle  dcfrrcc  of 
traction,  especially  when  muscle  spasm  is  very  |)roniinent.  'riierefore  it  is  hcst  in 
pronounced  cases  of  d(>formity  to  ))lace  patients  in  bed,  and  to  apply  traction  hy  wei<rht 
and  pulley  to  a  dcij;ree  which  actually  overcomes  the  defects  which  we  are  comhatin^. 
'l''his  will  oft(>n  retjuire  more  weif>;ht  than  many  men  are  in  the  habit  of  using.  It  should 
now  he  a  (juestion,  not  of  amount  of  wei<;;ht,  hut  of  elVect,  and  of  the  easiest  and  best 
way  of  bringiufi;  this  about.  Physicians  are  very  likely  to  use  too  small  an  amount  of 
weiijht,  and  to  nejijlect  the  use  of  counterextension  and  the  benefit  of  more  or  less  lateral 
traction,  as  well  as  that  in  direct  line  of  th(>  limb.  Moreover,  they  often  use  inade(|uate 
means  of  applyino;  traction,  resortinjj;  to  it  only  in  such  manner  that  traction  is  made 
at  the  knee  and  not  at  the  hi]).  Even  in  young  children  it  is  often  necessary  to  use 
twenty  pounds,  with  a  suitable  traction  ap|)aratus,  and  four  or  five  |)ounds  for  efiective 
lateral  traction. 

Tmrfioii  .s-hoii/d  he  maintained  until  deformity  has  been  overcome  or  the  effort  shown 
to  be  impracticable.  After  its  complete  benefit  has  been  (jbtained  it  should  be  followed 
by  fixation,  the  ideal  method  being  that  which  accomplishes  both  fixation  and  traction 
at  the  same  time;  as,  for  instance,  by  the  so-called  Thomas  sj)lint,  which  permits  the 
patient  to  l)e  up  and  about  \\'\i\\  the  use  of  crutches  and  a  high  shoe  beneath  the  well 
limb,  in  order  that  the  diseased  limb  may  not  be  permitted  to  touch  the  floor,  but  rather 
to  hang,  and  by  its  own  weight  aft'ord  a  certain  degree  of  traction.  The  Thomas  splint 
is  the  simplest  and  chea])est  for  hos[)ital  work,  while  modifications  in  more  elegant  and 
expensive  form  are  illustrated  in  works  on  orthopedic  surgery.  In  cases  which  seem  to 
demand  it  fixation  can  be  ett'ected  by  a  plaster-of-Paris  spica  put  on  while  the  patient  is 
standing  upon  the  well  limb  and  upon  an  elevation.  The  character  of  this  work  aft'ords 
space  neither  for  more  elaborate  description  nor  illustration  than  the  hints  embraced 
in  the  foregoing  paragraphs. 

The  siu'geon  as  such  is  perhaps  the  more  concerned  in  the  treatment  of  abscesses 
which  frequently  complicate  these  cases.  Much  that  has  been  already  said  about  psoas 
abscess  will  apply  here.  It  is  a  question  requiring  considerable  discrimination  as  to  just 
how  to  treat  a  small,  cold  abscess  about  a  diseased  hip.  Much  will  depend  upon  the 
environment  of  the  patient,  i.  e.,  upon  the  attention  and  expert  care  which  he  may 
receive.  Such  abscess  should  be  treated  kindly,  i.  e.,  by  nothing  more  severe  than 
aspiration,  until  ready  for  more  radical  treatment.  By  the  latter  term  is  meant  readiness 
for  following  it  down  to  the  joint  cavity  and  exsecting  the  head  of  the  bone,  if  need  be, 
following  this  with  extirpation  of  the  capsule,  etc.  When  there  is  actual  pyarthrosis  the 
condition  of  the  patient  is  sufficiently  serious  to  warrant  radical  measures.  Extra- 
articular abscesses  are  apparently  quite  common,  yet  most  of  these,  if  carefully  traced, 
will  be  found  to  lead  through  the  periosteum  at  some  point  into  the  osseous  structure 
beneath.  Such  abscesses  are,  moreover,  multilocular,  and  have  ramifications  in  even 
unsuspected  directions  which  should  be  followed  with  the  sharp  spoon  and  the  caustic, 
in  order  that  absorbents  may  be  seared  and  that  no  infectious  material  remain.  Old  and 
persistent  fistulas  should  also  be  treated  kindly  until  one  is  ready  to  be  radical.  Some 
long-standing  cases  will  heal  after  absolute  physiological  rest  of  the  joint,  i.  e.,  by  fixation 
in  plaster-of-Paris  splint,  with  openings  opposite  the  fistulas  for  dressing  purposes. 
The  general  constitutional  condition  of  patients  with  these  lesions  is  a  predominating 
factor  in  their  improvement— a  fact  which  should  never  be  forgotten. 

The  deformity  which  has  resulted  from  old,  long-standing,  and  quiescent  hip  disease 
affords  opportunity  for  the  best  of  surgical  judgment.  It  is  possible  to  eft'ect  great 
improvement  in  position  by  subcutaneous  osteotomy  after  ankylosis,  but  this  should  not 
be  attempted  during  the  active  stages  of  the  disease. 

The  question  of  excision  of  the  hip-joint  is  one  of  importance.  In  fe\v  other  instances 
do  social  surroundings  or  factors  enter  so  largely  into  the  question  of  surgical  judgment. 
The  wealthy  can  afford  long-continued  treatment,  which  to  the  poor  is  prohibited,  and 
one  maybe  tempted  in  one  case  to  exsect  early  when,  under  other  conditions,  he  would 
treat  the  case  tentatively.  Nevertheless  certain  indications  make  the  operation  expedient 
in  all  cases,  as,  for  instance,  when  the  destructive  process  is  steadily  progressing  or  so 
acute  as  to  shorten  not  only  the  limb  but  life  itself.  It  is  necessary  also  when  there  is 
necrosis,  and  in  most  instances  of  suppuration  extending  into  the  joint  cavity.     In  those 


456  SURGICAL   AFFECTIONS  OF  THE  TISSUES 

cases  where  skiagrams  confirm  other  indications  to  the  effect  that  the  disease  is  localized 
in  the  neck  or  head  of  the  femnr,  Hnntington's  suggestion  may  be  adopted,  after  exposing 
the  upper  end  of  the  femur,  to  drill  or  tuimel  in  the  direction  of  the  neck  until  its  dis- 
eased focus  is  reached  and  thoroughly  clean  it  out.  In  cases  treated  otherwise  conser- 
vatively, yet  accompanied  by  a  great  deal  of  pain,  especially  those  of  the  f(>moral  side 
of  the  joint,  one  may  frequently  get  relief  by  exposing  the  upper  end  of  the  femur  and 
making  ignipuncture  in  the  same  direction  as  above. 

In  general  it  is  impoftsible  to  laij  down  succinct  rules  for  the  treatment  of  Jiip  disease. 
Cases  differ  so  greatly  in  location,  in  severity,  as  well  as  in  environment  and  their  personal 
surroundings,  that  what  is  advisable  in  one  case  is  not  to  be  thought  of  in  another.  Of 
the  mechanical  features  of  treatment  one  may  say  that  that  is  the  best  splint  or  apparatus 
which  best  meets  the  indication  in  each  particular  case,  and  that  none  will  be  effective 
in  which  the  element  of  traction  is  neglected,  nor  that  of  physiological  rest.  No  patient 
should  be  released  from  treatment  whose  hip  is  still  sensitive  or  in  whom  there  remains 
any  muscle  spasm.  Rest  and  protection  should  be  maintained  for  months  and  even 
years  after  apparent  recovery,  while  the  same  attention  should  be  given  to  diet  and 
climatic  surroundings  as  in  any  other  case  of  well-marked  tuberculous  disease. 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT;  TUMOR  ALBUS. 

This  subject  deserves  special  consideration,  mainly  because  of  the  peculiar  deformity 
produced  by  the  disease  rather  than  any  of  distinctive  peculiarity  in  its  nature.  Years 
ago  it  received  the  name  of  tumor  alius,  and  is  frequently  called  wliite  swelling  by  the 
laity,  because  of  the  pallor  of  the  svu-face  and  the  increased  dimensions  of  the  limb  due 
to  thickening,  always  of  soft  parts,  and  usually  of  the  bone  itself.  The  disease  may 
begin  in  either  epiphysis,  in  the  patella,  or  in  the  synovial  membrane,  oftener  in  the 
bone  in  the  young  and  in  the  synovia  in  adult  cases.  Its  most  distinctive  feature  is  the 
deformity  produced  by  excess  of  muscle  spasm,  the  hamstring  muscles  especially  pro- 
ducing a  backward  subluxation  which  frequently  fixes  the  knee,  not  only  at  a  right  angle, 
but  with  very  much  disturbed  joint  relations,  so  that  the  head  of  the  tibia  is  in  contact 
with  the  posterior  surface  of  the  condyle  rather  than  with  their  proper  terminal  areas. 
The  soft  tissues  outside  of  the  bone  are  frequently  very  much  thickened  and  infiltrated, 
often  edematous,  while  the  joint  cavity  may  be  more  or  less  distended  with  seropus 
or  with  old  pyoid  material.  The  exterior  surface  is  so  anemic  from  ileficient  blood 
supply  as  to  make  it  appear  comparatively  white,  while  the  superficial  veins  are  made 
much  more  prominent  by  their  engorgement  owing  to  obstruction  of  the  deep  circulation. 
The  picture,  then,  of  an  advanced  case  of  tumor  albus  is  quite  typical. 

Here  the  joint  cavity  is  so  large  that  there  is  early  effusion  of  fluid,  in  most  cases, 
which  is  in  this  location  easily  recognizable;  hence  the  distinctive  symptoms  consist 
of  pain,  tenderness,  swelling,  limp  muscle  spasm,  with,  finally,  limitation  of  motion, 
deformity,  and  atrophy.  In  addition  to  these  features  there  may  be  added  those  due  to 
the  formation  and  the  escape  of  pus,  i.  e.,  one  may  have  the  signs  of  acute  or  old  suppu- 
ration, while  the  parts  about  the  joint  may  be  riddled  with  old  sinuses.  The  deformity 
of  these  cases  is  usually  characterized  by  a  certain  amount  of  external  rotation  of  the  leg, 
while  a  species  of  knock-knee  is  not  uncommon.  Actual  lengthening  of  the  limb  due 
to  overactivity  at  the  epiphyseal  jimctions  may  also  be  noted. 

Treatment. —  The  treatment  of  white  s%celling  is  based  upon  the  principles 
already  laid  down  for  the  treatment  of  spinal  and  hip  caries,  the  underlying  feature 
being  traction  to  a  degree  sufficient  to  overcome  muscle  spasm,  unless  it  be  too  late  to 
permit  a  subsidence  of  active  changes.  When  seen  early  a  few  weeks  of  confinement 
in  bed,  with  effective  traction,  followed  by  fixation  with  plaster-of-Paris  bandage,  com- 
bined with  the  Thomas  splint  (see  above)  or  with  some  other  form  of  more  elaborate 
apparatus,  by  which  rest  and  traction  can  be  continually  maintained,  will  be  needed. 
The  presence  of  tuberculous  disease  about  the  knee  permits  of  the  application  of  the 
elastic  bandage  above  the  knee,  by  which  the  congestion  treatment  of  Bier  can  be  more 
or  less  effectually  carried  out.  It  would,  however,  be  a  mistake  to  rely  entirely  upon  this 
to  the  neglect  of  traction  and  rest,  nor  should  too  much  be  expected  of  it  in  severe  cases. 
It  is  a  method  to  be  used  early  rather  than  late. 


roirricoLLis:  w  uy\i:ck  457 

The  filial  irsorl  i.s  t\rcisi()ii,\\\\\v\\  is  pnulically  ;ulu|)lc(l  (o  cjiscs  ol"  iiiodcratc  {y\K'  in 
youiif;  adults,  whore  the  hones  liave  attained  their  i'ull  jrpowth  and  where  it  will  alVord 
a  prospect  of  cure  in  a  niininiuni  of  time.  It  is  undesirable  in  children  because  it  is  so 
often  necessary  to  remove  the  epiphyses,  and  because  of  the  arrest  of  development  that 
follows  such  removal  and  the  conse(|uent  shortcnintr  of  the  limb.  Nevertheless  even  in 
cliildn>n  it  may  be  demanded  and  may  be  consid(>rc(|  as  a  resort  sn|)erior  to  am|)nlalion, 
the  latter  luMnji;  reserved  usually  for  a  life-saviiiir  measure  or  for  des|)erate  cases  where 
destruction  has  been  i)ra(tically  com|)lcte  and  the  limb  is  hopelessly  useless. 

Of  the  other  lari:;e  joints,  all  of  which  may  be  involved  in  tuberculous  processes 
similar  to  those  just  discussed,  it  may  be  said  that  they  come  under  the  general  rules  of 
treatment  already  laid  down. 


NON-CARIOUS  DEFORMITIES. 

TORTICOLLIS;  WRYNECK. 

This  term  includes  a  ])eculiar  postural  deformity  by  which  the  head  is  rotated  and 
inclined  abnormally  to  one  side  in  a  more  or  less  fixed  j)()sition.  As  to  the  causes  of 
the  deformity  two  will  be  considered: 

Congenital  causes  include: 

1.  Injury  to  the  sternomastoid  muscle  at  birth,  which  is  perhaps  the  commonest. 

2.  Abnormal  intra-uterine  position  and  pressure. 

3.  Arrest  of  muscular  development. 

4.  Intra-uterine  myositis,  the  muscles  being  sometimes  found  actually  altered  in 
structure. 

5.  Defective  development  of  the  upper  vertebra^  or  such  distorted  growth  as  is  often 
met  along  with  other  deformities,  c.  g.,  club-foot. 

The  acquired  causes  include: 

1.  Traumatisms,  either  direct,  as  by  injury  to  the  muscles,  such  as  may  happen  from 
gunshot  wounds,  etc.,  or  follow  operations  by  which  the  spinal  accessory  has  been 
injured,  or  by  burns,  and  other  lesions  which  cause  much  cicatricial  contraction. 

2.  Reflex  activity  in  connection  with  disease  of  the  lymph  nodes,  deep  cervical  abscesses, 
parotid  ))hlegmons  or  tumors,  etc.  Whitman  states  that  tuberculous  disease  of  the 
cervical  nodes  caused  the  condition  in  50  per  cent,  of  over  100  cases  analyzed  by  him. 

3.  Reflexes  from  the  eyes,  as  Bradford  and  Lovett  have  described  from  the  ortho- 
pedist's standpoint,  and  Gould  from  that  of  the  oculist,  refractive  errors  causing  the 
head  to  be  held  in  unnatural  positions  in  order  to  improve  vision. 

4.  Compensation  in  high  degrees  of  rotary  lateral  curvature,  the  effort  being  to  keep 
the  head  facing  to  the  front. 

5.  Myositis,  usually  rheumatic,  but  sometimes  a  sequel  of  the  infectious  fevers,  or 
even  of  gonorrhea. 

6.  Habitual  deformity,  the  result  of  occujmtion  or  sheer  bad  habit. 

7.  Tonic  or  intermittent  sj)asm  leading  to  spastic  contractures  whose  causes  are 
difficult  to  seek,  but  appear  to  inhere  in  the  central  nervous  system. 

8.  Paralyses  of  certain  muscles,  jiermitting  lack  of  opposition  and  consequent 
deformity. 

Pathology. — According  to  circumstances  significant  pathological  changes  may  be 
found  in  the  affected  muscles.  These  are  usually  the  sternomastoid  and  the  trapezius, 
although  in  long-standing  or  complicated  cases  the  deeper  muscles  of  the  neck  may  also 
particpate.     A  long  contracted  nniscle  may  change  almost  into  mere  fibrous  tissue. 

The  secondary  effects  of  contraction  of  the  sternomastoid  and  the  traj^ezius  are  really 
far-reaching  and  noteworthy.  The  jaw  may  be  drawn  down  and  to  one  side,  so  that 
teeth  do  not  appose  each  other  as  they  should,  or  perhaps  even  do  not  meet.  Compen- 
satory curvatures  occur  also  in  the  spine  and  there  is  well-marked  change  in  gait  and 
in  most  of  the  body  habits.  In  the  young  and  rapidly  growing  cranial  and  facial 
asymmetry  also  become  pronounced.  The  later  results  and  deformities  of  torticollis 
are  not  to  be  mistaken  for  congenital  elevation  of  the  scapula,  sometimes  known  as 


458  SURGICAL  AFFECTIONS  OF  THE  TISSUES 

"Spmigers  deformifi/,"  wliidi  consists  not  merely  in  elevation,  hut  in  rotation  of  the 
shoulder-blade  so  that  its  lower  angle  is  too  near  the  S|)in(>.  There  may  be  some 
limitation  of  motion  of  the  scapula  and  of  the  arm.  Sprengx^l  accounted  for  this  abnor- 
mality by  maintenance  of  the  intra-uterine  position  of  the  arm  behind  the  back.  The 
acute  forms  of  torticollis  occur  nearly  always  in  acute  phlegmons  of  one  side  of  the 
neck,  and  should  subside  with  the  other  and  causative  lesions.  Nevertheless  from  such 
spasm  may  develop  a  chronic  form  which  may  persist. 

The  position  of  the  head  varies  with  the  muscles  ])articnlarly  involved  and  the  asso- 
ciated spasm.  The  sternomastoid  muscle  alone  will  draw  the  mastoid  down  toward 
the  sternum,  with  rotation  of  the  face  to  the  other  side.  When  the  trapezius  is  involved 
the  head  is  drawn  backward  and  the  chin  raised.  The  more  the  ])latysma,  scaleni, 
sj)lenii,  and  deep  rotators  are  involved  the  more  complex  becomes  the  condition,  to  such 
an  extent  even  that  in  serious  cases  it  is  almost  impossible  to  decide  which  muscles  really 
are  at  fault.  When  the  superficial  muscles  are  involved  they  can  usually  be  distinctly 
felt  to  be  firm  and  contracted,  while  the  sternomastoid  will  stand  out  like  a  cord.  Pain 
is  a  rare  complaint,  but  a  feeling  of  tenderness  or  soreness  is  not  imusual. 

The  spasmodic  or  intermittent  form  is  less  common,  but  more  difficult  to  account  for 
and  even  to  treat.  It  seems  to  be  due  to  choreiform  spasm  of  those  muscles  which  pro- 
duce it,  and  here  the  condition  is  reflex,  the  causes  lying  deejily  in  the  nervous  system. 
In  some  instances,  however,  they  are  of  ocular  origin  and  can  l)e  relieved  by  correcting 
refractive  errors.  Intermittent  spasm  is  usually  absent  during  sleep  and  quiescent  in 
the  recumbent  position;  it  is  usually  confined  to  one  side. 

Diagnosis. — In  the  matter  of  diagnosis  it  is  necessary  mainly  to  eliminate  only  spinal 
caries,  while  as  between  involvement  of  the  anterior  and  posterior  groups  of  muscles 
the  determination  is  made  by  palpation  and  inspection. 

Treatment. — There  are  few  morbid  conditions  whose  cause  it  is  more  necessary 
to  discover.  Could  this  be  done  operative  treatment  would  be  less  often  demanded. 
Treatment  should  depend,  therefore,  on  the  exciting  cause  and  the  possibility  of  its 
removal.  The  spasmodic  or  intermittent  form  may  spontaneously  subside.  Cases  of 
essentially  ocular  origin  need  the  services  of  the  oculist,  and  other  acute  cases  usually 
subside  with  the  successful  treatment  or  the  subsidence  of  their  causes.  On  the  other 
hand,  chronic  cases  usually  need  either  mechanical  or  operative  treatment. 

The  most  common  operation  for  relief  of  torticollis  is  simple  tenotomy  of  the  sterno- 
mastoid, taking  care  to  divide  the  sheath  and  everything  which  resists,  and,  at  the  same 
time,  to  avoid  the  external  jugular  vein  as  well  as  the  deeper  structures.  Mere  tenot- 
omy of  one  or  both  of  its  lower  tendons  is  an  exceedingly  simple  measure,  but  in  serious 
cases  an  open  division  will  permit  of  more  thorough  work.  Here  an  incision  made  one 
inch  above  the  clavicle  and  parallel  to  it  will  permit  division  of  everything  which  resists 
and  also  any  recognition  of  that  which  should  be  spared.  In  any  event  the  position 
of  the  head  should  be  immediately  rectified,  and  kept  so  either  by  plaster  or  starch 
bandage,  or  by  a  traction  apparatus  ajiplied  to  the  head,  the  body  being  in  the 
recumbent  position,  while  later  some  efficient  and  well-fitting  brace  should  be  worn 
for  some  time.  The  posterior  cases,  i.  e.,  those  where  the  posterior  muscles  are  in- 
volved, afford  greater  operative  difficulty,  muscles  involved  lying  too  deeply  and  being 
in  too  close  relation  with  important  vessels  and  nerves  to  justify  the  ordinary  wide- 
open  division.  Nevertheless  in  extreme  cases  there  need  be  no  hesitation  in  extirpa- 
ting completely  those  muscles  which  are  primarily  and  mainly  at  fault.  The  writer 
has  removed  the  sternomastoid  and  the  trapezius,  with  sections  of  the  still  deeper 
muscles,  and  has  seen  nothing  but  benefit  follow  the  procedure.  It  should  be  resorted 
to  when  repeated  anesthesia  with  forcible  stretching  and  a  suitable  brace  fail  to  give 
relief.  These  forms  of  wryneck  which  are  due  to  contraction  of  muscles  infiltrated 
from  the  presence  of  neighboring  phlegmons,  etc.,  will  usually  subside  with  massage 
and  semiforcible  stretching  under  an  anesthetic.  They  need  conservative  rather  than 
operative  treatment.  Attack  upon  the  spinal  accessory  and  the  deep  cervical  nerves 
will  be  described  in  the  chapter  on  Surgery  of  the  Nerves.  It,  however,  will  rarely 
be  justified,  since  the  primary  causes  inhere  not  so  much  in  those  nerve  trunks  as  in 
the  nerve  centres.  Such  operations  are  usually  of  questionable  benefit,  and  cases 
should  be  carefully  watched  before  being  submitted  to  them. 


ROTARY   LATh'RAL   SPINAL  CURVATURE;  SCOLIOSIS  459 

ROTARY  LATERAL  SPINAL  CURVATURE;  SCOLIOSIS. 

UiulcM-  these  (cniis  arc  iiicliidcd  ccrlaiii  deviations  from  iKjniia!  rclatioiisliips  (jf  tlic 
vertebra',  both  in  tlieir  superposition  in  the  iiKHhan  hne  and  in  their  rotation  on  each 
other,  by  which  are  produced  hiteral  curvatures,  with  more  or  less  rotarv  <nsphicement. 
Of  these  deformities  there  is  a  rare  congenital  form  which  is  due  to  fetal,  or  ratlici-  intra- 
uterine, rickets,  but  ))ractically  all  rotary  lateral  curvatures  are  ac(|uired.  One-half 
of  such  cases  begin  before  the  twelfth  year  of  life.  It  may  also  come  on  during  adult 
life,  as  the  result  of  bad  postural  habits,  exclusive  use  of  the  right  hand,  etc.  Altogether 
it  occurs  in  about  1  jxm-  cent,  of  females  and  in  a  smaller  |)ercentage  of  males.  Scolio.sis 
being  not  a  disease  but  rather  a  })rocess  of  irregular  growth,  cannot  be  said  to  have  a 
symptomatology.  It  is  known  rather  by  signs.  Only  in  the  advanced  stage  can  it 
produce  symptoms.  It  is  rarely  seen  in  its  inci[)iency  by  either  the  surgeon  or  the  phy- 
sician. Not  until  parents  have  noticed  distortions  of  the  spine  are  these  children  usually 
taken  to  their  medical  advisers.  Exception,  however,  should  be  made  to  this  in  respect 
to  certain  gymnasia  and  athletic  training  schools,  where  trainers  are  (piick  to  notice 
irregularities  of  this  kind.  The  abnormal  curves  thus  j)ro(luced  are  at  first  flexible,  but 
later  become  fixed.  In  rapidly  growing  girls  who  take  but  little  exercise  there  may  be 
some  muscle  weakness,  which  may  cause  fatigue  or  even  actual  soreness.  Pain  is  rarely 
present.  The  rate  and  extent  of  deformity  are  not  subject  to  any  rule.  Spontaneous 
cessation  ensues  in  practically  every  case,  i.  c,  a  stage  of  convalescence  and  arrest, 
at  a  time  when  the  deformity  may  be  but  slight,  or  perhaps  liideous. 

The  nervous  phenomena  attending  lateral  curvature,  like  the  discomforts  attaching 
to  it,  are  mainly  due  to  the  increasing  strains  and  stresses  that  are  imposed  on  certain 
structures  as  the  deformity  occurs  and  increases.  Of  these,  muscles  and  ligaments 
suffer  most,  especially  those  uniting  the  thorax  and  spine.  Pressure  effects  on  nerves 
and  tissues  may  be  produced  by  distorted  ribs  and  vertebra?  or  by  final  displacement  of 
viscera.  The  conditions  which  lead  up  to  spinal  curvature  are  attended  often  by 
neurasthenic  and  neurotic  features,  both  mental  and  physical.  As  deformity  increases 
impairment  of  function  of  thoracic  as  well  as  of  the  upper  abdominal  viscera  will  occur, 
and  such  patients  are  usually  thin  and  anemic,  rather  than  fat. 

To  mere  lateral  distortion  is  added,  in  every  'pronounced  case,  more  or  less  rotation  of 
the  entire  trunk.  The  curvature  consists  of  one  primary  curve,  with  one  or  two 
secondary  curvatures,  according  to  the  location  of  the  first.  If  the  primary  curve  be 
located  in  the  mid-dorsal  region  there  will  occur  compensatory  curvature  above  and 
below^  in  order  that  the  head  may  still  be  kept  in  the  line  of  the  centre  of  gravity  above 
the  pelvis.  Such  secondary  alterations  are  of  much  less  import  than  the  primary. 
The  most  common  of  the  mid-dorsal  curvatures,  which  occurs  in  nearly  four-fifths  of 
the  cases,  has  its  convexity  to  the  right.  While  the  right  shoulder  seems  higher  its  scapula 
will  be  more  pronounced  and  carried  backward,  the  back  and  the  chest  below  it  will  be 
more  rounded,  and  in  front  the  breast  on  the  opposite  side  more  prominent.  The  whole 
trunk  in  marked  cases  becomes  so  warped  that  the  arm  on  one  side  will  hang  free  while 
the  other  touches  the  pelvis ;  thus  the  back  loses  its  symmetry  either  in  the  erect  or  stooping 
position.  In  the  lumbar  region  there  is  compensatory  curvature  to  the  opposite  side, 
which  makes  one  hip  and  flank  more  prominent.  By  virtue  of  the  rotation  of  such 
a  warped  spinal  column  there  result  certain  anterolateral  curvatures  that  may  later 
become  pronounced.  While  such  changes  are  going  on  in  the  upper  part  of  the  trunk 
there  is  sufficient  rotation  of  the  lumbar  segment  to  lead  to  tilting  of  the  pelvis,  w^ith 
consequent  limp,  or  a  peculiarity  of  gait. 

The  degree  of  torsion  of  the  spinal  column  is  the  best  index  of  the  real  severity  of  a 
given  case,  and  to  it  are  due  the  most  disfiguring  features  of  the  deformity.  Torsion 
may  even  precede  curvature,  causing  a  prominence  of  one  shoulder  or  hip  as  the  first 
visible  evidence  of  its  existence. 

Those  forms  of  lateral  curvature  due  to  rickets  occur  most  often  in  the  dorsal  region, 
anfl  as  frequently  in  boys  as  in  girls.  In  most  of  these  cases  the  constitutional  condition 
will  be  indicated  by  other  significant  features.  Another  form  much  less  frequent,  yet 
well  known,  is  the  result  of  inequality  of  the  length  in  the  limbs,  so  that  patients  stand 
ordinarily  with  tilted  pelves ;  hence,  the  limbs  should  be  carefully  measured  in  every 
instance.     A  truly  paralytic  form  of  scoliosis  is  also  known,  which  is  of  the  infantile 


460  SURGICAL  AFFECTIONS  OF  THE  TISSUES 

type  and  due  to  some  form  of  infantile  palsy.  Again,  scoliosis  is  produeed  by  slirinkagc. 
of  tissues  and  contraction  of  old  exudates  occnrrin*";  within  the  thorax  and  following 
chronic  disease,  as  when  the  ribs  on  one  side  are  drawn  down  after  an  old  j)leurisy  or 
empyema.  Extrinsic' causes  of  lateral  curvature  are  met  with  among  several  occupa- 
tions when  one  side  of  the  body  is  used  more  than  the  other,  or  when  the  individual 
habitually  stands  in  an  unsymmetrical  position.  In  addition  to  this,  the  habitual  right- 
hand  habit,  which  seems  instinctive,  and  which  the  majority  of  people  exhibit,  leads  to 
excessive  use  of  the  right  side  of  the  body,  with  overdevelopment  and  consequent  warp- 
ing of  the  upper  part  of  the  skeleton.  The  young  should  be  taught  the  use  of  the  left 
hand  as  well  as  the  right,  i.  e.,  to  become  ambidextrous. 

The  foreign  surgeons  have  given  the  term  ischias  scoliotica  to  a  form  of  lateral  curva- 
ture involving  rather  the  lower  j)art  of  the  spine  and  occurring  usually  in  adults  or  elderly 
people,  which  is  accompanied  by  more  or  less  acute  pain,  usually  assuming  the  type  of 
sciatica.  Its  etiology  is  obscure,  as  is  imjilied  by  the  synonym  scoliosis  neuropathica. 
It  is  not  a  frequent  malady,  but  usually  chronic  and  refractory.  It  is  best  dealt  with 
by  fixation  or  immobilization. 

Etiology. — Predisjxjsing  causes  of  scoliosis  may  be  both  constitutional  and  inherited. 
They  include  general  debility,  rickets — with  its  accompanying  osseous  instability  and 
liability  to  abnormal  curvature — the  consequences  of  various  diseases  of  childhood, 
and  anything  which  greatly  lowers  vitality.  The  actual  causes  include  congenital  or 
acquired  defects,  such  as  differences  in  the  lengths  of  the  limbs  or  other  skeletal  asym- 
metries; acquired  abnormal  position  of  the  head  due  to  defective  vision,  with  its  natural 
sequences;  results  of  intrathoracic  disease,  such  as  empyema;  faulty  attitudes  and  bad 
developmental  hal^its,  such  as  those  assumed  often  in  school  an.d  elsewhere  in  sitting  at 
a  desk  or  standing  in  bad  position,  or  at  work  in  various  ways.  To  these  should  be  added 
the  right-hand  habit  already  mentioned.  These  may  all  be  summed  up  as  among  the 
causes  of  asymmetrical  grow^th  and  deformity,  occurring  as  the  result  of  ignorance  or 
inattention,  and  allow^ed  to  go  on  indefinitely  or  until  it  is  too  late  to  correct  the  malposi- 
tion. Theories  of  paralysis  of  individual  muscles  or  certain  muscle  groups  have  been  ad- 
vanced, as  well  as  of  contractures,  but  usually  these  are  effects  which  have  been  mistaken 
for  causes.  The  bones  have  been  blamed,  but  their  changes  are  secondary  results  of 
pressure,  save  perhaps  in  some  cases  of  rickets.  The  structures  of  the  thorax  have 
relatively  considerable  superimposed  weiglit  to  carry,  and  both  lateral  halves  of  the  thorax 
should  be  developed  symmetrically  in  order  to  distribute  this  weight  evenly.  Nothing 
so  influences  skeletal  development  as  exercise;  thus  even  to  assume  and  maintain  the 
normal  erect  attitude  requires  a  certain  amount  of  muscular  effort,  and  if  each  side  be 
not  given  an  equal  task  one  will  develop  at  the  expense  of  the  other,  and  thus  lateral 
ciu'vature  is  sure  to  result. 

It  is  important  to  impress  this  on  parents,  teachers,  nurses,  dressmakers,  and  all  who 
have  a  part  in  the  care  of  the  young,  in  order  that  they  may  realize  the  importance  of 
ensuring  symmetrical  grow^th  and  of  preventing  the  right-hand  habit.  It  is  to  be 
expected  that  after  deformity  has  occurred  there  may  result  a  series  of  perversions  of 
function  in  nerves,  as  well  as  in  viscera;  thus,  respiration  and  circulation  may  be 
interfered  w^ith,  the  liver  may  be  compressed,  while,  of  course,  autopsy  will  show  all 
sorts  of  distortion  of  bone,  among  other  pathological  changes. 

Prognosis. — Too  often  the  condition  is  regarded  as  so  trivial  that  it  is  likely  to  be 
outgrown,  or  else  is  quite  disregarded,  or,  on  the  other  hand,  occasionally  it  is  regarded 
as  one  of  gravely  serious  import  and  maltreated  or  overtreated  on  this  account.  In  the 
majority  of  instances  scoliosis  is  a  self-limited  condition,  whose  limit  may  be  reached  at 
variable  stages  of  deformity  in  flifferent  individvuils.  In  slight  cases  any  serious  illness 
may  cause  such  muscular  weakness  as  to  permit  of  serious  increase  of  distortion.  There- 
fore, the  patient's  general  condition  is  to  be  taken  into  account  just  as  much  as  the 
shape  of  the  back. 

Treatment. — If  one  may  be  permitted  a  Hibernicism,  the  proper  treatment  for 
scoliosis  is  prevention.  This  may  be  made  to  include  the  earliest  possible  recognition 
of  trifling  deviations  from  the  normal.  It  should  be  made  to  include,  in  general,  super- 
vision of  school  desks  and  the  way  in  which  children  work  at  them,  as  well  as  of  children's 
games  and  exercises,  in  which  it  should  be  made  a  point  that  they  be  taught  to  make 
as  much  use  of  one  hand  as  of  the  other.  It  should  include  also  supervision  of  children's 
methods  of  seating  themselves  at  the  piano  or  at  the  sewing  table,  as  well  as  the  posture 


Cl'IiVATURh'S  FROM   OTiniH  SOCRCES  461 

which  thcv  assumr  (hiriii<f  slccj),  while  thry  should  In-  taught  to  stand  and  walk  properlv 
and  to  avoid  a  too  early  use  of  corsets.  Active  treatment  should  ronm-sf,  first,  of  correction 
of  had  postural  and  other  hahits  by  methods  as  virjorous  as  are  miiitary  drill  and  discipline. 
PatiiMits  tire  easily  after  such  exercise,  and  sulKeient  rest  should  he  taken,  the  patient 
lyinf^synunetrically  uj)on  tlu>  hack.  TluM'e  is  usually  opportunity  with  younj^ children  for 
^reat  iii^-enuity  in  devisinij;  suitable  exercises  without  niakinj;  them  too  irksome.  They 
should  he  (auii,ht  to  j)lay  frames  at  least  as  nnich  with  the  left  hand  as  with  the  ri^ht. 
(lymnastic  exercis(\s,  esju'cially  those  with  dumh-hells,  will  he  found  cfl'ective,  and  it 
is  advisable  to  have  a  heavier  dumb-bell  in  the  left  hand  than  in  the  riiflit.  The  more 
severe  cases  should  be  handled  with  ^reat  care  in  order  not  to  overdtj  that  which  should 
be  done.  Each  case  should  be  studied  by  itself,  which  means  that  such  ca.ses  should 
not  be  tauj2;ht  in  classes.  Roth  calls  that  "the  key-note  ])osition"  which  is  clo.sest  to  the 
normal  that  the  individual  can  voluntarily  and  comfortably  assume.  From  this  as  a 
basis  the  surii;e()n  should  work  up.  Perhaps  as  much  can  be  done  without  apparatus 
as  with  it,  particularly  if  will  power  is  concentrated  on  the  effort.  This  is  harder  with 
the  young,  but  pride  may  sometimes  be  ap])ealed  to  as  a  substitute  for  volition.  As 
strength  is  gained  more  strenuous  gymnastics  may  be  prescribed,  including  suspension 
from  rings  or  the  simple  horizontal  bar,  while  much  heavier  dumb-bells  may  be  used,  as 
taught  by  Teschner. 

Mechanical  corrective  treatment  is  directed  mainly  to  stretching  shortened  ligaments 
and  contracted  muscles.  For  this  purpose  many  forms  of  apparatus  have  been  devised. 
Their  princi])al  benefit  lies  in  increasing  backward  flexibility  at  the  point  where  curvature 
is  most  pronounced.  As  a  substitute  for  such  apparatus,  and  in  private  houses,  padded 
stretchers  or  lounges  may  be  supplied  on  which  patients  may  lie  either  quietly  or  during 
massage.  Finally  the  matter  of  corrective  corsets  and  braces  remains  to  be  considered. 
External  sup})ort  takes  away  from  the  muscles  and  ligaments  their  functions  and  work. 
Nevertheless  in  some  cases  this  is  necessary.  No  appliance  of  this  kind  that  may  be 
supplied  should  be  continuously  worn.  It  should  be  removed  for  work  and  exercise,  as 
well  as  for  toilet  purposes.  Recumbency  in  bed  is  much  better  than  too  vigorous  bracing. 
Only  in  old,  neglected,  or  peculiar  cases  should  it  be  considered  necessary  to  resort 
to  much  external  aid. 

CURVATURES  FROM  OTHER  SOURCES. 

The  relaxation  and  debility  of  old  age  permit  of  such  deformities  as  rounded  and 
stooped  shoulders,  certain  degrees  of  kyphosis,  and  sometimes  even  pronounced  stooping 
and  deformity,  whose  merely  senile  causes  are  more  or  less  combined  with  rheumatoid 
arthritis  of  the  vertebral  and  costovertebral  joints.  These  features  are  accompanied 
by  more  or  less  pain  or  difficulty  in  locomotion.  Many  instances  of  ischias  scoliotica, 
referred  to  in  the  preceding  section,  would  find  a  ])lace  among  these  clinical  pictures. 
Postmortem  there  are  found  exostoses,  synostoses,  or  ankyloses  sufficient  to  account  for 
the  deformity.  Rickets  also  causes  skeletal  deformities,  in  which  nearly  all  the  bones 
may  participate,  the  spine  rarely  totally  escaping.  In  such  cases  various  typical  and 
atypical  deformities  may  be  met. 

Paralytics  may  show  various  curvatures,  as  do  also  subjects  of  pseudomuscular 
hypertrophy  and  syringomyelia.  Lordosis  is  seen  in  pregnancy  and  in  congenital  hip 
dislocation,  wdiere  it  is  purely  compensatory  in  each  instance  and  does  not  outlast  its 
real  cause.  In  fact  it  may  be  encountered  as  a  compensatory  feature  of  any  other  kind 
of  sj)inal  curvature. 

A  still  more  marked  condition  of  chronic  ostitic  changes  is  seen  in  spondylitis  defor- 
7nans,  which  differs  little  from  arthritis  deformans  of  other  joints,  save  that  in  these 
cases  it  usually  spares  the  joints  of  the  extremities.  It  has  been  known  as  a  rare  sequel 
of  gonorrhea,  even  in  the  young.  Osteophytic  outgrowths  occur  frequently  and  fuse 
together,  causing  ankyloses  and  sometimes  great  deformity,  even  to  the  extent  of  making 
the  spine  assume  a  right  angle  with  the  extended  limbs.  Considerable  pain  is  frequently 
experienced  during  the  course  of  these  very  slow  changes.  The  entire  spine  becomes 
more  or  less  rigid,  consequently  there  is  little  or  no  angular  prominence,  while  the  ribs 
become  immobilized  as  well.  'For  this  condition  there  is  little  or  no  treatment  of  any 
avail.     Sometimes  paralysis  supervenes  and  the  condition  is  not  infrequently  fatal. 


462  SURGICAL   AFFECTIONS  OF   THE   TISSUES 

Acute  ostcom!jcliti.s  of  the  vertebra'  is  oceasioiially  noted.  It  oceurs  nearly  always 
in  young  and  growing  ehildren,  and  is  most  eomnion  in  the  lumbar  spine.  It  is  essentially 
the  same  here  as  oeeurring  in  the  long  bones  or  their  joint  ends,  and  has  been 
deseribed  in  the  previous  eha{)ter.  Its  symptoms  may  be  severe,  and  it  is  not  infrequently 
followed  by  abscess.  When  such  abscesses  point  posteriorly  they  may  be  recognized 
and  incised.  When,  however,  pus  takes  the  anterior  path  it  will  probably  escape  detec- 
tion, at  least  until  too  late.     The  prognosis  is  often  unfavorable. 


TYPHOID  SPINE. 

This  name  was  proposed  by  Gibney  for  what  seems  to  be  an  infectious  periostitis 
involving  the  vertebral  column,  of  a  character  similar  to  that  which  has  been  described 
in  a  previous  chapter.  It  is  characterized  by  excessive  pain,  tenderness,  and  later  stiff- 
ness.    It  may  occur  during  or  after  mild  as  well  as  severe  cases  of  typhoid. 

TRAUMATIC  SPONDYLITIS. 

Kiimrael  has  shown  that  a  traumatic  and  non-tuberculous  ostitis  of  the  vertebrae  occurs, 
with  succeeding  kyphosis  resembling  that  of  Pott's  disease,  but  not  so  angular,  usually 
without  associated  abscesses,  but  with  occasional  paralyses.  This  may  occur  without 
necessary  reference  to  that  curvature  which  may  follow  a  healed  or  healing  spinal  curva- 
ture. Inasmuch  as  the  condition  occurs  only  after  the  lapse  of  considerable  time  after 
injury,  it  is  questionable  whether  it  represents  any  distinct  form  of  disease. 


CANCER  OF  THE  SPINE. 

Malignant  disease  of  the  spine  may  assume  a  type  either  of  sarcoma  when  primary 
or  carcinoma  when  secondary.  The  latter  type  is  much  the  more  common,  and  is  not 
so  infrequent  as  an  exjiression  of  metastasis  from  cancer  in  various  other  parts  of  the 
body,  even  the  more  distant.  It  is  most  common  in  the  lower  spinal  region.  Pain 
occurs  early  and  is  usually  severe.  It  is  as  often  referred  as  localized.  It  may  lead  to 
curvature  of  the  spine  with  some  of  the  grosser  signs  of  spinal  caries,  but  the  prominence, 
if  any  occurs,  will  be  rounded  rather  than  angular.  When  paralyses  occur  they  usually 
assume  that  ty])e  described  by  Charcot  as  paraplegia  dolorosa.     (See  Plate  XXXVIII.) 

When  symptoms  of  a  general  type  like  those  produced  by  spinal  caries  occur  in  adults 
who  are  known  to  have  had  previous  or  present  malignant  disease  the  inference  will 
be  that  they  are  to  be  interpreted  as  local  expressions  of  the  same  character.  Under 
these  circumstances  treatment  can  only  be  palliative.     There  is  no  hope  of  cure. 


SPONDYLOLISTHESIS. 

The  term  spondylolisthesis  implies  a  partial  displacement  forward  of  the  body  of  the 
last  lower  or  next  to  the  last  lower  lumbar  vertebra,  usually  the  former,  which  slips  for- 
ward on  top  of  the  sacruin  with  very  little  perceptible  displacement  of  arches.  The 
condition  may  be  slight  or  ^\e\\  marked,  and  may  or  may  not  be  followed  by  second- 
ary changes.  There  appears  to  be  a  real  fragmentation  or  separation  of  the  body 
from  the  arch,  which  may  be  traumatic,  congenital,  pathological,  or  the  sole  result  of 
pressure  from  above ;  later  exostoses  or  osteoph\'tes  appear  about  the  separation,  thus 
forming  a  new  fixation  and  preventing  further  disj^lacement. 

The  condition  is  more  common  in  females  and  in  the  young,  and  most  cases  give  a 
traumatic  history.  In  those  which  do,  deformity  may  follow  accident  or  it  may  be  long 
postponed,  perhaps  until  pregnancy. 

Symptoms. — The  lesion  is  recognized  by  certain  alterations  of  gait,  with  a  sharp 
lumbar  lordosis  and  unduly  prominent  buttocks  and  iliac  crests,  so  that  these  patients 
much  resemble  those  having  congenital  hip  dislocation,  the  pubes  being  higher  and  the 
sacrum  lower  than  the  normal,  this  diminution  of   pelvic   obliquity  being  practically 


PLATE  XXXVni 


Sarcoma  of  the  Spine  and  Cord.     (Goldthwait.) 


KxncK  K.\h'h-  AM)  now  Li:<! 


463 


always  patliofjiiomoiiic     On  vajfinal  or  nctal  cxainiiiatioii  uiuliu'  |)r()iniiu'nc('  mav  l)c 
felt  above  the  .sacniin.     Some  of  these  cases  coinphiiii  of  mucli  pani,  either  loeal  or 
referred,  down  the  linil),  the  same  beini;  made  worse  hy  exercise. 

Diagnosis.  1  )i;i^Miosi.s  should  he  made  as  hetweeti  this  condition,  Pott's  disease, 
d()ul)l('  ciinj^cnital  dislocation  ol"  the  hi|),  and  rickets. 

Treatment.  The  condition  does  not  admit  of  extendccl  treatment,  save  that 
a  certain  |)r()|)orti()n  of  cases  are  benefited  by  such  fixation  as  is  alfonled  bv  a  plaster 
jacket,  which  lirmly  encloses  the  pelvis  and  supports  the  lower  part  of  the  trunk  upon  it. 


KNOCK-KNEE  AND  BOW-LEG. 


Fig.  261 


The  plane  of  the  terminal  articular  surface  of  the  lower  end  of  the  femur  is  not  at  ri^dit 
anjjles  with  tlu'  axis  of  its  shaft;  in  other  words,  the  inner  condyle  is  |)laced  a  little  lower 
or  beyond  the  location  of  the  outer.  In  this  way  sufficient  anfjular  arran<femeiit  of  the 
le<i:  upon  the  {\\\g\\  is  permitted  so  that,  with  the  upper  ends  of  the  femora  sej)aratcd  bv 
the  width  of  the  pelvis,  the  knees  and  the  ankles  may,  under  normal  circumstances,  be 
made  to  touch  when  the  limbs  are  fully  extended.  Thus  a  slight  degree  of  angular 
deflection  at  the  knee  is  normal.  When  this  is  exaggerated  to  a  degree  not  permitting 
the  ankles  to  touch  when  the  knees  are  in  contact  the  condition  is  knoAvn  as  genu  va/rpim, 
or  knock-knee.  \Yhen,  on  the  other  hand,  the  angle  is  lessened  or  reversed  so  that  the 
knees  are  more  or  less  separated  when  the  ankles  are  in  contact  the  condition  is  then 
known  as  rjenn  varnm,  or  bow-leg.  These  two  conditions  constitute  the  tyj)ical  and 
classical  types  of  knock-knee  and  bow-leg.  Other  conditions,  however,  which  lead  to 
the  same  result  occair  through  various  and  irregu- 
lar curvatures  or  irregularities  of  the  femur  or 
the  tibia,  or  both,  and  there  thus  may  be  produced 
atypical  yet  most  pronounced  instances  of  these 
same  deformities.  These  deformities  may  be  ap- 
j^arent  almost  from  birth,  may  appear  during  early 
childli()(jd,  or  not  until  adolescence.  As  a  rule 
they  are  not  manifested  until  young  children  are 
learning  to  walk.  Whenever  they  aj)pear  before 
this  time  they  are  expressions  of  infantile  rickets, 
which  should  be  recognized  as  such  and  corrected 
by  mere  manipulation  while  the  bones  are  still 
flexible,  the  correction  being  maintained,  and  by 
suitably  feeding  and  medicating  the  patient.  (See 
the  general  subject  of  Rickets.) 

In  fact  rickets  supplies  the  explanation  for  the 
great  majority  of  these  deformites;  incomplete  ossi- 
fication and  calcification  of  the  bones  accounting 
for  the  comparative  ease  with  which  they  }aeld  to 
pressure  or  other  deforming  influences.  Rickety 
children  always  manifest  a  tendency  to  defective 
ossification  at  epiphyseal  lines,  and  it  is  here  that 
the  change  usually  takes  place.  Nevertheless 
marked  instances  of  curvature  are  seen  in  all  the 
bones  of  the  lower  extremity.  As  deformity  in  any 
given  direction  becomes  more  pronounced  the  ten- 
dency to  its  exaggeration  becomes  greater.  Finally 
these  changes  involve  not  only  the  bones  proper  but 
the  ligaments  and  the  other  joint  structures,  which 

yield  where  pressure  is  abnormal  and  greatest,  thus  completely  changing  their  shai)e 
and  internal  relations.  Along  with  other  changes  in  knock-knee  there  is  a  tendency 
to  external  rotation,  ])erhaps  even  to  spiral  curvature  of  the  tibia;  the  patella  lies  outside 
of  its  normal  position,  the  tendons  are  more  or  less  displaced,  while,  at  the  same  time, 
there  may  be  inflection  of  the  feet  as  an  effort  at  compensation  (Fig.  261). 

With  the  exception  of  spinal  curvatures  and  torticollis  there  is  perhaps  no  more  con- 
spicuous deformity  than  that  produced  by  these  abnormalities  at  the  knee-joint.     While 


Rachitic  changes  in  limbs.     (Lexer.) 


464  SURGICAL   AFFECTIOXS  OF   THE   TISSUES 

at  first  gait  is  not  seriously  affected,  it  is  in  time,  especially  in  cases  of  double  knock-knee. 
When  these  knees  are  bent  to  a  right  angle  the  angular  deformity  disappears  and  all 
that  remains  is  the  rotation  of  the  tibia.  Hence  it  follows  that  all  correction  of  the.se 
deformities,  either  .slow  or  operative,  should  be  applied  to  the  fully  extended  leg.  In 
advanced  ca.ses  there  is  frecjuently  a  comjilication  with  flat-foot,  which  may  or  may  not 
be  painful.  The  condition  is  rarely  produced  by  paralytic  affections,  and  should  be 
differentiated  from  mere  atrophy  of  wasted  and  contracted  legs.  A  form  of  knock-knee 
is  occasionally  seen  in  the  adult,  which  is  of  traumatic  origin  and  is  due  to  improper  care 
or  neglect  in  the  treatment  of  the  injury. 

Treatment. — The  treatment  of  this  condition  is  either  mechanical  or  operative.  Me 
chanical  treatment  varies  between  the  gentlest  expedients  and  the  use  of  more  or  less 
extensive  antl  cumbersome  apparatus.  \Yhen  a  young  and  growing  child  begins  to  show 
evidence  of  either  of  these  deformities  it  is  usually  sufficient  to  sii])ply  shoes  which  are 
reasonably  stiff,  and  raise  one  or  other  border  of  the  sole  and  heel,  according  as  we  wish 
to  influence  the  growth  of  the  limb,  i.  e.,  in  knock-knee  the  inner  border  of  the  foot  is 
to  be  raised,  in  bow-leg  the  outer.  The  con,sequence  of  even  slight  influence  thus 
constantly  maintained  when  the  child  is  upon  its  feet  is  usually  sufficient  to  rectify  .slight 
degrees  of  these  deformities.  ^Yhen,  however,  the  case  is  pronounced  more  radical 
measures  should  be  applied.  Massage  has  been  recommended  along  with  manipula- 
tion, but  should  be  gently  performed.  The  different  forms  of  apparatus  in  use  afford 
various  methods  of  making  pressure  against  that  condyle  which  is  too  prominent.  It  is 
possible  to  make  them  efficient,  but  only  when  they  are  both  well  planned  and  well 
made  in  the  first  place  and  intelligently  applied  and  watched.  The  special  forms  of 
apparatus  sold  in  the  instriunent  stores  are  of  little  value.  Too  often  it  happens  that 
when  efficient  they  cannot  be  tolerated,  and  that  when  tolerated  they  are  inefficient. 
Much  speedier  and  more  satisfactory  results  are  achieved  by  operative  methods,  so  that, 
in  general,  they  may  be  regarded  as  the  more  desirable. 

Operative  treatment  consists  in  some  modification  either  of  osteoclasis  or  osteotomy. 

Osteoclasia  has  to  do  with  the  forcible  stretching,  bending,  or  even  breaking  of  those 
parts  which  show  the  greatest  effects  of  the  deformity  or  are  known  to  be  its  primary 
seat.  In  young  children  with  tender  and  still  somewhat  flexible  bones  this  may  be 
accomplished  by  the  hands  alone,  the  j)atient  being  under  an  anesthetic.  ^Manual  power 
failing  a  simple  instrument  known  as  the  osteoclast,  which  affords  a  means  of  applying 
powerful  pressure  by  the  agency  of  a  screw  at  just  the  desired  point,  is  used.  Pressure 
is  then  applied  and  carried  to  the  necessary  degree,  even  with  partial  or  complete  fracture 
of  the  bone  at  fault.  In  this  way  is  inflicted  a  simple  fracture  which  permits  of  the 
immediate  redressing  of  the  limb,  with  such  overcorrection  of  the  deformity  as  seems 
desirable.  The  limb  thus  treated  is  completely  encased  in  a  suitable  plaster-of-Paris 
splint,  and  should  be  held  in  the  desired  position  vuitil  the  plaster  is  completely  hardened 
and  not  likely  to  yield.  Osteoclasis,  though  it  often  appears  an  exceedingly  barbarous 
procedure,  is  one  of  the  most  beneficent  when  properly  managed,  and  is  rarely  followed 
by  an  undesirable  result. 

Osteotomi/  is  performed  by  the  use  of  the  chisel  and  mallet,  the  former  being  introduced 
through  a  small  incision  made  in  the  skin,  passed  down  to  the  bone  with  its  cutting  edge 
parallel  to  the  bone  axis  until  the  bone  itself  is  reached,  after  which  it  is  turned  at  right 
angles  to  it  and  the  mallet  used  until  the  chisel  has  been  driven  partly  or  completely 
through  the  shaft  of  the  bone  or  the  portion  which  it  is  intended  to  attack.  The  chisel 
should  be  partly  withdrawn  and  its  position  changed  if  it  is  necessary  to  continue  its 
use.  Thus  by  a  partial  division  of  the  bones  of  the  young  it  is  possible  usually  to  so 
weaken  them  that,  without  undue  force,  and  by  manual  ])ower,  they  are  fractured  at 
the  desired  point.  The  operation  should  be  done  with  the  most  complete  aseptic  pro- 
tection. The  procedure  recommended  by  Macewen  is  now  universally  acce]:)ted.  The 
incision  is  made  at  the  inner  side  of  the  thigh  just  above  the  tubercle  for  the  adductor 
magnus,  and  the  osteotome  (as  the  chisel  especially  made  for  this  purpose  is  called) 
is  passed  through  it,  down  to  the  bone,  turned  at  right  angles,  and  made  to  cut  nearly 
through  the  shaft.  Lest  it  become  too  firmly  wedged  it  may  be  moved  a  little  laterally 
after  each  blow  of  the  hammer.  The  operation,  if  properly  done,  is  practically  blood- 
less; the  small  opening  made  for  the  chisel  is  sealed  at  the  moment  of  its  withdrawal, 
the  deformity  corrected  with  the  least  amoimt  of  handling  or  disturbance,  and  the  plaster- 
of-Paris  bandage  immediately  applied,  with  the  leg  in  exactly  the  position  which  it  is 


CIA/ B  FOOT;   TMJI'HS  4(55 

desired  slimild  he  iiwiiiilaiiied.  Siicli  ii  dressiiijf  may  l)e  left  for  lliree  or  four  weeks 
l)etore  l)eiii<f  clianticd.  ( )iie  eliaiifje  is  usually  sudicieiil,  iiiid  in  I'loiu  six  to  seven 
weeks  the  |)a(ieMt  is  allowed  to  slowly  refrain  use  ol"  the  lueuiber. 

A  special  set  of  osteotomes,  after  INIaeeweu's  pattern,  is  furnished  by  the  instrument 
dealers  for  th()S(>  who  j)raetise  osteotomy.  It  consists  of  a  set  of  thr(>e  straifjlit  chisels, 
consecutively  minihered,  the  first  heiufi^  a  Uttle  thicker  and  the  third  the  tliiiiiiest  of  the 
thr(>e,  and  thus  made  with  tlie  intent  to  use  the  thickest  first  in  order  (hat  iu  tiie  notch 
made  by  it  the  thinner  instruments  can  be  subsecjuently  more  easily  manipulated. 

BOW-LEGS. 

Bnir-Irgs  are  nearly  always  of  rachitic  ori<i^in,  occurrinfj  with  less  anpjular  deformity, 
and  as  the  result  of  the  warping  or  bending  of  bones  which  are  nc^t  sufficiently  rigid 
to  sustain  the  weight  they  are  made  to  carry.  Most  cases  of  how-legs  have  their  origin 
within  the  very  early  years  of  childhood.  Other  cases  are  seen  in  infancy  and  before 
children  have  ever  borne  much  weight  upon  their  feet.  The  deformity  must  be 
accounted  for  by  muscle  tonus,  mere  muscle  activity  serving  to  ])lace  enough  stress  upon 
the  bones  to  swerve  them  from  their  normal  axes.  The  bones  jirobably  bend  outward 
because  the  muscles  on  the  imier  side  are  the  stronger.  Children  thus  affected  walk 
not  so  nuich  with  a  limj)  as  with  a  waddle,  with  the  feet  rather  ajwirt,  and  some  inversion 
of  the  toes.  Double  and  complicated  curves  occur  in  many  of  these  cases,  both  femurs 
and  tibias  participating,  and  having  an  anterior  as  well  as  a  lateral  bowing.  Such 
coni|)li(ati<)ns  materially  increase  the  difficulty  of  any  treatment. 

Treatment. — The  frratment  of  bow-leg  is  generally  considered  simpler  than  that 
of  knock-knee.  Occurring  in  young  and  growing  children  it  can  be  overcome,  if  taken 
early,  by  the  expedient  already  mentioned,  elevating  the  outer  border  of  the  sole  of  each 
shoe.  The  more  mechanical  and  the  purely  operative  methods  of  treatment  are  essen- 
tially the  same  as  those  just  described  for  knock-knee,  based  on  similar  but  reversed 
principles.  In  the  very  young  manual  force  will  often  serve  the  purpose  of  a  more  formal 
osteoclasis,  but  the  osteoclast  may  be  used  whenever  it  seems  indicated.  In  those  cases 
where  the  bowing  is  due  to  abrupt  and  almost  angular  deformity,  osteotomy  is  indicated. 
This  is  made  on  exactly  the  same  principles  as  mentioned  above.  In  all  instances  spiral 
curvatures  should  be  overcome  so  far  as  possible  during  the  process  of  forcible  correc- 
tion and  dressing  in  the  plaster-of-Paris  bandages  ordinarily  used.  Here,  as  previously, 
all  treatment  should  be  addressed  to  the  limbs  in  their  fully  extended  position.  If  the 
rings  of  the  ordinary  osteoclast  be  sufficiently  padded  and  protection  afforded  in  this 
way,  the  skin  rarely  sloughs,  and  the  damage,  which  is,  at  least,  theoretically  done 
to  the  tissues,  is  quickly  repaired.  Failure  in  union  after  any  of  these  operations  is 
exceedingly  rare. 

CLUB-FOOT;   TALIPES. 

In  general  the  term  talipes  is  applied  to  any  malformations  of  the  foot  by  which  it  is 
more  or  less  misshaped  and  its  function  imj)aired.  The  commonest  of  these  is  that 
known  and  described  below  as  talipes  equinovarus.  Of  these  various  deformities  there 
are  four  principal  types,  according  as  the  foot  is  inverted,  everted,  hyperflexed,  or  hyper- 
extended.     More  particularly  they  are: 

1.  Talipes  equinovarus,  the  commonest  type,  the  ordinary  club-foot; 

2.  Talipes  valgus,  or  flat-foot; 

3.  Talipes  equinus; 

4.  Talipes  calcaneus. 

These  forms  may  be  variously  blended,  as  well  as  seen  in  varying  degrees  from  the 
slightest  possible  deviation  to  the  most  pronounced  form.  Statistics  show  that  about 
one  child  in  every  five  hundred  is  born  with  some  form  of  club-foot. 

Club-foot  may  be  either  of  acquired  or  congenital  origin.  Acquired  club-foot  is  essen- 
tially always  of  paralytic  nature,  following  usually  infantile  paralysis  or  those  injuries 
by  which  nerves  have  been  divided  or  caught  in  callus  or  in  tumors.  As  the  result  of 
such  loss  of  nerve  or  muscle  power,  in  certain  muscle  groups,  malpositions  of  the  feet 
are  caused  w'hich  simulate  those  of  congenital  origin. 


4()()  SURGICAL   AFFECTIOXS  OF  THE  TISSl  FS 

1.  Congenital  Club-foot;  Talipes  Equinovanis.    This  coiLsLsts  anatoinkally  in  an 

inward  dislocation  at  the  metatarsal  joint  of  the  anterior  part  of  the  foot,  in  conse- 
quence of  which  the  relations  of  all  of  the  other  com[)on('nt  parts  of  the  foot  are  rleranged; 
the  scaphoid  is  swerved  on  to  the  inner  and  lower  side  of  the  astragalus  to  such  an 
extent  as  to  touch  the  internal  malleolus;  the  cuneiforms  follow  the  scaj)hoid  and  the 
metatarsals  follow  the  cuneiforms;  the  cuboid  is  shifted  to  the  iimer  side  and  does  not 

articulate  squarely  with  the  calcis.     In   infants  these 
^'^■-^~  bones  are  cartilaginous,  but  as  the  individuals  grow 

and  these  miniature  bones  develop  and  ossifv  they 
take  similar  and  abnormal  shapes  and  positions. 
The  calcis  is  drawn  into  a  more  vertical  position  than 
normal  by  drawing  up  the  heel,  and  Ls  even  somewhat 
rotated  on  its  own  vertical  axis;  thus  its  anterior  artic- 
ulating surface  is  made  to  look  obliquely  inward. 
This  displacement  of  bones  causes  dislocation  of 
tendons,  the  anterior  group  being  drawn  mostly  to 
the  inner  side.  The  patient  walks  more  and  more  on 
the  outside  of  the  foot,  and  as  he  does  this  adventi- 
tious bursae  develop  on  the  outer  border,  which  be- 
come very  thick  and  form  in  time  large   callosities. 

Talipes  equi nova r us.  t      ,i  ^  i  ,i  • 

In  the  most  pronounced  cases  there  occurs,  m  con- 
nection with  all  this,  curvature  or  spiral  inward  rotation  of  the  tibia,  and  even  of  the  femur 
of  the  affected  liml),  while  the  contracted  muscles  become  overdevelojied  and  those 
which  are  disused  underdeveloped  (Fig.  262). 

Among  the  causes  of  club-foot  heredity  seems  to  play  a  considerable  part,  as  it  often 
happens  that  two  or  three  club-footed  children  are  born  of  one  mother.  The  deformity 
has  been  ascribed  to  abnormal  or  exaggerated  posture  in  utern,  with  comj)ression.  This 
theory  is  at  least  attractive  and  has  the  force  of  argument  from  antiquity,  for  Hippo- 
crates thus  believed.  Unquestionallythe  normal  intra-uterine  position  of  the  fetus  includes 
a  certain  degree  of  equino varus.  Yet  if  this  were  the  real  cause  the  condition  would 
occur  apparently  much  more  frequently.  It  has  been  ascribed  also  to  disparity  in  strength 
between  opposing  groups  of  muscles,  that  group  which  causes  the  deformity  being 
nattn-ally  the  stronger,  it  being  at  the  same  time  unimportant  whether  one  group  is 
relatively  too  strong  or  the  other  relatively  too  weak.  Most  monstrosities  or  seriously 
defective  infants  have  also  club-foot,  from  which  some  argue  that  the  central  nervous 
system  has  something  to  do  with  it;  yet  it  has  been  shown  in  over  1200  cases  of  club-foot 
that  only  twice  did  such  defect  of  the  central  nervous  system  as  spina  bifida  occur. 
The  embryologists  and  comparative  anatomists  regard  it  as  an  expression  of  arrested 
development,  while  evolutionists  consider  it  an  atavistic  reversion  to  an  earlier  anthro- 
poid arrangement.  None  of  these  theories  really  satisfactorily  explains  the  deformity. 
Therefore  we  shoidd  hold  that  either  there  are  different  and  variable  causes  or  that  we 
have  not  yet  found  the  true  one. 

Treatment  of  Congenital  Club-foot. — There  being  in  these  cases  no  tendency  to  spon- 
taneous ini])rov('nicnt,  incchauical  or  operative  treatment,  or  both,  are  required.  If 
these  be  afforded  early  the  prospects  of  restoration,  practically  to  the  normal,  are  good, 
"but  treatment  should  be  begun  early  and  conducted  with  great  care  and  patience.  It 
is  not  so  difficult  to  correct  the  deformity,  but  correctional  sup})f)rts  shoukl  be  worn  for 
a  relatively  long  time,  while  the  older  the  case  the  more  difficult  become  all  the  features, 
both  mechanical  and  durational.  Parents  are  often  eager  at  first,  but  later  become 
inattentive  or  careless.  The  main  objects  are  to  be  attained  by  correction  of  position 
by  force  or  by  division  of  contracted  or  shortened  tissues,  or  retention  in  position,  with 
the  addition  of  any  other  features  which  may  influence  growth  and  development  accord- 
ing to  normal  standards.  Of  these  we  will  sjx-ak  first  of  rectification :  (rr)  bloodless,  as 
by  purely  mechanical  force,  or  by  means  of  certain  apj^aratus,  and  {h)  operative,  as  by 
subcutaneous  tenotomy,  aponeurotomy,  etc.,  or  by  open  incision,  through  which  are 
performed  osteotomy,  excision,  astragalectomy,  tarsectomy,  etc.,  as  the  operator  may 
see  fit. 

In  all  of  these  the  anterior  part  of  the  foot  is  to  be  forced  outward  as  well  as  raised, 
two  distinct  features,  which  should  be  combined  but  not  confused. 

In  the  young  infant  gentle  force  applied  many  times  a  day,  with  the  persuasion  of  a 


CLUH  FOOT;   TALirES  4(17 

.stri|)  of  adhesive  |)Ia.ster,  a|)|)li(Ml  beneath  th<'  foot  and  over  its  outer  border,  and  spirally 
n|)\vard  to  the  inside  of  the  lefjj,  can  he  made  effective  in  mild  cases;  but  overstretching 
of  tile  tendo  Aehillis  is  a  necessary  part  of  this  maneuver  every  time  it  is  practisccl. 
The  more  positive"  method  consists  of  fixation  of  the  foot  in  overcorrected  position  within 
a  plaster  or  starcli  l)an(la<;e,  the  same  extendiufj  al)ove  the  knee,  which  should  be  slightly 
flexed,  the  dressing  to  be  renewed  every  two  or  three  weeks,  and  correction  increased 
until  it  has  become  overcorrection. 

In  well-marked  and  in  resistive  eases  an  anesthetic  should  be  given,  while  by  the  use 
of  sufficient  force,  which  may  be  relatively  great,  but  which  should  be  gently  a[)[)lied, 
the  resisting  tissues  arc  so  stretched,  if  necessary  to  the  point  of  something  yielding,  that 
but  slight  pressure  is  required  to  hold  the  foot  in  an  overcorrected  j)()sition.  When 
the  knife  is  required  the  tendo  Aehillis  should  always,  and  the  j)lantar  tendons  and 
fascia^  usually,  be  sul)cutaneously  divided,  under  aseptic  ])recautions.  '^fhe  foot  is  then 
envelojH'd  in  suitat)lc  dr(\ssings  and  put  up  in  overcorrected  position  for  two  or  three 
days,  in  a  rigid  dressing  at  first  of  starch,  but  after  this  in  plaster  of  Paris;  this  is  the 
writer's  j)lan  of  procedure.  The  insertion  of  the  point  of  the  tenotome  sufficiently  deep  to 
divide  all  resistive  ligaments  and  tissues  {c.  g.,  the  astragaloscaphoid  or  the  calcaneo- 
cuboid) nowise  complicates  this  method,  but  makes  it  more  efficient. 

Cases  which  are  resistant  are  best  submitted  at  once  to  npm  oprrafion  (that  is,  after 
vigorous  stretching  of  the  contracted  tissues),  always  under  strict  asepsis.  After  decades 
of  milder  ineffectual  methods  it  remained  for  A.  M.  Phelps,  of  New  York,  to  show 
the  benefits  of  this  method  by  which  all  contracted  tissues  on  the  concave  aspect  of  the 
foot  are  exposed  and  divided.  Incision  is  made  here  from  the  top  of  the  inner  malleolus 
to  the  inside  of  the  first  tarsometatarsal  joint.  With  a  little  care  the  artery  can  be  avoided, 
but  I  have  never  seen  any  harm  come  from  its  division.  Everything  which  proves 
resistant  is  divided,  even  the  inner  osseous  ligaments.  Sometimes  the  incisions  can  be 
made  in  wedge-shape,  or  ol^liquely,  so  that  the  wound  does  not  remain  so  widely  open. 
No  attempt  is  made  to  close  this  wound.  The  operation  may  be  done  bloodlessly,  under 
the  Martin  rubber  bandage,  but  whether  this  be  used  or  not  any  vessel  which  can  be 
recognized  as  such  should  be  tied;  otherwise  the  wound  is  snugly  packed  with  gauze 
(upon  which  I  like  to  use  Peru  balsam).  An  ample  surgical  dressing  is  applied 
over  it.  This  is  covered  with  gutta-percha  tissue,  to  prevent  too  free  access  of  air  to 
the  blood  which  will  ooze  into  the  dressing,  and  the  whole  is  then  covered  with  a  starch 
bandage,  in  overcorrected  position;  this  is  left,  according  to  circumstances,  for  from 
three  days  to  a  week — the  longer  the  better.  Then  everything  is  removed,  fresh  gauze 
placed  in  the  wound,  which  will  be  found  already  largely  filled  up;  fresh  dressings  are 
applied,  and  the  foot  put  up  in  plaster  of  Paris,  with  or  without  a  fenestrum  or  any  pro- 
vision by  which  the  region  of  the  wound  may  be  easily  uncovered  for  necessary  renewal 
of  dressing. 

It  is  in  the  most  pronounced  types  of  cases  only,  with  marked  bone  deformity,  or 
those  in  which  previous  operations  have  failed,  that  the  still  more  radical  division  or 
removal  of  some  part  of  the  tarsus  is  necessary.  As  to  this  no  universal  rule  can  be 
applied  save  this :  take  out  sufficient  to  correct  deformity.  In  some  cases  it  will  be  sufK- 
cient  to  excise  the  astragalus  (astragalectomy).  In  other  cases  it  is  better  to  remove  a 
wedge-shaped  piece  of  tlie  tarsus,  without  reference  to  the  name  of  the  bones  attacked 
(farsectomy).  I  have  never  found  it  necessary  to  touch  the  external  malleolus,  though 
this  has  been  suggested,  nor  to  do  osteotomy  of  the  calcis  or  of  the  leg  bones  above  the 
ankle,  as  a  few  have  done. 

These  operations  are  usually  practised,  after  a  preliminary  stretching,  through  a 
curved  incision  on  the  outer  aspect  of  the  foot,  through  which,  at  the  same  time,  the 
thickened  bursse  may  be  removed,  or  the  callosities  included  in  the  incision.  The  chief 
convexity  of  the  incision  should  be  over  the  os  calcis  at  its  anterior  portion.  As  the 
dissection  is  made  the  tendons  are  drawn  aside  and  spared.  If  it  be  necessary  to  di\ide 
one  or  more  of  them  it  should  be  re-united  later.  According  to  the  density  of  the  struc- 
tures a  strong  knife  may  be  used,  and  strong  scissors,  or  an  osteotome  manipulated 
either  by  hand  or  with  the  hammer.  After  sufficient  V-shaped  or  wedge-shaped  bone 
has  been  removed  the  defect  should  be  held  together,  if  practicable,  l)y  buried  tendon 
sutures  or  wire;  it  is  rarely  necessary  to  use  drainage.  The  external  wound  may  be 
loosely  closed  with  buried  sutures,  a  suitable  dressing  applied,  and  the  foot  put  up  in 
a  rigid  splint;  this  should  permit  of  removal,  or  at  least  inspection  of  the  wound  after 


468  SURGICAL   AFFECTIOXS  OF   THE    T ISSUES 

a  few  days,  for  renewal  of  those  dressinffs  which  are  saturated  with  l)lood  and  for  a])[)H- 
eation  of  new  (h-essinjjs.  After  tiiis  tlie  foot  and  le<^  should  he  put  up  in  overeorreetcd 
position  in  phister  of  Paris. 

In  aggravated  eases  of  cluI)-foot  Wilson  l)elieves  combined  operation  to  give  better 
functional  results  than  can  be  obtained  by  any  other  method.  The  astragahjseaphoid 
joint  is  exposed  by  an  incision  over  the  prominence  of  the  scaj)lioid,  and,  being  cleared, 
is  opened  with  chisel  or  bone  foreejxs,  while  sufficient  of  the  articular  surfaces  is  removed 
to  destroy  them  as  such  and  to  take  out  a  sufficiently  large  wedge-shaped  piece  from 
eitlier  bone  so  that  the  desired  arch  of  the  foot  is  restored,  or  even  exaggerated.  Then 
the  tendon  of  the  extensor  proprius  hallucis  is  exposed  and  divided  just  al)()ve  the  great 
toe,  the  U|)per  end  of  the  tendon  })eing  drawn  out  through  the  first  incision.  To  this 
end  is  attached  a  strong  silk  ligature.  The  scaphoid  is  then  perforated  with  a  l)one  drill 
at  some  distance  from  its  superficial  aspect  and  at  such  an  angle,  with  the  foot  in  correct 
position,  that  the  canal  thus  made  shall  be  in  line  with  the  action  of  the  tendon.  The 
drill  is  then  withdrawn  and  the  tendon  passed  through  the  opening  by  means  of  its 
attached  silk.  One  inch  beyond  the  bony  canal  the  tendon  is  cut  off  and  split  in  halves, 
each  half  being  turned  in  opposite  direction  and  fastened  to  the  periosteum  of  the 
scaphoid  with  fine  silk,  while  the  foot  is  held  in  overcorrected  position,  so  that  the  tendon 
is  sewed  in  its  new  place  under  moderate  tension.  The  foot  is  then  dressed  in  this 
overcorrected  position  in  plaster  of  Paris,  the  splint  extending  nearly  to  the  knee,  and 
the  wound  area  being  exposed  by  a  fenestrum  cut  in  the  splint  before  it  is  hard. 

The  location  of  the  incision  over  the  dorsum  or  outer  aspect  of  the  foot  may  be  varied 
to  suit  the  needs  of  the  case  and  the  method  of  the  attack.  In  a  general  way  a  flap  of 
soft  tissues  is  raised  and  tendons,  so  far  as  possible,  are  held  outward.  This  is  usually 
practicable,  and  it  is  rarely  necessary  to  divide  the  latter.  After  o{)eration  of  any  type 
and  recovery  from  the  same  it  will  be  necessary  for  a  long  time  to  have  the  patient  wear 
a  corrective  appliance.  This  should  be  applied  as  early  as  possible,  and  should  l)e  worn 
continuously,  i.  e.,  night  and  day;  inasmuch  as  growth  is  continuous  there  should  also 
be  continued  correctional  influences.  ]Many  types  of  apparatus  have  been  devised. 
That  which  the  writer  has  found  effective  and  has  adopted  for  a  number  of  years  is  illus- 
trated in  Fig.  203.  It  may  be  made  single  or  double,  as  occasion  requires.  A  part  of 
the  appliance  is  a  spiral  s])ring  and  a  provision  for  a  constant  outward  pressure  is  made 
u]ion  the  foot,  by  which  inversion  is  more  easily  overcome,  as  well  as  any  inward  spiral 
twist  of  the  bones  of  the  leg.  No  such  apparatus  can  be  made  effective  unless  connected 
suitably  with  a  waist-band.  This  is,  therefore,  included  in  the  shoe  shown  in  Fig. 
263.  Furthermore  the  appliance  should  be  so  made  as  to  permit  adjustment  commen- 
surate with  the  rapid  growth  of  the  patient,  and  in  order  that  it  need  not  be  too  often 
renewed.  Some  degree  of  mechanical  ability  is  required  for  its  application  and  manage- 
ment. The  principles  are,  however,  easily  mastered  and  most  parents  can  soon  learn 
to  manage  it. 

2.  Talipes  Valgus. — This  condition  is  known  also  as  talipes  planus,  or,  more  briefly, 
pes  plan  //.v,  the  common  names  being  flat-foot,  spkuj-foot,  or  pronated  foot.  A  particularly 
painful  variety  has  f>een  often  spoken  of  as  pes  planus  dolorosus. 

This  type  of  deformity  is  rarely  of  congenital  origin.  It  is  characterized  by  abduction 
and  pronation  of  the  foot,  on  whose  inner  border  there  often  appear  two  prominences, 
one  the  head  of  the  astragalus  the  other  the  head  of  the  scaphoid.  The  bones  show 
much  less  alteration  in  actual  shape  than  in  club-foot.  The  scaphoid  is  deflected  some- 
what to  the  outer  side  and  the  astragalus  turned  a  little  outward  and  downward.  A 
prominent  feature  is  that  the  arch  of  the  foot  is  more  or  less  obliterated,  while  its  inner 
border  becomes  convex  instead  of  remaining  concave.  This  is  due  in  large  measure  to 
relaxation  of  the  ligaments  binding  the  foot  to  the  calcis,  especially  that  extending  from 
the  astragalus  (Fig.  264). 

Etiology. — The  common  cause  of  the  condition  is  lack  of  sufficient  strength  of  the  parts 
to  carry  the  weight  of  the  superimposed  body.  It  is  produced  often  l)y  ill-fitting  shoes, 
accompanied  by  excessive  strain  or  rapid  growth  and  gain  in  weight.  It  is  sometimes 
complicated  by  a  certain  shortening  of  the  gastrocnemius  (Shaffer),  which  prevents 
flexion  to  its  complete  degree  and  compels  some  degree  of  eversion  of  the  foot  in  com- 
pleting a  step.  In  some  instances  it  is  induced  by  previous  morbid  conditions,  such  as 
rickets,  paralysis,  diseases  of  the  s[)inal  cord,  and  postgonorrheal  arthritis.  Ill-fitting 
footwear  is  the  most  common  cause,  as  it  compresses  the  front  part  of  the  foot  and  pre- 


CLUHFOOT:  TALIPES 


400 


vents  a(la|)tiiti(>n  of  lli(>  foot  to  the  position  it  should  assume  when  the  weifjlit  of  the  body 
is  thrown  ujjon  it.  The  ell'ect  of  this  wei^jjhl  is  to  necessitate  a  fijreater  (hverf^eiiee  of  the 
toes  tlian  such  shoes  permit  and  <i;raduail_v  causes  tlie  patient  to  walk  on  the  inside  of 
the  foot.      FIdt-Joot  /.v  seldom  .seen  in  tho.sr  irlio  liahitiKtllij  ijo  Ixi  re  footed . 

The  condition  is  best  relieved  hy  makin<>'  a  <fra|)hic  record  of  each  ease.  This  is  done 
by  mal<in<2;  the  barefooted  patient  ste])  (irst  on  smoked  <rlassoron  wet  dusted  ])aper,  and 
then  u|)on  a  piece  of  plain  paper.  If  such  a  print  be  comj)are(l  with  the  j)rint  similarly 
ol)tained  from  the  normal  foot  it  will  be  seen  liow  dilferent  are  the  points  of  contact 
and  how  diH'(>r(M)tly  distributed  is  the  body  weight.  A  non-grajihie  l)ut  sufficient  insj)ee- 
tion  may  be  afforded  by  havint;  the  pati(>nt  stand  upon  a  stool  whose  top  is  made  of 
glass  and  by  using  a  mirror  beneath  the  feet.  In  iiny  event  it  will  be  shown  that  the 
inner  border  of  the  foot  is  at  least  nearly  straight  or  even  convex,  whereas  it  should  be 
neither. 

There  are  tender  points  over  the  astragaloscaphoid  joints,  at  the  base  of  the  first  and 
fifth  metatarsals,  in  front  of  the  intenud  malleolus,  as  well  as  often  beneath  the  heel. 
Patients  who  thus  sulfcr  find  that  the  feet  perspire  very  easily.     In  walking  the  feet 


Ki.;.  263 


Fio.  204 


Park's  club  foot  brace. 


Talipes  valgus. 


are  everted,  and  when  tenderness  is  very  great  it  is  because  too  much  weight  is  borne  on 
the  inner  borders  of  such  everted  feet.  Inspection  of  the  shoes  will  also  show  wearing 
of  the  inner  border  and  over  the  inner  malleolus. 

Spontaneous  cure  of  such  cases  does  not  occur,  except  perhaps  after  long  confinement 
in  bed  from  other  causes,  but  patients  occasionally  become  tolerant  after  a  time,  though 
many  of  them  grow^  steadily  worse  and  avoid  using  the  feet  more  than  is  absolutely 
necessary. 

Treatment. — Mild  cases  will  be  benefited,  often  practically  cured,  by  simply  raising 
the  inner  border  of  the  sole  and  heel  of  the  shoe.  This  causes  more  weight  to  be  borne 
on  the  outer  border  than  in  the  natural  attitude  of  the  foot.  It  will  be  sufficient  usually 
to  make  from  f  inch  to  f  inch  difference  in  the  level  between  the  inner  and  the  outer 
borders  of  the  sole  and  heel.  Shoes  may  be  so  constructed  that  this  difference  is 
made  invisible,  or  suitably  bevelled  narrow  strips  of  leather  may  be  .sewed  beneath  the 
sole  along  the  inner  side,  or  laid  in  between  its  upper  and  lower  layers. 

While  this  suffices  for  the  milder  cases  it  is  not  sufficient  for  the  more  severe  cases, 
which  require  forcible  correction,  ami  often  under  an  anesthetic.     The  best  way  to 


470  SURGICAL  AFFECTIONS  OF  THE  TISSUES 

accomplish  this,  after  havinoj  patients  thoroughly  relaxed  with  chloroform,  is  to  make 
a  thorough  manipulation  of  the  foot,  trving  especially  to  so  loosen  hs  outer  ligaments 
that  it  may  be  more  easily  put  in  j)roper  position  and  finally  overc-orrected.  The  foot 
is  then  put  up  in  plaster  of  Paris  in  this  much  overcorrected  position.  Such  splints  are 
worn  for  five  or  six  weeks,  after  which  suitable  shoes  should  be  provided,  either  with 
their  inner  borders  elevated  or  with  metal  flat-foot  plates  inserted,  or  both.  These 
plates  are  now  in  general  use,  and  may  be  procured  from  instrument  dealers  and  in 
shoe  stores.  In  particular  cases  it  is  advisable  to  make  a  mold  of  the  lower  aspect  of 
each  foot,  to  have  this  cast  in  iron,  and  then  over  the  iron  model  to  have  a  suitable  metal 
plate  hammered  so  that  it  shall  exactly  fit  the  individual  for  whom  it  is  intended. 

Only  in  extreme  cases,  rel)ellious  to  other  treatment,  has  it  been  shown  nece.ssary  to 
resort  to  such  treatment  as  division,  by  osteotomy,  of  the  neck  of  the  calcis  or  of  the 
astragalus. 

Most  of  these  cases  may  l>e  benefited  subsequently  by  gymnastics  and  massage,  i.  e., 
by  stretching  the  contracted  gastrocnemius,  if  necessary,  with  some  mechanical  de^•ice, 
and  improving  the  general  condition  of  the  leg  muscles  by  suitable  massage. 

Metatarsalgia;  Morton's  Disease. — Under  this  name  has  been  described  a  pecu- 
liar j)ainful  artection  of  the  third  and  fourth  or  the  fourth  and  fifth  toes,  which  gives 
rise  to  constant  sensitiveness  and  sometimes  attacks  of  acute  pain,  especially  when  the 
foot  is  shod,  and  which  is  often  only  relieved  by  immediately  removing  the  boot  or  shoe. 
These  affections  are  more  common  in  the  up]:)er  walks  of  society,  esix'cially  among  women 
who  are  disposed  to  cramp  their  feet  in  shoes  which  are  too  small  for  them.  Aside 
from  the  location  of  the  pain  there  will  often  be  found  a  tender  spot  at  the  point  of  greatest 
complaint.  As  these  cases  become  worse  pain  radiates  farther  and  farther  up  the  leg, 
and  may  even  assume  the  t\'pe  of  a  sciatica. 

Careful  inspection  usually  reveals  either  a  mild  degree  of  flat-foot,  or  of  distortion  by 
which  the  anterior  part  of  the  foot  Is  broadened  and  held  in  a  depressed  position — or 
else  the  dorsal  part  of  the  foot  is  depressed  behind  the  anterior  part;  there  is  also  usually 
limitation  of  dorsal  flexion  of  the  foot  and  plantar  flexion  of  the  toes. 

Morton,  who  first  described  the  affection  as  having  a  peculiar  type  of  its  own,  thought 
it  due  to  entanglement  of  the  external  plantar  nerve  between  the  heads  of  the  fourth 
and  fifth  metatarsal  bones,  and  recommendefl  for  its  relief  excision  of  the  head  of  the 
fourth  of  these.  The  etiology  of  the  affection  Is  not  always  apparent,  but  it  is  sometimes 
due  to  what  has  been  described  as  a  non-deforming  type  of  club-foot,  while  in  practically 
all  other  instances  it  is  in  some  way  connected  with  the  use  of  badly  fitting  footwear. 
Treatment. — Without  projx'r  treatment  it  does  not  subside.  A  really  weak  and  pro- 
nated  foot  should  be  suj^jiorted  with  a  projx^r  plate  and  elevation  of  its  inner  border, 
while  a  short  gastrocnemius  should  be  stretched.  Only  in  extreme 
cases  or  when  these  milder  measures  have  failed  need  resort  be  had 
to  Morton's  suggestion  and  excise  the  head  of  the  fourth  metatarsal. 
3.  Talipes  EquinUS. — In  this  condition  the  equinns  position  is 
simulated,  anil  the  patient  walks  upon  the  anterior  part  of  the  foot 
only,  |:)erhaps  even  upon  the  ends  of  the  metatarsal  bones.  While 
the  congenital  form  Ls  extremely  uncommon  the  acquired  form 
is  that  which  commonly  occurs.  Apjx'aring  thus  in  all  possible 
degrees  it  may  in  mild  cases  cause  merely  a  slight  limp,  M'hile 
the  extreme  cases  cause  a  pronounced  deformity  and  alteration  in 
gait.  The  actual  condhion  is  one  of  shortening  of  the  tendo  Achillis 
through  contraction  of  its  component  muscles,  with  corresponding 
change  in  shajie  of  the  bones  of  the  foot.  There  is  also  more  or 
less  shortening  of  the  plantar  aponeurosis,  and  depression  of  the 
astragalus,  which  is  drawn  down  upon  the  calcis  (Fig.  265). 

Causes. — Perhaps  the  most  common  cause  is  paralysis,  either  of 
^^  infantile  or   cerebral    and  spastic  t^-pe,  of  the  anterior  muscles  of 

Talipes  equinus.  the  leg,  the  condition  being  simulated  sometimes  in  hysteria.     The 

spasm  which  follows  disease  of  the  ankle-joint  may  also  produce 
it.  It  may  be  the  result  of  muscle  contraction  after  fractures  or  even  after  certain 
fevers,  the  foot  dropping  naturally  into  this  position  and  remaining  there  altogether  too 
long.  Hence  may  be  seen  the  necessity  for  putting  the  foot  in  the  right-angle  position 
whenever  the  lower  limb  is  dressed  in  plaster  or  other  rigid  dressings  after  fracture. 


CONGENITAL  MlSPLACiafESr  OF  Till-:  HIP 


471 


Talipes  cquimis  may  also  he  due  to  injury  to  and  loss  of  power  in  tlic  anterior  nuiscles 
of  the-  U'lj,  or  it  may  Ih-  compensatory,  as  when  one  le<^  is  lon^rer  than  the  other.  In 
any  of  these  events  the  hody  weiifjit  is  home  on  the  hall  of  the  foot,  and  some  de<jree  of 
archini;  of  the  foot,  which  may  he  excessive,  is  sure  to  occur. 

Treatment.  In  the  milder  cases,  when  .seen  early,  it  may  be  sufficient  to  thorouf^hiy 
and  ni)tatedly  stretch  the  sural  muscles,  but,  in  the  more  .severe  forms,  tenotomy  of 
the  tendo  .\chillis,  with  subcutaneous  or  perhaps  open  division  of  the  plantar  struc- 
tures, will  l)e  needed.  In  jiaralytic  cases  tendon  {i;rafting  {q.  v.)  will  be  required,  probably 
with  one  or  more  of  the  measures  mentioned  above.  In  .some  instances  nerve  graftin<r 
miirht  be  profitably  employed,  .\fter  recovery  from  operation,  braces  ada[)ted  to  eacli 
l)articnlar  case  will  in  all  probability  be  re(|uired,  at  least  for  a  time. 

\.  Talipes  Calcaneus. — In  this  deformity  the  anterior  [)art  of  the  UnA  is  drawn 
upward  by  its  anterior  fl(>xors  and  a  little  to  the  outer  side,  while  the  sural  nuiscles  are 
relaxed;  thus  the  ])atient  walks  upon  the  heel.  The  condition  is  often  more  or  less 
combined  with  talipes  valgus.     It  is  rarely  of  congenital  origin,  but  is  generally  due  to 


Fig.  266 


Fig.  267 


laiiijes  calcaneus. 


Fes  eavus,  hoiJow  clawfoot. 


paralysis  of  the  distal  muscles  following  injury  or  poliomyelitis.  It  is  sometimes  of 
hy.sterical  origin,  and  it  may  occur  as  the  result  of  muscle  spasm  f(jllowing  bone  or  joint 
disease  (Fig.  2(30). 

Those  forms  due  to  infantile  paralysis  are  to  be  treated  mainly  by  tendon  grafting 
or  some  similar  expedient,  and  this  to  be  followed  by  a  sutable  shoe  containing  a  sole 
plate  with  an  upright  attachment  and  a  joint  opposite  the  ankle.  Other  forms  must  be 
treated,  each  on  its  own  merits,  but  according  to  general  principles  already  enunciated. 

Pes  CavUS. — Here  the  anterior  part  of  the  foot  is  draw^n  backward  and  the 
plantar  arch  made  much  more  prominent.  It  may  even  be  converted  into  a  Gothic 
arch.  Extremes  of  this  type  are  seen  in  the  feet  of  Chinese  women.  One  form  is  due 
to  contraction  of  the  peroneus  longus,  owing  to  paralysis  of  the  sural  muscles,  by  which 
the  long  flexors  are  permitted  to  work  to  extra  advantage;  and  yet  another  form  is  often 
of  congenital  origin,  having  its  explanation  in  paralysis  of  the  interossei  and  other  small 
intrinsic  muscles  of  the  foot  (Fig.  267). 

When  an  ordinary  metal  sole  plate  fails  to  give  relief  a  subcutaneous  or  open  division 
of  the  contracted  structures  may  be  practised. 


CONGENITAL  MISPLACEMENT  (DISLOCATION)  OF  THE  HIP. 

Perhaps  a  more  proper  name  for  this  congenital  deformity  would  be  "misplacement" 
rather  than  dislocation.  It  is  seen  much  oftener  in  females  than  in  males.  It  may  be 
either  unilateral  or  bilateral.  The  displacement  is  usually  upward  and  backward  upon 
the  dorsum  of  the  ilium.  In  rarer  instances  it  is  anterior  and  sometimes  the  head  of 
the  femur  lies  not  far  away  from  the  anterior  superior  spine  of  the  ilium. 

Regarding  its  cause  absolutely  nothing  is  known.  It  represents  defective  deyelop- 
ment  rather  than  arrest,  and  is  a  condition  of  intra-uterine  life.  The  acetabulum  is 
usually  found  incomplete,  but  whether  this  is  the  cause  of  the  misplacement  or  whether 
it  fails  to  develop  because  of  the  absence  of  the  head  of  the  femur  from  this  cavity  it  is 


472 


SURGICAL  AFFECT  loss  OF  THE  TISSUES 


not  easy  to  decide.  The  influence  of  heredity  in  these  cases  is  undeniable,  for  it  is 
known  to  have  prevailed  in  certain  families.  Thirty  years  a<^o  but  little  was  known  in 
regard  to  the  affection,  and  nothing  could  Ik-  done  to  atone  tor  it.  Of  late  years  it  has 
been  the  subject  of  special  study  by  numerous  investigators  (Figs.  208  and  269). 


Fig.  268 


Double  congenital  displacxiueut  of  the  hip.      Buffalo  Clinic.      (Skiagram  by  Dr.  Plummer.) 

Fin.  269 


Skiagram   of  coxa   vara;   deformity  most    marked  at   the  epiphy.seal  junction.     This   illustrates  the    mechanical 
limitation  of  abduction  caused  by  the  deformity,  and  the  compensatory  tilting  of  the  pelvis.     (Whitman.) 

Pathological  changes  are  noted  in  the  capsule  itself,  as  well  as  in  the  bony  components 
of  the  jont.  Thus  the  capsule  is  usually  elongated  and  stretched  out  of  shape,  while 
its  lower  portion  may  be  adherent  to  the  margin  of  the  acetabulum  or  may  be  shut  off 


COXdEMTAL  MISI'LACEMKXT  OF   THI:   HIP 


473 


into  a  small  cavity  l)y  itself,  this  cavity  liavinjr  hut  a  small  connection  with  the  l)alancc 

of  the  ,a|)>iilc  and  atVordinfj  irresistible  obstacles  to  rednction.      With   chan<,'ed    joint 

relations  the  nuiscniar  arran>,'einen(s  are  also  clian<jed,  some  beinj,'  lenjrthened,  others 

shortened,  as  would  naturally  follow  from  the  apijroximation  or  separation  of  their  points 

of  orijjin  and  insertion,     ('onspicuous  chanjfe  is  seen  in  the  ui)|)er  end  of  the  femur, 

which    is  often   atrophied,   while  the   neck   is  shorter  than 

normal,  its   an<jle   lessened,  and  tiie  head  of  the  bone  often 

alteri'd    in    shape.       A   .secondary   acetabulum    is    in    time 

formed  and  is  usually  found  upon  the  side  of  the  ilium.   This 

is  shallow  and  insufficient  to  ensure  firm  suj)port  for  the  head 

of  the  ftMUur,  even  were  this  well  developed.      Aside    from 

these  ehanijes  the    jielvis   is  usually    j)oorly  developed   on 

the  ati'ected     side,   its   inclination     increased,   the    sacrum 

forced   forward  and  downward,   the   j)elvic  outlet    widened, 

wh.ile   a  considerable  de<rree   of  lumbar  lordosis  is  present 

(Fig.  270). 

The  condition  is  rarely  noted  until  a  growing  infant 
begins  to  learn  to  walk.  The  condition  is  one  which  has 
no  symjiloms,  onhj  fn'fju.f,  and  these  do  not  at  first  attract 
attention.  Sometimes  it  will  have  been  noted  that  there  is 
an  abnormality  about  the  hip,  with  too  free  i)lay,  or  a  snap- 
ping .sound  at)out  the  joint.  When  the  condition  is  unilateral 
there  is  a  marked  limp  which  increases  with  the  age  of  the 
child.  With  each  step  the  femoral  head  is  pushed  U|)ward 
on  the  side  of  the  ilium,  and,  in  consequence,  the  pelvis  is 
tilted  toward  the  outside,  as  well  as  twisted  downward  and 
forward.  The  limb  being  thus  actually  shortened,  the  limp 
or  waddling  gait  is  easily  accounted  for.  Along  with  it 
there  is  usually  flattening  of  the  tibia,  while  the  trochanter 
may  be  felt  antl  often  seen  on  a  level  considerably  above 
that  where  it  properly  belongs.  INIotility  in  the  joint  is 
abnormally  free,  and  with  a  child  on  its  back,  by  alter- 
nately pulling  and  pushing,  the  abnormally  free  play  of  the 
upper  end  of  the  femur  may  be  easily  demonstrated,  either 
with  the  limb  in  its  extended  or  the  flexed  position. 

When  the  misplacement  is  bilateral  the  individual  is 
more  symmetrically  deformed.  The  lordosis  is  increased, 
the  abdomen  protrudes,  the  thighs  are  separated  more  widely 
than  is  normal,  leaving  perhaps  a  considerable  space  in  the  perineum;  the  gait  is  of  a 
peculiar  waddling  character,  which  makes  locomotion  apparently  difficult,  although  it 
is  free  from  pain.  In  these  cases  abnormal  mobility  of  the  hip  may  be  demonstrated  on 
each  side. 

As  these  patients  grow  through  adolescence  into  maturity  they  sometimes  improve, 
but  usually  suffer  more  and  more  difficulty  in  locomotion,  while  the  abdominal  protrusion 
and  the  lordosis  become  more  and  more  pronounced. 

Three  varieties  of  congenital  misplacement  are  described  as  backward,  npxcard,  and 
forward.  It  is  in  those  instances  where  the  head  of  the  l)one  rests  well  back  or  well 
forward  upon  the  ilium  that  the  gait  is  most  pronounced,  but  in  all  instances  the  great 
trochanter  will  be  found  above  Nelaton's  line. 

Diagnosis. — The  diagnosis  offers  few  diflSculties.  The  peculiar  waddling  gait 
may  be  seen  in  extreme  cases  of  bow-legs,  but  then  the  hip-joints  will  be  normal.  Ex- 
treme lordosis  may  be  seen  in  cases  of  lumbar  spinal  caries,  but  here  again  the  hip-jonits 
will  be  normal,  w^hile  the  spinal  muscles  will  be  rigid  and  the  patient  disinclined  to  walk. 
Traumatic  dislocations  and  the  results  of  hip-joint  di.sease  will  be  indicated  by  a  history 
to  correspond,  as  will  also  early  acute  joint  affections  following  the  exanthems.  The 
diagnosis  is  to  be  made  principally  from  coxa  vara,  considered  below,  and  the  various 
defects  following  infantile  pal.sy.  In  coxa  vara  there  is  no  corresponding  abnormality 
of  motion,  while  in  the  paral^iic  cases  there  will  often  be  failure  in  muscle  power,  which 
is  not  present  in  cases  of  congenital  misplacement.  Finally  in  instances  which  offer 
difficulties  the  Rontgen  rays  now^  aft'ord  a  method  of  diagnosis. 


Congenital  misplacement,  with 
consequent  atrophy  and  short- 
ening.    (Calot.) 


474 


SURGICAL  AFFECTIONS  OF  THE  TISSUES 


Treatment. — For  a  long  time  after  this  condition  was  recognized  its  treatment 
was  unsatisfactory,  and  it  was  not  until  H(jffa,  al)ont  fifte(>n  years  ago,  advanced  liis 
operative  nietliod  of  relief  that  surgeons  fek  at  all  like  advising  operation  in  well-marked 
cases.  Then  came  Paci  and  Lorenz,  first  with  improvi-ments  on  the  Hoffa  ojicration, 
and  then  with  a  method  of  so-called  "bloodless"  reposition,  which  has  been  under 
severe  test  and  testimony.  Last  of  all  come  Bradford  and  Sherman  with  their  im|)roved 
methods  of  operation,  which  seem  to  me  the  most  promising  of  all  as  well  as  the  most 
scientific. 

Lorenz  was  doubtless  correct  when  he  stated  that  the  principal  obstruction  to  reduction 
is  the  narrowed  part  of  the  capsule,  just  at  the  upper  part  of  the  acetabulum,  and  that 
if  this  could  be  torn  here  sufficiently  to  permit  the  passage  of  the  head,  reduction  could 
be  accomplished  by  manipulati(jn  alone,  and  maintained  if  the  acetabulum  were  suffi- 
ciently deep.  An  almost  insuperal)le  difficulty  in  most  cases  is,  however,  this  narrowed 
capsule,  and  the  number  of  accidents,  including  not  only  fractures  of  the  femur  and 
the  pelvis,  but  various  other  injuries  which  have  resulted  from  too  great  violence,  is 
altogether  too  large  and  too  disturbing  to  justify  the  use  of  such  force  as  has  often 
been  used.  Of  more  than  one  hundred  children  upon  whom  Lorenz  operated  when 
making  a  tour  through  the  United  States,  but  little  over  10  per  cent,  have  given  anything 
like  ideal  results;  while  the  danger  from  fracture  and  laceration  of  muscles  and  nerves, 


Fiii.  271 


A  plaster  bandage  applied  by  Lorenz,  illustrating  the  extreme  thickness  r.f  the  pelvic  portion  and 
discoloration  of  the  adductor  region.     (Whitman.) 

as  well  as  of  bloodvessels,  is  fully  as  great  as  that  pertaining  to  any  open  operation.  It 
may  therefore  be  maintained  that  the  percentage  of  success  from  the  use  of  manual  force 
without  incision  does  not  justify  the  risks  of  the  method.  Sherman  argues  that  if  we  may 
open  a  knee-joint  without  hesitation  to  take  out  a  small  piece  of  cartilage,  we  need  not 
fear  to  open  a  hip-joint  in  order  to  clear  away  a  small  obstacle.  The  patient  is  thereby 
saved  from  many  dangers  and  exposed  to  so  few  that  it  seems  more  humane  and  desir- 
able in  every  respect. 

Sherman's  method  is  to  make  tractit)n  upon  the  limb,  drawing  the  femoral  head 
down  to  a  point  just  below  the  anterior  superior  crest,  where  it  can  easily  be  felt,  and  to 
here  make  an  incision  over  it  in  the  flirection  of  muscular  fibers  so  that  they  are  not 
divided.  After  division  of  the  capsule  the  head  of  the  bone  is  exposed  and  retractors 
substituted  by  long  loops  of  suture,  put  in  on  either  sifle  of  the  opening  in  the  capsules. 
In  many  cases  a  tenotomy  of  the  adductor  tendons  close  to  the  pubis  will  also  be  of 
advantage.  The  leg  is  next  released  from  traction  and  the  head  of  the  bone  allowed  to 
glide  upward,  while  the  finger  is  slipped  into  the  capsule  and  down  toward  the  acetab- 
ulum. Upon  this  finger  as  a  guide  a  long,  straight,  probe-pointed  bistoury  is  passed, 
and  with  it  the  narrower  portion  of  the  capsule  is  cut  through,  down  to  the  bone,  taking 
care  to  not  cut  off  the  ileopsoas  tendon.  The  incision  must  be  large  enough  to  give  free 
access  to  the  acetabulum.  Traction  is  then  again  made  with  sufficient  manipulation 
so  that  the  femoral  head  may  be  forced  into  its  proper  cavity.     When  the  head  is  in  the 


CO  AM    VARA    AM)    \  Al.dA 


47; 


acotahuliiin  the  rctractiiifi;  siitiiivs  are  tird  (()<,^clli(r  so  as  to  closi-  (lie  upper  \nivi  of  the 
capsuUs  and  other  sutures  are  intnHhiced,  as  needed,  to  dose  the  wound,   leaving  spaee 
for  a  eigarette  drain.     Tlie  linil)  is  then  |)ut 
into  a  position  of  ahthietion  of  from  5i)  to  i'i<:.  272 

90  degrees,  rotated   in    or  not,    as  needed,         

and  a  comprehensive  phister-of-Paris  s|>i(a 
apj)lied.  In  tiiis  both  limhs  or  only  one  may 
be  inehided.  Tlie  drain  siiould  he  removed 
in  two  days  and  the  dressing  left  otiierwise 
undisturbed  for  three  nioulhs. 

Bradford  lias  achled  somewliat  to  our 
metliods  by  showing  not  only  the  arrange- 
ment of  the  capsule,  but  the  fact  that  the 
acetabulum  is  often  filled  with  dense  fibrous 
tissue  which  sometimes  obliterates  it,  and 
that  this  tissue  can  be  curett(Hl  out,  but  that 
if  it  could  be  utilized  to  aid  in  retaining 
the  reilucetl  head  of  the  femur  it  would  be 
a  great  benefit.  He  operates  as  follows: 
The  hip  is  subjected  to  preliminary  forcible 
stretching  of  all  soft  parts  which  can  be 
stretched  by  manual  or  mechanical  force. 
A  posterior  incision  is  then  made,  which, 
without  dividing  muscles,  permits  free  open- 
ing into  the  capsule  and  affords  a  channel 
to  the  deepest  portion  of  the  acetabulum. 
The  posterior  w^all  of  the  capsule  is  then 
split,  after  which  all  constricting  and  other 
obstacles  at  any  point  are  carefully  dividefl. 
These  may  be  detected  by  the  finger,  and 
can  also  be  seen  by  a  small  electric  light 
passed  down  inside  of  a  sterilized  glass  test 
tube.  The  capsular  wound  is  then  retracted 
by  deep  retaining  silk  sutures,  placed  at 
the  lower  rim  of  the  acetabulum,  thus 
affording  a  pathway  for  the  reduction  of  the 
head.  After  this  has  been  accomplished 
as  described  above,  the  sutures  are  tied 
closely  around  the  femoral  neck,  and  these 
retain  it  in   position.     The  other  portions 

of  the  split  capsule  are  then  sewed  around  the  head  and  neck,  to  the  trochanter  and 
fascia,  in  such  a  way  as  to  retain  the  bone  where  it  has  been  placed. * 

The  earlier  the  operation  is  done  the  better.  It  is  necessary  to  always  maintain  the 
limb  in  a  position  of  well-marked  abduction,  and  for  a  long  time,  nor  can  patients  be 
released  from  this  at  the  expiration  of  the  first  dressing  period,  usually  twelve  to  fifteen 
weeks,  although  the  abduction  can  usually  be  reduced  with  each  dressing  until  at  last 
the  limbs  are  permitted  to  come  together  after  the  expiration  of  nine  to  eighteen  months. 
Even  after  the  lapse  of  this  length  of  time  it  may  be  necessary  to  provide  some  form  of 
apparatus  by  which  too  much  rotation  in  either  direction  may  be  prevented,  or  by  which 
pressure  may  still  be  made  over  the  trochanter,  in  order  that  it  may  be  kept  constantly 
pushed  into  the  acetabulum  (Figs,  271  and  272). 


Unilateral  congenital  disliicatioii,  sliowiiig  the 
fixation  bandage.  A  shoe  with  a  cork  sole  about 
two  inches  in  lieight  .should  be  worn  on  the 
operated  side,  while  the  attitude  of  exaggerated 
abduction  is  maintained.      (Whitman.) 


COXA  VARA  AND  VALGA. 

This  term  is  applied  to  an  abnormaltfij  in  the  shape  0/  the  neck  of  the  femur,  consisting 
of  a  downward  curvature  or  bending  of  the  femoral  neck,  which  is  thus  displaced  until 
it  stands  almost  at  a  right  angle  with  the  shaft  instead  of  at  the  normal  obtuse  angle. 
At  the  same  time  there  is  often  posterior  curvature,  or  sometimes  an  anterior  curve, 

American  Journal  of  Orthopedic  Surgery,  October.  1905. 


476 


SURCICM   AFFECTIOSS  OF  TIIF   TISSUES 


Fig.  273 


of  the  neck,  which  causes  a  corresponding  rotation  of  the  axis  of  the  whole  limh. 
The  pelvic  side  of  the  hip-joint  is  unafi'ected,  the  change  occurring  usually  solely  in 
the  upper  end  of  the  femur,  the  joint  not  being  involved.  It  may  appear  in  congenital 
form  and  then  may  be  attributed  either  to  intra-uterine  pressure  or  to  antenatal  rickets 
or  osteomalacia.  The  acquired  form  is  usually  due  to  a  non-inflammatory  softening, 
or  to  structural  changes  which  permit  of  yielding,  as  above  described.  Doubtless 
different  cases  have  different  causes,   and  they  are  not  to  be  included  in  one  brief 

sentence.  The  condition  cf)rrf'spf)iKls  to  those  abnor- 
malities at  the  knci'  A\liicli  pi'oiliicc  knock-knee  and 
bow-leg.  Were  the  bone  as  easily  examined  at  the  upper 
end  (jf  the  femur  as  at  the  knee  the  condition  would  Ije 
more  easily  recognized.  Therefore  the  term  has  refer- 
ence not  .so  much  to  the  results  of  active  disease  as  to 
deformities  of  congenital  or  acquired  character.  Fully 
three-fourths  of  the  cases  are  met  with  in  male  .subjects, 
and  the  majority  of  these  occur  only  on  one  side.  Thus 
of  190  quoted  by  AVhitman,  85  were  unilateral,  while 
only  26  occurred  in  females. 

The  more  nearly  the  angle  of  fixation  of  the  neck  of 
the  femur  approaches  a  right  angle  the  further  above 
Xelaton's  line  will  the  trochanter  appear,  and  the  more 
conspicuous  this  change  the  greater  the  difficulty  in  ab- 
duction. Moreover,  to  shortening  may  be  added  internal 
or  external  rotation,  with  consequent  tilting  of  the  pelvis 
and  compensatory  alteration  of  the  spinal  curves. 

The  disease  is  by  no  means  often  of  traumatic  origin, 
although  traumatisms  may  produce  an  arthritis  defor- 
mans, even  in  juvenile  cases,  and  that  this  may  simulate 
a  non-s\iBptomatic  coxa  valga  i>  nmv  well  established 
a- vs.  273j. 

Symptoms. — Coxa  vara  produces  certain  symptoms, 
among  tliem  pain  in  the  joint,  rafliating  down  the  front 
and  inside  of  the  thigh.  If  the  deformity  be  very  marked, 
joint  function  Is  impaired.  Tenderness  is  rarely  pre.sent. 
When  pain  or  tenderness  occur  they  may  lead  to  the 
mistaken  diagno.'^Ls  of  rheumatism  or  neuralgia.  The 
condition  may  arise  as  the  result  of  an  acute  ostitis,  in 
which  case  patients  will  he  confined  to  bed  for  some  time. 
Actual  shortening  may  vary  from  one  to  one  and  a  half 
inches,  while  the  limb  will  be  found  adducted,  the  gluteal 
region  flattened,  with  a  deep  curve  between  the  tro- 
chanter and  the  gluteal  muscles. 

Diagnosis. — The  diagnosis  is  to  be  made  mainly 
Ijetween  this  condition  and  hip-joint  disease  or  mis- 
placement. When  abnormalities  in  the  shape  or  position 
of  the  limbs  in  the  young  occur  in  a  comparatively  short 
time,  coxa  vara  may  be  suspected,  especially  in  the  ab- 
sence of  that  disability  which  coxitis  usually  produces. 
The  patient  should  be  examined  in  both  the  Uj>right  and 
horizontal  position.  Coxa  vara  may  have  an  abrupt  onset,  but  it  never  produces  ab- 
scess. It  is  practically  self-limited  and  will  be  followed,  sooner  or  later,  by  spon- 
taneous cessaticm  of  all  acute  features,  while  coxitis  is  progressive,  with  a  destructive 
tendency.  In  coxa  vara  we  do  not  have  the  starting  pains  nor  muscle  spasms  of 
coxitis,  while  the  actual  .shortening  is  much  more  marked.  In  doubtful  cases  the 
cathode  rays  may  be  employed  anrl  will  often  greatly  facilitate  diagnosis.  The  con- 
dition may  be  bilateral,  but  will  still  fail  to  show  the  muscle  atrophy  so  significant  of 
tuberculous  disease. 

As  l>etween  coxa  vara  and  that  senile  form  of  coxitis  already  described  in  the  chapter 
on  Joints  as  arthritis  deformans,  it  should  be  remembered  that  the  latter  is  a  disease  of 
advanced  life,  while  the  former  occurs  rather  in  its  earlier  periods.     Moreover,  in  the 


Coxa  valga,  with  defective  de- 
velopment of  the  right  femur 
f  Albert.  J 


Dl'.FOUMITIIlS  CMSh'l)    />')'    / .\ F.WT/I.h'   /MA.sVA'.S  477 

t'oniKT  tluTc  is  no  tciidciicy  to  cliaiij^c  in  (lie  rcinontccrvical  anj^lc,  no  inaltcr  wliat  clianf^cs 
nuiv  occnr  in  otluT  ivs|H'ct.s  al)oMt  tlic  joint.  When  in  the  senile  disease  shortening 
really  occurs  it  results  Ironi  actual  al)sor|)ti<)n  of  i)one. 

Coxa  vara  tends  usually  to  ffjxnitaucoiis  rcfi.s-dtioti,  wliicli  may  In-  c()iisiderc(|  recovery. 
Acute  symptoms  alter  a  time  subside,  and  function  is  retrained  to  the  full  extent  |)ermitted 
hy  whatever  changes  have  occurred  in  the  shape  of  the  hone.  If  sym|)toms  arc  at  all 
.severe  they  diMuand  physiological  rest  in  bed,  with  traction,  and  the  limb  should  not  be 
u.sed  until  pain  has  entirely  subsided.  Conspicuous  deformity  may  call  for  correction 
by  subcutaneous  osteotomy  made  ju.st  below  the  trochanter.  Only  in  exceedingly  .serious 
ca.ses  is  exsection  of  the  joint   necessarv. 


DEFORMITIES  CAUSED  BY  INFANTILE  PALSIES. 

Deformities  induced  by  more  or  less  acute  affections  of  the  cord  and  l)rain,  or  by 
hemorrhages,  have  assumed  an  ever-increasing  importance  in  orthopedic  work.  Most 
of  them  resolve  them.selves  into  tho.se  due  to  acute  anterior  poliomyelitis  and  tho.se  due 
to  cerebral  hemorrhages. 

Fic;.  274 


Anterioi  poliomyelitis.    Extreme  flexion  def()rmity  at  the  hips,  inducing  quadrupedal  locomotion.    (Gibney.) 

Anterior  Poliomyelitis. — Anterior  poliomyelitis  is  an  acute  inflammation  mani- 
fested especially  in  the  gray  matter  of  the  anterior  cornua  of  the  spinal  cord,  involving 
both  the  neuroglia  and  the  cells,  producing  atrophy  of  the  same  and  consequent  paralysis 
of  muscles  su|)})lie(l  by  the  motor  nerves.  It  may  assume  an  acute  febrile  type,  with 
rapid  onset  of  paralysis,  or  it  may  be  of  slower  development.  Usually  conceded  to  be 
of  infectious  origin,  it  still  lacks  the  minute  explanation  for  many  of  its  attendant 
phenomena.  It  may  appear  with  acute  symptoms,  febrile  antl  convulsive,  paralysis 
appearing  more  or  less  promptly.  With  the  subsidence  of  other  serious  symj)toms  this 
paralysis  remains.  There  may  then  be  a  period  of  partial  imjjrovement  in  the  muscular 
condition,  w4th  disappearance  of  some  of  the  most  pronounced  phenomena.  Finally 
with  the  growth  and  development  of  the  child  more  expressions  of  damage  remain,  and 
produce  various  distortions  and  deformities,  varying  with  the  muscle  groups  affected. 
Not  only  do  deformities  result,  but  there  is  more  or  less  arre.st  of  development,  with 
disproportion  in  size  between  the  limbs  involved  and  those  which  have  been  spared. 
It  is  the  early  paral}-tic  features  which  may  permit  diagnosis  to  be  made  in  the  early 
days  of  the  acute  febrile  attack 


478 


Sl/IiaiCAL   AFFI'J'TIOSH,  OF   TIfl'J   TISSUES 


Cerebral  Palsies. — The  ceivhral  palsies,  so  called,  are  llie  result  of  hemorrhages 
or  acute  disorifauization  of  the  brain.  The  former  are  usually  unilateral  and  give  rise 
to  a  correspondinij;  hemiplegia,  with  either  ])aralysis  or  spastic  rigidity,  and  usually  with 
atro[)hy.  The  paralysis  may  not  he  com})lete,  hut  is  rather  of  the  paretic  ty[)e,  in- 
volving the  entire  limb,  the  reflexes  being  increased  and  the  muscles  stiffened  rather 
than  flaccid,  with  loss  of  electrical  reactions. 

A  paraplegia  points  rather  to  lesion  in  the  spinal  cord  and  hemorrhage  than  to  cerebral 
lesion.  Transverse  myelitis  is  rare  in  children.  Multiple  neuritis  may  produce  some- 
what similar  effects,  as  may  also  the  toxic  |)aralyses  due  either  to  drugs  (especially  lead 

Fic.  273 


Anterior  iwliomyelitis.    Duration  seven  years.    Showing  atrophy  and  sliglit  lateral  curvatuie  of  the  spine; 
two  and  a  quarter  inches  of  shortening.    (Whitman.) 

or  arsenic)  or  that  ff)llowing  diphtheria,  in  which  case  it  is  the  muscles  of  the  throat  and 
nec-k  whicli  are  likely  to  be  involved.  Figs.  274  and  275  ])ortray  extreme  types  which 
are  rare,  but  instances  of  minor  degree  of  affection  are  frecjuent. 

Treatment. — As  two  cases  of  this  kind  are  seldom  alike,  treatment  should  be  planned 
to  meet  the  indications.  Massage,  electricity,  hot-air  baths,  and  similar  non-operative 
measures  find  here  a  large  field  of  usefulness,  but,  save  in  the  milder  ca.ses,  are  insuffi- 
cient. In  no  class  of  eases  do  tendon  grafting  and  nerve  grafting  find  a  wider  range 
of  applicability,  while  tenotomy,  myotomy,  aponeurotomy,  and  occasionally  osteotomy 
will  |)ermit  of  atonement  for  deformity  which  has  not  been  treated.  These  operative 
measures  have  been  considered. 


CHAPTER    XXXIV. 


FRACTURES. 

Tjik  term  frartiirr  is,  in  surfjerv,  applied  to  such  injury  of  l)ono  and  cartila^o  as  effects 
break  in  continuity.  This  injury  is  effected  instantly,  and  it  is  rarely  that  fracture  is 
|)roduced  l)y  any  slowly  actin*^  cause,  althoui^h  this  latter  may  so  affect  or  disinte<;rate 
hone  as  to  j)ernut  fracture  uj)on  the  aj)plication  of  a  mild  dc<rree  of  force.  Fractures 
are  variously  classified  and  ijrouped  for  convenience  of  description;  thus  we  speak  of 
traumafir  and  pathological  jmrturr.s,  implyino;  hy  the  former  those  which  occur  by  violence 
in  normal  conditions  of  health,  and  by  the  latter  those  which  are  produced  onlv  because 
of  some  previous  disease  in  the  bone.  The  difference  is  that  in  the  former  case  there  is 
no  preexisting  disease,  whereas  in  the  latter  it  is  an  essential  feature  of  the  case.  Frac- 
tures are  also  classified  as  complete  or  incomplete,  the  former  term  implving  injurv  to 
the  whole  thickness  of  the  bone,  while  the  latter  are  separately  classified:  (a)  Fii.virr, 
in  which  there  is  a  line  of  fracture  by  which  there  is  no  complete  separation  of  fragment, 
it  being  essentially  a  crack;  (h)  the  grren-stick  fracture,  such  as  occurs  in  the  voung, 
where  the  bone  is  not  thorougiily  calcified,  but  is  capable  of  bending  to  some  extent, 
while  a  portion  of  it  breaks;  (c)  depressed  fracture,  which  is  generally  produced  by  direct 
violence,  and  occurs  in  a  flat  bone,  i.  e.,  the  skull,  the  scapula,  etc.;  (d)  detachment  of 
a  fragment  or  separation  of  an  epiphysis;  (e)  partial  fractures,  corresponding  much  tg 
the  green-stick,  but  without  deformity  or  change  in  shape  or  position. 

Fig.  276 


Impacted   fracture  of  the  shaft  of  the  femur  produced  by  a  fall  upon   the  knee  in  a  man  aged  eighty-three 
years.      Illustrating  impaction.     (Bryant.) 

Fractures  are  also  described  by  means  of  the  following  adjectives,  which  practically 
explain  themselves,  for  instance: 

A.  Complete,  transverse,  oblique,  longitudinal,  dentated,  etc.  Spiral  fracture  is  also 
described  and  occasionally  seen.  It  involves  only  the  long  bones,  and  not  only 
implies  a  considerable  degree  of  violence,  but  is  itself  regarded  as  exceedingly  serious. 

B.  In  number  they  are  single,  multiple,  or  comminuted,  as  when  there  are  a  number 
of  fragments. 

C.  They  are  often  impacted,  which  means  that  one  fragment  is  driven  into  and 
more  or  less  embedded  in  the  other.  This  impaction  or  interlocking  of  fragments  occurs 
usually  in  the  neck  of  the  femur  and  the  lower  end  of  the  radius.  In  the  former  locality 
it  is  advisable  not  to  interfere  with  it;  in  the  latter  it  should  alw^ays  be  dislodged  in  order 
to  restore  the  fragment  to  its  proper  position  (Fig.  276). 

D.  As  to  their  nature  and  location,  fractures  are  referred  to  as  pathological,  gunshot, 
intra-nrticular,  or  extra-articular,  etc.,  the  latter  terms  referring  to  involvement  of  a  joint. 
If  blood  can  escape  from  the  site  of  the  fracture  into  a  joint  cavity,  or  if  synovial  fluid 
can  escape  from  the   latter  into  the  former,  then  the  fracture   is  called  intra-articular. 

Pathological  fractures  imply  preexisting  di.sease.  This  may  be  constitutional,  as  in  the 
case  of  the  fragilitas  ossium,  already  described  in  the  chapter  on  the  Bones,  or  it  may  be 
due  to  some  secondary  deposit  of  cancer  or  a  primary  sarcoma.  In  adults,  especially 
those  with  a  cancerous  history,  any  spontaneous  fracture,  or  even  one  occurring  with 

(479) 


480 


SURdlCAL   AFFJCCTIOSS  OF   Till-:   TISSUFS 


trifling  violence,  should  lead  to  suspicion  of  a  metastatic  focus  in  the  hone  at  the  site 
of  its  yielding.  The  atrophic  changes  which  notably  occur  in  various  bones  as  old  age 
comes  on  lead  also  to  a  condition  which  is  pathological,  i.  e.,  it  permits  of  fracture  from 
what  would  aj)pear  to  be  a  trifling  injury. 

Guii.shot  jmcturrs  are  practically  always  comminuted,  save  j)erhaf)S  stmie  of  those 
inflicted  with  the  modern  military  weapons.  A  Mauser  bullet  will  frequently  make 
an  almost  clean  perforation,  but  the  gunshot  fractures  met  with  in  civil  practice  are 
almost  invarial)ly  comminuted,  especially  those  of  the  skull  (Fig.  277). 

E.  The  term  compound  is  applied  to  any  fracture  in  which  there  is  wound  of  the  soft 
tissues  and  so  located  as  to  permit  access  of  air  to  the  injured  bone.  There  is  a  distinction 
between  a  compound  and  a  complicated  fracture.  A  fracture  of  the  femur  accompanied 
by  a  gash  or  extensive  wound,  so  long  as  air  cannot  come  in  contact  with  the  bnjken 
bone,  would  be  described  as  a  fracture  of  the  femur  complicated  by  a  lacerated  wound. 
On  the  other  hand,  if  through  the  slightest  ynmcture  of  the  skin,  even  at  a  distance  from 
the  fracture,  air  can  even  theoretically  enter  and  come  in  contact  with  Iwjne  surfaces  at 
the  site  of  the  fracture,  such  an  injury  constitutes  a  compound  fracture.     This  distinction 


Fig.  277 


Skiagram  of  compound  cornrninutfMl  (Kun.~!iot;  fracture  of  elbow,  inflicted  with  a   Dumdum  bullet. 
Illastratiug  the  extreme  of  comminution.     (Lexer .J 

is  not  a  trifling  one,  for  upon  the  exclusion  of  air,  which  to  a  certain  extent  means  the 
exclusion  of  germs,  depends  very  much  the  rapidity  and  j)erfection  of  recovery.  Cnm- 
pouml  fractures  are  all  dangerous  in  proportion  as  they  permit  of  injection,  and  while  air 
infection  is  not  necessarily  the  most  serious  of  any,  it  nevertheless  is  often  sufficiently 
so  to  set  up  sepsis  and  interfere  with  consolidation,  even  if  it  do  not  prevent  it.  Frac- 
tures are  made  compound  by  direct  violence  from  the  outside  or  by  indirect  violence, 
as  w^here  a  bone  end  perforates  soft  parts  and  the  skin.  Even  if  a  sharp  point  of  l)one 
thus  protruded  from  within  is  quickly  drawn  Vjack  again  it  is  enough,  since  both  the  skin 
and  the  air  in  contact  with  it  are  sources  of  germ  activity.  Thus  it  may  happen  that  a 
slight  and  a|>parently  trivial  injury  of  this  kind  is  more  serious  than  one  which  is  extensive. 

F.  Epiphyseal  separation.^  constitute  a  somewhat  distinct  form  of  injury,  having 
at  the  same  time  the  importance  and  dignity  of  fractures  in  the  truer  sense  of  the  term. 
In  the  chapter  on  Diseases  of  the  Joints  will  be  found  a  table  of  the  ages  at  which  epiphyses 
unite.  In  childhood  and  youth  a  fracture  near  the  joint  is  most  likely  to  partake  of  this 
character,  and  it  is  of  importance  that  it  should  be  recognizefl  as  such  when  it  occurs. 
Injuries  occurring  beyond  the  ages  mentioned  in  the  tn\)\e  are  not  likely  to  be  of  this 
character  unless  ossification  is  flelaycd  \>y  some  morbid  process. 

By  virtue  of  their  occupations  and  habits  men  suffer  frac-tures  more  frequently  than 
women.  Fractures  are,  moreover,  ten  times  as  frequent  as  are  dislocations.  The 
aged,  by  virtue  of  their  atrophic  changes,  are  more  subject  to  fractures  than  others. 
Fracture  in  the  vicinity  of  certain  joints  predisposes  as  well  to  dislocation  of  these  jointS; 


DLU.'XOSIS  OF  FUACTURKS  4,S1 

;ui(l  i(  often  liii|)iM'iis  that  tlu«  trcutnuMit  for  the  dislocation  is  rcdnction  and  treatment 
of  (lie  fractnre.  So  far  as  the  external  causes  of  fracture  are  concerned  thev  are 
fre(|iicntl\  referred  to  as  (a)  fractnre  hy  external  violence,  and  (h)  fracture  by  innscle 
activity.  Tiic  former  are  easily  explained ;  the  latter  occur  from  excessive  uuiscle  action, 
us  in  violently  thro\viii«f  a  hall,  or,  as  in  one  case  with  which  the  writer  was  conversant, 
where  a  colored  preacher  in  the  vehemence  of  his  (jjesticulatious  fractured  his  own 
humerus.  Ohvionsly  the  lonif  or  lartfe  hones  arc  more  liable  to  fractun;  than  those 
which  are  short  and  irre<i;ular.  Certain  bones,  especially  the  clavicle,  are  peculiarly 
ex|)().se(l. 

Infrd-utrrinr  jmrimrs  have  not  as  yet  been  mentioned.  These  occur  durinj^  the 
intra-nterine  life  of  the  fetus;  this  term  does  not  include  such  fractures  as  may  be  inflicted 
durinj;  delivery  with  or  without  instrum(>nts.  In  a  fetus  already  affected  with  con<,'cnital 
rickets  it  may  not  retjuire  any  severe  contusion  upon  the  abdomen  of  the  mother  to  inflict 
a  fracture.  Starvation  (/.  c,  scurvy,  .syj)hilis,  and  struma)  in  the  mother  may  so  disturb 
mitrition  as  to  weaken  the  osseous  system  of  her  offs|)riii^. 

Such  |)revious  conditions  as  ensue  from  osteomyelitis  (/.  r.,  caries  and  necrosis) 
may  often  weaken  the  bone.  Nevertheless  w^itli  distinct  necrosis  there  is  usually  so  much 
new  bone  formation  as  to  strengthen  rather  than  weaken  the  part.  Bon(>s  may  alsf) 
become  fragile  as  the  result  of  syj)hilis,  especially  when  gummas  develo])  within  them. 

Fractures  frecjuently  produce  certain  dcjonniiic.s  which  are  more  or  less  conspicuous 
and  easily  recognized.  They  are  designated  as  angular,  lafrral,  or  a.rial  (/.  c,  when  the 
axes  of  bone  are  considerably  displaced,  even  though  they  may  be  more  or  less  ])arallel), 
lonf/ifiidlnal  (when  ends  overlaj)),  rotarif,  etc.;  while  by  the  interposition  of  nmscles  and 
other  soft  tissues  more  or  less  wide  .separatum  may  be  produced,  the  same  result  occurring 
when  the  olecranon  or  the  upper  half  of  the  patella  is  widely  separated  from  the  main 
bone  or  portion  by  muscle  pull. 


DIAGNOSIS  OF  FRACTURES. 

Fractures  give  rise  to  subjective  symptoms  and  objective  signs.  In  diagnosis 
the  history  is  also  of  value,  especially  in  those  cases  w^iere  it  is  a  Cjuestion  of  some 
constitutional  affection  and  a  minimum  or  absolute  absence  of  violence.  The 
apparent  immunity  which  the  intoxicated  enjoy  is  in  large  measure  due  to  the  fact 
that  by  virtue  of  their  condition  one  of  the  predisposing  causes  of  fracture  is  avoided. 
There  can  be  no  doubt  but  what  muscle  tension,  due  to  voluntary  or  instinctive  efforts 
to  avoid  harm,  is  a  contributing  factor  in  the  separation  of  many  bones  or  their  processes. 
A  patient  stupidly  drunk  will  not  make  these  efforts,  and  will  fall  in  a  relaxed  condition, 
in  which  violence  will  probably  be  much  less  extensive,  and  the  consequences  less  dis- 
astrous than  if  he  made  an  effort  to  save  himself  from  falling. 

Pain  and  tenderness  are  evidences  of  injury,  and  will  often  serve  for  its  location;  even 
the  reference  of  i)ain  is  somewhat  suggestive.  It  is  stated  as  a  universal  rule  that  when 
pressure  is  ap})lied  laterally  or  in  the  long  axis  of  a  bone  and  evokes  pain,  referred  to  a 
distance  from  the  point  where  pressure  is  made,  it  will  indicate  fracture  at  the  point  to 
which  it  is  referred.  There  is  always  impairment,  usually  loss  of  function,  while  effort 
to  move  a  thus  injured  limb  will  give  rise  again  to  localized  pain  and  tenderness.  The 
pain  of  contusion  is  usually  diffuse,  and  that  of  fracture  is  referred  to  a  limited  area. 
The  tenderness  produced  by  handling  or  examination  will  vary  with  the  stolidity,  the 
age,  and  the  character  of  the  patient,  as  well  as  the  nature  of  the  injury. 

Objective  signs  are  crepitus,  mohilittj,  deformiti/,  ecchijmosis,  rcdisplaceincnt.  Crepitus 
means  the  sensation  of  grating  or  rubbing  produced  when  fractured  bone  surfaces 
are  moved  upon  each  other.  It  is  recognized  by  the  sense  of  touch,  sometimes  by  that 
of  hearing.  Its  presence  is  pathognomonic,  but  its  absence  is  a  negative  sign,  and  an 
effort  should  be  made  to  obtain  it.  To  repeat  the  demonstration,  especially  to  demon- 
strate it  to  others,  means  superfluous  manipulation,  which  is  not  to  the  best  interest  of 
the  patient.  Crepitus,  then,  should  be  carefully  sought  for;  once  detected  it  should 
be  sufficient. 

Abnormal  mobility  is  explained  only  by  fracture.     It  is  (>asy  to  detect  it  in  the  shaft 
of  a  long  bone,  but  when  near  the  joint  it  is  confusing.     Its  determination  by  manipu- 
lation is  not  seen  in  green-stick  or  impacted  fracture  unless  these  are  further  broken 
31 


482  SUmnCAL   AFFKCTIOXS  OF   TIfl'J   T/SSl'I'S 

u|)  1)V  manipulation.  When  evident  it  should  serve  as  a  caution  against  unnecessary  or 
rough  liandHng,  for  if  it  he  easily  recognizable  crepitus  need  not  he  sought. 

Dcjormit!)  is  a  striking  and  pathognomonic  feature  of  fracture.  It  may  be  imitated 
by  hematoma  or  sudden  swelling  of  the  soft  parts  or  of  joints.  It  may  consist  of 
shortening  or  of  angular,  lateral,  or  rotary  displacement,  or  perhaps  of  depression  or 
indentation.  Careful  inspection,  th(>n,  and  palpation  should  precede  other  methods  of 
examination,  as  they  are  often  sufficient  to  indicate  the  location,  the  nature,  and  sometimes 
even  the  character  of  the  active  causes. 

Inspection  of  the  injured  part  alone  is  not  ahvaij.s  .sufficient.  Careful  comparison 
between  the  two  sides  of  the  body  should  be  made  in  order  that  actual  measurement  or 
com])arative  examination  may  reveal  what  mere  inspection  would  not.  In  connection 
with  inspection  it  should  be  ascertained  whether  the  individual  has  ever  received  previous 
injuries.  The  writer  recalls  a  case  where  a  physician  claimed  a  recovery  after  fracture 
of  the  femur,  treated  by  incompetent  method,  yet  with  ideal  result,  inasmuc-h  as  he  said 
there  was  absolutely  no  shortening.  A  personal  cpiestion,  however,  to  the  patient 
revealed  the  fact  that  he  had  had  the  other  thigh  broken  some  years  previously,  and 
that  an  a])])ar(Mitly  similar  amount  of  shortening  followed  in  each  case. 

The  ordinary  indications  of  fracture  are  frecjuently  followetl  by  ecchymo.sis.  This 
will  appear  at  a  date  corresponding  Avith  the  depth  of  the  injin-y  beneath  the  skin  (it 
may  occur  within  an  hour  or  three  or  four  days).  The  blood  will  follow  the  fascial 
planes  and  work  its  way  to  the  surface  along  them.  The  sign  is  of  the  greatest  value 
in  the  diagnosis  of  basal  fractures  of  the  skull  and  certain  fractures  of  the  hip  and  pelvis. 
When  it  occurs  after  an  interval  it  is  a  confirmatory  rather  than  a  ]:)romptly  available  sign. 

Rcdl.s place nient  imj)lies  that  the  parts  when  properly  put  into  ap])osition  quickly 
fall  out  of  it  unless  mechanically  supj)orted — that  is,  they  do  7iot  .sfaij  reduced.  This 
sign  is  not  universally  a])plical)lc.  It  ap|)lies  especially  to  the  fractures  of  the  long  l)ones 
of  the  extremities,  and  particularly  to  the  humerus,  the  femur,  or  double  fractures  of  the 
radius  and  ulna  in  the  forearm  or  both  l)on('s  of  the  leg. 

Diagnostic  Aid  Afforded  by  the  Fluoroscope  and  the  Skiagram.— Since  Ront- 

gen's  memorable  discovery  the  cathode  or  .r-rai/.s  have  be(Mi  of  greater  and  greater  use  in 
the  diagnosis  and  jjortrayal  of  injuries  and  morbid  conditions  in  the  osseous  system.  To 
such  an  extent  is  this  now  true  that  well-ec|ui})ped  hos])itals  have  ample  conveniences 
for  fluorosco])ic  and  photographic  work,  while  many  medical  men  are  doing  it  in  their 
private  prac-ticc.  There  can  be  no  question  but  that  diagnosis  and  methods  oi  treatment 
have  been  made  more  perfect  since  this  new  method  of  investigation  has  been  made 
available.  On  one  hand,  however,  it  has  led  ])erha])s  to  something  of  neglect  of  the 
methods  previously  in  vogue,  which  necessitated  anatomical  knowledge  and  logical 
reasoning.  On  the  other  hand,  the  knowledge  thus  obtained  has  been  sometimes  a 
two-edged  sword,  since  the  display  of  skiagrams,  or  .r-ray  pictures,  in  court  has  too 
often  worked  harm  or  discredit  to  the  surgeon  or  the  institution  with  which  he  was 
connected.  Moreover,  even  this  method  of  diagnosis,  with  its  apparent  certainties,  is 
not  always  reliable,  anrl  (lisai)pointments  have  sometimes  followed. 

Intra-articular  Fractures  are  subject  to  peculiar  comjjlications  which  enhance  the 
difhculty  of  treatment  and  jeopardized  the  result.  Among  the  more  common  of  these 
are  the  following: 

1.  Too  wide  se])aration  of  fragments  by  hemorrhage  or  distention,  with  failure  in 
resorption  of  fluid  before  fixation  in  bad  position  lias  resulted. 

2.  Complete  or  partial  rotary  displacement,  preventing  proper  a])]K)sition  of  bone 
surfaces. 

3.  Interposition  of  soft  or  fibrous  tissues  between  fragments  by  which  bony  union  is 
prevented.  This  is  conspicuously  common  in  fractures  of  the  olecranon  and  ])atella, 
and  is  of  itself  sufficient  reason  to  justify  operation  in  otherwise  suitable  cases. 

4.  Separation  of  a  fragment  within  a  joint  capsule,  by  which  its  blood  supply  is  cut 
off,  making  it  essentially  a  foreign  Ixxly.  This  occurs  especially  at  the  anatomical 
necks  of  both  the  humerus  and  femin-. 

5.  Exuberance  of  callus  with  consec(uent  limitation  of  motion. 

6.  Insufficient  amount  or  absence  of  callus,  which,  when  bone  ends  are  l)athed  in 
joint  fluids,  is  not  often  thrown  out. 

All  of  these  are  immediate  consequences.  The  following  are  among  the  more  unde- 
sirable remote  con.sequences  of  the  same  injuries: 


lih'I'AIfi  OF  FRACTURES  483 

1.  Exuhcrant  callus,  which  may  be  the  result  of  too  early  attem|)t  to  move  the  parts, 
or  may  result  from  other  causes;  it  oti'ers  more  or  less  mechanical  obstruction  to  joint 
movements. 

2.  S{>|)aration  of  fra<jments  to  an  extent  j)reclu(ling  the  ])Ossil)ility  of  rej)air,  and  inter- 
fering witii  function. 

3.  P.seudo-ankylosis,  as  a  result  of  condensation  and  organization  of  blood  clot 
between  joint  surfaces. 

4.  Adhesion  of  tendons  to  surrounding  callus  or  within  their  own  sheaths. 

5.  l)is])lacenient  and  distortion  of  bone  ends  with  vicious  union,  for  whi<h  the  medical 
attendant  is  somrt'nncs  resj)onsible.  Unfortunate  consequences  of  this  kind  are  generallv 
seen  at  the  elbow  after  fractures  of  the  condyles;  at  the  wrist,  after  incomplete  reduction 
of  Colles'  fracture;  at  the  hip,  when  insufficient  traction  has  been  made;  at  the  ankle, 
after  the  c-omplete  form  of  Pott's  fracture. 

(■).   Exostoses  and  osteophytic  outgrowths,  which  often  complicate  fractures. 

7.  Absorption  of  bone,  which  is  usually  seen  after  fractures  of  the  neck  of  the  femur. 

8.  Involvement  of  nerves  by  ])ressure  of  callus,  most  often  seen  about  the  ellxnv. 

9.  'I'hrombosis  leading  to  obliteration  of  the  deeper  and  enlargement  of  the  more 
.superficial  veins. 

10.  Edema,  also  the  result  of  venous  obstruction  by  pressure  of  callus. 

11.  Chronic  hydrarthrosis. 

12.  Arthritis  deformans  traumatica.  This  is  usually  a  remote  result  of  fractures, 
and  manifests  itself  by  slow  changes  in  shape  and  position,  with  defc^rmity  and  dis- 
al)ility.     It  occurs  most  often  in  the  aged. 

13.  Necrosis,  which  may  be  the  result  of  failure  in  the  process  of  repair  and  will 
prol)al)ly  necessitate  operation. 

14.  ^Malignant  changes.  These  have  to  do  with  the  occurrence  of  sarcoma  in  bone 
callus,  a  complication  which  is  known  to  occasionally  arise.  (See  Sarcoma.)  It  also 
refers  to  primary  sarcoma,  by  which  bone  is  weakned,  or  secondary  carcinoma,  which 
produces  the  same  result. 

15.  Syphilis.  Chronic  syphilitic  disease  is  well  known  to  weaken  bones  by  atrophic 
processes  as  well  as  ))y  the  deposition  of  gumma.  It  is  known  also  to  delay,  or  some- 
times almost  prevent,  the  process  of  callus  formation,  ossification,  and  later  absorption. 
Syphilitic  patients  with  fractures  need  to  be  kept  under  antispecific  medicines. 


REPAIR    OF    FRACTURES. 

The  immediate  consequence  of  a  fracture  is  outpour  of  blood  both  from  the  broken- 
bone  surfaces  and  from  whatever  other  tissues  may  have  been  lacerated.  This  produces, 
first,  a  hematoma,  which  is  followed  by  a  certain  degree  of  local  edema,  perhaps  even  of 
general  cflema  of  the  distal  parts.  The  latter  will  subside  with  a  rapidity  proportionate 
to  the  promptness  of  suitable  treatment  and  the  nature  of  the  injury.  The  blood 
begins  to  coagulate  within  a  short  time,  while  with  the  disappearance  of  the  more  fluid 
portion  granulations  l^egin  to  form  from  the  periosteum,  as  well  as  bone  surfaces,  exter- 
nally and  internally,  and  even  from  the  marrow.  The  clot  loses  its  original  character- 
istics and  is  permeated  more  or  less  rapidly  by  granulations.  With  the  site  of  the  injury 
wrapped  in  a  mass  of  granulation  tissue  we  speak  of  the  so-called  'provisional  callus, 
whose  amount  will  depend  upon  the  severity  of  the  injury  and  the  accuracy  of  the  replace- 
ment of  the  parts.  If  laceration  has  been  but  trifling  and  the  bones  are  accurately 
apposed  the  amoimt  of  callus  will  be  small,  otherwise  it  may  be  large;  so  large,  in  fact, 
as  to  be  easily  palpated  and  even  to  cause  edema  and  pain  by  pressure.  Repair  of  the 
fracture  is  effected  by  the  gradual  conversion  of  this  callus  into  cartilaginous  tissue  and 
then  into  bone.  So  much  of  it,  at  least,  as  lies  on  the  outer  side  of  the  bone  and  is 
known  as  external  callus  goes  through  this  change.  The  internal  callus,  i.  e.,  that  within 
the  marrow  cavity,  undergoes  a  more  direct  transformation,  which  amounts  to  immediate 
ossification.  The  internal  callus  usually  ossifies  completely,  and  then  forms  a  medullary 
plug  that  serves  as  an  internal  splint  and  affords  support  and  strength.  In  time  it  com- 
pletely disappears,  this  time  varying  in  different  cases. 

The  external  callus  is  converted  into  bone  by  passing  through  the  intermediary  con- 
dition of  cartilage.     Between  the  broken-bone  ends  granulation  occurs  more  slowly,  and 


484 


SURGICAL   AFFECTIONS  OF   THE   TISSUES 


repair  at  this  point  is  delayed,  partly  because  of  poor  circulation  and  nutrition;  but  the 
internal  callus  acting  as  a  bobbin  within,  and  the  external  callus  acting  as  a  solder  on 
the  outside,  give  sufficient  support  and  strength  to  effect  a  final  and  absolute  ossification 
of  all  the  interfragmentary  granulation  tissue.  When  the  time  comes  when  callus  is 
no  longer  necessary  it  begins  to  disappear  by  absorj)ti()n.  When  everything  proceeds 
normally  callus  is  absorbed  in  a  proportion  commensurate  with  its  loss  of  utility.  When 
bone  ends  have  liadly  united  considerable  callus  remains  permanently.  When  ajjpo- 
sition  has  been  ideal  it  almost  completely  disappears,  even  the  medullary  cavity  being 
restored. 

Fragments  w^hich  are  completely  detached  may  be  reunited  by  practically  the  same 
primary  process,  but  fragments  of  considerable  size  usually  become  surrounded  by 
granulation  tissue,  by  which  they  are  nourished    and  may  be  finally  reunited,  with 


Fig.  278 


Fiu.  279 


Compound  fractures  resulting  from  arm  being  caught  in  belting  and  wound  around  shafting.  End  of  radius 
united  to  ulna  and  lower  end  of  ulna  to  the  radial  fragment.  Pseudarthrosis  of  humerus,  thrice  operated,  the 
third  time  in  the  Buffalo  Clinic.     (Skiagram  by  Dr.  Plummer.)      (Arch.  Phys.  Therap.,  May,  1905.) 


more  or  less  departure  from  their  original  shape  and  location.  It  is  in  this  way  that  a 
comminuted  fracture  may  heal.  Fragments  that  are  separated  sometimes  necrose  and 
have  to  be  removed. 

The  repair  of  the  flat  bones  is  effected  by  a  similar  j)rocess,  which  is  referred  to  as 
callus  formation.  In  the  skull  it  is  brought  about  chiefly  througli  the  agency  of  the  diploe, 
whose  powers  in  this  direction  are  somewhat  limited.  Cancellous  bone  tissue  usually 
throws  out  but  little  callus.  Its  repair  occurs  from  within.  Cartilage  heals  by  a  very 
similar  process,  though  it  is  not  now  ossific  tissue  but  fibrous  which  reunites  the  fractured 
surfaces.  Instances  of  both  kinds  can  be  seen  when  a  fracture  has  crossed  a  joint 
surface. 

In  a  compound  fracture  much  will  depend  upon  the  existence  or  absence  of  septic 
complications.     In  a  clean  wound,  whence  blood  and  fluid  may  have  escaped,  there 


DELAYED   UNION;  NON-UNION 


485 


will  he  little  Imt  <>:rimiilati()n  tissue.  Should  (his  wound  suppurate  the  exposed  hone 
surfaces  will  under<^o  at  least  a  superficial  ue<"rosis,  ueerotie  particles  heiuff  removed 
by  the  same  "lanulation  tissue  which  will  later  hind  the  hone  ends  toffetlier.  Here,  too, 
the  internal  callus  l)lays  the  Iar<;'est  role  in  (he  |)rocess  of  re])air.  The  hone  tissue  first 
formed  is  always  coarse  and  soft,  (-omj)lete  calcification  and  restoration  of  ori^iiud 
density  and  va.scularity  occur  slowly.  Neither  cartilage  nor  bloodvessels  alone,  appear 
capable  of  formin<:f  bone;  the  latter  is  produced  only  undci-  ihc  influence  of  the  offiro- 
blafit.t,  which  pcurlrdir  from  the  prno.tfriiiii  and  the  hone  ilsclj  jilono-  the  course  of  the 
bloodvessels. 

'^riie  process  is  one  of  conversion  of  blood  clot  into  provisional  callus,  which  (hen 
chanti'cs  into  <>'ranulation  tissue  or  into  cartila<>;e,  both  of  thes(>  materials  uudcrt>-oin<'- 
subse<jueut  conversion  into  bone  (hrouo'h  the  medium  of  the  osteoblasts  and  osteoclasts 
(or  fjiant  l)oue  cells),  the  nei(;-hl)()rino;  bone  itself  uu(lero;oin<f  a  rarefyiujf  ostitis,  to 
chaii<j;e  back  into  its  original  condition  with  the  final  cha,nji;es  of  the  callus. 


n      _  ■ _    fi ■" 1-1^ •■■'    -.^. ■•.... 

licjjair  of  intra-articular  fractunss  has  already  been  described  as  infiuenced  by  the 
,)reseuce  of  synovial  fluid  and  cartilage.  The  latter  does  not  proliferate,  and  the  line 
of  fracture  usually  appears  as  a  groove  on  its  surface.  At  epi])hyseal  junctions  union 
is  usually  rapid  and  satisfactory,  for  the  changes  taking  ))lace  at  this  j)oiut  are  in  the 
direct  line  of  what  is  needed  for  repair. 


Fig.  280 


DELAYED  UNION;    NON-UNION. 

The  above  description  refers  to  the  process  which  is  su|)poscd  to  take  place  in  normal 
bone  repair.  When,  however,  this  is  disturbed,  as  it  may  be  from  a  variety  of  causes, 
there  may  be  flr/ai/rd  union;  when  it  completely  fails  we  have  non-vnion.  (General 
conditions  have  l)(>ariug  on  these  local  failures.  Whatever  makes  a  strain  upon  the 
system  may  interrupt  the  process,  c.  r/.,  pregnancy,  lactation,  exhausting  hemorrhages, 
acut(>  diseases,  starvation.  Again,  failure  may  result  from  purely  local  conditions,  such 
as  marked  dis|)lac(Mnent,  and  ])articularly  the  intervention  of  some  of  the  soft  tissues,  or 
any  foreign  body.  Suppuration  will  also  frequently  cause  great  disappointment.  The 
humerus  is  the  bone  most  often  troublesome  in  this  direction;  next  the  bones  of  the  leg, 
the  femur,  and  the  bones  of  the  forearm.  It  is  necessary  to  distinguish  between  delayed 
union  and  absolute  non-union.  In  the  former  normal  processes  may  be  simply  retanjed. 
WJu'u  thus  (Ir/ai/rd  fhr;/  niaij  he  .'ifimulafrd  hy  rough  handling,  rubbing  the  l)ones  together, 
or  by  perforating  the  callus  with  thi'  j)oint 
of  a  drill,  from  several  directions.  This 
method  of  drilling  was  introduced  by  Brain- 
ard,  of  Chicago.  The  existence  of  syj^hilis 
has  much  to  do  with  delay,  and  should  be 
combated  by  free  use  of  antispecifics.  Many 
patients  will  be  found  to  have  pJiosphaturia, 
i.  e.,  to  be  eliminating  phos])hates  which 
should  go  to  repairing  the  bone.  Such 
j)atients  should  be  given  phosphoric  acid, 
with  some  of  the  phosphates,  j)referably  of 
calcium,  in  order  to  make  up  for  loss  in  this 
direction.  Much  can  be  done  also  by  mas- 
sage, and  by  everything  which  stimulates 
nutrition  and  general  health  (Fig.  280) . 

In  non-union  efforts  at  repair  are  at  a 
.standstill ;  the  bone  ends  become  rounded 
ofi',  the  marrow  cavity  is  plugged  on  either 
side,  while  in  time  the  surrounding  gran- 
ulation or  connective  tissue  undergoes 
condensation,  as  well  as  organization,  and 
a  capsule  is  formed  in  which  a  certain 
amount  of  fluid  resembling  true  .synovia 
collects,  and  thus  is  formed   sometimes   an 

almost  perfect    pseudarthrosis  or  false   joint,        yj^j,,,,,  y„i„n  ^.j,,,  great  deformity  after  fracture, 
\vhose    perfection    as     a   joint    must    be    ad-  requiring  extensive  operation.    (Buffalo  Clinic.) 


486  SURGICAL   AFFECTIONS  OF   THE   TISSUES 

mired,  although  its  presence  is  so  deplored.  The  causes  of  nf)n-union  are  now  better 
understood  than  formerly,  and  consist  largely  in  the  interposition  of  fibrous  and 
muscular  tissues,  that  act  as  a  barrier  and  keep  the  granulation  tissue  or  the  callus 
on  one  side  from  coalescing  with  that  on  the  other. 

Treatment  of  these  cases  will  vary  with  their  causes.  In  dehiijrd  union  patients  should 
be  encouraged  to  use  the  parts,  thereby  causing  greater  activity,  l)ut  in  the  presence  of 
an  actual  false  joint  no  method  is  of  avail  except  that  of  actual  exposure,  by  incision,  with 
removal  of  all  intervening  fibrous  tissue,  and  fresliening  of  the  bone  surfaces  by  saw  or 
chisel,  the  endeavor  being  to  so  shape  them  that  they  may  lie  in  contact,  and  then  be  so 
maintained,  by  some  mechanical  expedient,  such  as  a  wire  nail  or  suture,  an  ivory  peg, 
a  chromicized  tendon,  a  bone  ring,  a  small  metal  brace  fastened  with  screws,  or  by  any 
other  expedient  which  may  suggest  itself  to  the  ingenuity  and  the  means  of  the  oj>erator. 
There  are,  however,  occasions  when  one  deliberately  endeavors  to  secure  a  pseudar- 
throsis,  as  after  ankylosis  of  the  shoulder-joint,  if  in  making  powerful  effort  to  break  up 
adhesions  the  neck  of  the  humerus  should  snap  it  would  be  better  to  prevent  union 
rather  than  favor  it,  as  in  this  way  something  resembling  the  original  joint,  so  far  as 
function  is  concerned,  would  be  obtained.  At  the  hip,  also,  after  such  an  accident,  the 
same  principles  may  be  adhered  to  or  more  deliberately  secured  by  a  subcutaneous 
osteotomy,  as  is  sometimes  done  for  relief  of  deformity. 

Fihroii.s  union  implies  such  organization  (jf  granulation  tissue  as  converts  it  into  simple 
fibrous  or  ligamentous  tissue,  the  change  stopping  here  and  not  g(nng  on  to  formation 
of  cartilage  or  bone.  There  are  three  localities  especially  where  fibrous  union  is  some- 
times the  best  that  can  be  obtained  and  often  proves  sufficient  of  itself;  these  are  the 
olecranon,  the  patella,  and  the  neck  of  the  femur.  Even  though  the  halves  of  the  patella 
be  separated  by  two  inches  of  ligamentous  tissue  the  patient  may  still  have  reasonable 
use  of  the  limb.  A  separation  of  half  an  inch  to  one  inch  at  the  olecranon  does  not 
materially  disable  the  arm,  while  at  the  hip-joint  two  or  three  inches  of  ligamentous 
tissue  between  the  main  end  of  the  bone  and  the  fragment  will  not  totally  interfere  Avith 
locomotion,  except  so  far  as  it  permits  an  equivalent  amount  of  shortening  of  the  leg. 
There  are,  then,  occasions  especially  when  the  hip  is  involved  in  elderly  and  decrepit 
pe(jple,  when  ligamentous  union  is  the  best  that  can  l)e  hoped  for  or  attained. 

TREATMENT   OF  FRACTURES. 

In  principle  the  treatment  of  fractures  is  very  simple.  It  consists  in  putting  the  parts 
in  apposition  and  maintaining  them  there  for  sufficient  time  to  permit  of  complete  repair. 
That  which  is  so  simple  in  theory  is  often  very  difficult  and  sometimes  even  impossible 
in  practice,  made  so  by  the  nature  of  the  injury  or  the  disposition  of  the  j)atient.  In 
the  aged,  who  cannot  lie  long  in  one  position  for  fear  of  pulmonary  stasis;  also  in  the 
insane,  in  the  epileptic,  and  in  those  sufi'ering  from  delirium  tremens,  will  be  met  diffi- 
culties which  are  insuperable.  In  such  instances  the  first  indication  is  to  preserve  the 
life  of  the  patient,  the  second  is  to  get  a  good  result,  the  third  is  to  do  the  best  we  can. 
Good  management  is  not  the  least  important  feature  of  such  treatment  This  will  include 
suitable  nutrition,  provision  for  elimination,  prevention  of  bed-sores  or  pressure-sores, 
and  many  other  less  important  features. 

Diagnosis  having  been  made,  the  surgeon  should  study  how  he  may  best  carry  out  the 
fundamental  principle  of  putting  the  parts  in  apposition  and  so  maintaining  them. 

The  greatest  obstacle  to  reduction  and  maintenance  in  position  is  muscle  pull.  After 
an  injury  of  this  kind  there  will  be  more  or  less  muscle  spasm,  the  more  powerful  groups 
displacing  bones  in  the  natural  direction  of  their  pull.  In  the  humerus  and  femur 
especially  all  arm  or  thigh  muscles  will  cf)operate  to  produce  shortening.  As  indicated 
in  the  chapter  on  Joint  Affections,  nothing  so  thoroughly  overcomes  chronic  muscle 
spasm  as  traction.  The  principle  underlying  treatment  by  traction  is  exceedingly  simple, 
})ut  there  are  numerous  ways  and  mechanical  expedients  for  effecting  it.  In  the  lower 
limb,  whether  this  shall  be  done  by  anterior  suspension,  by  weight  and  pulley,  by  elastic 
contraction,  or  by  some  of  the  more  complicated  splints,  matters  little  so  long  as  it  be 
efficiently  made.  Of  all  these  methods  it  may  be  said  in  general  the  simplest  is  the  best. 
In  the  upper  extremity  traction  may  be  made  by  similar  methods  with  the  patient  in  bed, 
or  the  patient  may  be  allowed  to  rise  and  be  about  with  a  weight  hanging  from  the  elbow 
or  some  simple  expedient  of  this  kind. 


COAf  POUND  FliACTCniJS  AM)   rili:ik   THE  ATM  EST  457 

The  iiiclliod  of  iraclioii  is  one  to  In-  coiiihincd  usually  uilli  I'lirllicr  |)rolccl  ioti,  hv  wliicli 
not  oiilv  lon<,nlU(linal  hut  lateral  (lis|)laccuifnt  may  he  ovcrcoiiic  Tlii.s  su^^^'csts  tlic  use 
of  .splints  in  addition  to  mutc  tnictiou  iiictliods. 

It  is  not  always  jjossihlc  to  put  in  ojuTation  at  first  that  nu'tiiod  which  we  may  prefer 
a  little  later,  as  .swrlliiuj  is  usually  so  |)ronounee(l  as  to  make  it  advisuhle  only  toput  the 
parts  at  rest  and  hasten  absorption.  The  same  is  true  of  hemorrhajije.  In  rarer  instances 
it  may  ))e  a  (jiiestion  as  to  whether  the  distal  parts  may  under<;o  (jiinfjrene  from  the  dis- 
iniliance  of  circulati;)n.  These  are  matters  to  be  duly  regarded  before  the  later  and 
more  complet(>  dressing.  Mcr/uinira/  aids,  usually  in  the  shape  of  sj)lints,  are  therefore 
necessary.  'I'he  physiological  rest  which  it  is  so  necessary  to  ensure  will  lead  to  a 
(•(M-tain  wasting  of  muscles  and  stiffening  of  joints,  which  are  only  temporary,  but 
which  by  no  means  lessen  disability  when  splints  are  removed.  That  spliul  i.s-  hr.s-f  for 
a  (jivni  case  wliirli  hr.s-f  fif.s  if  and  prnnifs  fJir  snirgeon  to  carry  out  il.s  prrv/iar  iiidirafions. 
The  writer  is  (){)posed  to  manufactured  splints,  as  they  seldom  fit  the  j)art.  I'his  can 
be  obviated  by  packing  cotton  or  other  compressible  material  into  the  splint.  For  tem- 
porary jnirposes  they  will  frefiuently  suffice.  For  fixed  dressing,  hf)wever,  it  is  preferal)le 
to  make  a  splint  which  shall  fit  the  limb  to  which  it  is  affixed.  Immol)ili/,ation  is  difficult 
of  accomplishment  and  at  many  points  impossible.  Thus  in  fracture  of  the  ribs  or 
clavicle  it  is  impossible  to  avoid  a  certain  amoimt  of  mention  with  each  respiratorv  effort, 
even  though  an  uncomfortably  tight  dressing  be  applied, 

Sjjlints  are  made  of  various  materials,  metal,  wood,  varions  compositions  hardened  in 
molds,  plaster  of  Paris,  or  some  of  its  sul)stitutes,  i.  c,  glue,  soluble  glass,  or  a  composi- 
tion like  one  made  of  equal  parts  of  powdered  starch  and  fine  isinglass,  added  to  a 
solution  of  potassium  silicate,  this  being  allowed  to  stand  for  several  days,  after  which  a 
little  fine  boric  acid  powder  is  added;  when  this  is  painted  over  gauze  dressings  it  solidi- 
fies and  forms  a  light  and  rigid  splint.  There  is  one  ol)jection  to  all  methods  which 
com])nse  a  solution  that  hardens  slowly — that  is,  that  during  the  time  recjuired  for  the 
pur])o.se  redisplacement  may  occur.  It  is  not  advisable  to  dress  a  recent  fracture  in  a 
wet  pasteboard  s])lint  or  in  such  a  composition  as  that  mentioned  above.  Later,  when 
a  certain  amount  of  c(Misolidation  has  already  occurred  they  may  serve  a  useful  purpose.' 

There  are  two  methods  of  using  plaster  of  Paris:  one  is  gauze  bandages  sprinkletl  with 
it,  rolkd,  and  kept  ready  for  use,  to  be  placed  in  water  at  the  time  of  their  employment. 
A  limb  may  be  enveloped  in  these,  after  being  covered  with  a  layer  of  wadding  or  some 
other  protective  material,  by  which  the  plaster  shall  not  come  in  actual  contact  with 
the  skin.  It  is  also  a  good  |)lan  to  place  a  strip  of  tin  or  pasteboard  along  the  exposed 
surface  of  the  limb,  over  which  the  surgeon  cuts  to  remove  the  splint.  Thus  one  may 
avoid  any  danger  of  injuring  the  skin  with  the  point  of  the  knife.  It  is  also  a  good  j)lan  to 
make  a:  least  a  part  of  this  cut  Ijefore  the  plaster  has  sufficiently  hardened,  i.  e.,  to  do 
most  of  the  work,  leaving  perhaps  a  layer  or  two  of  gauze  to  be  cut  through  some  time 
later,  .t  is  necessary^  to  impress  the  fact  that  when  a  quickly  hardening  fixed  dressing 
is  used  ipproximation  should  be  ensured  by  the  greatest  attention,  maintaining  it  until 
the  splint  is  so  hardened  that  redislocation  is  impossible.  Another  method  of  using 
plaster  of  Paris  is  by  sopping  strips  of  surgeons'  lint,  ordinary  canton  flannel,  or  almost 
any  other  similar  material,  in  plaster-of-Paris  cream,  then  molding  these  to  the  injured 
limb,  ma  ntaining  the  same  rigid  precaution  as  to  the  proper  position  of  the  same  while 
the  splini  hardens.  In  this  way  a  splint  can  be  adapted  to  the  part,  and,  at  the  same 
time,  made  removable,  permitting  as  frequent  access  to  it  as  may  be  desired. 


COMPOUND  FRACTURES  AND  THEIR  TREATMENT. 

As  alrealy  stated,  it  is  the  communication  of  fractured  bone  surfaces  with  the  external 
air  which  nakes  a  fractin-e  compound  in  the  strictly  surgical  sense.  This  may  occur 
through  a  minute  and  tortuous  opening  or  through  a  large  and  extensive  wound. 
Although  tie  communication  is  with  the  atmosphere  the  danger  comes  not  so  much  from 
germs  floathg  in  the  air  as  from  those  on  the  surface  of  the  liody  and  within  the  pores  of 

1  Jenkins'  pa-king,  such  as  is  used  on  some  engines,  has  been  recommended  by  Spotswood  as  a  substitute  for 
plaster-of-Pari;- bandages,  its  advantages  being  that  it  is  not  affected  by  any  antiseptic  washes  as  a  plaster 
dressing  would  be,  that  it  is  lighter,  and  that  by  placing  it  in  hot  water  it  can  be  molded  to  assume  the  shape 
of  the  limb. 


488  SURGICAL  AFFECTIONS  OF  THE  TISSUES 

the  skin,  or  else  from  foreign  material  admitted  through  tlie  external  wound.  Obviously 
the  great  danger  is  of  se])tie  infeetion.  Whether  tlie  tissues  may  prove  more  or  less 
susceptible,  and  thus  resist  or  break  down,  cannot  at  the  outset  be  foretold.  This  leaves 
but  one  imperative  rule  to  follow,  to  act  in  every  instance  as-  though  serious  injection  had 
occurred  and  to  take  precautions  accardingly.  Even  a  small  puncture  made  by  a  spicule 
of  bt)ne  may  permit  germs  to  be  withdrawn  into  the  tissues  as  the  bone  is  replaced.  If, 
then,  the  surgeon  seals  such  a  puncture  he  necessarily  takes  the  chances  and  must  abide 
the  result.  Whether  he  shall  do  this  or  not  will  depend  upon  the  patient  and  the  injury. 
At  all  events,  the  site  of  puncture  should  be  carefully  cleansed  and  disinfected  and  the 
case  so  dressed  that  it  may  be  carefully  watched.  Complete  sterilization  of  every  par- 
ticle of  exposed  tissue  is  absolutely  necessary,  and  for  this  purpose  hydrogen  dioxide 
or  some  of  its  later  substitutes  will  prove  effective.  A  protruding  s])linter  of  bone 
should  be  removed  with  cutting  forceps,  unless  the  wound  must  be  enlargt>d  as  a  part  of 
the  treatment  of  the  fracture.  In  most  instances  it  will  he  safer  to  pursue  this  course, 
i.  e.,  to  extend  the  wound  which  makes  the  fracture  compound,  tf)  a  degree  permitting 
thorough  exploration  and  cleansing.  Not  infrequently  fragments  of  bone  will  be  found, 
which  when  nearly  or  completely  detached  should  be  removed.  Such  a  free  opening 
permits  also  of  wiring,  or  other  means  of  fastening  together  bone  ends,  by  which  appo- 
sition may  be  more  perfectly  secured.  A  compound  fracture  which  has  been  long  unat- 
tended may  he  safely  assumed  to  he  septic.  Here  free  incision,  with  cleansing  and  ample 
drainage,  will  be  a  far  safer  course  than  non-compliance  with  the  general  rule. 

Compound  fractures  of  the  skull  are  nearly  always  depressed  fractures,  and  practically 
always  call  for  operation.  Their  proper  treatment  will  be  dealt  with  when  considering 
Injuries  to  the  Head.  A  fracture  of  the  ribs  may  be  made  compound  by  penetration  of 
a  sharp  bone  end,  and  such  injury  to  the  lung  as  may  permit  air  to  escape  into  the  ])leural 
cavity.  Such  a  pneumothorax  may  be  followed  by  a  hemothorax  and  hydrotliorax, 
and  these  perhaps  by  empyema.  Compound  fractures  of  the  pelvis  are  not  infreq\iently 
complicated  by  perforation  of  the  bladder  or  bowel,  or  rupture  of  the  urethra,  or  some 
other  serious  visceral  injury  which  may  determine  their  fate.  Compound  fractures  are 
difficult  of  treatment  because  they  entail  frequent  changes  of  dressing  and  prevent  the 
use  of  desirable  splints.  These  fractures  are  also  sometimes  so  serious  as  to  necessitate 
amputation,  which  may  be  necessitated  either  by  such  comminution  of  bone  as  to  make 
repair  impossible,  or  such  injury  to  vessels  as  may  determine  gangrene.  If  the  cirmlation 
can  be  shown  to  be  sufficient,  either  at  the  time  or  perhaps  l)y  delay  of  a  few  hours  or  a 
day,  a  limb  may  be  saved  by  the  resection  of  one  or  both  bones,  which  in  pre-antiseptic 
days  would  have  required  amputation. 

The  surgeon  does  not  always  see  these  cases  in  their  recent  or  fresh  state.  He  may 
be  called  to  a  case  complicated  by  suppuration,  cellulitis,  and  sepsis.  Here  though 
amputation  may  be  required  he  may  still  delay  it,  hoping  to  improve  local  conditions, 
and  thus  to  make  it  more  promising,  or  he  may  have  to  resort  to  various  ex]X'dients, 
such  as  suspension  with  constant  irrigation,  or  temporary  packing  with  yeast,  in  order 
to  justify  any  further  attack  upon  the  parts  already  involved. 

In  the  treatment  of  compound  as  of  simple  fractures  we  should  never  lose  sight  of 
the  dangers  of  too  tight  bandaging  and  of  pressure  sores.  I  have  seen  both  these  lead  to 
gangrene,  with  its  necessary  mutilation,  in  cases  where  the  attendant  has  foroc:)tten  the 
proneness  of  injured  parts  to  swell,  and  has  either  not  allowed  for  this  within  thedressings 
or  has  not  atoned  for  it  in  time  when  it  has  already  occurred. 

In  the  treatment  of  all  these  cases  the  operator  should  never  forget  the  medicolegal 
aspects  of  such  a  case  nor  the  necessity  for  constant  attention  and  caution  oi  his  part. 
He  should  remember  that  his  minutest  precautions  will  often  be  disobeyed.  He  may, 
however,  be  cheered  by  the  fact  that  only  in  cases  of  carelessness  will  he  Jncur  legal 
responsibility. 


FRACTURES  OF   TIIF  SLFFRJUR  MAXILLA  489 


SPECIAL    FRACTURES. 

Frachirt's  of  the  skull  and  of  the  vortchni'  will  1h>  considered  under  (he  respective 
lieadin<:;s  of  injuries  (o  (he  Ili'ad  and  (o  the  Spine. 

FRACTURES   OF   THE  NOSE. 

The  nose  is  (h(>  most  fre(|uentiy  broken  of  ail  the  hoiiy  |)arts  about  the  face.  One 
nasal  bone  or  both  may  be  broken,  and  each  may  be  se|)arated  from  its  bony  supports 
as  well  as  from  the  other.  The  fracture  may  be  com|)ound  in  either  direction,  most 
frequ(>ntly  so  into  the  nasal  cavity,  as  a  result  of  which  infection  may  as  easily  take 
l)lace  from  within  as  from  without.     The  cartilages  may  also  parti<'ij)ate  in  the  injury. 

The  injury  would  be  easy  of  recoojnition  were  it  not  for  the  amount  of  swelling  that 
often  aceom|)aiiies  it.  The  si^^ns  are  mobility  and  cre])itus,  with  more  or  less  deformity. 
So  loni>;  as  the  nose  can  b(>  ijrasped  between  the  fingers  recognition  of  fracture  is  easy. 
If  swelling  jirevents  this  an  instrument  or  the  finger  can  be  ])assed  into  one  nostril  and 
combined  niani|)ulati()n  practised.  There  is  generally  more  or  less  bleeding  from  the 
nose,  and  sometimes  consideral)le  eni])hysema.  Swelling  and  ecchymosis  are  also 
often  pronounced.  This  will  all  subside  under  cool  and  sootliing  applications.  The 
mo.st  imi)ortant  indication  is  to  rei)lace  the  nose  and  hold  it  where  it  should  remain. 
The  difficulty  is  increased  by  the  efforts  which  the  patient  instinctively  makes  to  dis- 
lodge clot  or  secretion.  The  im])ortance  of  accurate  reposition  is  in  some  cases  sufficient 
to  justify  an  anesthetic  and  instrumental  h(>lp.  This  will  ])(>rmit  of  the  ap])lication  of 
such  force  as  may  be  necessary  to  elevate  or  to  shift  fragments,  while  a  gutta-percha 
splint  may  be  molded  upon  the  outside,  or  a  sterilized  jmu  or  needle  made  to  transfix 
the  nose  from  one  side  to  the  other  (Mason),  jiassing  behind  the  fragments  and  through 
the  septum  in  such  a  w^ay  as  to  keep  it  from  dropping  backward.  A  good  plan  is  to 
introduce  a  tube  into  each  nostril,  perhaps  a  piece  of  silk  catheter,  around  which  a  certain 
amount  of  gauze  can  be  packed,  and  which  can  thus  be  used  as  an  internal  splint,  while 
on  either  side  anfl  externally  a  little  roll  of  gauze  is  held  in  place  by  adhesive  plaster 
crossing  the  cheeks.  The  operator  should  take  as  much  pains  to  see  that  the  septum 
is  in  its  original  position  as  in  attending  to  outside  and  cosmetic  eflfects.  The  septum 
can  be  controlled  l)y  a  pair  of  forceps. 

A  nose  properly  held  in  j)lace  will  heal  within  a  few  days,  to  a  point  requiring  little 
if  any  support.  A  transfixion  pin  should  not  be  needed,  if  used,  for  more  than  four  or 
five  days.  An  internal  splint  should  be  removed  each  day,  so  that  the  nose  may  be 
spraye(l  with  cleansing  solution  (Dobell's)  and  retained  secretions  removed. 

Tlie  disfigurement  resulting  after  this  injury  is  dropping  in  at  the  root  of  the  nose, 
constituting  the  so-called  saddJe-nose  defect.  Such  disfigurement  as  results  can  be  later 
atoned  for  by  subcutaneous  injection  of  paraffin.     (See  chapter  on  Surgery  of  the  Face.) 

FRACTURES  OF  THE  SUPERIOR  MAXILLA,  WITH  OR  WITHOUT  OTHER 

BONES  OF   THE   FACE. 

The  more  protected  portions  of  the  upper  jaw^  are  rarely  fractured,  save  by  extreme 
violence.  The  alveolar  process,  with  one  or  several  teeth,  may  be  partially  or  completely 
detachetl.  Such  fractures  are  compound,  and  after  replacement  neetl  antiseptic  mouth- 
washes as  well  as  other  attention.  Usually  the  teeth  in  the  fragment  can  be  utilized 
for  the  purpose  of  fastening  it  l)ack  into  place  by  means  of  the  uninjured  teeth,  retention 
being  secured  by  wire  or  waxed  silk.  Elxtensive  detachment  may  n(>cessitate  sutures 
through  drill  holes.  The  lower  jaw  can  usually  be  utilized  as  a  splint  for  the  upper  by 
binding  the  jaws  firmly  together  and  feeding  the  patient  on  fluid  food.  When  one  or 
two  teeth  are  loosened  or  displaced  it  will  often  be  possible,  if  they  ean  be  promptly 
secured,  to  successfully  reimplant  them  in  their  sockets.  Both  the  sockets  and  the 
teeth  should  be  thoroughly  cleansed.  After  replacement  it  will  be  necessary  only  to 
ensure  absolute  rest  and  retention  in  position. 

In  regartl  to  other  facial  hones  there  is  no  injury  which  may  not  occur,  as  the  result 
of  direct  violence.  The  zygoma  and  the  malar  hone  may  be  broken  away,  or  the  entire 
collection  of  facial  bones  may  be  loosened  from  their  connection  with  the  bones  of  the 


490 


SURGICAL  AFFECTIOXS  OF  THE   TISSUES 


skull  proper.  The  margins  of  the  orbit,  or  its  walls,  may  also  he  injured,  and  the  sinuses 
opened,  with  perhaps  more  or  less  entrance  of  foreign  material.  These  fractures  are 
generally  compound  and  are  accompanied  sometimes  by  injuries  to  the  soft  tissues.  It 
becomes  then  a  question  not  merely  of  cosmetic  result,  but  of  avoiding  infection  and 
saving  life.  The  latter  is  the  more  important,  and  measures  should  first  be  directed  to 
that  object.  Satisfactory  results  can  be  attained  by  drilling  and  holding  bone  fragments 
together  with  tendon  or  other  sutures,  and  by  neatly  trimming  and  cleaning  wounded 
surfaces  and  bringing  them  together.  Subcutaneous  sutures  should  be  used  for  this 
purpose. 

FRACTURES  OF  THE  INFERIOR  MAXILLA. 

This  bone  is  l)r()ken  nearly  as  often  as  the  nose,  and  almost  invariably  by  direct 
violence.  Here,  as  in  the  upper  jaw,  there  may  be  trifling  or  serious  fractures  of  the 
alveolar  frocess,  which  should  be  treated  on  the  same  principle  as  above  set  forth.  Frac- 
tures of  the  rami  occur  more  often  in  those  jiarts  which  are  occupied  by  teeth,  or  from 
which  teeth  have  drop]:)etl  out  by  senile  changes,  the  jaw  being  weakened  at  these  loca- 
tions. The  most  frequent  seat  of  fracture  is  near  the  middle  line.  Fractures  of  the 
ascending  ramus  and  of  the  upper  processes  are  rare.  Double  fractures  are  not  infre- 
quent, the  lines  of  separation  being  rarely  symmetrical.  The  gum  and  the  skin  are 
often  torn   and   the  majority  of  these  fractures  are   compound.     The  bone  is  con- 


Fir..  281 


Fig.  282 


Fio.  283 


Use  of  silver  wire  in  fixation  of  fragments  by 
utilizing  the  teeth. 


Bandage  and  splint  for  fracture  of  lower  jaw.  (Bryant.) 


sidered  to  be  weakened  at  the  dental  foramen;  at  all  events  it  often  yields  in  this  vicinity. 
By  fracture  with  much  displacement  posterior  to  this  opening  the  inferior  dental  nerve 
may  be  injured  or  torn.  The  condyle,  after  extreme  violence,  has  been  known  to  have 
been  driven  up  into  the  cranial  cavity  through  the  base  of  the  skull.  G^ms hot  fractures 
are  nearly  always  comminuted  (Figs.  281,  282  and  283). 

The  signs  of  fracture  of  the  lower  jaw  are  unnatural  mobility,  crepitus,  displacement, 
pain,  and  loss  of  function.  No  bone  in  the  body  is  more  easily  investigated  by  sight  and 
touch,  and  recognition  of  these  fractures  is  usually  easy.  Pain  is  provoked  by  attempting 
to  move  the  jaw,  even  in  talking,  and  dej)ends  on  the  extent  to  which  the  inferior  dental 
nerve  is  injured.  Irregularity  in  the  line  of  the  teeth  will  sometimes  permit  recognition. 
These  fractures  furnish  excellent  illustrations  of  the  eflPect  of  muscles  in  producing  dis- 
placement. Those  of  the  tongue  and  the  floor  of  the  mouth,  as  well  as  the  anterior 
muscles  of  the  neck,  will  pull  the  fragments  in  various  directions,  according  to  the 
direction  of  the  line  of  fracture  and  its  location.  This  displacement  may  be  trifling 
or  serious.  These  fractures  are  often  compound,  internally  or  externallv,  such  injuries 
constituting  an  unpleasant  complication,  but  affording  occasionally  an  o])portunity  for 
fastening  fragments  by  drill  or  wire  suture,  which  would  otherwise  require  an  opening 
to  be  made.     In  every  instance  antiseptic  mouth-washes  should  be  frequently  used. 

Treatment. — The  treatment  is  simplified  when  the  dentition  is  good  and  regular  so 
that  the  fragments  may  be  fastened  together  with  wire  or  waxed  silk  ligature  around  the 


FRACTURES  OF   THE  STERXUM  A.\D  RlJiS  491 

adjoininfi:  trctli,  and  then  fixation  acconiplislicd  with  a  simple  rnoldod  prutta-pcrclia  or 
])last('r-of-rari.s  splint,  l)y  wliicli  tlu-  lowi-r  jaw  is  held  (irmly  against  tlic  upjx-r.  Sucli  a 
drt'ssintf  is  lu>ld  in  position  hv  a  four-tailed  I)anda<^e  (Fi<;.  '2S'.i).  A  silk  or  wire  looi), 
used  for  tlie  purpose  just  mentioned,  should  include  two  teeth  on  either  side  of  the  frac- 
ture, for  l)V  constant  tension  the  nearest  tooth  will  soon  loosen,  and  if  this  were  next  to 
the  break  the  efiect  of  such  displacement  would  he  injurious  (l''i<:;.  2Slj.  When  the 
line  of  fracture  is  ()l)li(|ue  there  is  often  <rreater  difficulty  in  adjustment. 

While  the  simplest  means  by  which  the  fragments  may  l)e  kept  in  position  are  the  best, 
there  should  be  no  hesitation  in  serious  cases  to  resort  to  operative  measures  having  for 
their  j)nrpose  the  insertion  of  wire  sutures  or  their  equivalent.  'l''he.se  are  in.serted  after 
drilling  the  bone  at  suitable  points,  and  are  introduced  with  a  view  to  their  sul)se(juent 
removal,  the  ends  being  left  ])rojecting  in  order  to  facilitate  this.  In  clean  cases,  where 
the  incision  is  made  in  unbroken  skin,  the  ends  may  l)(>  twisted  short  and  turned  in, 
previously  to  closing  the  wound.  Such  operative  treatment  is  rc(|uired  when  there  has 
been  a  double  fracture,  the  central  fragment  being  badly  displaced  by  groups  of  muscles 
which  tend  to  pull  it  downward  and  backward. 

A  dentist  should  be  consulted,  as  he  may  be  able  to  make  a  mold  and  then  construct 
a  plate  or  intcrdenial  splint,  by  which  a  more  perfect  reposition  may  be  efiected. 

Swelling,  emjjhysema,  ecchymosis,  etc.,  may  be  treated  in  the  usual  way.  Irritation  is 
likely  to  provoke  free  secretion  of  saliva;  this  may  be  combated  by  small  doses  of  bella- 
donna. Patients  should  be  fed  by  fluid  or  thin  semiffnid  food,  and  mouth-wa.shes  should 
be  frequently  used. 

FRACTURES  OF  THE  HYOID  BONE. 

The  hyoid  may  be  broken  by  direct  violence,  either  locally  applied  or  by  forcing  the 
head  backward.  Fracture  of  the  bone  itself  is  not  so  serious  as  the  lesions  which  accom- 
pany or  follow  it,  either  hemorrhage  or  inflammation,  with  edema  of  the  larynx,  which 
may  impede  respiration  or  cause  strangulation.  Fracture  produces  difficulty  in  breathing, 
swelling,  and  pain  on  talking.  It  is  doubtful  if  bony  union  is  attained,  but  fibrous 
union  answers  equally  well.  The  treatment  consists  essentially  of  jihvsiological  rest. 
Edema  may  necessitate  tracheotomy,  and  dysphagia  feeding  by  an  esophageal  tube  or 
by  the  rectum.  Should  the  fracture  be  compound,  or  should  a  fragment  be  displaced 
so  as  to  be  detected,  it  may  be  removed  through  suitable  incision. 


FRACTURES  OF  THE  LARYNX. 

This  may  be  fractured  by  injuries  of  the  same  character  as  those  which  fracture  the 
hyoid,  except  that  it  is  more  exposed  to  the  direct  violence  of  a  blow,  as  from  a  baseball. 
In  elderly  people  in  whom  calcification  of  the  laryngeal  cartilages  has  occiuTcd  fractiu'e  is 
more  dangerous  than  in  the  young.  Injuries  which  produce  these  lesions  are  of  a  serious 
nature,  as  prompt  swelling,  either  from  hemorrhage  or  edema,  occurs  and  threatens 
respiration.  For  illustration  a  death  occurred  on  the  baseball  field  within  a  few  minutes 
after  reception  of  a  blow  upon  the  front  of  the  neck  with  laryngeal  fracture;  the  cause 
of  dc'ath  was  suffocation  due  to  swelling,  which  might  have  been  averted  if  tracheotomy 
could  have  been  ])erformed.  In  the  milder  injuries  of  this  kind  much  can  be  done  with 
sprays  of  cocaine  and  adrenalin,  to  quiet  larjugeal  irritation  and  reduce  vascularity. 


FRACTURES  OF  THE  STERNUM  AND  RIBS. 

Fracture  of  the  fiiernum  in  childhood  is  exceedingly  rare.  In  adults  it  may  occur  in 
connection  with  other  injuries  or  as  a  solitary  lesion.  Such  a  fracture,  of  itself,  would 
indicate  in  most  cases  excessive  violence.  It  is  usually  more  or  less  transverse,  the 
periosteum  being  rarely  so  torn  as  to  permit  of  much  escape  of  blood.  Cases  are  recorded 
in  which  it  has  been  broken  in  straining  during  the  act  of  parturition.  It  is  most  com- 
monly injured  by  compressing  and  crushing  injuries. 

Sternal  fractures  are  followed  by  much  pain,  aggravated  by  deep  respiration  and 
made  worse  by  pressure.     Sometimes  displacement  can  be  made  out,  while  crepitus 


492  SURGICAL   AFFECTIONS  OF   THE   TISSUES 

may  be  detected  with  the  stethoscope.     Occasionally  there  is  sufficient  deformity  to 
make  the  injury  apparent  at  a  <^lance. 

Displacement  slujuld  he  reduced  and  apposition  tlien  maintained  by  a  plaster-of 
Paris  jacket  or  other  suitable  a{)paratus.  It  is  advisable  in  some  cases  to  anesthetize 
the  patient  and  to  make  a  sufficient  opening  that  instruments  may  be  used  by  which 
fragments  may  be  lifted  or  pried  into  place.  This  should  be  done  under  aseptic  precau- 
tions. 

Dicifitases  or  sejiarations  of  ribs  or  cartilagr.s'  from  the  sternum  or  from  each  other  have 
essentially  the  dignity  of  fractures,  are  recognized  by  the  same  general  signs,  and  are 
treated  in  the  same  general  way.  A  cartilage  may  snaj)  in  the  young,  and  in  tlic  old, 
when  calcified,  may  break  as  would  a  Ixjne  or  even  a  ])ipe-stem. 

The  ribs  are  usiudly  broken  in  their  lateral  aspects,  but  rarely  between  the  head  and 
angle.  They  may  be  fractured  by  muscle  action  or  by  external  violence,  examples  of 
the  former  being  violent  efforts  at  lifting  or  sneezing.  Violence  may  be  applied  in 
so  many  ways  that  it  is  not  necessary  to  specify  them.  Fractures  may  pertain  to  one  or 
to  several  rifjs  in  proportion  to  the  extent  and  violence  of  the  exciting  injury.  In  some 
crushing  injuries  an  entire  section  of  the  chest  wall  may  be  broken  loose  and  depressed, 
this  corres[)onding  to  a  depressed  fracture  of  the  skull.  Rib  fractures  are  usually  of 
themselves  innocent,  but  may  be  made  serious  by  cmnplirafionn,  as  wlien  the  ])leura  is 
torn,  or  an  intercostal  artery  bleeds  ])rofusely,  or  when  a  jagged  fragment  of  bone  first 
scratches  and  then  perforates  a  lung.  This  will  lead  first  to  the  outpour  of  blood  and 
then  of  jjleuritic  fluid,  by  which  in  a  short  time  the  lung  will  be  separated  from  the  chest 
wall.  Should  infection  occur  through  the  injured  lung,  /.  r.,  entrance  of  germ-ladened 
air,  then  emj^yema  may  seriously  comjilicate  matters  and  later  necessitate  operation. 
Even  the  heart  has  Ijeen  injured,  in  several  reported  cases,  by  projecting  fragments  of 
bone.  Gunshot  fractures  of  the  thf)racic  wall  im})ly  those  features  pertaining  to  every 
compound  fracture,  plus  the  injury  possibly  done  to  the  lungs,  heart,  or  mediastinal 
contents,  such  as  hemothorax  or  pneumothorax. 

Tlie  first  and  second  ribs  are  so  ])rotected  and  the  eleventh  and  twelfth  so  movable 
that  by  far  the  greater  proportion  of  rib  fractures  j)ertain  to  the  eight  intervening  ribs. 

Symptoms. — These  are  often  vague,  when  but  a  single  rib  has  been  cracked 
through  and  not  displaced,  and  comprise  ])ain  on  pressure,  as  well  as  that  provoked  by 
deep  breathing,  coughing,  and  certain  other  movements.  Should  this  pain  be  limited, 
or  constant  and  made  worse  by  pressure,  fracture  of  the  rib  may  be  suspected.  If 
auscultation  crepitus  can  be  heard,  diagnosis  is  at  once  made.  When  abnormal  mobility 
is  unmistakable,  or  when  by  any  means  crepitus  is  elicited,  the  signs  are  positive. 
Sometimes  the  patient  himself  will  recognize  crepitus.  This  may  be  learned  either  by 
auscultation  or  by  pressure  with  the  flat  hand  over  the  affected  area.  Emph ijsrma  is  an 
unmistakable  evidence  of  fracture  with  perforation,  while  tlie  signs  of  the  ))resence  of 
fluid  in  the  chest  cavity  will  also  indicate  fracture. 

Treatment. — Fracture  of  one  or  two  ribs  with  displacement  is  ordinarily  a  matter 
of  trivial  import,  the  adjoining  ribs  acting  as  splints.  It  necessitates  |)ractically  nothing 
but  physiological  rest,  which  may  be  best  afforded  by  keej)ing  the  j)atient  in  bed,  with 
firm  comjyresslon  around  the  chest,  made  either  with  a  binder  of  strong  cloth  or  a  broad 
piece  of  adhesive  })laster  (-arried  nearly  around  the  body,  or  in  more  aggravated  ca.ses 
by  a  plaster-of-Paris  jacket.  In  thin  individuals  the  formation  of  callus  can  be  recog- 
nized by  the  sense  of  touch.  So  Sfjon  as  this  is  fairly  formed  displacement  is  less  likt'ly 
to  occur  and  uncomfortable  compression  may  be  relaxed.  Should  ther<>  be  external 
angular  displac'cment  this  may  be  corrected  by  pressure.  A  projecting  fragment  which 
threatens  to  j)erf(jrate  should  be  cut  away  with  bone  forceps  through  a  small  incision, 
taking  pains  to  permit  as  little  air  as  possible  to  enter.  If  there  be  a  fmumatir  piiritnio- 
tfiorax  the  air  should  be  removed  with  an  aspirating  needle.  When  it  is  evident  that 
there  is  serious  injury  to  the  chest  wall  and  that  air  has  already  separated  the  lung  from 
it  (traumatic  atelectasis)  the  parts  should  be  freely  exi)osed,  to  permit  the  rounding  off 
of  bone  ends,  the  seizure  of  intercostal  vessels,  the  cleansing  out  of  the  ])leural  cavity, 
with  perhaps  later  wiring  of  fragments  or  else  their  complete  removal  and  closure  of 
the  external  wound  with  or  without  drainage,  as  may  be  rcfjuired.  If  blood  or  air  has 
already  escaped  into  the  pleural  cavity  the  blood  should  Ix-  speedily  removed.  The  same 
plan  is  advisal)le  in  fractures  of  the  cartilages.  Sedatives  to  check  cough,  e.  g.,  heroine, 
are  also  indicated. 


FUACTLIIES  OF   THE  CLAVICLE  493 


FRACTURES  OF  THE  CLAVICLE. 


'V\i('  rlaviclc  and  tin-  nuiiiis  arc  llic  twD  hones  most  i'n'{|ucnily  Itrokcii,  the  former 
more  often  in  tlie  yomi«;,  tlu-  latter  in  tlie  elderly;  the  elaviele  yields  hoth  to  direct  violence, 
as  hy  hlows  on  the  shoulder,  and  that  which  is  transmitted  thron<^h  the  arm. from  the 
elhow  or  hand.  For  convenience  of  description  the  bone  is  divided  into  thirds,  the  most 
common  location  for  fracture  being  near  the  junction  of  the  middle  and  outer  third. 
Save  for  ej)iphyseal  se])arations  the  extremities  of  the  bone  are  seldom  broken.  In  spite 
of  its  subcutaneous  position  and  its  proximity  to  large  vessels,  comj)ound  injuries  or  other 
complications  are  ({uite  uncommon. 

The  clavicle  is  the  brace  which  kee|)S  the  shoulder  proper  from  falling  ujton  and 
around  the  thorax.  Con.srtjurtiflij  wlirn  if  As"  hrokni  flir  .shoulder  lends  to  drop  downirard, 
forit'drd,  and  inward,  except  in  a  green-stick  fracture,  while  even  then  there  may  be  some 
displacement  in  these  directions.  Deformity  is  usually  easily  recognized,  one  or  other 
fragment  projecting  beneath  the  skin  in  such  a  way  as  to  be  easily  f)alpated.  There  is 
enough  spasm  of  cervical  muscles  to  draw  the  head  over  toward  the  afi'ected  side,  while 
there  is  loss  of  function  in  the  afi'ected  arm.  Pain  is  made  worse  by  pressing  the  shoulder 
inward  as  well  as  by  moving  it  in  any  direction. 

In  young  children  the  bone  is  often  broken  with  a  niininuim  of  displacement.  Frac- 
ture of  both  clavicles  is  not  so  very  rare.  Trouble  may  occiu'  later  in  the  course  of  the 
case  fnnn  ])ressure  of  exuberant  callus  upon  nerves  and  even  vessels.  This  is  to  be 
prevented  by  foresight  and  by  careful  attention  to  maintenance  of  parts  in  pro])er  position. 

Treatment. — The  multiplicity  of  dressings  which  have  been  suggested  for  frac- 
tures of  the  clavicle  attest  the  fact  that  so  long  as  primary  indications  are  observed  the 
treatment  can  be  made  very  simple.  These  indications  are  to  keep  the  shoulder  upward, 
outward,  and  backward,  as  it  tends  to  drop  in  the  opposite  way.  The  action  of  three 
muscles  is  of  great  importance  in  considering  the  proper  treatment  of  these  cases,  i.  e., 
the  sternomastoid  ami  the  trapezius,  because  they  tend  to  pull  fragments  upward,  and 
the  pectoralis  major  because  advantage  can  be  taken  of  its  arrangement  to  overcome 
upwartl  displacement.  It  was  ^Nloore,  of  Rochester,  who  taught  many  years  in  BuHalo, 
who  showed  how  this  could  be  done.  The  fibers  of  the  great  pectoral  whicli  arise 
highest,  i.  c.,  from  the  clavicle,  are  those  which  are  inserted  lowest  along  the  bicijiital 
groove  of  the  humerus,  because  of  the  semi-revolution  made  by  the  tendon  of  this  muscle 
as  it  passes  to  its  insertion.  By  putting  the  arm  in  such  a  position  that  these  fibers  are 
pulled  upon  the  operator  may  counteract  the  ujjward  pull  of  the  other  muscles  just 
mentionetl.  This  is  the  underlying  feature  of  ^Moore's  suggestion;  to  force  the  elbow  far 
backward,  into  a  position  which  is  for  the  time  being  uncomfortable,  in  order  thus  to 
pull  down  fragments  which  jut  up  beneath  the  skin.  Any  dressing  which  j)ermits  this 
position  to  be  maintained  will  be  equally  serviceable.  INIoore  suggests  for  this  jnirj)ose 
what  he  calls  a  double  figure-of-eight,  which  is  shown  in  Figs.  284  and  2S5.  It  is  put  on 
as  follows:  A  .strip  of  cloth,  sheeting,  or  anything  of  the  kind,  about  two  yards  hi  length 
and  folded  sufficiently  to  make  a  strong  strip  eight  hiches  wide,  is  held  near  its  middle 
over  the  surgeon's  hand.  This  hand  is  placed  beneath  the  elbow  of  the  injured  side, 
.so  that  the  strip  crosses  the  under  surface  of  the  flexed  forearm  at  the  elbow.  One  end, 
which  should  be  the  longer,  lying  to  the  inner  side,  is  j)assed  uj)ward  and  in  front  of  the 
arm,  carried  over  the  shoulder  across  the  back  and  under  the  opposite  axilla,  then  over 
in  front  of  the  sound  shoulder,  meeting  on  the  back  the  other  end,  which  is  carried  up 
first  over  the  outside  of  the  forearm,  then  behind  the  shoulder  and  across  the  spine.  This 
bandage  should  be  pulled  tightly,  while  an  assistant  holds  the  elbow  as  far  backward  and 
ujnvard  as  the  patient  can  tolerate  it,  as  the  more  the  position  is  exaggerated  the  more 
are  the  clavicular  fibers  of  the  muscle  pulled  upon  and  the  better  are  the  fragments  held 
in  place.  This  dressing  not  only  meets  the  three  primary  indications  laid  down,  but  gives 
the  added  advantage  just  described.  By  it  the  shoulders  are  drawn  backward  and  fixed 
to  each  other.  The  elhow  should  be  lifted  as  the  dressing  is  applied,  st)  as  to  lift  the 
shoulder.  Most  of  the  cloth  materials  used  for  such  a  dressing  are  more  or  less  elastic, 
and  it  may  need  to  be  tightened  once  or  twice  a  day  during  the  time  that  it  is  worn. 
After  a  few  days,  when  consolidation  should  have  occurred,  it  may  be  changed  for  some 
other  less  irksome  form  of  dressing.  The  hand  should  be  supported  in  a  sling.  This 
dressing  is  useful  in  dislocations  of  the  clavicle,  especially  of  its  outer  end,  and  in  every 


494 


SURGICAL  AFFECTIONS  OF  THE  TISSUES 


kind  of  injury  in  which  the  indication  is  to  hold  the  shoulder  upward  and  backward. 
In  simple  cases  without  much  displacement  the  primary  indications  may  be  more 
simply  met  by  a  dressing  of  adhesive  plaster,  known  in  the  East  as  Sayre's  and  in  the  West 
as  Freer's.  It  consists  of  two  strips  of  plaster  of  about  the  width  of  the  arm  itself.  One 
of  them  is  wound  around  the  upper  end  of  the  arm,  close  to  the  shoulder,  in  such  a  way 
that,  as  it  is  passed  around  the  back  and  brought  over  the  chest,  the  arm  and  shoulder 
are  pulled  backward.  The  other  strip  passes  from  beneath  the  elbow  of  the  injured 
side  obliquely  up  and  over  the  opposite  shoulder.  When  it  is  applied  the  elbow  should 
be  finnh/  lifted.  After  the  completion  of  either  of  these  dressings  the  injured  shoulder 
should  appear  at  least  one  inch  higher  than  the  well  one.  Should  the  patient's  arm  and 
chest  be  hairy  they  should  be  shaved  before  the  application  of  the  plaster  strips.  Like 
other  material,  plaster  will  stretch  and  slip,  and  these,  like  other  dressings,  should  be 
readjusted  every  day  or  two,  for  the  shoulder  should  be  kept  elevated  for  at  least  a  week. 


Fig.  284 


Fig.  285 


Moore's  apparatus  (back  view). 


Moore's  apparatus  (front  view). 


When  the  case  is  complicated  by  other  injuries  necessitating  confinement  in  bed  it  is 
sufficient  to  keep  the  patient  flat  upon  the  back  and  without  a  pillow.  In  this  j)osition 
the  shoulder  falls  naturally  in  the  direction  desired,  and  perhaps  no  other  attention 
wall  be  required.  Many  other  methods  are  combined  with  a  figure-of-eight  bandage, 
crossing  the  back  and  forming  a  loop  over  each  shoulder,  so  as  to  keep  it  from  dropping 
forward. 

While  the  results  of  treatment  are  nearly  always  good,  if  one  is  insistent  upon  a  mini- 
mum of  deformity,  confinement  upon  the  back  on  a  hard  bed  is  the  surest  way  to  obtain 
satisfactory  results.  Cases  in  which  there  is  little  or  no  tendency  to  deformity  need  only 
the  simplest  support  by  which  rest  may  be  ensured. 

Epiphyseal  separations  are  to  be  treated  as  fractures. 


FRACTURES  OF  THE  SCAPULA. 

The  most  frequent  fracture  of  the  scapula  is  that  of  the  aeromion;  this  is  usually  the 
result  of  direct  violence,  such  as  a  fall  upon  the  tip  of  the  shoulder.  Detachment  of  this 
fragment  permits  a  peculiar  flattening  of  the  shoulder,  but  without  dislocation.  The 
fragment  can  be  easily  felt,  while  the  deltoid  is  displaced  and  its  rounded  contour  lost. 
Treatment  consists  solely  in  forcing  the  arm  upward,  by  dressings  applied  beneath  the 
elbow,  thus  lifting  the  fragment  into  its  place;  fibrous  union  occurring  here  much  more 
often  than  osseous,  the  latter  is  possible  only  in  case  a  good  apposition  be  maintained. 


FR.U'Tl'RHS  OF  Till-:  uiMFncs  495 

AliV  form  of  drcssiiiji;,  tlicii,  hy  wliicli  tlic  ('ll)o\v  is  crowded  M|)\\ard  and  rest  niaiiitaiiicd 
will  he  appinpriatc. 

Tlu'  suniintl  iiccic  is  occasioiially  detached,  soiiictiiiics  witli  and  soinetiines  without 
the  coracoid  process.  As  the  humerus  is  attached  to  it  by  tiie  capsular  li<i;ameiit  the  arm 
drops  with  the  i"raj;uuMit  when  the  patient  is  in  the  uprii^ht  position,  and  the  elbow 
will  i)e  found  lower  than  that  of  the  injured  side.  The  arm  is  unduly  mobile,  and  the 
fra'nni'iU  can  usually  be  seized  and  crepitus  obtained  within  the  axilla.  Here  it  is  neces- 
sary to  hold  the  arm  up,  as  it  controls  the  jjosilion  of  the  frajinicnt.  It  is  usually  sufficient 
to  lift  the  elbow  up  and  bind  the  arm  Hrnily  to  the  side,  the  scapula  bein<f  immobilized 
by  broail  straps  of  adhesive  i)lastcr. 

The  rorarnid  prorr.s.s  is  occasioiudly  detached,  usually  by  muscular  violence,  i.  e.,  it 
is  ])ulled  off  by  the  coracobrachialis  and  the  coracoid  head  of  the  biceps  which  ari.se  from 
it.  'I'he  injury  is  reco<2;nized  by  failure  to  detect  the  ])rocess  in  its  j)r(jj)er  place,  ;ind 
usuallv  bv  discovery  of  the  fragment  at  a  ])oint  below  its  normal  position,  to  which  it 
has  been  drawn  out  by  the  nniscles  arisino;  from  it.  Litfamentous  union  can  be  secured 
bv  relaxing  these  nmscles,  which  is  done  by  jjlacing  the  hand  over  the  oj)j)(jsite  shoulder 
aiid  dressing  the  arm  firmly  against  the  chest.  I  have  seen  paralysis  of  the  arm  result 
from  excessive  callus  after  fracture  of  the  coracoid. 

The  spine,  body,  and  the  angles  of  the  scapula  are  occasionally  broken  by  .severe 
violence.  In  the  aged  comminution  may  occur.  Crepitus  can  be  nearly  always  obtained. 
It  may  be  necessary  to  distinguish  the  scapular  fracture  from  one  of  the  ribs  beneath  it. 
The  treatment  consists  in  simply  fixing  the  should(>r-l)ladc  upon  the  chest,  to  which  it 
is  naturally  adaptctl,  by  firm  bandages,  which  shall  immobilize  not  only  it  but  the  arm 
as  well. 

FRACTURES  OF  THE  HUMERUS. 

At  the  upper  end  of  the  humerus  we  deal  with  fracture  of  the  processes,  i.  e.,  the  tuber- 
osities, which  may  be  torn  off  by  violent  action  of  the  muscles  therein  inserted ;  of  the 
aiuiiomical  neck,  which  is  rare  and  occurs  most  often  in  the  aged;  of  the  surgical  neck, 
which  is  the  most  common;  or,  in  the  young,  epiphyseal  separation,  which  is  the  equiva- 
lent of  the  last  named.  Separation  of  the  tuberosities  is  diagnosticated  mainly  by 
exclusion,  possibly  by  .I'-rays.  The  anatomical  neck  lies  Avithin  the  capsule,  and  should 
the  head  be  thus  detached  it  might  remain  as  a  foreign  body  in  the  joint,  having  no  means 
of  securing  nutrition.  Fractures  of  the  head  of  the  bone  are  not  classical  and  are  usually 
the  result  of  gunshot  injuries  or  extreme  violence.  In  all  of  these  injuries  there  will 
be  swelling,  loss  of  function,  wdiile  crepitus  is  sometimes  obtained,  but  is  very  difficult 
to  locate,  even  under  an  anesthetic.     The  diagnosis  is  to  be  made  mostly  by  exclusion. 

The  surgical  neck  is  the  most  frecpiently  broken;  the  line  of  fracture  passing  l)elow 
the  tuberosities  and  above  the  muscles  inserted  along  the  bicipital  groove.  Therefore 
the  pectoralis  and  the  latissimus  muscles  will  both  conspire  to  pull  the  upper  end  of  the 
shaft  toward  the  thorax  to  such  an  extent  that  it  can  be  felt  in  the  axilla.  This  gives 
its  axis  a  different  direction,  while  all  the  muscles  extending  from  the  shoulder  to  the 
forearm  will  tend  to  produce  shortening.  Deformity  is  usually  distinct,  crej^titus  is  easily 
obtained,  and  undue  mobility  is  well  marked.  The  head  of  the  bone  can  be  detected  in 
its  proper  place  beneath  the  deltoid,  but  does  not  rotate  with  the  shaft.  In  rare  instances 
a  certain  amount  of  impaction  may  make  this  evidence  of  fracture  obscure.  Epiphyseal 
separation  will  give  the  same  signs  and  symptoms. 

Treatment. — The  primary  indication  here  is  to  overcome  muscle  jnill  by  traction 
in  a  direction  toward  the  crest  of  the  pelvis  of  the  same  side.  At  the  same  time,  with  a 
certain  degree  of  coaxing  of  the  upper  end  of  the  shaft  outward  and  a  little  forward, 
it  may  be  possible  to  so  re-a])ply  broken  surfaces  to  each  other,  and  so  affix  the  arm  to 
the  thorax,  as  to  be  effective.  When  serious  difficulty,  however,  is  encountered  the  writer 
advises  traction,  applied  to  the  arm  alone,  if  the  patient  be  able  to  be  upright,  or  to  the 
arm  and  forearm,  if  he  be  confined  in  bed.  It  will  take  considerable  stretching  to  over- 
come the  coml)ined  action  of  all  the  muscles  which  tend  to  produce  displacement.  Along 
with  such  treatment  a  coaptation  splint  should  be  applied,  the  best  being  that  which  can 
be  carefully  molded  to  the  parts  and  adapted  to  their  needs.  For  this  purpose  a  molded 
plaster-of-Paris  splint  is  preferable  to  one  of  metal  made  to  some  standard  size.  In 
the  dressing  it  is  necessary  to  include  not  only  the  shoulder  and  arm  but  also  the  forearm, 


496 


SURGICAL   AFFECTIONS  OF   THE   TISSlfES 


otherwise  the  priiic-iplc  of  physiological  rest  would  iK)t  be  enforced.  Fig.  28G  illustrates 
the  coinmou  tendency  to  dis{)lacenient  in  these  injuries. 

Fracture  of  the  surgical  neck  is  occasionally  combined  with  dislocation  of  the  head 
of  the  humerus,  by  which  such  an  injury  is  seriously  complicated.  Reduction  may  be 
attempted  by  manipulation.  Until  recently  it  was  generally  advised  to  wait  for  a  week 
or  ten  days,  and  until  consolidation  had  occurred,  and  then  to  make  the  attempt  at 
reduction ;  but  Porter  and  jNlcBurney  have  shown  that  it  is  advisable  to  cut  down  upon 
the  dislocated  uj^per  fragment,  and,  fixing  it  with  forceps  or  with  an  instrument  shaped 
like  a  corkscrew  or  hook,  to  force  it  back  into  place  again.  If  this  be  done  untler  the 
strictest  precautions  it  lends  no  serious  features  to  the  case,  while,  in  most  respects, 
such  a  procedure  would  greatly  sim|)lify  it,  the  wound  being  closed  with  or  without 
drainage,  and  the  usual  fracture  dressing  being  applied. 

In  cases  of  old  fracture  and  dislocation  the  head  of  the  bone  should  be  exsected,  the 
functional  result  thus  obtained  being  excellent. 

Epiphijseal  separation  has  been  too  often  miMalcen  for  dislocation.  Fig.  287,  from 
INIoore,  shows  how  the  periosteum  is  not  necessarily  entirely  detached,  but  is  stri}>ped 


Fig.  286 


Fig.  287 


Fracture  of  the  surgical  neck  of  humerus.     (HofTa.)  Separation  of  the  upper  epiphysis  of  the  humerus;  dis- 

placement forward  of  tlie  lower  fragment.    (Moore.) 

up  to  forni  a  hinge,  the  fragment  displaced  forward,  and  its  outer  aspect  often  turned 
upward.  This  makes  traction  in  an  outward  direction  an  essential  feature  of  the  rc- 
jilacement  of  the  fractured  surfaces,  the  manijjulation  being  combined  with  fixation  of 
the  fragment  so  far  as  it  can  be  seized  through  the  axilla.  If  the  ejiiphvsis  is  properly 
sli{)ped  over  upon  the  end  of  the  humerus  the  case  assumes  ordinary  features,  and  is  to 
be  dressed  as  usual. 

The  shaft  of  the  bone  is  frequently  broken,  lines  of  fracture  running  in  all  directions 
ami  occurring  at  all  levels.  A  variety  of  displacement  may  take  place.  The  evidences 
of  fracture  are  usually  recognizable  and  diagnosis  is  not  difficult.  The  brachial  artery 
and  the  musculos])iral  nerve  are  occasionally  involved,  either  in  callus  or  by  primary 
injury  from  a  spicule  of  bone.  These  fractures  are  more  liable  to  delav  in  union  or  even 
to  non-union  than  almost  any  others.  These  occur  often  without  evident  cause,  while 
more  or  less  absorption  of  bone  has  been  known,  by  which  complications  are  produced. 

In  the  treatment  of  fractures  of  the  shaft  posture  is  necessarv  to  olxserve,  the  fragments 
not  only  being  held  in  position,  but  the  axis  of  the  bone  being  maintained.  An  external 
splint,  extending  up  to  and  rounded  over  the  shoulder,  and  an  internal  splint  molded  to 


Fh'.U-rrix'h'S  OF   TJIh'  IIUMERVH 


497 


the  iiiiKT  side  of  (he  arm,  takiii<j  in  (lu-  dhow  and  I'orcariii,  and  jjlaccd  al  a  rifflit  angle, 
and  tlion  tho  iniinohilization  of  the  entir(>  arm  hy  i(s  fixation  to  the  body  will  pve  the 
best  result.  The  writer  i)rel"ers  to  make  these  of  |)laster  of  Paris,  hy  mdldiriff  stri|)s  of 
snr«i;e()ns'  lint  sopped  in  plaster  eream,  and  maintainin<r  the  limh  in  the  desired  position 
while  they  harden.  Should  comminution  he  extreme,  or  shorteiiin*,' difHcult  to  overcoir)e, 
a  few  days'  eonfinemenl  in  bed,  with  traction  upon  the  forearm,  either  extended  or 
included  in  the  above  dressiiifj,  by  the  usual  method,  with  w(>i<riit  and  |)ulley,  will  jjive 
the  l)est  result.  So  soon  as  callus  has  bound  the  ends  of  the  bone  tojrcther  the  |)atient 
may  be  released  from  bed  and  the  arm  left  in  the  rit;lit-ano;lc  position,  in  |)laster,  as  above. 
Or  over  such  a  s])lint  as  has  been  described,  made  of  molded  j)laster,  may  be  hung 
by  a  bamlajre  at  the  elbow  sufHcient  weijjht  (a  baj;  containing  shot)  to  maintain  con.stant 
traction  upon  the  lower  fragment,  while  the  patient  is  in  the  Uj)right  position,  and  to 
influence  for  good  any  overlapping  or  displacement  of  any  kind  during  the  critical  period 
when  the  bone  ends  are  being  united  by  callus. 

The  (■pir()it(li//rs-  are  occasionally  chipped  off  from  the  condyles,  the  internal  beingthe 
more  fre(|uently  injured.  These  detachments  are  extra-articular  and  are  relatively 
unimportant,  the  fragments  being  kej)!  from  displacement  by  their  fil)rous  investments. 
If  such  an  injury  should  be  compound  any  fragment  comjjietely  loosened  should  be 
removed.  It  is  sufficient  to  dress  such  an  injured  elbow  with  cold  wet  compresses  in  the 
flexed  position.     Swpracondyloid  fracture,  or  its  equivalent  in  the  young  (an  epiphyseal 


Fig.  288 


Supracondyloid  fracture  or  epiphyseal  separation.     (Lejars.) 

separation)  are  somewhat  similar,  the  latter  occurring  nearer  to  the  articulation  than 
the  former.  In  each  of  these  injuries  the  arm  is  flexed  and  shortened,  the  fragment 
lying  usually  in  front  of  the  shaft  and  the  olecranon  protruding  posteriorly.  The  more 
the  arm  is  extended  the  more  prominent  the  deformity,  while  by  flexion  it  is  much 
diminished.  Hence  the  advantage  of  dressing  it  in  the  position  of  overflexion  sometimes 
called  Jones'  position.^  Injury  to  the  vessels  at  the  bend  of  the  elbow  may  occur  in 
these  fractures.  If  not  dressed  in  this  position  the  elbow  should  be  put  at  a  right  angle, 
while  a  weight  is  slung  over  the  elbow,  as  already  mentioned  above.  Joint  function 
will  be  greatly  hampered  if  complete  extension  and  reduction  be  not  effected  (Fig.  288). 
In  considering  fractures  about  the  elbow^  no  greater  aid  can  be  obtained  than  by  a 
study  of  the  relations  of  the  three  prominent  or  salient  anatomical  points  to  each  other. 
These  are  the  internal  and  ex-ternal  condyles  and  the  tip  of  the  olecranon.  They  afford 
a  key  to  nearly  all  the  displacements  which  may  be  produced  after  fracture  or  even  dis- 
location, and  the  only  conditions  under  which  they  cannot  be  made  available  are  those 
where  there  has  been  tremendous  swelling  before  the  case  is  seen  by  the  surgeon.  A 
fourth  prominent  feature,  the  head  of  the  radius,  is  also  of  much  assistance,  but  is  less 
often  available,  especially  in  muscular  or  swollen  forearms.  When  a  normal  arm  is  flexed 
to  a  right  angle  and  viewed  from  behind  the  three  points  above  mentioned  constitute 
the  angles  of  a  nearly  equilateral  triangle.     When  seen  from  the  side  the  point  of  the 

»  In.  supracondyloid  fractures  there  is  almost  always  posterior  and  upi)er  displacement  of  the  lower  fragment. 
WTien  the  parts  are  found  in  this  position,  and  especially  when  the  skiagram  shows  the  line  of  fracture  in  the 
usual  location  (from  above  downward  and  forward),  the  fracture  should  be  treated  by  flexion  of  the  arm  in  the 
so-called  Jones  position.  By  this  the  fragment  is  best  restored  to  its  proper  position,  being  pried  there  by  the 
muscular  cushions  of  the  forearm  and  arm.  (Ashhurst.) 
32 


498 


SURGICAL  AFFECTIONS  OF   THE  TISSUES 


olecranon  is  just  helow  the  external  condyle  and  in  the  same  {)lane;  wlicn  the  arm 
is  completely  extended  and  viewed  from  behind  these  three  points  are  practically  in  the 
same  line.  By  a  careful  study  of  the  variations  from  the  above  relations  which  are 
produced  by  injury  diagnosis  can  be  greatly  facilitated. 


Fig.  289 


Fig.  290 


T-fracture  of  liumerus.      (Helferich.) 


T-shaped  fracture  of  lower  epiphysis  of  humerus. 


The  condyles  may  each  be  broken  loose  by  itself,  or  they  may  be  both  broken  at  the 
same  time.  Fig.  291  illustrates  what  is  known  sometimes  as  a  T-fracture,  where  the 
lower  extremity  is  not  only  separated  from  the  shaft  but  is  broken  into  halves;  such 


Fig.  291 


Fig.  292 


Intracondyloid   fracture   of    humerus.     Almost   perfect 
functional  result.      (Parmenter.) 


Gunstock  deformity  after  fracture  of  internal 
condyle,  illustrating  neglect  of  precautions 
mentioned  in  text.      (Beatson.) 


fractures  imply  great  violence,  and  are  particularly  difficult  to  treat.  Should  the  con- 
dyles be  detached  in  such  a  way  as  to  leave  the  lower  end  of  the  humerus  in  pointed 
wedge  shape  it  may  perforate  or  do  much  harm  to  the  soft  parts  (Fig.  290).     In  these 


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FRACTURES  OF   THE  JIlMhh'l'S 


499 


iiil('rc(>>i(li/l(ii(l  IriH-turcs  tlic  writer  would  advise  drcssiiij^  in  (lie  extended  position,  uitiia 
molded  jjlaster-ol'-Piiris  anterior  s|)lin(  and  a  <fentle  de<free  of  traction,  the  |)atient 
l)ein<;  eonlined  to  l)ed  for  a  few  days.  In  applying;  such  a  splint  the  sur>:;e()n  should 
give  extreme  care  to  holdiiifij  the  fraf^ments  in  |)ropt'r  position  while  the  splint  hardens, 
and  in  preserving  the  "carryinjj  function"  (Fi<i;  2',)1).     (See  below.) 

The  c.rtcrnal  condi/lc  when  fractured  is  displaced  by  muscle  pull;  when  the  internal 
roixli/lr  is  broken  the  tendency  is  to  backward  (lisplacement  of  the  fra<jinent  and  widening 
of  the  joint. 

Fmctinr  of  the  intcrual  rondi/lr  is  often  an  exceedingly  serious  matter,  because  it  is 
so  often  associated  with  more  or  less  dislocation  and  with  permanent  deformity,  as  a 
result  of  inattention  to  the  anatomical  relations  of  the  bones.  The  ulna  sustains  peculiar 
relations  to  the  inner  condyle;  at  its  Uj)j)er  end  it  is  wra])j)ed  around  the  process,  holding 
it  much  as  a  monkey-wrench  can  be  matle  to  seize  an  ordinary  object,  and  being  heJd  to 
it  by  the  internal  Uiteral  ligament.  Herein  lies  the  secret  of  success  or  failure  in  treat- 
ment, for  the  fragment,  being  so  fixed  to  the  ulna,  should  be  controlled  by  it,  i.  e.,  the  posi- 
tion  of  the  ulna  is  the  most  essential  feature  of  the  treatment  of  the  fracture.  The  forearm 
makes  an  angle  with  the  arm  ])r<)per,  by  which  a  considcrabU*  degree  of  divergence  is 
maintain(>d.  This  has  been  alluded  to  by  AUis  and  others  as  the  "carrying  function." 
It  r;\u  on/i/  he  r.sflmatrd  in  ihr  crfnidrd  po.s-ifiou,  ntid  be  nrciirafrh/  jiidgrd  hij  rompari.s-on 
trlfli  flic  othrr  arm.  If  the  arm  be  flexed  all  j)ossibility  of  estimating  it  is  lost ;  there- 
fore to  dress  suck  a  fracture  in  the  right-angle  position  is  bad  practice  (Fig.  292).     The 

Fig.  293 


Fracture  of  external  condyle.     (Lejars.) 


only  position  in  which  the  carrying  function  can  be  preserved  is  the  extended,  or  one  a 
little  short  of  it  for  the  ])urpose  of  comfort.  If  the  ulna  is  put  in  the  proper  position 
the  fragment  will  be  held  equally  so  or  as  nearly  as  possible  (Fig.  294). 

In  the  treatment  of  fractures  of  the  inner  condyk  the  patient,  if  a  child,  should  be  anes- 
thetizeil,  the  upper  jmrt  of  the  body  exposed,  both  arms  extended,  and  the  injured  arm 
made  to  correspond  exactly  with  the  other  so  far  as  concerns  the  angle  of  divergence. 
Upon  the  arm  so  placed  an  anterior  plaster-of-Paris  molded  splint  should  be  carefully 
applied,  extending  from  axilla  to  wrist,  and  then  lightly  secured  with  bandages,  the  surgeon 
holding  the  arm  in  the  proper  position  imtil  the  plaster  is  suffieieuthj  hardened  to  permit 
no  displacement.  The  arm  should  be  kept  in  this  position  for  at  least  ten  days,  after 
which  the  splint  may  be  removed  and  gentle  motion  ])ractised.  It  may  then  be  reapplied 
for  two  or  three  days,  after  which  we  may  Ijegin  to  flex  the  arm,  applying  either  a  new 
plaster  splint  or  any  other  that  seems  suitable,  and  in  such  a  way  that  at  the  expiration 
of  another  week  the  forearm  is  brought  to  a  comfortable  position  of  right  angle,  where 
it  may  be  maintained  with  a  light  splint  or  simply  with  a  sling,  according  to  the  age  and 
tractability  of  the  patient.  F'ig.  294  illustrates  the  splint  and  the  position,  which  is  the 
only  one  in  which  the  surgeon  maintains  his  own  security  and  can  properly  estimate  the 
carrying  function.  The  mistake  has  been  in  dressing  this  fracture,  like  most  others  at 
the  elbow,  in  the  right-angle  position. 

In  fractures  of  the  outer  condyle  these  anatomical  conditions  do  not  prevail,  and  these 
may  be  dressed  in  whatever  position  best  meets  the  indications  of  comfort  and  accurate 
reduction.     Inter  condyloid  fractures  are  subject  to  the  same  conditions  as  those  of  the 


r^K) 


SURGICAL   AFFKCTinSS  OF   THE   TISSUES 


internal  condyle,  plus  others  which  arc  added,  and  should  therefore  \>e  dressed  in  the 
same  jx)xitwn. 

Epiphyseal  separation-'^,  as  well  as  supracond} lend  fractures,  should  be  dressed  either 
with  traction  in  a  somewhat  extended  position,  or  in  that  of  extreme  flexion,  called  also 
Jones'  position,  according  as  the  fra^rnients  may  best  fall  into  place  in  one  or  the  other. 

The  writer  has  for  his  own  purposes  discarded  almost  all  other  splint  material  for  the 
upper  extremity  in  favor  of  the  plaster-of-Paris  splints  already  mentioned.      Figs.  294, 

Fig.  294  ^ 


Molded  plaster  splint  for  entire  arm.  and  especially  for  fractures  of  the  internal  condyle,  showing  proper 

position  for  dressing  same. 

295  and  296,  may  illustrate  the  method  and  purpose  of  their  use;  many  other  modifica- 
tions can  lie  devised  as  may  be  demanded.  It  is  customary",  after  such  a  splint  is  hard  and 
firm,  to  remove  it  for  a  few  moments,  trim  it,  smooth  the  edges,  line  it  with  a  fresh  piece 
of  soft  lint  or  its  equivalent,  and  then  reapply  it  to  the  arm  with  a  roller  or  starch  band- 
age, the  arm  meantime  not  having  been  disturbed,  but  maintained  in  its  proper  position, 
and  being  restored  to  the  splint  and  made  to  take  its  previous  position.     Such  a  splint 


Fig 


295 


Fig.  296 


Molded  plaster  splint  for  forearm. 

fits  accurately  the  indi%-idual  for  whom  it  is  made. 
It  is  worthless  for  anyone  else;  nor  should  it  e^ver 
be  used  again,  the  intent  being  to  mold  a  splint  for 
each  case  ichich  shall  serve  its  individual  purpose 
and  none  other. 

Too  early  passive  motion  with  the  intent  to  re- 
gain mobility  Is  inadvisable  and  often  dangerous. 
.\  fractured  joint  should  be  kept  at  rest  until  the 
hone  Ls  consolidated.  If  callus  be  thus  reduced  to 
the  minimum,  and  consolidation  be  undisturbed, 
the  patient  will,  in  due  time,  recover  motion,  often 
to  the  extreme  limit.  In  fractures  of  the  humerus  five  or  six  weeks  are  required 
for  the  attainment  of  perfect  union.  In  spite  of  precaution  callus  formation  will 
sometimes  be  excessive  and  interfere  with  motion.  Absorjition  of  exuberant 
material  then  is  most  desirable.  This  can  be  encouraged  by  constant  but  gentle 
pressure  Thus  when  callus  in  front  of  the  lower  articular  surface  of  the  humerus 
obstructs  the  coronoid  process  of  the  ulna  and  prevents  complete  flexion  the  patient 
should  wear  for  several  hours  at  a  time  an  elastic  sling,  made  with  a  piece  of  Martin 


Molded  plaster  splint  for  arm. 


FRACTURES  OF   TIIF  FOREARM;   THE   VENA 


501 


nihhor  handafrr  sufnciontly  loner  to  make  a  loop  around  the  neck,  into  which  the  hand 
is  passed.  It  should  he  made  so  tifjht  as  to  exert  gentle  hut  constant  pressure;  the 
result  of  this  will  be  to  cause  rapid  disappearance  of  the  callus  upon  which  it  is  made. 
Conditions  may  he  reversed  when  necessary,  and  the  j)atient  may  have  some  weight 
affixed  to  the  hand  by  which,  when  the  arm  hangs  down,  reversed  pressure  shall  he 
made,  or  when  desirable  these  measures  may  be  alternated,  (^)ne  should  not,  how- 
ever, l)e  temj)ted  into  resorting  to  them  too  early,  since  much  is  done,  even  in  unfavor- 
able cases,  by  purely  natural  jjrocesscs,  this  being  especially  true  (;f  children  who  are 
growing  rapidly. 


FRACTURES  OF  THE  FOREARM;  THE  ULNA. 

At  the  upper  end  of  the  ulna  the  most  fre(picnt  fracture  is  that  of  the  olrrranon,  who.se 
separation  by  direct  or  indirect  violence  corresj)onds  to  fracture  of  the  patella.  The 
fragment  is  pulled  upward  along  the  back  of  the  arm  by  the  triceps  muscle,  and  the  power 
of  extension  is  almost  lo.st.  There  is  rarel,y  any  difficulty  in  diagnosis,  except  in  con- 
ditions of  extreme  swelling,  which  of  itself  would  be  suspicious,  as  under  hardly  any  other 
circumstances  could  a  joint  be  so  distended  (Figs.  297  and  298). 


Fig.  297 


Fig.  298 


Fracture  of  olecranon.      (Krichsen.) 


Fracture  of  ulna,  upper  end.     (Lejars.J 
Fig.  299 


Fracture  of  olecranon  with  fibrous  union.     (Park.) 

Treatment. — The  difficulty  here,  in  ircaiment,  consists  in  the  necessity  for  counter- 
acting the  pull  of  the  triceps.  The  arm  first  of  all  should  be  dressed  in  the  extended  posi- 
tion. Sometimes  it  is  possible,  by  partly  encircling  the  posterior  surface  of  the  arm  ju.st 
above  the  fragment  with  a  strong  piece  of  adhesive  plaster,  to  which  is  attached  some 
rubber  tubing,  to  make  a  constant  ela.stic  pull  upon  the  fragment,  the  tubes  being  brought 
down  and  attached  to  the  sides  of  the  anterior  splint  below  the  elbow.  In  the  absence 
of  swelling  this  can  often  be  made  quite  effective.  So  long  as  much  fluid  is  present 
no  means  will  be  efficient.  It  may,  therefore,  be  well  to  wait  two  or  three  days  until 
the  fluid  has  disappeared,  aspirating  the  joint  if  neces.sary.  In  young  and  otherwi.se 
healthy  subjects  there  is  strong  reason  for  advising  operation,  as  only  by  absolutely 
approximating  the  fragment  to  the  main  bone  and  maintaining  it  in  position  can  bony 
union  be  secured.  In  projierly  selected  cases,  and  when  performed  with  every  precau- 
tion, this  measure  frequently  gives  ideal  resuhs.  A  .short  ligamentous  union  is  repre- 
sented in  Fig.  299.  At  other  times  the  fibrous  band  will  stretch  out  to  an  inch  or  more, 
not  completely  disabling  the  arm  but  weakening  it.     The  extended  position  may  be 


502  SURGICAL  AFFECTIONS  OF  THE  TISSUES 

relaxed  within  a  week  after  operation,  but  not  for  at  least  two  weeks  after  other  treat- 
ment.    Passive  motion  should  not  be  begun  too  early  in  the  latter  cases. 

Fracture  of  the  coracoid  process  is  often  combined  witli  backward  dis'location  of  the 
forearm,  which  is  no  tloubt  an  incident  of  the  injury  or  may  cccur  later  l)y  mere  muscle 
pull.  The  brachialis  anticus,  which  is  inserted  into  it,  will  pull  the  fragment  up  against 
the  anterior  surface  of  the  humerus.  This  fracture  should  be  dressed  in  the  right-angle 
position,  in  order  to  relax  the  muscle,  taking  care  to  prevent  backward  displacement, 
while  ligamentous  union  is  ordinarily  all  that  can  be  hoped  for. 

The  ulnar  shaft  may  be  broken  at  almost  any  point,  usually  as  a  result  of  direct  vio- 
lence. As  it  is  weaker  in  its  lower  half  the  greater  number  of  fractures  occur  here. 
Fracture  of  the  shaft  is  easily  recognized,  crepitus  being  always  obtained,  unless  muscle 
tissue  has  intervened,  this  l)eing  a  condition  which  will  occasionally  prevent  bony  union. 
If  it  can  be  established  by  .r-rays  that  bony  surfaces  are  not  in  contact  and  cannot  be 
so  placed,  it  is  advisable  to  cut  down  upon  the  site  of  the  fracture,  remove  the  obstacle, 
and  fasten  the  fragments  together.  So  long  as  one  bone  is  broken  in  the  forearm  the 
other  may  be  relied  on  to  act  as  a  more  or  less  efficient  splint.  There  is  but  one  position 
in  which  any  of  these  fractures  can  be  dressed  with  safety,  that  is  midway  between  pro- 
nation and  supination,  i.  e.,  with  the  thumb  pointing  toward  the  patient's  face.  Splints 
used  for  this  purpose  should  always  be  wider  than  the  forearm  itself,  lest  by  pressure  the 
ends  be  forced  toward  the  other  bone.  Some  hold  that  by  gentle  pressure  along  the  line 
between  the  bones,  as  by  a  narrow  pad  or  splint,  the  muscles  may  be  made  to  press  the 
injured  bone  away  from  the  other;  nevertheless  only  moderate  pressure  can  be  tolerated 
for  this  uncertain  purpose.  It  has  been  generally  customary  to  use  two  liglit  wooden 
splints,  one  along  the  jmlmar,  the  other  along  the  dorsal  surface  of  the  forearm,  padding 
them  properly  and  securing  them  in  position  by  strips  of  adhesive  plaster  and  suitable 
bandages.  The  same  plaster-molded  splints  mentioned  above  can,  however,  be  made 
just  as  eifective  for  this  purpose,  if  properly  applied. 

When  either  bone  is  broken  near  the  wrist,  and  especially  when  both  are  broken,  we 
have  to  combat  the  tendency  of  the  pronator  quadratus,  which  tentls  to  pull  the  lower 
fragments  together. 

The  sti/Ioid  process  is  occasionally  detached,  as  in  violent  s|)rains,  or  broken  oft"  in 
connection  with  other  injuries.  Inasmuch  as  it  carries  the  upper  end  of  the  internal 
lateral  ligament  its  detachment  can  be  quickly  recognized  by  the  abnormal  freedom 
of  motion  which  such  an  injury  would  permit. 


FRACTURES  OF  THE  RADIUS. 

The  radius  vies  in  frequency  of  fracture  with  the  clavicle.  The  head  is  seldom  broken, 
its  fracture  being  most  likely  when  the  shaft  is  driven  against  the  humerus  by  falls  upon 
the  open  hand.  The  neck  is  more  frequently  broken  in  children  than  in  adults.  These 
fractures  have  sometimes  to  be  determined  by  a  process  of  exclusion  or  by  the  use  of  the 
•T-rays.  In  muscular  forearms  they  lie  so  deeply  that  it  is  not  always  possible  to  recog- 
nize them.  Ordinarily,  however,  if  the  head  of  the  bone  can  be  found  to  remain  sta- 
tionary while  the  rest  of  the  bone  is  being  rotated,  and  if,  at  the  same  time,  crepitus 
be  felt,  the  matter  may  be  regarded  as  settled.  So  far  as  the  shaft  of  the  radius  is  con- 
cerned the  remarks  made  above  regarding  the  ulna  mostly  hold  true  for  its  fellow-bone. 
When  the  neck  of  the  bone  is  broken  the  shaft  will  l)e  ])ulled  ujiward  by  the  biceps 
tendon,  while  when  the  shaft  is  broken  below  its  insertion  the  u])]x^r  fragment  is  dis- 
placed by  it.  In  either  of  these  cases,  then,  the  forearm  should  be  dressed  at  a  right 
angle  with  the  arm  in  order  to  relax  the  muscle.  The  supinator  brevis  and  the  j^ronator 
radii  teres  should  also  not  be  neglected,  for  the  former  will  tend  to  rotate  and  the  latter 
to  more  or  less  displace  the  upper  portion  of  a  shaft  broken  high  u]:>.  W^ith  a  fractiu'e 
near  the  upper  end,  in  a  powerfully  muscular  arm,  diagnosis  is  not  always  easy.  Frac- 
tures in  the  lower  portion  of  the  shaft  are  to  be  treated  like  those  of  the  ulna.  But  those 
high  up  should  be  dressed  with  the  elbow  at  a  right  angle  and  the  forearm  supinated. 
A  plaster-of-Paris  molded  splint  here  can  be  ada]>ted  to  the  needs  of  every  individual 
case  if  the  surgeon  will  give  minute  care  at  the  time  of  its  hardening  to  placing  the  parts 
just  as  he  desires  them  to  remain. 


FRACTURE  OF  TllK  LOWER  ESI)  OF   THE  R.\J)f['S 


503 


FRACTURES  OF  BOTH  BONES  OF  THE  FOREARM. 

Tlifse  iur  nut  iincoiiunoii,  tliouj^li  nuuli  Irss  fnMjiiciit  tliaii  iiijiiries  to  cither  hone  alone. 
They  may  oeeur  at  the  .same  level  or  he  (juite  widely  sejjarated.  The  lo.ss  of  function 
is  complete  in  these  instances,  while  deformity  will  depend  lar<;ely  upon  whether  the  frac- 
tures lie  near  toijjether  or  not.  It  isof  the  ii;rcatest  importance  to  remember,  in  these  cases, 
that  the  mass  of  muscles  around  the  upper  fra};incnts  tends  to  crowd  them  to<;cther, 
while  the  lower  frat^mcnts  arc  l>rou>,dil  lo«;cthcr  especially  hy  the  |)ronator  (piadratus. 
Evcrytliin<;  then  conspires  to  convcriicncc  of  the  four  fra<{ments,  a  tendency  which  it  is 
sometimes  dilHcult  to  comhat.  Kvcry  larife  nuiseum  contains  specimens  showing  a 
common  callus,  in  which  all  four  hone  ends  are  involved,  and  illustrating  the  permanent 
loss  of  rotation  that  ensues.     This  is  to  be  combated,  not  alone  by  rest,  which  tends  to 


Fi<:.  300 


Fig.  301 


Obliteration  of  the  inter- 
osseous space  in  a  fracture 
of  the  forearm. 


Fracture  of  both  bones  near  lower  extremity.     (Lejars.) 


limit  callus  formation,  but  by  position  iciih  ihe  arm  midiray  heiuren  pronation  and 
■supination,  in  which  the  bones  are  naturally  farthest  separated,  and  by  splints-  applied 
with  such  gentle  pressure  as  may  hold  the  bones  apart.  This  pressure  shouki  be  ajiplied 
between  the  dorsal  and  palmar  surfaces,  while  the  lateral  aspects  of  the  forearm  should 
be  kept  absolutely  free  from  it  (Figs.  300  and  301). 

It  is  a  serious  matter  to  dress  any  of  these  injuries  with  moistened  pasteboard,  or  other 
material  which  does  not  take  its  desired  shape  and  strength  jiromptly,  for  no  matter 
how  carfully  the  desired  position  may  be  enforced  at  first  the  very  nature  of  a  material 
which  remains  too  long  plastic  will  permit  the  loss  of  all  that  should  be  maintained. 
The  writer  has  seen  malpractice  suits  instituted  and  men  forced  out  of  the  State  by 
inattention  to  this  precaution. 


FRACTURE  OF  THE  LOWER  END  OF  THE  RADIUS;  COLLES'  FRACTURE. 

This  is  perha|)S  one  of  the  commonest  fractures  in  the  body,  occurring  at  all  ages; 
when  seen  in  growing  children  it  is  to  be  regarded  as  an  epiphyseal  separation  rather 
than  as  a  distinct  fracture.  It  derives  its  name  from  the  fact  that  until  Colles,  a  Dublin 
surgeon,  over  one  hundred  years  ago,  described  this  injury  as  a  fracture  it  had  been 
always  regarded  as  a  peculiar  dislocation  at  the  wrist.  It  is  produced  by  falls  upon  the 
hand"  in  the  hyperextended  position,  the  force  being  usually  transmitted  through  the 
carpus  to  the  radial  end.     The  name  is  usually  limited  to  those  fractures  which  occur 


504 


SURGICAL  AFFECTIONS  OF  THE  TISSUES 


within  one  and  a  quarter  inches  of  the  articuhir  surface  (Fig.  303).  Here  the  structure 
of  the  bone  is  cancellous  and  impaction  may  easily  occur,  this  being  a  decided  feature 
in  many  of  these  accidents,  and  making  replacement  more  difficult.  The  deformity 
which  results  from  the  fracture  is  characteristic  and  more  or  less  uniform.  This  is 
called  the  "silver-fork  appearance,"  the  lower  fragment  being  so  displaced,  and  usually 
more  or  less  tilted,  as  to  raise  the  tendons  and  the  structures  on  the  back  of  the  wrist; 
at  the  same  time  it  is  usually  drawn  toward  the  radial  side.  The  more  the  fragment 
is  impacted  or  driven  into  the  shaft  of  the  bone  the  less  easily  is  crepitus  elicited. 

The  fracture  is  more  common  than  is  supposed,  and  there  is  no  doubt  but  that  many 
alleged  sprains  of  the  wrist  illustrate  cracks  in  the  bone  without  displacement,  which, 
nevertheless,  are  slow  to  heal  and  are  sometimes  followed  by  thickening  and  impairment 
of  function.     (See  Plate  XL.) 

Along  with  the  radial  fracture  separation  of  the  styloid  process  of  the  ulna  may  also 
occur,  or,  as  Moore  has  shown,  the  process  itself  may  perforate  the  internal  lateral  liga- 
ment so  as  to  protrude  through  the  skin ;  and  the  surgeon  has  occasionally  to  withdraw  the 
styloid  from  the  ligament  whic-h  has  been  impaled  upon  it.  The  radio-ulnar  ligament  is 
also  frecjuently  injured,  and  this  permits  the  ulna  to  become  more  prominent  than 
normal.  If  the  styloitl  has  perforated  the  skin  it  lends  a  compound  feature  to  the 
case.     The  interarticular  fil)r()cartilage  may  also  be  displaced. 

Treatment. — The  secret  of  obtaining  a  good  result  and  the  explanation  for  failures 
lie  in  the  completeness  or  incompleteness  of  the  reduction  of  the  fragment.       If  the 
latter  be  absolutely  and  accurately  replaced  it  makes  but  little  difference  what  dressing  is 
applied.     On  the  other  hand  any  fragment  not  completely  restored  will  lead  to  sub- 
sequent deformity  and   impairment  of 
F'"-  2^2  function.     Successful  reduction,  then,  is 

the  keynote  to  success,  and  should  be 
accomplished  at  any  reasonable  cost. 
Sometimes  it  is  not  difficult,  and  then 
no  anesthetic  is  required;  sometimes 
it  is  extremely  difficult,  and  the 
operator  has  to  exert  all  the  strength 
he  has  in  his  arms,  aided  by  profound 
anesthesia.  Moderate  cases  can  usually 
be  dealt  with  successfully  under  nitrous 
oxide  gas.  The  surgeon  grasps  the 
hand  as  if  to  shake  hands,  ?".  e.,  with 
his  corresponding  hand,  the  elbow  being 
firmly  held  by  an  assistant.  Traction 
is  then  made  upon  the  hand  to  which 
the  fragment  is  affixed,  while  with  his 
other  hand  the  operator  makes  such 
pressure,  rotation,  or  coaxing  manipu- 
lation with  his  thumb  and  fingers  as  may 
assist  in  restoring  the  fragment  to  its 
place.  With  whatever  other  effort  may 
be  made  traction  should  be  combined. 
Forcible  swaying  movements,  com- 
bined with  hyperextension,  may  be 
necessary  to  dislodge  an  impacted  frag- 
ment. Any  degree  of  force  is  prefer- 
able to  failure  in  this  respect.  Perfect 
reduction  is  the  key  of  success ;  without 
it,  no  dressing  is  efficient ;  with  it,  almost 
an_\i:hing  will  suffice. 

Reduction  once  accomplished  it  is  usually  an  easy  matter  to  hold  the  arm  in  position. 
The  writer  prefers  above  all  other  means  a  molded  plaster-of-Paris  splint,  which  should 
extend  from  the  line  of  the  knuckles  u])on  the  palmar  surface  well  up  toward  the  elbow. 
It  should  be  fitted  neatly  to  the  hand  and  forearm,  bandaged  comfortably  upon  it,  while 
as  it  solidifies  the  surgeon  should  hold  the  hand  slightly  flexed  to  the  ulnar  side  as  well 
as  anteriorly.     When  the  splint  is  hardened  and  bandaged  a  simple  sling  will  suffice. 


Comminuted  but  not  compound  fracture  of  wrist. 
(Beatson.) 


PLATE  XL 


Skiagram  of  a  Fracture  of  the  Lower  End  of  the  Radius.     (Wharton.) 


FRACTURE  OF  THE  LOWER  END  OF  THE  RADIUS 


505 


T\\v  hand  should  he  (h'csscd  with  llic  thiiiiih  point iiijr  toward  tlu-  fuco,  while  upon  the 
hack  of  the  wrist  an  ice-l)aij  can  he  ap|)He(L  Eccliyniosis  is  .sometimes  extreme;  I 
have  seen  it  extend  even  to  the  shoulder  after  an  apparently  simple  break  (Figs.  304 
and  305). 


Fk;.  303 


Colles'  fracture.      (Anger.) 


I  have  not  described  other  splints  for  dressings,  at  this  point,  for  two  rea.sons:  the 
dressintij  given  above  i^  anij)le  and  sufficient  for  all  ca.ses,  and,  aside  from  it,  the  number 
of  sj)lints  and  methods  devi.sed  is  .so  large  as  to  be  confusing.  It  is  much  better  to  know 
one  method  well  than  to  have  a  slight  working  acquaintance  with  several. 


Fig.  304 


Fig.  305 


H 

f" 

'^"^HBHI^H 

M 

pw| 

|Hn3~V^B| 

^^^^^^^^^ 

m 

B^'' 

1  J 

^^^^^^^1 

m 

^^f^' 

1 

K^'ikJa^K 

i 

^^1 

1 

^^H 

1 

1 

Deformity  trom  faulty  union  following  fracture  of  wrist.     Buffalo  Clinic.     (Skiagrams  by  Dr.  Pluminer.) 

While  Colles'  fracture  is  far  more  frequent  than  all  other  fractures  about  the  wrist, 
it  is  possible  to  have  less-known  forms  with  different  displacements;  thus  a  fracture 
the  rever.se  of  Colles'  has  been  described  by  Barton  and  by  R.  W.  Smith,  being  occasion- 
ally produced  by  falls  upon  the  back  of  the  hand  in.stead  of  upon  the  palmar  surface. 


506  SURGICAL  AFFECTIONS  OF  THE  TISSUES 

Figs.  306  and  307,  from  photographs  given  me  by  Dr.  Beatson,  of  Glasgow,  illustrate 
both  the  clinical  |)ictiire  and  the  actual  condition  of  the  bones.     Of  all  these  fractures 

Fic.  3u(i 


A  BaitDii  (ir  Siuilli  fracture  at  wrist.      ( IJeatsfin.) 
Fig.  307 


Smith's  fracture;  rever.se  of  Colles'.      (Beatson.)      (Skiagram  of  case  represented  in  Fig.  306.) 

it  may  be  said  that  accurate  reposition,  as  in  the  case  of  Colles'  fracture,  is  the  key  to 
success.  Once  the  fragments  are  reduced  the  same  plaster-of-Paris  molded  splints 
will  answer  for  these  as  for  the  others. 


BENNETT'S  FRACTURE. 

When  considerable  force  is  ap])lied  to  the  distal  end  of  the  first  metacarpal,  as  in 
striking  with  the  clenched  fist,  or,  as  in  a  fall  upon  the  outstretched  thumb,  the  first 
metacarpal  is  often  fractured  transversely  at  its  neck  or  longitudinally,  its  interior  basal 
projection  Ijeing  broken  ofF,  both  injuries  being  often  associated.  This  is  a  condition 
lately  proved  by  Rnss,  of  San  Francisco,  to  be  more  common  than  has  been  generally 
supposed.  It  was  first  described  by  Bennett,  of  Dublin,  in  1885,  and  is  known  as  Ben- 
nett's fracture  of  the  thumb.  Its  peculiar  features  can  be  best  seen  in  a  radiograph. 
It  produces  much  pain  and  swelling  of  the  hand,  with  tenderness,  especially  at  the  base 
of  the  bone  involved,  i.  e.,  at  the  root  of  the  thumb.  There  may  be  more  or  less  dis- 
placement of  fragments.  The  injured  thumb  should  be  treated  by  traction  and  with 
such  coaptation  splints  as  may  be  extemporized  or  prepared  for  the  purpose,  in  the 
position  of  abduction.  If  accin-ate  coajjtation  and  suflicient  traction  be  made  to  over- 
come both  deformity  and  muscle  spasm  the  result  obtained  will  be  satisfactory.  Other- 
wise more  or  less  loss  of  function  and  local  tenderness  may  long  persist. 


PLATE  XLI 


Skiagram  of  Fracture  of  the  Proximal  Phalanx  of  the  Ring  Finger.      (Wharton.) 


FRACTURES  OF   TIIF  PELVIS  507 


FRACTURES  OF  THE  WRIST  AND  HAND. 

Fractures  of  the  carpal  hones  seldom  occur,  except  when  the  parts  have  been  crushed. 
The  scaphoid  is,  however,  broken  nuich  more  often,  and  doubtless  many  cases  of  .so- 
called  severe  sprain  include  this  injury.  The  use  of  the  .r-rays  has  done  more  to  teach 
the  relative  frc(|uency  of  carpal  fractures  than  was  ever  previously  appreciated.  The 
scaphoid  ossifies  by  two  centres,  which  do  not  appear  until  the  ei<jhth  year.  When 
the  bone  has  been  thus  cracked  tiie  usual  si<i;ns  of  sprain  arc  |)resent,  which  subside  and 
leave  a  tender  wrist  and  hand  whose  hngers  can  be  normally  moved,  but  whose  wrist 
movements  arc  reduced  one-half,  while  attemj)ts  at  motion  beyond  these  limits  produce 
fjreat  muscle  sj)asm  and  pain.  Codman  and  Chase'  have  shown  that  the  sheaths  of 
the  radial  extensor  tendons  are  in  close  relation  to  the  ])eriosteum  of  the  boTie  at  this 
|)()int,  as  well  as  to  that  of  the  radius,  so  that  by  injury  here  blood  may  escape  into  the 
sheath  without  appearinji;  at  other  parts;  the  result  beino;  a  tense,  fluctuatin<r,  trianfrular 
swellinji;  over  the  radial  half  of  the  wrist,  the  blood  bein<ij  ett'used  so  (lce|)ly  as  not  to 
discolor,  or  at  least  not  at  first.  They  re(»;ard  the  pi'csence  of  such  an  en(;()r<i;ed  bursa 
as  diagnostic  of  fracture  either  of  the  radius  or  the  scaphoid. 

While  carpal  fractures  call  ordinarily  for  treatment  by  absolute  rest,  Codman  and 
Chase  have  advised  removal  of  any  loose  fragment,  especially  of  the  sca))hoi(l,  by 
incision  along  the  back  of  the  wrist  just  to  tlie  inner  side  of  the  long  radial  extensor. 
The  annular  ligament  is  to  be  divided  between  it  and  the  long  extensors  of  the  fingers, 
and  without  o])ening  tendon  sheaths;  inasmuch  as  this  ligament  does  not  retract  when 
divided  its  borders  must  be  held  apart.  In  this  way  the  joint  may  be  comj)letely  exposed 
over  the  proximal  half  of  the  sca))hoi(l.  The  line  oi  fracture  being  made  out,  a  blunt 
hook  is  introduced  into  the  fissure  and  the  fragment  elevated,  loosened  by  a  tenotome,  and 
removed,  its  removal  seeming  nowise  to  interfere  wuth  the  function  of  the  whole  bone 
or  the  usefulness  of  the  wrist. 

The  mr-tacarpal  bones  are  frequently  broken,  usually  as  the  result  of  violence,  the  distal 
portions  suffering  more  than  the  proximal.  The  diagnosis  is  best  made  with  the  fingers 
closed,  when  any  lack  of  symmetry  in  the  row  of  knuckles  may  be  seen  or  any  protrusion 
of  a  fragment  noted.  Here  the  .r-rays  are  useful.  Such  injury  should  be  treated  by 
placing  the  hand  upon  a  palmar  splint  extending  well  up  the  forearm  and  maintaining 
rest  by  suitable  pressure,  with  or  without  traction  upon  the  finger  of  the  bone  involved. 
For  thi.'^  purpose  adhesive  plaster  may  be  passed  up  and  down  the  finger  and  attached 
to  an  elastic  band  which  is  fixed  to  the  end  of  the  splint. 

The  same  is  true  of  fractures  of  the  'phalanges,  which  arc  often  made  compound  by 
the  injury.  Here  the  danger  is  not  so  much  to  the  bone  as  to  the  tendon  sheaths  or 
thecse,  along  which  infection  may  easily  spread.  Widespread  and  prolonged  suppura- 
tion might  disable  a  hand  thus  injured  miless  properly  and  promptly  dressed.  Ordi- 
narily adjoining  fingers  can  be  utilized  for  splints,  and  if  the  outstretched  hand  be 
fastened  upon  a  })almar  splint  and  the  injured  finger  kept  in  position  by  its  neighbors 
a  good  result  can  generally  be  obtained.  Occasionally  distinc-t  splints  for  one  or  more 
fingers  are  required,  and  occasionally  also  the  suggestion  made  above  with  regard  to 
traction  may  need  to  be  enforced. 


FRACTURES  OF  THE  PELVIS.  ' 

Fracture  of  the  pelvis  may  be  serious  not  only  in  and  of  itself  but  because  of  frequently 
accompanying  injuries  to  the  various  pelvic  viscera.  Save  in  the  possible  separations 
that  may  occur  during  parturition  it  is  always  the  result  of  direct  violence.  Such  injuries 
are  usually  divided  into  fractures  of  the  pelvic  r/irdle  and  those  of  the  more  exposed  promi- 
nences, such  as  the  iliac  crest,  the  ischiac  tuhewsihf,  the  coccyx,  etc.  Lines  of  fracture 
may  run  at  any  point,  although  it  is  at  the  .synchondrosis  that  the  i)elvis  is  usually  broken 
loose  from  the  sacrum.  As  in  the  skull  and  the  lower  jaw  double  fractures  or  even  com- 
minutions may  occur.  The  same  considerations  concerning  the  transmission  of  .serious 
violence  may  account  for  some  of  the  vagaries  seen  in  the.se  cases.     The  sacrum  is 

'Annals  of  Surgery,  March,  1905. 


508 


SURGICAL  AFFECTIONS  OF  Till':  TISSUES 


usually  broken  as  the  result  of  great  violence.  The  pelvic  girdle  is  perhaps  weakest 
opposite  the  joints  and  in  the  neighborhood  of  the  pubis.  Here  there  may  be  a 
separation  of  the  symphysis,  but  the  break  usually  occurs  a  little  to  one  side  of  the 
middle  line.  In  rare  instances  the  head  of  the  femur  has  been  forced  through  the 
acetabulum  (Fig.  308). 

In  a  general  way  fractures  of  the  pelvic  girdle  can  be  recognized  not  merely  by  local 
evidences  of  injury  and  shock,  but  by  the  resulting  more  or  less  complete  loss  of  function ; 
patients  will  be  disabled  in  proportion  to  the  violence  and  extent  of  the  injury.  The 
more  unilateral  the  symptoms  tiie  easier  it  is  to  localize  the  site  of  the  injury.  Mobility 
can  often  be  detected  upon  examination,  sometimes  crepitus.  This  is  essentially  true 
of  fractures  of  the  pubis.  Occasionally  combined  manipulation,  with  a  finger  in  the 
rectum  or  vagina,  will  permit  more  accurate  localization  of  the  injury.  When  the 
crest  of  the  pelvis  is  fractured,  or  any  of  the  parts  to  which  the  abdominal  muscles  are 
inserted,  then  the  patient  will  be  still  further  disabled  in  movements  of  the  lower  part 
of  the  body,  while  by  palpation  the  fracture  is  sometimes  easily  determined. 

Not  the  least  serious  features  of  these  injuries  are  those  which  pertain  to  the  viscera. 
These  include  not  only  the  ordinary  results  of  abdominal  contusions  which  may  produce 
all  sorts  of  harm,  for  example,  ruptures  of  the  kidneys,  spleen,  or  liver,  but  also  more 


Fig.  308 


Fig.  309 


Fracture  of  pelvis.      (Mudd.) 

localized  lesions,  such  as  ruptures  of  the  rectum,  blad- 
der, or  urethra,  or  even  the  pelvic  connective  tissue.  If 
the  urinary  passages  be  torn  there  is  always  opportunity 
for  urinary  infiltration  and  infection.  The  same  is  true 
of  the  rectum  so  far  as  possibility  of  infection  is  con- 
cerned. Therefore  one  of  the  earliest  maneuvers  in 
dealing  with  such  a  case  should  be  the  passage  of  a 
catheter,  to  determine  if  the  urine  be  bloody  or  the 
urethra  obstructed.  In  such  a  case,  in  the  male  at  least, 
it  will  usually  be  wise  to  make  a  perineal  .section  and  to 
open  widely  and  then  drain  the  bladder.  In  not  a  few 
of  these  in.stances  the  laceration  takes  place  internally, 
and  a    pelvic  crushing  injury,   which    is    followed   by 

collapse  and  abdominal  rigidity,  without  satisfactory  explanation  as  above,  should  be 
promptly  explored  by  abdominal  section,  the  danger  of  doing  it  being  considerably  less 
than  the  risk  of  leaving  it  undone. 

Some  of  the.se  fractures  are  conspicuously  compoiwrl,  and  the  treatment  for  the  external 
wound  will  permit  of  more  careful  exploration  of  the  bone  injury,  as  well  perhaps  as  the 
insertion  of  wire  sutures  or  other  means  of  fixation. 

Fig.  309  illustrates  a  serious  complication  that  ensued  in  one  case  after  multiple  frac- 
tures of  the  pelvis  and  hip,  with  .synostosis  at  the  hip,  as  well  as  extensive  deformity 
following  fracture  of  the  shaft  of  the  femur. 

Treatment. — Treatment  of  pelvic  fractures  should  compri.se,  first,  absolute  rest. 
This  means  not  merely  confinement  in  bed,  with  traction  applied  to  one  or  both  limbs, 


CJreat  deformity  after  multiple  frac- 
ture of  femur,  with  synostosis.  (From 
the  Buffalo  Museum.) 


FRACTIRKS  OP'    Till':    Til  Kill  5()f) 

Ijiit  |)n)I)al)ly  fixalioii  of  (lie  pelvis  aiul  pcrliaps  (lie  tlii{;li.s,  cither  in  a  eonipressing 
baiulaije  or  in  a  |)la.s(er-of- Paris  doiihle  s|)iea,  the  |)elvie  jacket  niimiiif^  as  hi^h  as  may 
he  necessary  u|)on  the  trunk  of  the  body.  Cases  which  seem  to  ])erniit  of  o|)eration  and 
sutiirinj;  are  entitled  to  it,  l)nt  they  will  coiistitntc  hnt  a  small  proportion  of  the  total. 
While  |)atients  are  so  rij^idly  confined  |)rovision  should  he  made  for  free  elimination, 
and  possihly  conveniences  provided  for  receivin<f  the  evacuations  without  j)o>isihilitv 
of  infection.  Recovery  is  in  many  instances  complete;  occasionally  it  occurs  with  con- 
sidcrahle  displacement.  If  the  viscera  e.sc-a})e  injury  much  may  Ik-  expected  in  the  way 
of  repair  of  the  l)ones  under  suitable  treatment. 

The  in(tr(/iii  »}  tlir  an't(thi(/iiiii  is  occasionally  chipped  off,  sometimes  by  itself,  sometimes 
as  a  comj)lication  of  dislocation  of  the  hij).  The  j)osterior  marfjin  of  the  brim  is  the 
part  which  usually  suffers.  I)iaf2;nosis  should  be  made  by  the  ease  with  which  such  a 
dislocation  recurs  after  manual  reduction.  Sufficient  traction  to  keep  the  limb  from 
displacing;  the  fragment,  and  snu*;  banda<jin<2;  with  pressure,  especially  around  the 
injured  hip  and  above  the  trochanter,  is  indicated  in  such  cases. 

The  coccyx  and  even  the  lower  portion  of  the  sacrum  are  occasionally  broken  k)o.se, 
either  by  external  violence  or  during  parturition.  Here  the  fragment  is  drawn  forward 
by  the  levator  ani,  displacement  is  marked,  and  pain  and  soreness  are  great.  Should 
there  be  doubt  as  to  the  nature  of  the  injury,  combined  manipulation,  with  a  finger  in 
the  rectum,  will  make  diagnosis  positive.  Fibrous  uni(jn  is  about  all  that  can  l)e  expected 
in  either  of  these  cases.     The  fragment  may  be  justifiably  removed  at  any  time. 


FRACTURES  OF  THE  THIGH. 

Fractures  at  the  upper  end  of  the  thigh  are  more  common  than  those  at  the  lower. 
At  the  upper  end  there  may  be  fractures  of  the  head,  of  the  neck,  those  which  pass  between 
the  trochanters,  and  epiphyseal  separations.  All  of  these  are  rare  except  those  of  the 
neck. 

Fractures  of  the  neck  of  the  femur  occur  most  commonly  in  those  who  have  passed 
the  fiftieth  year  of  life.  They  occur,  however,  during  the  middle  period  and  even  in 
children,  and,  as  Whitman  has  shown,  are  by  no  means  so  rare  in  the  young  as  was 
until  recently  supposed. 

The  shape  and  structure  of  this  portion  of  the  bone,  and  the  peculiar  changes  which 
occur  with  advancing  years,  constitute  the  explanation  for  the  frequency  of  this  injury 
in  late  life.  As  the  jaw  begins  to  change  in  shape,  and  the  teeth  to  drop  out,  there  occur 
also  unseen  changes  within  the  cancellous  structure  of  the  head  and  neck  of  the  femur  by 
which  the  strength  of  the  latter  is  materially  reduced.  It  is  still  further  weakened  by 
the  change  in  shape  which  the  bone  also  undergoes  as  it  loses  its  obtuse  angle  and  becomes 
.set  more  at  a  right  angle  with  the  shaft.  The  reduced  al)ility  to  resist  strain  produced 
by  these  changes  is  remarkable,  and  accounts  for  the  ease  with  which  fractures  occur, 
even  from  so  apparently  trivial  an  accident  as  tripping  on  the  floor.  With  all  the  violence 
directly  transmitted  there  is  usually  present  an  element  of  twist  or  torsion  by  which 
fracture  is  still  further  favored. 

As  between  so-called  intracapsular  and  extracapsular  fractures  surgeons  have  made 
distinctions  to  which  unnecessary  importance  has  been  attached.  Anteriorly  the  capsule 
is  attached  to  the  intertrochanteric  line,  while  posteriorly  it  does  not  extend  nearly  so 
far  outward;  it  can  thus  be  seen  that  many  fractures  are  partly  intracapsular  and  partly 
extracapsular.  These  lines  vary  in  different  individuals,  especially  that  of  the  posterior 
insertion;  it  is  not  usually  possible  to  make  minute  distinctions  of  this  kind.  The  prin- 
cipal importance  which  attaches  to  them  is  in  the  direction  of  prognosis,  for  if  the  frag- 
ment be  absolutely  intracapsular  it  can  derive  its  blood  supply  only  through  the  liga- 
mentum  teres,  which  is,  to  say  the  least,  a  precarious  method  of  existence  and  u.sually 
disappointing.  In  general  it  'may  be  assumed  that  a  fracture  close  to  the  head  is  intra- 
capsular, but  that  when  it  occurs  well  out  toward  the  shaft  it  may  partake  of  both  charac- 
ters. In  this  connection  the  .r-rays  will  afford,  usually,  more  satisfactory  information 
than  can  be  obtained  by  even  extensive  or  rude  manipulation. 

Impaction  occurs  with  considerable  frequency  in  these  cases,  and,  unless  accompanied 
by  too  much  deformity  or  displacement,  is  rather  a  fortunate  occurrence,  since  by  it  is 
afforded  an  automatic  "splint  which  it  should  be  the  surgeon's  endeavor  to  not  break  apart. 


510 


SURGICAL   AFFECTIONS  OF   THE   TISSUES 


Tliere  can  be  no  (loiil)t,  moreovt-r,  hut  that  trifling  dcgrot's  of  impaction  with  incomplete 
fracture  occur,  e.s{)ecially  in  the  aged,  in  many  injuries  to  the  hip.  It  would  he  the  greatest 
misfortune  to  the  patient  in  one  of  these  cases  to  complete  the  separation,  and  when 
assured  of  the  existence  of  such  a  lesion  it  is  best  to  treat  the  case  as  though  it  were  a 
fracture.  I  am  sure  that  many  cases  which  have  gone  into  court  have  been  due  to 
incom})lete  fractiu'es  with  imjiaction,  where  there  has  been  later  absorption  of  bone,  by 
which  the  femoral  neck  has  been  much  shortened,  so  that  recognizable  deformity  as 


Fig.  310 


Fig. 311 


Sections  of  impacted  extracapsular  fractures  of  neck  of  femur, 
shf)wing  the  degree  of  impaction  and  of  splintering  in  different 
cases.      (Erichseu.) 


Extracapsular  fracture  of 
thigh. 


well  as  more  or  less  disal)ility  have  resulted  Other  changes  com])rised  among  tho.se 
already  described  in  the  cluipter  on  Joints,  under  the  section  on  Arthritis  Deformans, 
may  also  occur.  Callus  which  has  been  at  one  time  abuntlant  may  also  undergo  too 
great  absor})tion. 

Fig.  311  illustrates  extracapsular  fracture  and  comminution.  Figs.  312  and  313, 
also  from  sj^ecimens  in  the  author's  collection,  show  some  of  the  changes  described 
above,  including  impaction,  displacement,  and  some  osteoph^iic  outgrowth. 


Fig.  312 


Fig.  313 


Impacted  fractures  of  necks  .1  fcinur.s. 


Signs  of  Jmcfure  of  ihc  neck  of  tJir  femur  of  special  imjjort  are  hisiorij  of  injury,  pain, 
loss  of  function,  shortening,  rotary  displacement,  usually  eversion,  crepitus,  relaxation 
of  the  fascia  lata,  and  disarrangement  of  the  lines  of  triangulation  between  the  bony 
prominences  of  the  pelvis  and  the  trochanter.  Diagnosis  should  be  attempted  with  as 
little  manipulation  as  possible  lest  impaction  be  dislodged.  The  patient  sln)uld  be 
placed  upon  a  comfortably  hard  surface.  Anesthesia  will  sometimes  afford  important 
aid.     It   should  be  ascertained,  first,  that   there   had   been  no   previous   injury  which 


FRAcrrix'h's  OF  Tiir.  riiiaii 


nil 


Nelaton's  line,  dark.     Bryant's  iliofemoral  triangle, 
dotted.      (iM'ichsen.) 


could  |)r(»(liic('  ,sli(»r(cnin<^.  If,  tlicii,  .sliorliiiiii;/  In-  ii|i|>iircnt  it  is  of  itself  almost  a  <liu^- 
noslic-  sign.  Siicii  a  liiiih  is  practicallv  helpless,  and  unless  the  neck  he  so  driven  in  u|)on 
itself  us  to  j)r()(lu(c  impaction  the  foot  will  he  usually  everted,  while  the  tension  of  the 
fascia  lata  will  he  relaxed  and  there  will  he  fulness  in  Scarpa's  triangle.  Ahsolute 
inahility  to  use  the  limh  iin|)lies  fracture  without  impaction.  Should  the  patient  have 
been  ahle  to  help  himself  or  work  after  the  injury,  impaction  may  he  safelv  assumed. 
The  |)arts  are  exceedingly  tender  and  pain  is  easily  j)roduced.  Shortening  Is  to  he 
assumed  only  after  |)la(ing  the  limhs  and  body  in  ;i  j)crfi(i//j  sipnvirfriral  pofillion  (the 
pelvis  being  at  right  angle  with  the  spine),  after  which  th(>  measurement  most  usuallv 
made  is  from  thi'  anterior  su})erior  sj)ine  to  the  internal  malleolus.  Neluton's  /inc  is 
the  shortest  line  which  can  be  made  to  pass  around  the  hip,  in  one  plane,  from  the 
anterior  superior  spine  to  the  tuberosity  of  the  ischium.  While  the  line  is  curved  it 
should  lie  in  the  same  plane.  Nor- 
mally this  passes  just  over  the  great  ^'  "-•  '^^^ 
trochanter.  If  there  be  real  shortening 
the  trochanter  should  rise  above  this 
line  to  an  extent  corresponding  with 
the  shortening  made  out  by  other 
measurements.  Still  another  method 
of  measurement  is  to  hold  a  straight 
edge  opj)osite  to  the  superior  spine  and 
perpendicular  to  the  surface  upon 
which  the  patient  is  lying;  the  distance 
between  this  edge  and  the  great  tro- 
chanter should  be  as  much  less  than  the 
distance  found  by  similar  measurement 
on  the  other  side  as  the  amount  of 
shortening  mcasiu'cd  by  the  other 
methods.  This  is  the  easiest  way  to 
measure  the  lines  included  in  Bryant's 
iliofemoral  triangle.  Both  are  illustrated  in  Fig.  314.  Impaction  can  sometimes 
be  determined  by  comparing  triangles  drawn  between  three  points  on  either  side,  these 
points  being,  respectively,  the  great  trochanters,  the  anterior  spine,  and  the  centre  of 
the  pubis,  which  is  common  to  both.  The  lower  line  of  the  triangle  on  the  injured 
side  should  be  shorter  than  on  the  other,  in  pro{)ortion  as  the  head  and  the  end  of  the 
shaft  have  been  driven  tt)ward  each  other. 

Crepitus  is  a  sign  to  be  elicited  wath  care  and  gentleness.  Uj)-and-down  movements 
of  the  thigh  upon  the  side  of  the  pelvis  or  gentle  rotary  movements,  combined  with  cir- 
cumduction of  the  knee,  will  yield  it  if  it  is  to  be  easily  detected.  Every  effort  of  this 
kind  disturbs  the  injured  bone  and  should  be  minimized  as  much  as  possible.  One 
other  sign  of  considerable  value  is  the  fact  that  if  the  patient  be  tiu'ued  upon  his  face  a 
fractured  femoral  neck  will  permit  the  leg  to  l)e  hijpnr.rfrtKlrcl  to  a  degree  not  permitted 
by  the  normal  condition.  In  making  this  test  the  pelvis  should  l)e  held  firmly;  it  should 
be  made  but  onic,  the  intent  being  to  disturb  the  parts  as  little  as  possible. 

Diagnosis. — The  diagnosis  of  fracture  is  often  easy,  but  in  some  cases  it  is  accom- 
panied l)y  many  difficulties.  It  Avould  be  better  to  give  the  patient  the  benefit  of  a  doubt 
and  treat  him  for  a  fracture  with  rest  than  to  sul)ject  him  to  excessive  manipulation. 
Such  an  injury  is  not  likely  to  be  mistaken  for  anything  else  save  a  dislocation  of  the 
hip,  although  occasionally  separation  of  the  margin  of  the  acetabulum  might  cause 
confusion. 

Prognosis. — The  prognosis  <Iepends  upon  the  age  and  vitality  of  the  patient,  the 
location  and  extent  of  the  fracture,  the  method  of  treatment,  and  upon  causes  which  seem 
at  first  foreign  to  the  subject.  Patients  with  pulmonary  or  cardiac  trouble,  who  need 
frequent  change  in  position,  or  perhaps  absolute  rest,  are  likely  to  develop  something 
hurriedly  which  will  disarrange  ordinary  calculations.  Sometimes  they  die  suddenly 
or  they  may  develop  pulmonary  edema  or  hypostatic  pneumonia.  The  circulation  may 
be  so  poor  as  to  lead  to  early  development  of  bed-sores,  while  ordinary  complications 
in  prostatics,  or  habitual  constipation  in  the  aged,  may  make  care  and  treatment  exceed- 
ingly difficult.  It  should  be  emphasized,  then,  that  treatment  of  the  fracture  alone  is  by 
no  means  all  that  these  patients  require,  and  prognosis  means  something  more  than  w^hat 


512 


SURGICAL   AFFECTIONS  OF   THE   TISSUES 


may  merely  hapjien  to  the  bone.  In  this  last  respect,  however,  the  better  nourished 
the  fragment  the  more  likely  is  bony  union  to  take  j)laee  if  good  position  can  be  main- 
tained. When  osseous  union  has  failed  patients  get  fairly  useful  limbs  with  fibrous 
or  ligamciiioiis  union,  even  with  one  or  two  inches  of  shortening,  and  such  j)atients  may 
hobble  al)out  for  years,  with  a  cane  or  a  crutch,  with  limbs  that  are  semiserviceable. 

Treatment. — Of  these  cases  it  may  be  said  that  interests  of  life  are  paramount  to 
those  of  limb,  and  the  treatment  should  be  directed  to  that  which  the  patient  can  tolerate. 
Reasonably  healthy,  muscular  people  can  bear  the  application  of  adhesive  strips  and 
traction  such  as  the  thin  and  delicate  cannot  tolerate.  The  ideal  method  is  that  by  which 
sufficient  traction  is  made  to  overcome  all  muscle  pull  which  shall  produce  shortening, 
the  measure  of  weight  to  be  used  in  these  cases  being  the  efi'ect  thereby  produced.  Thus 
if  twenty  pounds  be  sufficient,  well  and  good;  if  not,  it  should  be  increased  to  thirty  or 
forty  pounds,  ])roviding  that  the  patient  can  tolerate  it.  At  the  same  time  a  broad  binder 
around  the  pelvis  may  afford  sufficient  supjjort  with  a  tractable  patient,  while  many 
will  require  a  long  side  splint,  extending  from  the  axilla  to  beneath  the  foot,  to  which 
both  body  and  the  injured  limb  should  be  fastened,  in  order  to  more  perfectly  main- 


FiG.  315 


Fig.  316 


Fig.  317 


Fracture  of  upper  third  of  femur. 
Vicious  union. 


Shortening  resulting  from 
overlapping. 


Overlapping  fracture 
of  femur. 


tain  that  physiological  rest  which  is  so  necessary.  This  last  is  the  so-called  "  Physick" 
splint,  which  has  been  variously  modified,  while  the  method  of  traction  has  been 
usually  spoken  of  as  Buck's  extension.  It  seems  well  thus  to  commemorate  the  names 
of  the  American  surgeons  who  showed  the  value  of  these  methods.  When  a  long  side 
splint  cannot  be  borne,  sandbags  15  in.  or  20  in.  in  length  and  3  in.  in  diameter  may  be 
used  to  give  support.  Any  decided  tendency  to  eversion  of  the  limb  should  be  corrected 
as  well  as  the  shortening.  When  the  long  side  splint  is  used  the  foot  can  be  held  in  place 
with  it  and  thus  the  position  of  the  shaft  of  the  femur  controlled.  At  other  times  this 
may  be  done  by  flexing  the  knee  and  thus  preventing  upward  rotation.  In  all  methods 
of  traction  it  is  advisable  to  keep  the  heel  free  from  the  bed,  in  order  that  the  effect  of  the 
method  may  not  be  lost  by  the  obstruction  of  the  mattre-ss. 

Other  methods  of  treatment  of  these  fractures  are  common  as  well  to  those  of  the  shaft, 
and  will  be  considered  later.  These  include  the  single  and  double  inclined  plane  and 
the  method  by  anterior  suspension.  In  general  the  first  indication  is  efficient  traction. 
This  should  be  made  as  efficiently  as  possible.     When  the  patient  cannot  tolerate  any 


Fh'ACTl  h'KS  Oh    7JIJ-:   'I'll Kill 


of  (lu-  usual  iiiclliods,  tlicii  llu-  (loiihlc-iiicliiicd  plane  may  \)v  used,  llic  knee  iK-iiij;  liiuij,^ 
over  ils  apex,  or  aiilcrior suspension  may  he  practised.  In  severe  eases  |)a(ients  slioiild 
be  simply  made  eonifortable,  with  such  local  (reat merit  as  they  can  hear.  It  may  he  even 
necessary  to  place  them  in  the  semi-upri<;ht  ])(;;jition  in  In-d',  in  order  to  free  the  lunj^s, 
or  to  rre(|ucnlly  (liaii^'c  their  |)()sition  to  avoid  the  formaticju  of  pressure  sores. 

Fractures  of  the  Shaft  of  the  Femur.-  Fractures  of  the  shaft  of  the  fi-mur  are 
usually  ol)li(jue  and  accompanied  by  considerable  displacement,  because  of  the  powerful 
thio;h  muscles  Avhich  tend  to  shorten  the  limb.  These  fractures  are  often  rmnpomid, 
and  occasionally  the  femoral  fraji;ment  causes  serious  damage  to  important  vessels 
or  nerve  trunks.  When  the  fracture  is  just  below  the  insertion  of  tlie  j)soas  into  the 
lesser  trochanter  this  muscle  tends  to  not  only  j)ull  up  but  to  externallv  rotate  the  u])i)er 
fra<2:ment.  Inasnnich  as  there  is  no  way  of  eontrollino;  this  muscleOr  the  fra(,nnent, 
the  frac'tured  limb  should  be  dressed  uj)()n  an  inclined  plane,  or  in  anterior  sus])ension, 
in  such  a  way  as  to  make  the  axis  of  the  shaft  fall  into  line  with  tliat  of  the  fra<,niieiit. 
When  the  fracture  is  in  the  middle  of  the  thii2;h,  or  lower,  there  is  sufficient  Ic-ngth  of 
the  upper  portion  so  that  pressure  can  be  made  ui)on  it,  or  that  psoas  activity  can  he 
vercome.      Fi";.    315    illustrates    the    tremendous 


ov 


Fig.  318 


i 


deformity  that  may  result  from  neglect  of  these 
j)recautions.  Fig.  316  illustrates  a  certain  degree 
of  overlajiping  without  conspicuous  other  deformity. 
Fig.  317  shows  the  shortening  which  is  often  inev- 
itable. 

Muscle  spasm  should  be  overcome  as  an  essential 
j)art  of  successful  treatment,  the  most  important 
feature  in  making  traction  being  to  use  force  sufficient 
to  tire  out  and  overcome  the  irritated  muscles. 

Fractures  of  the  Lower  End  of  the  Femur. — 
Fractures  of  the  lower  end  of  the  femur  are  usually 
the  result  of  extreme  violence,  and  may  be  classified  as 
were  those  of  the  lower  end  of  the  humerus.  W'hen 
there  is  a  supracotidijloid  fracture  the  two  heads  of 
the  gastrocnemius  will  hel[)  to  displace  backward 
the  upper  end  of  the  lower  fragment  to  an  extent 
permitting  injury  to  the  bloodvessels,  while  there  is 
always  marked  shortening.  Here  the  patella  will  be 
made  unduly  prominent,  and  there  will  be  depression 
above  it.  Either  condijle  may  be  broken  loose  alone, 
or  there  may  be  intercondijloid  or  T-fractures  which 
are  serious  because  the  amount  of  force  required  to 
produce  them  may  have  ])layed  serious  havoc  with 
the  soft  tissues.  The  joint  caj)sule  will  probaljly 
be  filled  with  blood,  the  ligaments  rent,  and  perhaps  the  blood  supply  of  the  limb  com- 
promised. In  such  a  case  as  this  the  joint  may  be  opened,  the  contents  turned  out,  and 
the  fragments  readjusted  and  wired  or  fastened  in  place  (Fig.  318).  Epiphi/seal  separa- 
tions, which  may  occur  up  to  the  twentieth  year,  are  not  essentially  different,  although 
lateral  displacement  is  perhaps  more  common,  while  they  are  often  compound. 

Treatment. — Oblicjue  fractures  of  the  femoral  shaft  can  be  more  easily  adjusted  under 
the  influence  of  powerful  and  continuous  traction  than  the  transverse,  where  lateral  dis- 
placement and  overlapping  tend  to  occur.  A  more  general  application  can  l)e  made  of 
the  method  described  above  when  dealing  with  fractures  at  the  upper  end  of  the  shaft,  /'.  e., 
when  the  upper  fragment  cannot  be  controlled  the  balance  of  the  limb  nuist  be  adju.sted 
to  it  in  whatever  position  it  may  be  required  to  maintain.  By  the  use  of  sufficient 
traction,  combined  with  molded  or  other  splints,  a  fair  result  may  usually  be  obtained. 
In  stout  individuals  it  is  by  no  means  easy  to  determine  just  how  the  fragments  lie,  save 
by  the  use  of  the  .r-rays.  If  traction  be  so  adjusted  as  to  maintain  the  limb  at  equal 
length  with  the  other  the  surgeon  may  feel  that,  with  certain  coaptation  splints,  he  is 
doing  the  best  he  can.  Ai)|)lication  of  the  same  rule  given  above  would  lead  him  to  place 
the  limb  on  a  double  inclined  j)lane,  in  case  of  fracture  near  the  knee-joint,  in  order  that 
in  this  position  the  sural  muscles  (the  calf)  may  be  relaxed  and  backward  displacement 
of  the  lower  fragment  be  adjusted.  If  the  apex  of  this  plane  be  arranged  sufficiently 
33 


Fracture  of  lower  end  of  femur,  will 
great  displacement  of  condyles. 


514 


SURGICAL   AFFECTIONS  OF   THE   TISSUES 


high,  so  that  the  patient's  knee  is  practically  hung  over  it,  and  that  the  weight  of  the  body 
makes  sufhcient  counicrtr action,  then  the  use  of  weight  and  pulley  may  not  be  necessary. 
Here,  however,  pressure  which  will  be  efficient  may  produce  numbness,  as  will  any  long- 
continued  pressure  in  the  popliteal  space,  and  after  a  few  days  it  may  be  necessary  to 

Fig.  319 


Extension  band  and  foot-piece. 


assume  some  other  position.  Fractures  which  loosen  the  condyles  will  need  lateral 
pressure,  while  the  position  of  each  condyle  may  be  controlled  by  the  position  of  the  leg, 
through  the  medium  of  the  corresponding  lateral  ligament. 


Fig.  320 


Same,  folded  and  ready  for  use. 

The  standard  "Buck's  extension"  (for  which  latter  word  I  prefer  to  substitute  the 
term  "traction"),  by  weight  and  pulley,  with  the  limb  in  the  extended  position,  is  still 
the  resort  of  the  majority  of  surgeons,  but  combined  with  other  support  by  long  side  splints 
or  coaptation  splints  as  may  be  needed.     Fig.  321  illustrates  the  method  of  its  use. 


Fig.  321 


Mode  of  applying   adhesive  plaster. 


(When  the  dressings  are  completed  the  limb  should  not  be  allowed 
to  rest  on  the  bed.) 


except  that  the  ends  of  the  adhesive  strips  should  be  extended  upward  to  a  point  nearly 
opposite  the  site  of  the  fracture.  The  amount  of  weight  to  be  used  should  be  graduated 
to  the  effect  produced.  From  ten  to  forty  pounds,  or  even  more,  may  be  needed.  After 
the  muscles  are  thoroughly  tired  the  amount  of  weight  may  be  somewhat  reduced* 
(Figs.  319,  320  and  321). 

Continuous  and  anterior  traction  was  devised  by  Nathan  R.  Smith,  in  the  use  of  a 
so-called  anterior  splint,  which  was  later  modified  and  improved  in  device  by  Hodgen. 
The  method  of  its  use  is  shown  in  Fig.  322.  Adhesive  strips  are  used  in  this  method  as 
well,  permitting  the  leg  and  foot  to  be  attached  to  the  lower  bar  of  the  wire  frame.     The 

1  Before  applying  the  strips  of  adhesive,  the  best  for  the  purpose  being  that  made  of  m(jleskin  spread  with 
material  with  which  zinc  oxide  is  incorporated,  the  limb  shc«uld  be  carefully  washed  and  shaved  and  then 
completely  dried.  A  little  cotton  should  be  placed  over  each  malleolus,  in  order  to  avoid  pressure-sores,  while 
the  strip  of  wood  beneath  the  foot  should  be  sufficiently  wide  to  prevent  or  minimize  this  pressure.  The  heel 
should  be  kept  off  the  mattress, 


Fh'ACTCh'hS  OF    THE    TIllCIl 


515 


j)i),siti()ii  of  (lie  franio  which  contains  tlic  linih,  swuiifr  within  it  upon  turns  or  strips  of 
ban(h»|i;c,  is  then  controlled  by  a  sus|M'nsion  apparatus,  as  shown,  which  tends  to  con- 
stantly j)ull  the  frame  and  its  attached  lower  i)art  of  the  limb  au'a/y  from  the  patient, 
the  effect  being  to  make  a  constant  but  gentle  traction.  If  the  j)oint  of  suspension  were 
placed  directly  above  the  liml)  there  would  be  no  traction  whatever.     The  essential 


Fiu.  322 


Fifi.  323 


The  Hodgen  suspension  splint. 

feature  of  the  method,  then,  consists  in  arranging  it  as  shown,  so  that  the  pull  shall  be 
oblique,  and  that,  according  to  the  obliquity  of  the  suspension  cords,  the  amount  of 
traction  shall  be  regulated 

In  this  method  of  treatment  there  is  no  violent  attempt  made  at  reduction  or  over- 
coming displacement,  but  dependence  is  placed,  at  least  for  two  or  three  days,  on  the 
effect  of  the  constant  pull  and  its  overcoming  muscular  activity.  After  this  such  added 
splints  or  expedients  may  be  adopted  as  the  case  may  require. 
The  knee  is  usually  flexed  at  a  comfortable  angle,  the  intent 
being  not  to  lift  the  foot  too  high,  so  as  to  avoid  being  compelled 
to  overcome  this  added  weight,  but  to  regulate  the  tension  by  the 
obliquity  of  the  suspending  cord. 

This  method  has  found  favor  in  the  West  under  the  enduring 
influence  of  Hodgen's  teaching.  In  the  East  it  is  not  so  generally 
practised.  It  has,  however,  several  advantages,  as  follows:  (1) 
Equably  perfect  and  comfortable  extension;  (2)  easy  adjust- 
ment; (3)  easy  exposure  for  inspection;  (4)  when  a  fracture  is 
compound  it  permits  of  easy  application  of  dressings;  (5)  adapta- 
bility to  nearly  all  fractures  of  the  femur.  It  is  peculiarly  service- 
able for  feeble  and  aged  patients  who  chafe  at  restraint.  If  it 
be  desirable  to  flex  the  knee  to  a  considerable  degree  this  can  be 
done,  e.  g.,  in  fractures  near  the  lesser  trochanter. 

In  fractures  of  the  thigh,  patients  are  frequently  disturbed  by 
muscle  spasms  occurring  during  sleep.  This  can  usually  be 
obviated  or  minimized  by  suitable  doses  of  sul phonal,  given  early 
in  the  evening. 

Fractures  of  the  femur  in  children  are  not  uncommon.  In 
those  who  still  wear  diapers,  and  perhaps  in  those  a  little  older, 
these  injuries  may  be  best  treated  by  vertical  suspension,  with  sufficient  weight  to 
overcome  all  shortening.  Here  the  adhesive  strips  and  the  suspending  cords  should 
be  attached  to  both  limbs  alike,  'in  order  to  have  sufficient  access  to  the  perineum,  and 


PVacture 
femur      in 
treated     by 
extension. 


of  tlie 
a     child 

vertical 
(Bryant.) 


516  SURGICAL  AFFECTIONS  OF   THE   TISSUES 

in  order  to  judge  of  the  effect  which  we  are  obtaining.     Figs.  323  and  324  ilhisf  rate  tiiis 
method. 

Phister-of-Paris  dressings  for  fractures  of  the  thigh  appeal  especially  to  those  who  are 
most  familiar  with  the  use  of  the  material.  Some  patients  with  fracture  of  the  neck 
of  the  femur  may  be  early  put  in  the  erect  posture,  upon  an  elevated  surface,  allow- 


Fiacture  of  the  thigh;  vertical  suspension.     The  fracture  is  compound  in  the  patient  on  the  right.     (Stimson). 


ing  the  injured  limb  to  hang  down  while  the  ])atient  rests  upon  crutches.  In  this  upright 
position,  with  the  down-hanging  leg,  to  which  traction  can  be  made  by  an  assistant,  a 
plaster-of-Paris  spica  may  be  applied,  extending  from  the  waist-line  down  to  or  below 
the  knee.  As  a  limb  is  thus  drcs.sed  so  it  will  heal,  and  it  is  of  importance  that  complete 
reduction  be  efi'ected  as  a  part  of  the  procedure. 


FRACTURES  OF  THE  PATELLA. 

During  the  active  period  of  micklle  life  the  i)atclla  is  the  bone  most  frequently  broken 
by  muscular  violence.  In  many  cases  it  is  })ractically  cracked  over  the  condyles, 
as  one  would  crack  a  piece  of  wood  over  the  knee.  If  direct  force  l)e  apjjlied,  as  by  a 
fall,  in  connection  with  the  above,  the  efl'cct  is  even  more  marked.  In  such  cases  the 
fracture  is  sometimes  comminuted  (Fig.  325),  or  the  line  of  fracture  niay  run  more  or 
less  perpeiidicularly  rather  than  horizontally.  Ordinarily,  however,  these  fractures  are 
transverse,  while  the  ujiper  fragment  is  ])ullcd  U])war<l,  sometimes  to  a  considerable 
distance,  by  the  powerful  extensors  of  the  leg.  When  the  fracture  runs  vertically  the 
displacement  is  very  slight.  Occasionally  these  fractures  are  comjiound,  a  most  unde- 
sirable complication,  since  the  knee-joint  is  thus  exposed  to  infection,  from  which  it 
suffers  unless  first  attention  be  prompt  and  scientific.  There  is  usually  sufficient 
hemorrhage  to  distend  the  joint  cavity,  and  it  may  at  first  be  quite  impossible  to 
bring  the  fragments  near  enough  to  each  other  to  get  cre])itus,  but  the  loss  of  the  power 
of  extension  and  the  evident  gap  l)etwecn  the  fragments  will  serve  to  make  diagnosis 
positive,  at  least  in  all  transverse  fractures.  A  vrrfical  fractm-e  without  much  separation 
is  a  milder  form  of  injury  which  may  be  regartled  in  a  nuich  more  favorable  light 
(Figs.  326,  327  and  328).  ' 

In  these  transverse  fractures  it  is  rare  that  l)ony  union  can  be  secured  by  non-o})erative 
methods.  This  is  not  only  because  of  the  difficulty  in  maintaining  parts  in  apposition, 
but  because  it  is  notably  the  case  that  fragments  of  periosteum  or  other  tissue  drop  in 
between  bony  surfaces  and  tend  to  prevent  their  actual  contact,  no  matter  how  firmly 
they  may  be  pressed  toward  each  other.  Osseous  imion  then  tnay  occur  without  opera- 
tion, but  is  rare.  The  best  that  can  be  expected  is  fibrous  vmion,  the  intervening  fibrous 
band  being  short  or  long,  according  to  the  success  met  with  in  treatment  and  to  th^ 


FRACTURhS  OF   TIIK   1' AT  HI. I.  A 


517 


ninoiiiit  (>r  strain  later  put  ii|)(>ii  il  Ky  loo  cai'lv  use  of  tlic  liiiil).  l*'\cii  willi  (wo  inclics 
of  lihroiis  tissue  iulcrvcuiu^'  patients  are  not  completely  disabled.  The  usefulness  ol" 
a  Hull)  under  these  eonditions,  however,  is  seriously  impaired.  Somethin<^  will  dep(«nd, 
also,  on  the  extent  to  which  the  joint  capsule  and  the  a|)oneni-osis  terniinatin;^  the  vasti 
mu.sele.s  may  luive  snil'ered. 

Treatment. — 'I'he  non-operative  treatment  consists  in  |)lacin<i;  such  a  limh  upon  a 
sin<;le  inclined  |)laiie,  for  the  purpose  of  relaxiuf^  (he  (|uadrice|)s  exten.sor  (ijroup.  In 
this  position  the  linih  should  he  maintained  for  at  leas(  from  (en  (o  fourteen  days.  Some 
expedient  should  he  added,  so  soon  as  sw(-llin<:;  has  subsided,  hy  which  the  upj)er  fragment 
can  be  coaxed  downward  toward  its  fellow.  A  neatly  molded  splint,  formed  out  of 
gutta-percha  or  of  plaster  of  Paris,  may  he  fitted  to  (he  thigh  above  the  fragment,  held 
in  position,  and  then  drawn  downward  by  elastic  traction  on  either  side  of  the  leg,  the 
principle  of  traction  being  thus  given  a  special  application.  Something  of  this  kind  should 
be  done  if  (he  fragments  are  to  be  approximated  to  each  other. 


Fig.  325 


Fig.  326 


Fig.  327 


Fi(!.  328 


Comminuted  fracture. 


Stellate  fracture  of  the  patella. 
(Jirichsen.) 


Fracture  of  patella, 
united  by  ligamentous 
tissue.     (Erichsen.) 


Side  view  of  same. 


The  more  completely  mechanical  method,  partaking  of  the  operative,  is  afforded  by 
the  use  of  certain  hooks,  whose  points  are  permitted  to  pass  through  the  skin  above  and 
below  the  fragments  and  to  engage  in  the  bone.  By  a  screw  mechanism  these  points  are 
drawn  toward  each  other,  and  thus  approximation  is  effected.  This  method  was  first 
devised  by  Malgaigne  and  is  usually  known  under  his  name,  although  his  device  has 
been  much  improved.  This  is  far  from  ideal,  and  yet  has  given  good  results  in  some 
ca.ses.  The  surgeon  should  constantly  guard  again.st  infection  through  the  punctures. 
_  By  far  the  most  ideal  method,  when  it  can  be  suitably  carried  out,  is  the  open  opera- 
tion, a  transverse  incision  being  made  across  the  front  of  the  joint,  which  is  completely 
opened;  this  affords  an  opportunity  to  empty  out  clots  and  to  thoroughly  cleanse  it, 
which  of  itself  is  a  great  advantage,  since  these  clots  often  produce  subsequent  adhesions. 
The  exposed  surfaces  may  now  be  freed  from  clot  and  all  soft  tissue,  or  they  may  be 
neatly  sawed  as  near  to  the  fractured  surfaces  as  possil)le,  the  intent  being  to  permit 
them  to  come  into  absolute  and  complete  contact,  and  to  hold  them  there  by  wire  or 
other  sutures,  for  a  length  of  time  sufficient  for  absolute  bony  union.  When  })ro[)erly 
performed  this  operation  gives  ideal  results;  it,  of  course,  exposes  to  great  danger  if 
improperly  done. 

Treatment  by  non-operative  method  rarely  affords  a  useful  member  under  an  average 
period  of  from  thirteen  to  fourteen  weeks,  while  the  operative  method  |)ermits  a  reduction 
of  this  time  to  less  than  half.  It,  therefore,  has  obvious  advantages  for  those  (e.  g., 
laboring  men)  to  whom  time  is  of  great  importance.     The  operation,  however,  is  not 


518 


SURGICAL  AFFECTIONS  OF   THE   TISSUES 


to  be  practised  as  a  rude  emergency  affair,  but  only  when  we  may  be  absolutely  certain 
of  everything  pertaining  to  aseptic  technique.  After  operation  it  is  rarely  necessary 
to  use  a  drain,  and  such  a  limb  can  usually  be  dressed  in  a  plaster-of-Paris  splint.  Com- 
pound fractures,  however,  will  probably  need  drainage  at  least  for  a  day  or  two,  and 
because  of  this  need  may  as  well  be  operated  at  once.  In  comminuted  frachtres  the 
method  is  desirable,  since  by  a  loop  or  by  some  other  expedient  fragments  can  be  held 
together  as  in  no  other  way  (Figs.  329  and  330). 


Fig.  329 


Fig.  330 


Wiring  patella      (Lejars.) 

Injuries  to  the  patellar  region,  equivalent  to  fractures,  are  separationf!,  either  of  the 
tendon  from  the  bone,  or  of  the  bone  from  the  ligament  vi'hkh  holds  it  to  the  tibia.  Such 
injuries  can  be  recognized  by  the  fact  that  the  contour  of  the  bone  itself  is  preserved;  in 
the  former  case  it  is  not  drawn  up,  although  the  extensor  muscles  have  lost  their  power 
while  in  the  latter  it  is  drawn  up,  leaving  a  well-marked  gap  below  it. 

Remarks  concerning  the  treatment  of  fractures  apply  equally  here.  Choice  can  be 
made  between  the  operative  and  the  non-operative  treatment.  In  well-selected  cases  the 
former  seems  much  the  more  desirable,  the  fibrous  end  of  the  tendon  or  ligament  being 
held  to  the  bone  by  strong  sutures  of  silk  or  wire. 


THE  LEG;  FRACTURES  OF  THE  TIBIA. 

The  head  of  the  tibia  is  occasionally  broken  as  the  result  of  extreme  violence,  the 
fragment  being  usually  held  reasonably  in  place  by  one  or  other  of  the  lateral  ligaments. 
Hemorrhage  into  the  joint  will  be  profuse,  with  swelling  extreme,  while  disability  will 
be  complete.  Not  a  few  of  these  cases  justify  operation,  directed  toward  opening  the 
joint,  removing  all  clot,  and  fastening  the  fragment  in  place  with  suitable  sutures  (Figs. 
331  and  332). 

Transverse  fracture  below  the  tubercle  is  less  rare.  The  insertion  of  the  terminal  liga- 
ment of  the  quadriceps  extensor  group  will,  in  all  of  these  injuries  to  the  upper  portion 
of  the  tibia,  tend  to  pull  up  the  upper  fragment  and  make  it  project  beneath,  even  pro- 
trude through  the  skin.  Fractures  of  the  lower  part  of  the  tibia  are  freer  from  such 
distorting  influences.  Fig.  333  illustrates  the  distortion  produced  as  above,  while  Fig. 
335  shows  one  of  the  tendencies  in  fracture  of  the  lower  end  of  the  tibial  shaft,  which 
has  to  be  overcome  by  correct  emplacement  of  the  foot  within  the  dressing.  Fig.  334 
illustrates  synostosis  as  the  result  of  fracture  of  both  bones  at  about  the  same  level. 


FRACTURES  OF  TIIF  FIBULA 


519 


Torsion  is  a  factor  of  no  small  impoHaiuv  in  tlir  production  of  most  of  the  fractures  of 
the  Icij:,  to  such  an  extent  as  somelinu^s  (o  n)ake  a  coni|)leteiy  spiral  fracture,  a  con- 
dition <j:(>ncraily  held  to  he  more  serious  than  fracture  of  the  ordinary  type.  The  line 
of  fracture  often  extends  in  such  a  direction  as  to  leave  a  sharj)  spicule  of  hone  close 


Fig.  331 


Fig.  332 


Wiring  tibia.     (Lejars.) 


beneath  the  skin ;  here  rough  handling,  or  carelessly  made  pressure  in  the  dressing,  may 
cause  a  perforation  within  a  few  hours  or  days  after  the  injury,  by  which  a  simple  is 
converted  into  a  compound  fracture.     Such  a  complication  should  always  be  avoided. 


FRACTURES  OF  THE  FIBULA. 


The  lower  end  of  this  bone  is  much  more  often  fractured  than  the  upper,  although  it 
may  be  broken  at  any  point.  Into  its  upper  termination  is  inserted  the  external  lateral 
ligament,  and  this  insertion  may  be  torn  off  from  the  bone  in  cases  of  violent  sprain  of 
the  knee,  damage  occurring  which  is  similar  to  that  which  happens  in  injuries  about  the 
ankle.  The  upper  portion  of  the  bone  lies  well  buried  beneath  muscles,  and  fractures 
here  are  not  so  easily  recognized.  A  good  maneuver  for  their  recognition  is  to  seize 
the  bones  at  the  lower  portion  of  the  leg  and  press  them  together;  if  such  pressure  gives 


520 


SURGICAL   AFFECTIONS  OF  THE  TISSUES 


severe  pain  above,  or  if  it  be  shown  that  the  fibuhi  is  more  movable  than  natural,  fracture 
may  be  practically  diagnosticated,  even  though  crepitus  be  not  detected.  A  skiagram 
would,  of  course,  clear  up  such  a  diagnosis. 

Fractures  of  both  bones  of  the  leg  occur  almost  as  frequently  as  of  either  alone,  usually 
as  the  result  of  direct  violence,  with  or  without  more  or  less  torsion;  as,  for  instance, 
when  the  foot  is  more  or  less  entangled,  and,  at  the  same  time,  twisted  at  the  time  of 
injury.  These  (lou])le  fractures  are  by  no  means  necessarily  placed  ujion  the  same  level; 
thus  the  til)ia  may  be  broken  low  down  and  the  fibula  high  up,  so  high  indeed  that  the 
latter  fracture  may  escape  observation.  With  fracture  of  both  bones  disal)ility  becomes 
complete,  while  shortening  is  very  likely  to  occur,  all  the  muscles  passing  from  the  leg 
to  the  foot  conspiring  to  this  effect.  These  fractures,  moreover,  are  often  comminuted 
and  compound,  sometimes  to  an  extent  necessitating  exsection  of  fragments  or  of  an  inch 


Fig.  33.3 


Fifi.  335 


(  i 


J 


Fracture  of  upper  end  of 
tibia. 


Transverse  fracture,  with 

anterior  displacement. 

(From  the  Buffalo  Museum.) 


Line  of  fracture  at   junction  of 
lower  and  middle  thirds  of  tibia. 


or  more  from  the  .shaft  of  each  bone.  In  ex.section  of  the  tibia  an  equivalent  amount 
should  for  obvious  reasons  be  taken  from  the  fibula.  Displacements  are  extremely 
likely  to  occur,  and  in  every  compound  fracture  the  presence  of  the  opening  may  be 
utilized  for  the  emplacement  of  sutures  or  suitable  means  for  enforcing  appro .ximat ion. 
Indeed,  other  means  failing,  resort  may  be  had  to  this  measure  in  order  to  secure  an 
ultimately  good  result. 

While  wire  sutures  may  be  used  as  freely  as  may  be  indicated  it  will  })e  well,  at  least 
in  the  majority  of  cases,  to  leave  the  ends  protruding  in  such  a  way  that  they  c-an  later 
be  untwisted  and  removed.  The  presence  of  wire  after  a  certain  length  of  time  rather 
interferes  with  the  process  of  ossification  than  helps  it. 

Fractures  of  the  lower  end  of  the  leg  nearly  always  involve  the  joint,  to  some  extent 
at  least,  in  respect  of  being  accompanied  by  sjirain  if  nothing  el.se.  They  are  accom- 
panied by  displacement  of  the  foot,  and  are  produced  by  violence,  which  first  involves 


FRACTURES  OF  THE  FIBULA 


521 


thr  foot.  The  term  " P(,it'.s'  jrartan''  is  iiicant  to  iiicliidc  tlic  injiirv  ori<i;iii:illy  (Icscrihcd 
by  Pott  hinisi'lf.  In  the  ty|)iful  I'ott's  frjutuiv,  us  shown  in  Fij^s.  WM)  and  'XM ,  there  are 
a  ehippini:^  ott'  of  the  internal  niaUeolus,  of  the  outer  portion  of  the  articular  end  of  the 
tibia,  and  fraeture  of  the  fibula  a  little  above  the  joint.  In  spite  of  the  ela.ssical  descrij)- 
tion  whic-h  l\)tt  tjave  fractures  of  the  fibula  alone,  those  accompanied  by  tearing  of  the 
internal  lateral  ligament,  or  (•hi|-j)ing  oH'  of  the  malleolus,  are  frequently  ref(Tred  to 
under  the  same  term.  The  more  c()m|)lete  the  injury  the  greater  the  ])ossibility  for  di.s- 
placement.  Kversion  and  outward  (lis])lacemenl,  of  course,  are  cons|)icuous.  I^^sser 
degrees  of  injury  are  accompanied  by  less  displacement,  but  all  of  these  injuries  will 
be  followed  by  extreme  swelling  of  the  ankle-joint,  which  may  at  first  make  diagnosis 
somewhat  difficult,  because  of  the  extreme  tenderness  which  prevents  the  handling 
necessary  for  careful  determination.  It  is  not  always  easy  to  so  completely  re])lace  the 
bones,  when  we  have  the  comljination  of  three  fractures  as  above,  as  to  get  an  ideal  result. 
Nevertheless  with  suitable  treatment  usually  very  useful  limbs  are  secured.     When  the 


Fig.  336 


Fig.  337 


Pott's  fracture.     (Hoffa.) 


Exaggerated  deformity  in  Pott's  fracture. 


iniurv  has  been  made  compound  the  difficulties  are  increased.  Such  a  result  will  not  be 
obtained,  however,  unless  the  tendency  to  backward  and  lateral  displacement  be  over- 
come, when  the  limb  is  placed  in  its  permanent  plaster-of-Paris  sphnt,  as  it  should  be 
after  a  few  davs.     Great  care  should  be  given  to  this  point  in  the  management. 

Treatment  of  Fractures  of  the  Leg.— Nearly  all  these  fractures  are  hkely  to 
be  followed  bv  swelling,  even  to  a  degree  which  makes  it  impracticable  to  put  them  up  m 
permanent  dressing  until  the  swelling  has  subsided.  This  means  a  period  of  two  to 
several  davs,  during  which  the  limb  should  be  kept  absolutely  at  rest,  and  the  bones 
maintained  in  apposition  bv  side  splints,  while  the  limb  is  restrained  within  a  folded 
pillow  or  other  comfortable  cushion.  ISIore  frequently  here  than  in  any  other  part  ot 
the  bodv  there  will  form  l)lebs  or  large  blisters,  which  are  most  liable  to  occur  in  alcoholic 
subjects.  The  leg  should  be  scrubbed  and  shaved  before  putting  on  dressings,  in  order 
that  the  skin  may  be  reasonably  clean  before  its  surface  epithelium  is  raised,  hcchv- 
mosis    infiltration,  and  sometimes  general  edema  may  become  somewhat  pronounced. 


522  SURGICAL  AFFECTIONS  OF  THE  TISSUES 

and  the  splint  which  wouhl  l)o  required  to  fit  a  linil)  under  these  eireumstanees  would 
soon  he  too  large  when  this  disturbance  has  subsided.  Tiie  linil)  should  not,  therefore, 
be  placed  in  a  fixed  or  permanent  dressing  until  it  is  in  every  respect  ready. 

While  these  disturbances  are  subsiding,  or  perhaps  being  encouraged  to  subside  by 
the  use  of  an  ice-bag  or  of  cold  wet  apj)lications,  extreme  care  should  ])e  taken  that 
proper  position  and  aj)position  are  maintained.  This  will  at  times  need  considerable 
ingenuity.  A  delirious  or  maniacal  patient  would  need  restraint  far  beyond  that  required 
for  one  who  is  rational  and  docile.  Moreover  in  all  of  these  fracture  cases  which  entail 
confinement  to  bed  there  Is  a  tendency  to  deficiency  of  elimination  which  will  require 
judicious  use  of  laxatives  and  other  eliminatives. 

The  writer  prefers  a  well-molded  set  of  side  splints,  properly  padded,  to  any  other 
first  dressing  for  fractures  of  the  leg.  A  limb  thus  dressed  may  he  supported  on  a  pillow 
and  even  made  adaptable  for  transportation  should  it  be  necessary  to  remove  the  patient 
from  one  place  to  another.     The  fracture  box  can  be  well  superseded  by  this  method. 

So  soon  as  swelling  has  subsided,  plaster  of  Paris  should  be  used  for  a  fixed  dressing. 
The  limb  should  be  enveloped  in  a  layer  of  cotton,  by  which  the  skin  is  protected,  within 
which  swelling  may  occur  without  much  strangulation.  Over  this  and  down  the  front 
of  the  leg  a  strip  of  thick  pasteboard  should  he  ])laced,  which  can  be  moistened  and 
made  to  adapt  itself,  or  a  strip  of  sheet  tin,  an  inch  wide,  which  can  be  made  to  fit  the  part, 
and  u{)on  which  one  may  cut  down  later  in  removing  the  splint.  This  refers  especially 
to  the  use  of  the  roller  bandage  saturated  with  plaster  of  Paris.  Molded  splints  can  be 
made,  as  recommended  for  the  upper  extremity,  out  of  surgeons'  lint,  canton  flannel, 
or  old  blanketing,  while  at  the  lower  end  of  these  splints  may  be  incorporated,  with  the 
plaster,  a  strip  of  bandage  or  other  material,  by  which  a  loop  is  formed  beneath  the  foot, 
which  may  be  utilized  for  the  ])urpose  of  traction. 

The  foot  should  cdicaijs  he  placed  at  a  rif/ht  atigle  to  the  leg.  If  there  be  too  much  muscle 
spasm  to  permit  this,  or  make  it  too  uncomfortable,  the  tendo  Achillis  may  be  divided. 
This  position  should  be  maintained  during  the  period  of  re])air,  in  order  tliat  so  soon 
as  one  resumes  the  use  of  the  liml)  the  foot  may  be  planted  naturally  upon  the  ground. 
In  addition  to  this  precaution  it  must  be  noted  that  backward  displacement  is  completely 
overcome,  and  that  eversion  is  perhaps  a  trifle  overcorrected. 

In  all  fractures  of  the  lower  end  of  the  leg  the  foot  and  entire  leg  should  be  enclosed 
in  a  bandage.  In  fractures  near  or  above  the  middle  not  only  the  leg  but  the  lower  part 
of  the  thigh  should  be  immobilized  if  the  promptest  and  most  satisfactory  results  are  to 
be  oljtained. 

The  limb  being  immobilized  it  soon  becomes  a  question  as  to  how  quickly  the  patient 
can  leave  the  bed  and  begin  to  move  about  on  crutches.  This  will  depend  to  some  extent 
on  the  patient's  temperament.  Timid  women  are  less  desirous  of  getting  out  of  bed 
than  are  active  men  and  children.  Some  patients  accjuire  facility  with  crutches  very 
slowly.  Others  are  so  tenderly  built  that  crutches  give  pain  and  even  produce  crutch 
paralysis.  It  is  advisable  to  get  patients  at  least  into  the  sitting  posture  so  soon  as 
the  immobilization  has  been  secured,  while  those  inclined  may  be  encouraged  to 
use  the  uninjured  limb  and  move  about  with  crutches.  A  foot  and  leg  too  long  kept 
off  the  ground  will  swell  when  again  lowered.  The  later  this  dependent  position  is 
attained  the  greater  the  liability  to  edema.     Patients  should  be  cautioned  about  this. 

The  so-called  amhulatori/  method  of  treatment  has  found  favor  with  some  surgeons. 
This  implies  something  more  than  merely  permitting  motion  with  crutches;  it  means 
really  such  dressing  as  to  permit  use  of  the  injured  limb  in  locomotion.  The  various  forms 
of  splints  used  for  immobilizing  the  limb  in  hi]>-joint  disease  may  be  used  in  this 
way.  A  useful  splint  is  made  with  body  and  perineal  bands,  or  an  inside  steel  bar  with 
ischiatic  crutch  and  a  cross-bar  below  the  sole  of  the  foot,  on  which  the  weight  of  the  body 
may  be  .supported.     This  is  to  be  combined  with  a  plaster-of -Paris  support. 

The  ambulatory  treatment  is  occasionally  of  value,  but  the  advantages  claimed  for 
it   have  not  been  orenerallv  sustained. 


FRACTURES  OF  TIIF  FOOT  523 


FRACTURES  OF  THE  FOOT. 


Tlir  jistrairalus  juul  the  cjilcis  sull'cr  more  often  than  the  other  tarsal  hones,  partly 
because  of  their  size  and  partly  because  they  arc  in  I  he  line  of  transmission  of  force  as 
usually  directed  after  accident.  When  the  ])ostcrior  end  of  the  calcis  is  broken  off  there 
remains  a  frajfnu'iit  whicii  is  easily  jjalpated,  and  which  would  l)e  (hsplaced  backward 
and  u])ward  by  the  tendo  Achillis  were  it  not  for  the  plantar  fascial  fibers  which  are 
inserted  into  it.  The  bone  may  also  be  comminuted,  in  which  case  that  part  of  the 
foot  will  lose  much  of  its  sha|)e  and  distiiu'tive  peculiarities.  The  sole  will  be  flattened, 
but  sweHiufi;  and  hcniorrhaj^e  will  at  first  be  so  threat  that  there  will  be  nuich  difficulty 
in  recogni/.iuii;  the  exact  nature  of  the  injury. 

The  a.siraf/alu.s-  is  usually  broken  by  being  caught  between  the  calcis  and  the  lower 
end  of  the  leg.  It  is  generally  broken  through  the  line  of  its  .so-called  neck.  Not  in- 
frequently one  or  more  of  the  fragments  is  forced  out  of  place,  usually  l)eneath  the 
anterior  tendons.  When  such  extensive  displacement  occurs  the  fragments  should  be 
removed  if  the  fracture  is  compound.  In  both  of  these  bones  results  are  generally 
satisfactory  when  displacement  is  not  marked,  also  after  removal  of  the  entire  astragalus. 
The  foot  and  leg  should  be  immobilized  in  the  best  ])ossible  position,  and  this  can  be  best 
accomplished    within    a    plaster-of-Paris    dressing. 

In  regard  to  the  tarsal  bones,  diagnosis  can  now  be  made  accurately  by  the  use  of  the 
•T-rays.  These  bones,  according  to  Eisendrath,  may  be  fractured  in  any  one  of  the 
folk)wing  w^ays:  (1)  Compression,  as  when  the  weight  of  the  body  is  violently  thrown  upon 
the  feet;  (2)  sudden  dorsal  flexion,  often  with  fracture  of  the  inner  malleolus;  (3)  forced 
supination  or  pronation,  the  interosseous  ligaments  being  stronger,  the  bf)nes  forcibly 
pulling  the  latter  ajmrt;  (4)  violent  traction  upon  the  heel  through  the  calf  muscles,  by 
whicli  the  tuberosity  of  the  calcis  may  be  torn  from  the  rest  of  the  bone;  (5)  extensive 
crushing  injuries,  in  which  several  tarsal  bones  may  be  invtjlved;  (0)  gunshot  fractures. 
Some  assistance  in  diagnosis  may  be  obtained  by  computing  the  distance  from  the 
malleoli  to  the  bottom  of  the  heel,  which  \\\\\  be  shortened  when  the  bones  are  compressed; 
or  shortening  of  the  length  of  the  foot,  or  by  fixed  abnormal  positions. 

The  mrfafarmi  hones  are  broken  by  direct  violence,  the  first  and  fifth  being  most  ex- 
posed. As  in  other  fractiu'es  of  the  foot  contusion  will  be  a  serious  feature,  and  swelling 
and  laceration  will  frequently  seriously  complicate,  while  the  fractures  themselves  may 
be  com])ound.  The  same  is  true,  also,  of  fractures  of  the  phalanges,  crushing  and  com- 
minution being  common.  The  matter  of  treatment  often  includes  an  estimation  of  the 
blood  supply  and  of  the  vitality  of  the  distal  portion.  The  operator  may  sometimes 
temporize  with  an  antiseptic  dressing  until  this  matter  is  settled.  Simple  fractures 
require  only  immobilization  in  good  position. 


CHAPTER    XXXV. 

DISLOCATIONS. 

A  SPRAIN  has  already  been  described  as  a  momentary  change  of  emplacement  or 
disturbance  of  the  normal  relations  Ijetween  joint  surfaces,  which,  so  far  as  displacement 
is  concerned,  is  but  a  momentary  affair  and  is  promptly  overcome.  The  term  dislo- 
cation implies  something  more  permanent  as  well  as  complete  in  both  respects.  It  indi- 
cates an  absolute  and  direct  separation  of  articular  surfaces  of  nuich  more  than  moment- 
ary duration  and  rec|uiring  skilled  assistance  for  its  reduction.  It  pertains  to  articular 
surfaces  which  are  enclosed  within  a  capsule.  The  term  luxation  is  synonymous  with 
dislocation.  When  the  condition  is  evidently  partial  or  incomplete  it  is  often  referred  to 
as  suhhi.rafion.     As  compared  with  fracture  dislocations  are  about  one-tenth  as  frequent. 

Disloc-ations  are  described  as  compound  when  through  a  co-existing  wound  air  may 
enter  the  cavity  of  the  joint,  and  as  complicated  when  accompanied  by  other  lacerations 
or  injuries.     When  unaccompanied  by  these  conditions  they  are  described  as  simple. 

To  dislocations  which  result  from  external  violence  or  from  sudden  muscular  action 
is  given  the  term  traumatic.  Pathological  dislocations  are  those  which  are  brought  about 
by  slow  morbid  processes,  muscle  spasm  being  the  most  prominent  factor  in  their  pro- 
duction. A  third  variety  of  dislocations,  the  so-called  congenital,  do  not  belong  strictly 
in  this  class;  by  common  consent  the  term  is  applied  to  congenital  abnormalities  where, 
from  errors  in  development,  normal  emplacements  and  relations  are  altered. 

The  distal  bone  is  the  one  described  as  that  which  is  dislocated;  thus  we  speak  of  dis- 
locations of  the  forearm  upon  the  arm,  of  the  leg  upon  the  thigh,  etc. 

Subluxations  or  incomplete  dislocations  are  frecjuently  accompanied  by  fracture  of 
a  bony  prominence,  e.  g.,  the  rim  of  the  acetabulum,  the  coronoid  process  of  the  ulna,  etc. 
The  direction  in  which  the  distal  member  of  the  joint  has  been  displaced  is  indicated  by 
one  of  the  common  terms,  as  forward,  inward.  A  consecutive  or  secondary  dislocation 
implies  a  shifting  of  position  from  that  at  first  occupied  by  the  displaced  bone  end. 
These  injiu'ies  may  occur  at  any  age,  although  usually  during  the  more  active  period  of 
life,  from  childhood  to  middle  age,  when  mankind  are  more  subject  to  injuries. 

Certain  conditions  predispose  to  dislocations.  Abnormalities  or  previous  injury  or 
disease  of  joint  structures  figure  especially  in  this  respect.  A  joint  already  relaxed 
by  hydrarthrosis  will  exercise  a  relatively  small  restraining  influence  and  a  subluxation, 
at  least,  may  easily  occur. 

The  immediate  cause  is  violence,  either  from  without  or  within,  generally  the  former. 
This  may  be  direct,  as  from  a  blow,  or  transmitted,  as  when  the  shoulder  is  disjilaced 
by  a  fall  upon  the  open  hand.  It  occasionally  happens  that  the  component  bones  of 
a  dislocated  joint  were  in  a  i)ositi(Mi  of  extreme  flexion  or  extension  at  the  time  of  injury. 
The  factors  of  leverage  and  spiral  tension  or  wrenching  are  also  imj)ortant  ones.  Luxa- 
tion from  muscular  activity  is  occasionally  met  with;  most  frequently  when  the  lower  jaw 
is  dislocated  by  the  act  of  yawning  or  violent  laughter.  The  shoulder  has  been  displaced 
in  a  violent  effort  at  throwing  or  pitching  a  ball,  or  in  wild  gesticulation. 

A  few  individuals  have  been  in  the  habit  of  exhibiting  themselves  whose  normal  liga- 
ment and  joint  arrangements  are  so  lax  that  they  can  voluntarily  displace  one  or  more 
of  them  and  as  easily  replace  them.  These  may  be  spoken  of  as  instances  of  voluntary 
dislocation 

A  joint  once  displaced  may  never  fully  recover  its  normal  degree  of  tension,  and  will 
yield  more  readily  to  subsequent  similar  injuries.  In  this  way  there  may  occur  so-called 
recurrent  or  habitual  dislocations.  Expressions  of  this  kind  are  seen  most  often  in  the 
lower  jaw  and  in  the  patella. 

Actual  injury  to  tissues  is  to  some  extent  unavoidable.  In  arthrodial  joints  the  cap- 
sule is  nearly  always  lacerated,  at  least  upon  one  side.  In  hinge  joints  both  lateral  liga- 
ments are  likely  to  be  ruptured.  It  is  probable,  however,  that  about  the  maxillary 
(524) 


SVAfl'TOMS   AM)  J)IA(;\()SIS  OF  DISIJK'ATIOS S  525 

joints  the  lii;f;iuu-iils  may  slrc'tcli  without  truriiiji;  to  uiiy  extent.  Not  only  arc  iif^anients 
torn,  but  bony  prominences  are  I'retjuently  detached,  while  sometimes  there  is  extensive 
teariufi;  away  of  tissue. 

In  connection  with  these  injuries  to  joints  |)ro|)cr  otiicr  complications  may  occur,  such 
as  fractures  of  i)romincnccs  about  joints  and  cpipiiyscal  separations,  or  such  injuries  as 
compound  fracture  of  the  neck  of  the  humerus  willi  (hshxation  of  its  head.  Further- 
more, bh)odvessels  are  occasionally  lacerated  and  nerves  are  fretjuently  injurc(l.  'i'his 
latter  lesion  is  liable  to  occur  after  shoulder  dislocations,  the  head  of  tiie  ixjue  injuring 
the  circumflex  nerve,  paralysis  of  the  deltoid  being  the  cons(>(juenec.  This  is  a  feature 
of  the  injury,  antl  yet  the  result  has  often  been  unjustly  imputed  to  the  physician  in  attend- 
ance. Even  a  momentary  contusion  of  the  nerve  may  be  followed  by  lasting  effects, 
for  which  the  medical  attendant  should  be  held  blameless.  Other  injuries,  c.  (/.,  con- 
tusions or  lacerations  of  nerves,  may  occur  about  any  of  the  joints. 

Dislocations  of  the  spine  subject  the  cord  to  a  special  class  of  injuries  which  will  be 
dealt  with  later  in  this  work.  In  very  rare  instances  the  head  of  the  humerus  has  l)een 
forced  within  the  thorax  or  the  head  of  the  femur  within  the  pelvis,  these  injuries  being 
practically  always  fatal. 

Compound  tlisloeations  rarely  occur  about  the  jaw  or  shoulder.  They  pertain  usually 
to  the  joints  below.  In  every  case  of  such  character  the  (juestion  will  be  j)romptly  raised 
whether  a  more  or  less  comj)lete  exsection  of  the  joint  will  not  be  preferable  to  mere 
reduction  with  the  ensuing  probability  of  ankylosis.  Such  injuries  will,  under  all  cir- 
cumstatices,  re(juire  ase])tic  measures. 

So  far  as  repair  is  concerned,  dislocations  by  themselves  are  so  rarely  fatal  that  there 
have  been  but  few  opportunities  for  a  study  of  tissue  recovery  under  these  circumstances. 
It  is  apparent  that  repair  is  complete,  for  after  almost  any  simple  dislocation  there  is 
restoration  of  function. 

The  obstacles  to  reduction  are  spasm  of  muscles  pertaining  to  the  injured  limb,  by 
which  the  dislocated  bone  end  is  firmly  held  in  its  abnormal  position,  and,  in  those  joints 
provided  with  a  capsule,  the  fact  that  the  head  of  the  bone  is  frequently  forced  out  through 
a  comparatively  small  opening,  thrf)Ugh  which  it  is  only  with  the  greatest  difficulty  re- 
duced. It  is  a  part  of  the  manijnilation  in  most  cases  to  enlarge  this  rent  in  the  capsule, 
after  which  reduction  is  comparatively  easy,  although  im])ossible  until  it  is  accomplished. 

Dislocations  which  have  long  gone  unreduced  are  called  old,  inveterate,  or  aneietit. 
By  common  consent  a  period  of  six  weeks  has  been  fixed,  beyond  which  the  dislocation 
is  spoken  of  as  old  or  ancient;  up  to  that  time  it  is  usually  described  as  wired ueed.  In 
proportion  to  the  length  of  this  period  the  difficulties  of  reduction  are  materially  enhanced. 
So  soon  as  a  dislocated  joint  has  been  put  at  rest,  i.  e.,  fixed  by  muscle  spasm  and  by 
the  timidity  of  the  patient,  the  blood  which  has  been  poured  out  will  begin  to  coagulate 
and  conditions  are  soon  favorable  for  organization  of  clot  and  formation  of  adhesions 
in  abnormal  position.  In  the  course  of  a  few  weeks  these  adhesions  become  strong,  and 
in  the  course  c^f  months  they  are  frec|uently  strong(>r  than  the  bone  itself,  which  has  been 
disused  and  has  undergone  a  certain  amount  of  fatty  atroj)hy.  Thus  it  happens  that 
even  with  well-directed  effort  the  bone  will  yield  before  the  adhesions,  and  thus,  in  spite 
of  every  precaution,  fracture  sometimes  complicates  the  eft'ort  to  reduce  these  ancient 
dislocations. 

So  generally  is  this  fact  now  recognized  that  surgeons  do  not  hesitate  to  make  open 
incisions  for  the  purpose  of  separating  adhesions  and  reopening  what  remains  of  the 
capsule  in  the  endeavor  to  replace  the  head  of  a  bone.  Nor  do  they  hesitate  sometimes 
to  cut  down  upon  the  latter  and  exsect  rather  than  run  the  risk  of  more  extensive  injury. 

Efforts  at  reduction  under  these  circumstances  subject  the  ])atient  not  only  to  risk 
of  failure,  or  oi  fractiu'e  of  bone  ends,  l)ut  to  ruj>ture  of  v(\ssels  or  laceration  of  nerve 
trunks.  I  recall  seeing  one  case  of  enormous  traumatic  aneurysm  of  the  axillary  artery 
which  was  brought  about  by  unsuccessful  attempt  in  this  direction. 


SYMPTOMS   AND   DIAGNOSIS   OF    DISLOCATIONS. 

The  cardinal  indications  of  a  dislocation  are  deformity  with  alteration  in  contour 
and  position  of  the  affected  joint.  It  usually  happens  that  the  dislocated  bone  ends 
cannot  be  felt  in  normal  position,  but  are  felt  somewhere  else  in  the  vicinity.    About  the 


.520  SURGICAL   AFFECTIOXS  OF   THE   TISSUES 

shoulder  and  hip  of  stout  or  fat  individuals  it  may  not  be  easy  to  feel  the  head  of  the 
bone,  but  unless  the  case  be  ((jniplicated  by  a  fracture  it  can  usually  be  detected  by  aid 
of  anesthesia.  The  deformity  may  include  a  lenrjihening  or  shorteninfj  of  the  limb, 
api)arent  or  real,  as  well  as  abnormal  rrcrsion  or  in  ver.s-ion,  or  other  ixH-uliarity  of  position. 

Whatever  alterations  in  position  appear  will  be  accentuated  by  spasm  of  the  muscles 
which  pertain  to  the  movement  of  the  uifccted  joint  or  even  of  the  entire  limb.  These 
are  usually  so  tightly  contracted  as  to  form  a  complicating  feature  of  such  cases  and  to 
lead  to  that  loss  of  mobility  which  is  diagnostic  of  every  dislocation.  Limitation  of 
motion  is  not  entirely  a  matter  of  muscle  spasm.  It  is  not  under  voluntary  control  and 
subsides  only  under  anesthesia.  To  some  extent  motion  may  be  limited  by  escape  of  the 
head  of  a  bone  through  a  small  rent  in  the  enveloping  capsiale,  by  which  "it  is  afterward 
tightly  dasfx-d.  This  is  panicularly  true  of  the  shoulder  and  hip.  Certain  dislocations 
of  the  fingers  or  thumbs  are  also  made  more  rigid  by  fixation  of  the  tendons,  which  become 
tightly  stretched  within  the  neighboring  tendon  sheaths. 

A  sort  of  crepitus,  which  may  be  easily  mistaken  for  tliat  (A  fracture,  is  occasionally 
detected  during  the  examination  of  a  dislocated  joint.  It  lacks  the  peculiar  grating 
character  of  true  bony  crepitus. 

In  addition  to  these  features  there  are  certain  subjective  .symptoms,  of  which  loss  of 
function  is  the  most  prominent,  while  pain  is  a  more  or  less  frequent  but  variable  accom- 
imniment,  and  dependent  on  the  amount  of  tissue  injury  or  pressure  upon  nerves.  More- 
over, the  displacement  once  completely  rectified  ("reduced")  does  not  tend  to  recur,  as 
is  the  case  with  fractures. 


PATHOLOGICAL    AND    CONGENITAL   LUXATIONS. 

The  .statements  made  above  refer  almost  entire  ly  to  ret  cut  and  traumatic  dislocations. 

Patholor/irn/  dislocations  are  those  which  are  produced  gradually  and  through  the 
mechanic]!  of  disease  affecting  the  joint  structures.  The  head  of  the  bone  is  gradually 
drawn  out  of  the  acetabulum,  in  tonic  spasm  of  hip-joint  disease,  by  the  continuous  action 
of  muscles,  the  result  being  the  complete  displacement  of  the  "bone  from  hs  original 
socket,  or  what  is  known,  at  the  hip,  as  the  migration  of  the  arcfahulum,  where  its  upper 
margin,  being  softened  by  disease,  is  gradually  extended  and  altered,  so  that  the  femoral 
head  rests  an  inch  or  more  higher  upon  the  side  of  the  pelvis  than  is  normal.  Patho- 
logical dislocations,  then,  may  occur  both  in  the  course  of  the  infectious  joint  diseases 
as  well  as  in  the  neuropathic. 

Congenital  luxations  are  those  which  occur  from  defect  in  the  shape  or  arrangement  of 
joint  structures,  permitting  a  departure  from  the  normal  standard.  While  no  joint  in 
the  body  is  exempt  from  abnormalities  of  this  description,  the  congenhal  hip  disloca- 
tions are  tho.se  which  have  attracted  attention  by  their  frequency  and  the  disability 
whieh  they  produce. 

W  liile  the  general  character  of  these  changes  is  easily  made  out  by  the  ordinary  methods 
of  examination,  coupled  with  a  suitable  history,  a  well-made  skiagram  will  tell  at  a  glance 
a  .story  which  it  may  take  some  effort  to  elicit  by  other  means;  hence  radiography  has 
here  been  of  great  value  to  the  surgeon.  Congenital  dislocations  are  devoid  of  nearly 
all  the  features  which  charac-terize  traumatic  dislocations,  and  their  consideration  will 
be  found  in  the  chapter  on  Orthopedics. 

Differential  diagnosis  as  hetuseen  fractures  and  dislocations  is  not  always  easy.  Further- 
more it  is  frequently  the  separation  of  a  prominence  bv  fracture  which  permits  of  dislo- 
cation, this  being  panicularly  true  of  the  elbow  and  the  ankle.  The  extent  of  a  fracture 
may  seriously  complicate  the  problem  of  treatment,  as,  for  instance,  Avhen  the  head 
of  the  humerus  is  not  only  dislcK-ated  below  the  clavicle  but  se[)arated  from  the  shaft 
by  fracture  at  the  surgical  neck.  A  dislocation  made  possible  only  by  fracture  will 
not  remain  reduced  as  will  one  which  is  simple  and  uncomplicated,  while' it  will  display 
even  a  greater  amount  of  motility  and  displacement.  Other  complications  may  occur, 
many  of  which  are  common  both  1o  dislocations  and  to  fractures  in  the  vicinity  of 
joints,  .such  as  lacerations  of  bloodvessels  or  ner\e  trunks,  pressure  upon  the  latter, 
compound  injuries  with  infections,  etc. 


1)16L0CATI0.\S  OF    Till-:  LOW  I:R  .1  .\\V 


TREATMENT  OF  DISLOCATIONS. 


527 


The  essential  rcMiiiisitc  of  every  case  is  (•()iii|)ictc  rcduciidti  or  r<'|)la<-cnicnt  of  llie  dis- 
located hone  (lid.  Tlic  earlier  tliis  is  attempted  the  better  the  resuh.  Brief  as  sucli 
a  st;iteineiit  is,  (Hsl()catioiis  fre(|iieiitly  offer  considerable  difKculties,  both  in  reduction 
and  in  inaintenanee  in  pro|)er  position  with  the  necessary  physiolojrical  rest  of  the  injured 
part.  Thus  dislocations  of  the  clavicle,  which  can  hjirdly  occur  without  consid<'rable 
injury  to  the  lipments,  may  be  reduced  with  sli<rht  effort,  but  are  ke|)t  in  place  with  diffi- 
culty .  The  simplicity  of  the  after-treatment  is  proportionate  to  the  difficulty  experienced 
in  reduction,  so  that  while  "to  \)n{  the  part  in  place  and  keep  it  there"  sounds  very 
simple,  it  will  often  perj)lex  the  inireiniity  of  the  surji^eon. 

Reduction  havinj^;  been  effected,  rest  is  the  essential  feature  of  the  after-treatment, 
which  should  be  absolute  for  a  few  weeks  and  relative  for  many  months.  Should  reacti(jn 
be  extreme,  ice-cold  applications  will  afi'ord  relief. 

The  causes  which  prevent  reduction  of  dislocation  are  either  those  attributable  to 
ignorance,  carelessness,  or  failure  in  diagnosis  on  one  liand,  or,  on  the  other,  mechanical 
difficulties,  including  "button-holing"  of  the  capsule  around  the  expanded  end  of  a 
bone  or  the  interposition  of  some  of  the  adjoining  tissues.  Dislocations  of  the  class 
referred  to  above  as  unreduced  or  ancient,  ofTer  great  difficulties,  jjroportionate  to  their 
duration,  which  arc  due  to  the  formation  of  adhesions  that  sometimes  take  place  and 
become  very  dense.  Judgment,  skill,  and  effort  are  needed  in  their  management.  A 
dislocation  which  has  become  unreducible  is  only  to  be  treated  by  arthrectomv  and  the 
establishment  of  a  false  joint.  Nevertheless  in  a  small  proportion  of  cases,  especially 
of  the  hip  and  shoulder  dislocations,  the  adhesions  which  first  form  gradually  relax, 
and  in  time  there  is  formed  a  natural  substitute  for  a  joint  which  may  be  regarded  as 
a  nearthrosis,  and  which  will  sometimes  prove  as  serviceable  as  any  result  afforded 
by  arthrectomy.  The  duration  of  time  after  which  reduction  is  impossible  or  imprac- 
ticable varies  so  widely  with  different  cases  that  it  can  scarcely  be  stated.  It  rarely 
is  more  than  a  few  months  and  often  but  a  few  weeks.  It  is  greater  when  it  is  a  ball-and- 
socket  joint  which  is  affected. 

Nearly  everything  that  has  been  stated  in  the  previous  chapter  concerning  compound 
fractures  applies  here  to  compound  dislocations.  They  are  subject  to  the  same  dangers, 
both  of  infection  and  of  injury  to  important  adjoining  structures.  There  is  the  same 
necessity  for  aseptic  management  if  the  case  be  seen  early,  and  for  antiseptic  treatment, 
including  drainage,  if  seen  late.  In  many  instances  there  is  so  much  liability  to  subsequent 
ankylosis  that  the  first  treatment  may  well  he  made  to  include  an  arthrectomv,  or  the 
total  removal  of  a  small  bone,  e.  g.,  the  astragalus.  Fortunately  compound  features  are 
less  frequent  in  dislocations  than  in  fractures. 

SPECIAL  DISLOCATIONS. 

DISLOCATIONS  OF  THE  LOWER  JAW. 

Unless  accompanied  by  fracture  there  is  but  one  direction  in  which  the  condyle  of 
the  inferior  maxilla  can  be  dislocated,  i.  e.,  fonvard.  One  side  or  both  may  be  affected, 
i.  e.,  dislocation  may  be  unilateral  or  bilateral,  the  latter  being  more  frequent.  It  is 
rare  during  the  extremes  of  age,  and  most  common  during  middle  life.  There  is  con- 
siderable variation  in  the  degree  of  tension  of  the  capsule  of  the  maxillary  joint.  In  some 
it  is  so  loose  that  dislocation  may  occur  during  the  act  of  yawning  or  vomiting.  Ordi- 
narily it  occurs  only  as  an  expression  of  violence  from  without.  By  a  blow  which  shall 
thrust  the  jaw  forward,  whether  the  mouth  be  closed  or  open,  the  ramus  may  be  made 
to  carry  the  condyle  over  the  articular  eminence.  The  capsule  is  not  necessarily  torn, 
but  is  always  tightly  stretched,  while  as  a  reflex  result  the  temporal  muscle  is  thrown 
into  a  condition  of  tonic  spasm  by  which  the  jaw  is  fixed  and  firmly  held  in  its  abnormal 
position.  This  produces  the  symptoms,  then,  of  a  more  or  less  widely  opened  mouth, 
with  rigidity  and  inal)ility  to  close  it,  with  protrusion  of  the  chin  and  tense  contraction 
of  the  temporal  muscle,  which  can  be  easily  recognized.     When  the  dislocation  is 


528 


SUm.ICAL   AFFECT  loss  OF    TIJF   TISSUES 


unilateral  the  symptoms  are  essentially  the  same,  save  that  the  protrusion  is  toward  the 
si<le  that  is  injured. 

Treatment. — The  method  of  reduction  is  simple  and  consists  in  depressing  the 
anjrle  of  the  jaw,  while,  at  the  same  time,  the  chin  is  sup])orted  and  carried  Ixjth  upward 
and  backward.  If  temjjoral  s])asm  be  not  too  pronounced  the  reduction  is  rather  easy 
and  may  be  effected  while  the  j)atient  is  seated  in  a  chair,  the  surgeon  standing  in  front 
of  him  and  gras])ing  the  jaw  witli  the  fingers  of  each  hand,  while  the  thuml)  is  utilized 
within  the  mouth  to  press  the  angle  of  the  jaw  downward  and  backward.  At  the  .same 
time  the  fingers  should  lift  the  chin.  The  operator  should  protect  his  thumbs  by  wrap- 
ping them  with  some  material  in  order  that  they  may  not  be  injured  by  the  patient's  teeth. 
Should  muscle  spasm  offer  much  resistance  it  would  be  well  to  administer  nitrous  oxide 


Fig.  338 


Fig.  339 


Reduction  of  dislocation  of  lower  jaw. 

or  one  of  the  other  anesthetics,  at  lea.st  to  the  point  of  primary  anesthesia,  with  sufficient 
rela.xation  of  muscle  to  make  reduction  easy.  When  once  this  has  been  effected  the  lower 
jaw  should  be  bound  to  the  u|)per  and  kept  at  rest  for  at  least  two  weeks.  When  this 
injury  has  taken  place  it  is  likely  to  recur  with  much  less  effort  until  it  becomes  almo.st 
a  habit. 

There  is  a  condition  of  relaxation  of  the  capsule  and  elongation,  with  abnormal 
loosening  of  the  interarticular  fibrocartilagc,  ])eculiar  to  this  joint,  by  which  it  has  too 
free  play,  to  such  an  extent  that  a  clicking  sound  in  its  movements  may  be  frcfjuently 
heard  by  others  than  the  patient.  This  condition  is  either  congenital  f)r  the  result  of 
previous  injury,  and  is  one  for  which  little  can  be  done,  although  this  exj)lanation  should 
be  afforded  to  all  who  suffer  from  it. 

DISLOCATIONS  OF  THE  LARYNX. 

The  rartUacjcs  of  the  larjjnx  are  sometimes  displaced  as  the  result  of  direct  violence 
applied  to  the  anterior  region  of  the  neck.  Almo.st  any  lesion  of  this  character  may  take 
place  between  the  independent  cartilages  of  the  larynx  or  the  attachments  of  the  larynx 
to  the  hyoid.  The  injury  may  simply  give  rise  to  pain  and  soreness,  or  may  cause  so 
much  interior  damage  as  to  be  (|uickly  followed  by  edema  of  the  glottis  and  suffocation. 
If  the  latter  be  impending  a  fiuick  tracheotomy  should  be  done,  after  which  time  may 
be  afforded  for  such  replacement  as  may  l)e  required,  by  mani])ulation,  and  subsidence 
of  swelling  with  relief  from  occlusion  of  the  respiratory  tract. 


DISLOCATIONS  OF  THE  STERNUM. 


The  various  portions  of  the  .sternum,  especially  the  u])])er  and  the  lower,  may  be  dis- 
placed as  the  result  either  of  direct  violence  by  forcil)le  backward  flexion,  or  by  muscular 
action  accompanied  In'  flexion  of  the  trimk  and  neck.  When  the  latter,  it  is  usually 
forward;  when  produced  by  violence,  it  is  usually  backward. 


Disijuwrioss  OF  THE  <j..\\jiL/-: 


529 


'I'licsc  (lisplaci'iiuiits  ari'  soiiuiiiiics  so  easily  reducrd  \>\  im-rc  jjicssurc  as  to  make 
it  almost  iinpossihlr  to  ivtain  tliciii.  At  other  times  anesthesia  with  firm  pressure,  aeeom- 
paiiied  hy  flexion  ofthe  trunk  hackwanl  or  forward,  may  he  required;  reduction  has  been 
possible  soin<"times  only  throu^ii  incision  and  hy  the  \ise  of  instruments  a|)plied  as  levers 
or  hy  the  use  of  a  screw  dri'cn  into  one  ofthe  fra<;ments,  thus  affording,'  a  handle  hv  which 
to  manage  it.  Serious  dislocations  are  fre(|uently  acconi|)anicd  hv  fractures  of  the 
rihs  or  of  the  sternum.  The  same  fixation  of  the  thorax  is  re(|uired  as  in  fractures  of 
these  parts,  ami  should  be  conducted  in  the  simplest  manner  p(jssible. 


DISLOCATIONS  OF  THE  RIBS. 

"^ro  displace  a  rib  from  its  sternal  connections  re(|uires  actual  fracture  of  bone  or 
cartilaije.  Forward  dislocation  at  its  posterior  and  s])inal  connection,  especially  of  the 
eleventh  and  twelfth  ribs,  has  been  (lescril)ed.  (/Onsideral)le  efi'oil  is  necessary  for  its 
production,  and  the  case  should  be  treated  on  its  individual  merits. 


DISLOCATIONS  OF  THE  CLAVICLE. 

Either  end  or  both  ends  of  the  clavicle  may  be  dislocated.  Its  .sternal  end  may  be 
thrown  in  any  direction  })ut  downward ;  its  acromial  end  in  any  directi(jn,  althoujjh  usually 
upward.  Dislocations  (jf  the  sternal  end  can  only  occur  in  con.sequence  of  .serious  damage 
to  the  .sternoclavicular  ligaments,  })ecau.se  of  which,  and  in  the  ab.sence  of  a  socket, 
it  is  extremely  difficult  to  maintain  the  parts  when  restored  to  position.  Violent  back- 
ward traction  upon  the  shoulder  permits  anterior  dis])lacement  when  the  joint  is  thus 
weakened.  Backward  disi)lacement  is  usually  the  result  of  indirect  violence  when  the 
shoulder  is  forced  forward  and  inward,  while  upward  displacement  is  the  result  of  tilting 
which  occurs  Avhen  the  shoulder  is  vio- 
lently depres.sed.  Respiration  is  generally  ^^^-  340 
more  or  less  disturbed,  while  in  backward 
luxations  deglutition  may  be  made  diffi- 
cult and  |)ainful. 

Reduction  is  not  difficult  to  effect,  but 
extremely  difficult  to  maintain.  Pressure 
in  the  proper  direction,  accompanied  by 
traction  upon  the  shoulder,  suffices  for  the 
former.  For  the  latter  there  should  be  a 
combination  of  fixation  of  the  shoulder 
and  arm  with  proper  traction,  and  at  the 
same  time  pressure  upon  the  end  of  the 
clavicle.  For  all  of  the  clavicular  disloca- 
tions the  dressing  and  position  advLsed  by 
Dr.  jNIoore,  of  Rochester,  and  referred  to  in 
the  chapter  on  Fractures  as  his  double 
figure-of-eight,  serves  admirably  for  main- 
taining the  proper  position  of  the  shoulder, 

while  pressure  can  be  made  by  a  pad,  retained  either  by  adhesive  plaster  or  by  some 
further  addition  to  the  dressing  it.self.  (See  p.  494.)  Acromial  dislocation  is  usually 
in  the  upward  direction,  and  is  produced  by  violence  upon  the  shoulder,  which  has 
expended  itself  in  rupturing  ligaments  rather  than  in  fracturing  the  acrcnnion  process. 
The  indication  here  is  to  kec])  the  shoulder  elevated  by  any  dressing  which  will  accom- 
plish the  purjjo.se  and  the  clavicle  bound  down. 

Dislocation  of  both  end.'!,  i.  c,  complete  loosening  of  the  bone,  occurs  occasionally, 
in  which  case  the  indic-ations  already  given  are  reinforced,  while  the  difficulties  of  treat- 
ment are  considerably  aggravated.  Here  the  shoulder  should  be  kept  upw^ard,  outward, 
and  backward,  and  the  clavicle  retained  by  pressure  or  some  other  means. 

Treatment.— Clavicular  dislocations  "  yield  fair  results  to  intelligent  treatment. 
Ideal  results  are  difficult  to  secure  without  cooperation  on  the  part  of  the  patient 
Functional  results,  however,  are  usually  satisfactory. 


Position  of  clavicle  in  <lis;location  of  sternal  end 
ui)ward. 


530 


SURGICAL  AFFECTIONS  OF   TIIF   TISSUES 


DISLOCATIONS  OF  THE  SHOULDER-JOINT. 

The  upper  end  of  the  hunicnis  is  attaclied  to  the  niar<j;iii  of  the  rjlenoid  eavity  by  a 
capsule  which  has  a  certain  de<free  of  elasticity,  and  which  resembles  a  short  section  of 
a  sleeve  or  a  cuft".  It  is  sufKciently  loose  to  jx'rmit  a  wide  ran<j;e  of  motion,  and  were  it 
not  for  the  acromial  process  above  it  there  would  be  as  much  motility  in  the  upward 
direction  as  in  any  other.     It  is  not  the  capsule  which  keeps  the  articular  surfaces 

Fig.  341 


Subcoracoid. 


Subclavicular.  Subspinous. 

Dislocations  of  the  head  of  the  humerus. 


Subglenoid. 


(l')richseii.) 


together,  but  the  tension  of  the  muscles  which  are  wrap])ed  ai'ound  the  shoulder-joint, 
all  of  which  contribute  to  this  effect.  The  glenoid  cavity  is  made  a  more  comj)lete 
socket  by  a  fibrocartilaginous  rim.  Thus  a  certain  degree  of  subluxation  or  dis{)lace- 
ment  may  be  permitted  without  very  serious  damage  to  this  rim  and  capsule,  but  a  com- 
plete dislocation  is  hardly  possible  without  more  or  less  laceration.  The  prominence 
and  exposure  of  the  joint  and  its  natural  freedom  of  motion  hel])  to  account  for  the 
fact  that  more  than  half  of  all  dislocations  occur  here,  and  that  this  rarely  ever  occurs  in 

Fig.  342 


Relation  of  circumflex  nerve  to  the  head  of  the  humeru.s,  explaining  mechanism  of  deltoid  paralysis.     (Marion.) 

children  or  in  the  aged,  in  whom  the  violence  which  may  be  expanded  produces  either 
epiphyseal  separations  or  fractures  of  the  surgical  neck.  The  relation  of  structure  to 
function  also  accounts  for  their  far  greater  frequency  (/.  e.,  four  to  one)  in  men  than  in 
women.  The  influence  of  atmospheric  pressure  should  not  be  forgotten,  as  in  the 
shoulder  this  afl^ords  a  force  of  some  fifty  pounds,  and  in  the  hip  of  nearly  double  that 
amount,  of  pressure. 

For  convenience  of  description,  and  in  the  order  of  their  frequency,  shoulder  dislo- 
cations are  referred  to  as  anterior,  downward,  posicrior,  and  j)ossibly  upward,  when 
combined  with  acromial  fracture.     Anterior  displacements  vary  in  degree,  so  that  they 


Disijxwrioxs  ()!•'  Tin:  sirori.nhh'  joist 


5;]i 


arc  df.scTilK'd  as  .siihcordcoid  or  .s-iihclarictilur.  Coiupk'tt'  (lisplacciiiciil  in  this  dircctioii 
can  only  occur  tliroufjh  a  rent  in  the  anterior  portion  of  the  capsule,  while  the  sub- 
clavicnlar  muscle  is  pushed  away  or  torn.     The  nearer  the  head  ot"  the  hone  rests  to  the 


Vk..  :>A:i 


•Subclavicular  dislocation.     (Lejars.) 


stcrinim  the  greater  the  amount  of  laceration  of  the  cap.sule,  while  its  posterior  portion 
is  either  stretched  tightly  or  torn.  In  aggravated  ca.ses  the  tendon  of  the  biceps  is  also 
torn  out  of  its  groove  (Figs.  341,  343  and  344). 


Fig.  344 


riubcoracoiil  ciislncatiuii.     (Lejars. 


In  the  downward  or  .subglenoid  luxahons  the  capsule  is  lacerated  lower  down.  These 
displacements  occur  when  the  shoulder  has  been  dislocated  with  the  arm  in  the  extended 
and  elevated  i)osition.     Here  the  head  of   the  humerus  is   found  in  the  axilla,  resting 


Fig.  345 


Subglenoid  dislocation.     (Lejars.) 


against  the  border  of  the  scapula,  and  the  axillary  structures,  especially  the  circumflex 
nerve,  usually  suffer,  while  the  external  rotators  are  either  ruptured  or  their  insertions 
detached  (Fig.  345). 


532  SURGICAL   AFFF.CTIOSS  OF   TIIF   TJSSUFS 

The  posterior  or  subspinons  dislocation  is  the  least  common  of  all.  In  its  production  the 
arm  is  apparently  adducted  and  the  elbow  raised.  Here  the  humeral  head  is  found  l)eneath 
the  i)()steri()r  surface  of  the  acromion  or  beneath  the  spine  of  the  scapula  (Fig.  341). 

Symptoms. — The  indications  of  shoulder  dislocation  are  pain;  flafieuing  of  the 
shoulder;  undue  prominence  of  ihe  acromion;  depression  opposite  the  glenoid  cavity,  with 
loss  of  the  rounded  contour  due  to  the  presence  therein  of  the  head  of  the  humerus; 
appearance  of  a  more  or  less  globular  mass  in  the  position  now  abnormally  occupied  by 
the  head  of  the  humerus;  change  in  the  axisoi  this  latter  bone;  inabilitij  to  bring  the  elbow 
to  the  side;  more  or  less  complete  loss  of  function,  and  more  or  less  spasm  of  the  muscles 
about  the  joint.  Owing  to  the  fact  that  the  thorax  presents  a  curved  or  warped  surface, 
to  which  a  straight  line  can  be  tangent  only  at  one  point,  it  results  that  the  hand  of  the 
injured  side  cannot  he  made  to  wrap  itself  over  the  opposite  shoulder  while  its  elbow 
still  touches  the  chest  or  side  (Dugas'  test). 

Diagnosis. — As  between  fracture  and  dislocation  the  surgeon  may  be  greatly  helped 
by  deciding  that  the  head  of  the  humerus  is  still  in  its  proper  poshion;  that  the  deltoid 
is  not  flattened  as  in  dislocation;  that  the  arm  is  shortened  rather  than  lengthened; 
that  motility  is  increased  rather  than  diminished;  that  bony  crepitus  is  usually  ol)tain- 
able,  and  that  replacement,  which  may  be  comparatively  easily  secured,  is  maintained 
only  so  long  as  the  parts  are  held  in  position  by  the  operator's  hands.  An  additional 
sign  of  value  is  the  fact  that  a  straight  edge  cannot  ordinarily  be  made  to  touch  the  tip 

Fig.  346 


Exhibits  a  subcoracoid  dislocation  and  the  position  of  the  patient  in  his  endeavor  to  find  relief  from  pain. 

(Mudd.) 

of  the  acromion  and  the  external  condyle  of  the  humerus  at  the  same  time,  because  of 
the  protrusion  caused  by  the  presence  of  the  head  of  the  humerus  in  its  socket.  When 
the  straight  edge  can  be  so  applied  it  must  be  either  because  the  head  of  the  bone  is  out 
of  the  socket  or  the  upper  end  of  the  bone  broken.  A  still  more  crucial  test  which 
should,  however,  only  be  applied  when  others  prove  unsatisfactory,  may  be  furnished 
by  passing  a  sterilized  hat-pin  through  the  sterilized  skin  over  what  seems  to  be  the 
dis])laced  head  of  the  bone  and  into  the  globular  mass.  Rotation  of  the  humerus 
will  then  cause  its  end  or  head  to  make  an  excursion  which  will  be  quite  distinctive. 

Treatment. — Prompt  reduction  is  the  only  treatment  for  shoulder  or  other  dis- 
locations. This  may  be  first  attempted  without  anesthesia.  Should  muscle  spasm 
prevent  easy  reduction  it  should  be  relaxed  by  an  anesthetic,  for  which  purpose  nitrous 
oxide  will  often  suffice.  In  the  forward  or  forward  and  downward  dilsocations  it  will 
sometimes  be  sufficient  to  sim])ly  make  firm  traction  in  a  direction  obliquely  outward 
and  upward,  with  rotation.  When  this  is  insufficient  it  may  be  assumed  that  there 
is  more  or  less  laceration  of  the  capsule  and  entanglement  of  the  head  of  the  bone, 
as  well  as  that  it  is  caught  around  the  border  of  the  glenoid  cavity,  against  which  it  is 
firmly  held. 

The  above  simple  maneuver  failing,  the  luxation  is  to  be  reduced  by  a  more  scientific 
manipulation,  in  which  traction  figures  largely,  the  method  now  generally  in  vogue 
being  that  suggested  by  Kocher,  by  which  rotation  and  leverage  are  added  to  traction, 
and  a  minimum  of  power  made  to  do  a  maximum  of  good.     Kocher's  method  is  especially 


DISLOCATIONS  OF   THK  SIIOVLDKR  JOINT 


i33 


applicahle  to  the  antrrior  disphicctiKMits.  It  consists  ol"  a  triple  niaiiipulation  whose 
three  stages  are  portrayed  in  Fifjjs.  347  to  34'.).  The  lirst  proce(hire  is  to  flex  the  forearm 
to  a  right  angh'  with  the  arm,  apply  the  former  (irmly  to  the  side,  and  then,  while  keeping 
the  ell)ow  at  the  side,  foreihly  rotate  the  limb  outward  until  the  forearm  points  away 
from  tiie  body  (Fig.  348).     This  having  been  done  the  arm  is  abdueted  and  the  elbow 

Fio.  348 


Fio.  347 


First  position  in  Kocher's  rotation  method. 


Arm  is  being  carried  forward  and  upward  toward 
second  position. 


Fig. 349 


moved  upward  until  the  limb  is  in  the  horizontal  ])lane  of  the  shoulder,  the  scapula 
being  held  firmly  during  tiiese  movements,  as  shown  in  Fig.  348.  After  the  arm  has 
been  brought  to  the  level  of  the  shoulder  it  is  rotated  inward  and  brought  downward 
by  a  process  of  circumduction,  the  elbow  being  made  to  describe  some  part  of  the  are 
of  a  circle  as  it  comes  down.  The  displaced  head  should  slip  into  place  during  this 
movement,  and  will  do  so  unless  the  capsular 
tear  is  too  small.  In  that  case  the  movements 
should  be  repeated,  perhaps  with  more  force, 
until  the  opening  is  sufficiently  enlarged  to  per- 
mit the  button-hole  in  the  capsule  to  slip  over  the 
head  of  the  bone. 

This  method  of  manipulation,  wnth  such  modi- 
fication as  circumstances  may  require,  or  such 
addition  as  pressure  with  the  hand  or  fingers  of 
the  assistant,  has  superseded  all  the  older  more 
crude  and  forceful  methods,  and  proves  sufficiently 
applicable  for  all  cases.  It  is  assumed  that  the 
o{)erator  has  sufficient  judgment  to  modify  any 
method  to  fit  the  exigencies  of  a  given  case,  else 
he  should  not  proceed  with  it.  For  instance,  in 
the  axillary  dislocations  upward  traction  affords 
valuable  assistance.  In  the  subspinous  form 
the  arm  is  raised  to  a  level  while  extension  is 
made  upw^ard  and  forward.  In  other  words,  all 
these  methods  depend  upon  the  combination  of 
traction,  rotation,  and  leverage.  The  old  method 
of  Astley  Cooper,  wath  the  foot  in  the  axilla,  the 
shoe  having  been  removed,  coupled  with  trac- 
tion upon  the  arm  and  swaying  movements,  combined  with  rotation,  abduction,  and 
adduction,  may  be  made  efi^ective,  but  is  not  nearly  as  elegant  as  the  simpler  manipu- 
lation above  described.  On  the  other  hand,  old,  unreduced  dislocations,  complicated 
with  adhesions,  are  often  exceedingly  difficult. 

In  rare  instances  dislocations  several  months  old  have  been  reduced  after  adhesions 
have  been  broken  up  bv  more  or  less  violent  manipulations.  When  forcible  eff()rts 
of  this  kind  prove  futile"  fair  restoration  of  function  may  be  obtained  by  maintaining 


Completion  of  third  movement  in  Kocher's 
method. 


534  SURGICAL  AFFECTIOXS  OF  TIIK  TISSUES 

reo;ular  motif)!!,  at  first  passive,  later  aetiv(>,  to  ])revent  reformation  of  adhesions,  the 
head  of  the  bone  grachially  forming  a  new  and  false  soeket  for  itself.  Finally,  the  method 
of  excision  can  be  emj)loyed  should  occasion  demand.  The  experience  of  a  number  of 
surgeons  has  shown  that  in  old  cases,  or  those  impossible  of  reduction  l)y  justifiable 
force,  an  open  division  of  the  joint,  with  severance  of  those  tissues  which  prevent  reduc- 
tion, may  be  profitably,  safely,  and  satisfactorily  practised.  Porter  and  ^IcBurney, 
among  the  American  surgeons,  have  devised  a  corkscrew  instrument  Avhich  may  be 
driven  into  the  head  of  the  bone,  by  which  manipulation  after  arthrotomy  is  materially 
facilitated. 

The  .v'miiltaneovs  occurrence  of  fracture  and  dislocation  has  been  treated  of  in  the  pre- 
vious chapter.  When  difficulty  presents  the  best  result  will  be  obtained  by  open  incision, 
replacement  of  the  head  of  the  humerus,  and  fixation  of  fragments  by  sutures,  wire  or 
otherwise.  If  seen  late  the  upper  fragment  should  be  removed.  The  possibilities  of 
aseptic  surgery  have  led  to  the  abandonment  of  the  old  method  of  first  permitting  the 
fracture  to  unite  and  then  attempting  to  reduce  dislocation. 

Physiological  rest  is  the  essential  feature  of  the  after-treatment  of  all  these  cases,  a 
sling  and  a  retentive  bandage  being  sufficient  for  the  purpose.  Function  shoukl  be 
restored  by  an  increasing  degree  of  motion. 

One  of  the  most  serious  complications  of  shoulder  dislocations  is  deltoid  paralysis 
from  injury  to  the  circumfiex  nerve.  The  momentary  pressure  of  the  head  of  the  bone 
upon  the  nerve  is  sufficient  to  more  or  less  permanently  impair  its  function.  In  its 
medicolegal  aspect  it  should  always  be  maintained  that  the  surgeon  is  never  to  blame 
for  the  accident,  and  is  only  to  some  degree  blamable  in  case  he  has  failed  to  diagnose 
the  dislocation  so  soon  as  opportunity  was  afl'orded  and  has  thus  j)ermitted  prolonged 
pressure  to  possibly  intensify  the  efi'ect  which  has  already  been  produced  by  the  injury.^ 


DISLOCATIONS  OF  THE  ELBOW. 

The  irregularities  of  the  elbow-joint  have  permitted  a  complicated  dovetailing  of  its 
com])onent  parts  which  would  seem  to  make  dislocations  almost  impossiljle  without 
fracture.  Nevertheless,  and  especially  in  the  tender  years  of  childhood,  both  bones 
may  be  dislocated  in  either  direction,  or  either  bone  of  the  forearm  alone  in  any  direc- 
tion save  toward  the  other.  Diagnosis  will  be  greatly  aided  by  observance  of  the 
anatomical  facts  stated  in  the  section  on  fractures  of  the  elbow-joint  and  by  an  estimate 
of  tlie  relative  positions  occupied  by  these  bony  landmarks.  When,  however,  intense 
swelling  prevents  this  then  we  should  either  wait  for  its  subsidence  or  depend  upon  a 
skiagram. 

The  most  common  dislocation  is  that  of  both  bones  bacJcivard,  one  of  the  possible  con- 
sequences of  a  fall  upon  the  extended  arm  and  palm  of  the  hand.  The  coronoid  process 
may  rest  beneath  the  joint  end  of  the  humerus,  making  the  dislocation  incomplete,  or 
back  of  it,  making  it  complete.  If  the  coronoid  process  has  been  broken  oft"  the  dis- 
location can  be  made  and  reduced  as  often  as  desired.  The  fan-sha]:)ed  lateral  ligaments 
are  always  more  or  less  lacerated.  The  arm  will  be  ]iartially  bent  and  there  will  be 
prominent  deformity  upon  the  posterior  aspect  of  the  joint  wliilc  the  axes  respectively 
of  the  arm  and  the  forearm  will  be  somewhat  disturbed.  Usually  the  lower  end  of 
the  humerus  can  be  felt  in  front  of  the  normal  situation  of  the  elbow-joint  (Figs. 
350,  351  and  352). 

Reduction  is  more  or  less  easily  accomplished  by  traction  with  an  easy  movement, 
by  which  the  upper  end  of  the  forearm  shall  be  directed  toward  its  proper  position. 

'  The  shoulder  is  liable  to  numerous  injuries  that  produce  disability.  Pain  in  some  of  these  conditions  may  be 
almost  constant  and  spread  upward  to  the  neck  and  be  aggravated  by  even  passive  motion.  Loss  of  power 
varies  from  moderate  paresis  to  complete  paralysis.  When  the  circumflex  nerve  is  especially  involved  it  is  the 
deltoid  which  shows  the  effects.  More  severe  injuries  may  involve  the  muscles  of  the  arm  and  the  forearm. 
Muscle  atrophy  may  be  greater  than  can  ordinarily  be  accounted  ffir  by  mere  disease.  In  rheumatic  i)atients  a 
dry  synovitis  may  be  added  to  the  other  comiilications.  Most  of  these  features  are  due  to  traumatic  neuritis. 
When  aggravated  they  may  result  from  rupture  of  nerves  or  cicatricial  formations  around  them.  The  best 
treatment  consists  of  immobilization  for  three  or  four  weeks  to  favor  nerve  rei)air,  counterirritation,  especially 
with  the  fl.ving  cautery,  over  the  roofs  of  the  branchial  plexus,  with  massage,  electricity,  an<l  even  deep  injections 
of  strychnine  to  stimulate  the  paralyzed  muscles.  When  paralysis  is  persistent  and  scar  tissue  seems  to  (jress 
upon  nerves,  exposure  of  the  plexus  and  freei-.ig  its  branches  from  all  source  of  pressure  will  be  necessary. 


DISLOCATIOXS  OF   THE  KlJiOW 


535 


Lateral  (li.s-placrnicnt.f  result  also  Iroin  falls  in  cxlrciiu'  j)<)si(ions.  I^ateral  disloca- 
tious  aro  rare  and  the  rcsnlt  of  violence,  and  may  compel  am|)utation.  In  these  cases 
(lie  lateral  diameter  of  (lie  juiiil  is  mai'kedh   increased,  while  the  normal  relaticjn  (jf  the 


I'K,.  3.-)() 


Hackwartl  dislocafion  <if  l»i(li  lirmos.      (T,o.iats.) 


condyles  to  tiie  olecranon  is  greatly  altered.      In  these  cases  movement  is  painful  and 
limited. 

The  ulna  aluuc  may  he  dislocated  backward,  in  which  case  the  orlncular  ligament 


Fig.  o 

..1 

(X. 

(^ 

V 

> 

L 

v^ 

^ 

(  lutwaid  ilisplacenient  of  hntl 


(Lpjars.) 


mu.st  be  lacerated  and  the  upper  ends  of  the  adjoining  hones  forcibly  separated.  The 
Olecranon  will  ])resent  back  of  its  proper  position,  while  the  head  of  the  radius  will  rotate 
where  it  belongs. 

Fi(i.  352 


Dislofafion  furward  and  outwaiil  of  head  of  radius.      (Lejars.) 

Anterior  dislocation  of  both  bones  is  exceedingly  rare  unless  com[)licatcd  by  fractures 
of  the  olecranon.  When  thus  injured  the  forearm  is  lengthened  and  fixed.  The  poste- 
rior surface  of  the  humerus  here  has  only  a  skin  covering,  the  condyles  are  bulging,  the 
olecranon  fossa  empty,  and  the  upper  ends  of  the  forearm  bones  felt  in  front  of  the  elbow. 


536  SURGICAL  AFFECTIONS  OF   THE   TISSUES 

The  head  o]  the  radius  alone  may  l)e  displaced  in  any  direction  save  toward  the  ulna. 
The  forward  dislocation  is  the  most  common,  which  may  he  ])roduced  hv  a  fall  upon  the 
overextended  and  pronated  hand.  'J'he  orbicular  lit^mment  here  is  lacerated  or  the  head 
of  the  radius  is  slipped  out  of  it.  In  the  latter  case  it  may  he  difficult  to  replace  it.  "When 
dislocated  backward  the  capsule  is  torn  posteriorlv  as  well  as  the  orbicular  ligament 
(Fig.  353). 

Fig.  353 


Position  of  the  bones  in  an  old  unreduced  dislocation  forward  of  the  radius.      (I'.richsen.) 

Treatment. — The  treatment  of  elbow  dislocations  is  liased  uj)on  general  and  but 
slightly  differing  principles.  It  consists  of  a  combination  of  traction  with  sufficient 
force,  made  with  one  hand,  while  with  the  other  pressure  should  Ijc  made  upon  one  or 
both  bones  in  the  desired  direction;  at  the  same  time  by  a  combination  of  swaying  and 
rotary  movements  more  or  less  massage  may  be  given  to  the  {)arts,  by  which  complete 
reduction  may  be  more  easily  effected.  Anesthesia  is  nearly  always  necessary,  not 
alone  for  the  relief  of  pain,  but  to  produce  muscular  relaxation,  by  which  manipulation 
is  materially  assisted. 

A  peculiar  form  of  dislocation  of  the  head  of  the  radius  in  young  children  has  received 
considerable  attention.  It  is  produced  by  a  firm  pull  upon' the  wrist  or  f(jrearm,  as  in 
lifting  or  jerking  a  child  by  the  forearm  or  hand.  Pronation  of  the  hand  is  usually 
a  feature  of  the  injury.  It  is  probable  that  the  head  of  the  bone  is  pulled  out  of  the 
orbicular  ligament  and  displaced  forward.  The  forearm  is  slightly  flexed,  movements 
of  the  elbow  are  very  free,  except  that  supination  of  the  forearm  meets  with  resistance. 
The  displacement  is  rectified  by  a  forced  supination  with  traction.  An  epiphyseal 
separation  of  the  head  may  simulate  this  injury.  Such  cases  necessitate  a  few  days' 
rest  in  a  splint,  with  the  arm  flexed  and  supinated,  although  recovery  often  occurs  without 
particular  restraint. 

DISLOCATIONS  OF  THE  WRIST  AND  HAND. 

Wrist  dislocations  are  rare,  the  posterior  being  more  frequent  than  the  anterior.  It 
simulates  the  deformity  of  a  CoUes  fracture,  and  is  produced  in  a  similar  way.  The 
deformity  is  more  marked,  the  outlines  of  the  various  bones  more  distinct,  except  in 
front,  where  they  may  be  masked  by  the  flexor  tendons.  There  is  no  alteration  in  the 
relations  of  the  styloid  processes.  The  forward  dislocation  may  possibly  simulate  Smith's 
fracture,  the  symptoms  being  the  reverse  of  those  above  mentioned. 

Firm  traction,  with  pressure  in  the  proper  direction  upon  the  carpus,  will  suflSce  for 
reduction  of  these  cases.  The  subsequent  dressing  may  be  practically  that  of  a  CoUes 
fracture. 

The  lower  ends  of  the  ulna  and  radius  are  sometimes  dislocated  from  their  proper  rela- 
tions. Reduction  is  easy,  but  rest  and  restraint  are  required  for  some  time  until  the 
ligaments  have  recovered  their  tonus. 

Of  the  carpus  the  os  magnum  is  the  only  one  likely  to  be  displaced,  it  being  occasionally 
forced  backward  so  that  it  forms  a  projection  on  the  dorsum  of  the  hand.  It  requires 
extreme  force  to  displace  the  carpal  bones,  enough  frequently  to  produce  other  injuries 
at  the  same  time,  some  of  which  may  be  compound.  A  carpal  bone  which  cannot  be 
reduced  to  position  by  pressure  may  be  safely  removed  through  an  incision. 

Of  the  carpometacarpal  dislocations,  the  thumb  is  the  most  frequently  displaced, 
usually  in  a  backward  direction.  Traction  and  pressure  suffice  for  its  reduction.  When 
the  bone  is  forced  forward  it  is  usually  as  the  result  of  direct  violence.  Wherever  the 
ba.se  of  the  bone  may  rest  it  is  easily  detected,  while  pressure  with  traction  suffices  for 
its  replacement. 

Of  the  dislocations  of  the  phalanges  upon  the  metacarpus  those  of  the  thumb  are  the 


DIST.nCATinXS  OF   THE   HIP 


537 


Nearly  all  of  (licsc  (lislocatioiis  arc  acconi- 
tiic   (liuiiil)  ari'   (lillicult    oi"   rcdiK-tion;  tliis 


:554 


MetacarpophalanReal  dislocation. 


more  frcfuicnt.     This  may  occur  as  the  result  of  a  fall,  hy  which  the  thuinh  is  forced 

hackwani  iiilo  a  |)osili()ii  of  hypercxtensiou. 

paiiied  by  a  ruj)turc  of  capsule.     Those  of 

appears  to    he  ihie  to  the  tendons  of 

the  short  flexor,  which    surround  the 

head  of   the  nietacar|)al    hone.     Tlie 

sesamoid  hones  also  furnish  a  source 

of  (Hlliculty,   while  the  lon<f  tendons, 

when   contracted    hy    their   respective 

nuiscles,  incri'ase  it  (Fi*;.  ii')!). 

Treatment,  especially  of  the  thumh 
dislocations,  is  facilitated  by  first 
exafigiTating  tiie  abnormal  j)osition, 
then  makinii;  traction  and  pressure  in 
the  proper  direction  at  the  same  time. 
Special  forceps  have  been  devised  for 
seizinfj  and  hoklin<j  the  di<i;its,  or  a 
elove-hitch  can  be  thrown  over  the 
thumb  or    fin<jcr.      Extension  should 

not  be  first  made  in  the  axis  of  the  metacarpal  bone,  but  rather  af  an  ahnipt  anfjlr  in 
it  in  order  to  relieve  the  expanded  phalangeal  end.  The  majority  of  writers  concede 
that  in  some  cases  reduction  is  practically  impossible.  When  effort  has  jjroved  futile 
the  parts  should  be  sterilized  and  incised,  the  incision  being  utilized  for  open  reduction 
or  for  excision,  as  deemed  best. 

Dislocations  of  the  other  phalanges  are  usually  easily  recognized  and  treated  by 
traction  and  pressure. 

DISLOCATIONS  OF  THE  HIP. 

Hip  dislocations  constitute  about  5  per  cent,  of  the  total.  As  they  are  produced  by 
violence  they  are  much  more  frequent  in  men,  and  occur  mostly  Ijetween  the  ag(  s  of 
twenty  and  fifty  years.  Before  the  twentieth  year  epiphyseal  separations  often  take 
place,  while  after  the  fiftieth  year  violence  will  usually  break  the  neck  of  the  femur. 
Nevertheless  dislocations  may  occur  at  any  age.  The  hip  is  a  ball-and-socket  joint, 
with  a  deep  socket  still  further  extended  by  caitilage,  in  which  the  head  of  the  bone  is  not 
only  retained  by  the  ligamentum  teres,  but  by  atmospheric  pressure,  which  in  the  natural 
state  furnishes  a  factor  of  perha])s  one  hundred  pounds.  The  strongest  muscles  and 
tendons  of  the  body  envelop  the  joint.  When  dislocation  occurs  the  cajxsulc  is  usually 
torn  along  its  inferior  aspect.  Tlie  limb  is  usually  in  an  extreme  position,  or  it  would 
require  more  violence  to  tear  the  head  from  the  socket.  The  anterior  dislocations  occur 
during  abduction  without  outw^ard  rotation ;  posterior  dislocations  occur  during  flexion. 
Thus  when  a  person  is  stooping  over  in  work  and  a  heavy  weight  falls  upon  the  back  the 
head  of  the  bone  is  more  easily  pushed  l)ackward,  especially  if  the  feet  be  close  together. 

While  hip  dislocations  are  classified  for  convenience,  and  because  of  their  final  form, 
the  head  of  the  bone  may  rest  upon  almost  any  segment  of  the  margin  of  the  acetabulum, 
though  within  a  short  time  it  will  assume  a  position  justifying  a  designation  as  anterior 
or  j)ostcrior,  meaning  thereby  in  front  of  or  behind  Nelaton's  line.  This  is,  moreover, 
a  convenient  distinction,  as  the  symptoms  vary  between  the  two  groups.  Another 
classification  is  into  the  jorward,  the  backward  or  backward  and  upicard,  and  the  down- 
ward, which  are  again  referred  to  as  iliac,  ischiatic,  dorsal,  and  supracotj/loid  among  the 
posterior,  and  perineal,  obdvraior,  suprapubic,  etc.,  among  the  anterior  (Fig.  355). 

Allis,  howe^er,  has  simplified  the  subject  by  showing  that  all  forms  of  dislocation 
escape  primarilv  from  the  lower  segment,  shifting  their  position  later  either  upward  or 
downward.     He    classifies    them    as    follows: 


1.  Lower  thvroid. 

2.  Middle  thVroid. 

3.  Hig;h   thyroid. 

1.  Low   dorsal. 

2.  Middle  dorsiil. 

3.  High  dorsal. 


All   present   the   fj;eneral   characteristics   of    adduction    and 
rotation  outward. 

.\11    present    the    seneral    characteristics   of   abduction    and 
rotation  inward 


538 


SURGICAL  AFFECT  JONS  OF  THE  TL-^SUES 


The  relation  of  the  so-called  Y-liijaments  to  the  .successful  reduction  of  these  disloca- 
tions, as  well  as  to  their  formation,  is  of  considerable  importance. 

Fig.  850  illustrates  the  manner  in  which  this  ligament  receives  its  name,  it  being  simply 
a  reduplication  of  fibers  which  strengthen  the  capsule  and  which  are  arranged  in  the 
shape  of  an  inverted  Y.     No  matter  how  serious  the  injury  it  is  seldom  entirely  detached. 


Fig.  355 


Upward  anfl  snmpwhat  back-  Backward  toward  Downward  into  Forward  and  upward 

ward  on  dorsum  ilii.  sciatic  notch.  ftjramen  ovale.  on  the  i)ubic  hone. 

Dislocations  of  the  head  of  the  tliigh  bone,  according  to  Astley  Cooper's  classification.      (Krichsen.) 


Fig.  356 


Inverted  Y-ligament. 


While  it  ])revents  too  great  displacement  it  is  of  special  ser- 
vice in  that  it  may  be  made  to  serve  as  a  fulcrum  for  the 
leverage  required  in  certain  manij)ulations.  American  sur- 
geons are  entitled  to  the  credit  for  the  establishment  of  the 
importance  of  this  ligament  in  this  consideration,  and  while 
Bigelow's  name  is  most  prominently  mentioned,  the  names  of 
Gunn,  of  Chicago,  and  Reid  and  ^loore,  of  Rochester,  New 
York,  deserve  almost  equal  prominence,  not  only  for  their 
anatomical  studies,  but  for  working  out  the  entire  method  of 
manipulation  which  has  completely  supplanted  the  old  and 
more  violent  methods  in  wliich  the  use  of  ])ulleys  and  tackle 
was  not  infrequent.  The  Jarvis  "adjuster,"  a  powerful 
mechanism,  which  was  formerly  employed  for  this  purpose,  is 
not  now  seen  except  in  museums. 

Symptoms  and  Signs. — These  vary  decidedly  in  the  differ- 
ent forms.  In  every  case  where  the  head  of  the  l>one  rests  on  a 
higher  level  than  the  acetabulum  there  will  be  shortening.  In 
nearly  every  instance  a  certain  degree  of  flexion  is  present.    In 


DlSLnCATfOXS  OF   TffK  HIP 


539 


aiiU'i-Ior  (lis|)l;ict'incnt.sflu'r(>  is  ociicially  alxluctidii  and  oulwani  rotation.  When  the  head 
of  the  hoiii'  is  Ix'iicath  (lie  piihcs  or  in  the  ohiiirator  foraincii  tlic  iiinh  may  l)c  Iciiji-tliciicd 
as  well  as  flexed,  wliili'  the  (iDehanter  is  shifted  to  a  eorres|)on(hii<rIy  lower  position.  In 
most  instances  (he  hc-ad  of  the  hone  can  he  felt  in  its  ahnormal  position,  and  nms(le 
spasm  is  always  a  pronounced  feature,  especially  when  there  is  actual  eloufjation  and 
muscles  are  really  stretched.  In  the  l)ackvvard  displacements  adduction  and  inward 
rotation  are  the  conspicuous  features,  the  reverse  of  those  of  forward  dislocation.  When 
the  head  of  the  bone  is  actually  in  the  ischiatic  notch,  and  even  when  it  is  on  the  dorsum 
of  the  ilium,  the  limb  is  th(>  more  (Icxed,  wiiile  the  trochanter  will  be  found  above  Nc|a- 
ton's  line.  Fi<i;s.  Wl'u  and  ',\r)S  illusti-ate  the  two  types  of  anterior  and  posterior  displace- 
ment, with  tlu;  usual  and  i)redoniinatin<>^  postural  features,  while  Fi<rs.  '.\')\),  ;{(•(),  'M\\  and 
'M)l  (from  Lcjars)  |)<)i'tray  the  anatomical  features  of  the  four  |)rincipal  fyp(  s  in  <rraphic 
form.     By  these  can  be  determined  the  class  to  which  the  dislocation  belongs. 


Fig.  357 


Fig.  358 


r 


Anterior  di.sloeatinn  of  head  of  femur.      (Lejars.)  Posterior  dislocation  of  liead  of  femur.     (Lejars.) 

This  classification  into  the  anterior  and  posterior  seems  to  the  writer  to  simplify  the 
general  subject  and  to  be  serviceable  for  its  particular  pur])ose  and  place.  Inasmuch 
as  anesthesia  is  nearly  always  required  for  these  injuries  it  may  be  exjiected  to  clear  up 
difficulties  in  diagnosis  by  its  ai(l. 

Treatment. — Through  the  anatomical  researches  of  the  surgeons  above  named, 
as  well  as  those  of  Allis  and  others,  the  method  of  reduction  of  hip  di-slocations  is  prac- 
tically always  that  by  manipvlafion,  and  is  in  nearly  every  instance  commenced  with 
flexion.  In  fact  a  consiflerable  number  of  backward  dislocations  can  be  reduced  almost 
alone  by  flexion  and  rotation  with  traction,  the  patient  being  upon  his  back,  preferably 
upon  the  floor,  and  the  surgeon  standing  over  him.  While  anesthesia  is  not  necessary 
in  all  cases  it  affords  sufficient  assistance  to  justify  its  general  employment. 

In  the  backward  dislocations,  the  patient  and  surgeon  being  in  position  as  above, 
it  is  well  to  employ  the  Koeher  method,  which,  consists  of  (1)  inward  rotation,  by  which 
the  capsule  is  relaxed  and  the  head  of  the  bone  carried  from  the  pelvic  surface;  (2) 
flexion  to  a  right  angle,  preserving  the  existing  adduction  and  inward  rotation;  (3) 
traction,  by  which  the  capsule  is  made  tense  and  tlie  head  of  the  bone  raised  to  the  level 


540 


SURGICAL  AFFECTIONS  OF   THE  TISSUES 
Fig.  359 


Fig.  360 


Fig. 361 


Fig.  362 


Illustrating  various  types  of  dislocition  at  (he  hip.      (bejar.'^.; 


niS/.OCATIOXS  OF    'I'lir:   nil' 


541 


of  llic  socket;  (-1)  oiitwunl  rotutioii,  hv  wliicli  tlic  poslcrioi'  |)ail  of  llic  <a|).sulc-  and  the 
outer  l)jiiul  of  the  Y-lifraineut  are  tiijjhtened  and  the  liead  turned  forward  into  the  socket. 

Durinij;  the  |)raetice  of  this  or  any  other  method  the  pelvis  shouhl  he  firmly  held  in 
place  by  assistants,  who  may  seize  it  with  the  hands  and  hold  it  down.  If  the  patient  lay 
upon  the  tahle  the  pelvis  may  he  hound  to  it.  The  sur<feon  may  need  help  in  niakintj 
a  suflicient  decree  of  traction.  This  can  he  furnished  by  a  strong  loo[)  passed  under  the 
patient's   knee   and    over     the   siu'geon's 

shoulders,  the  hands  thus  remaininii;  free  ^"^-  '^^''^ 

for  manipulation,  traction  beinif  the  most 
important  feature. 

Stimson  accomplishes  the  same  pur- 
])ose  by  placing  the  patient,  face  down- 
ward, upon  a  table,  the  dislocated  limb 
hanging  downward  as  represented  in 
Fig.  3()3.  Traction  is  here  partly  af- 
fected by  the  weight  of  the  lin)b,  while 
in  some  instances  the  surgeon  has  to 
wait  only  for  the  muscles  to  relax  and 
the  bone  to  resume  its  place  without 
nuich  further  effort  than  a  slight  rock- 
ing or  rotation.  Stimson  claims  that 
this  often  succeeds  without  anesthesia, 
and  sometimes  so  quietly  that  there  is 
scarcely  any  jar  or  sound  to  indicate  the 
effcction  of  the  reduction. 

In  those  forms  of  dorsal  dislocation 
Avhich  are  accom])anied  by  eversion  in- 
stead of  inversion  it  is  necessary  only  to 
convert  them  into  the  ordinary  dorsal 
type  before  proceeding  as  above. 

In  high  dis])lacement  of  the  head  of 
the  bone  traction  should  be  made  in  the 
extended  position,  by  which  the  head  will 
be  brought  back  of  the  acetabulum,  and 
then  proceed  as  above. 

Of  the  anterior  dislocations  the  obtu- 
rator is  perhaps  the  more  common,  while 
for  its  reduction  the  following  directions 
usually  suffice:  The  limb  is  flexed  toward  the  perpendicular  to  disengage  the  head 
of  the  bone,  then  rotated  inward  and  adducted  while  the  knee  Is  carried  to  the 
floor.  As  Bigelow  suggested,  in  this  maneuver  we  may  need  the  aid  of  a  towel 
passed  around  the  upper  part  of  the  thigh,  an  assistant  making  upward  and 
outward  traction  while  the  ojierator  is  bringing  the  limb  downward.  Inward  rota- 
tion is  likely  to  transform  the  dislocation  into  a  posterior  one.  On  account  of  this  fact, 
Kocher  Avould  give  the  following  advice:  (1)  Flex  the  thigh  to  a  right  angle  with  the 
pelvis,  preserving  abduction  and  outward  rotation  until  (2)  traction  is  made,  by  which 
the  posterior  part  of  the  capsule  is  tightened  and  the  head  brought  nearer  the  socket; 
then  (3)  forcible  outward  rotation  is  made,  which  should  bring  the  head  upward  and 
backward  into  place. 

A  perineal  dislocation  is  usually  accompanied  l)y  laceration  of  the  capsule.  This 
will  permit  of  easy  reduction,  which  can  probably  be  effected  by  traction  in  the  axis 
of  the  limb  in  its  abnormal  position  and  by  direct  pressure,  with  some  rotation  or  rocking. 

The  pubic  and  suprapubic  dislocations  require  forcible  flexion  with  traction  in  the 
axis  of  the  limb,  followed  by  inward  rotation  and  circumduction  of  the  knee.  Some  of 
these  maneuvers  are  illustrated  in  Figs.  364  and  365. 

So  of  the  other  dislocations  of  the  hip;  an  application  of  principles  similar  to  the 
above,  coupled  with  such  assistance  as  may  be  afforded  by  manipulation,  practised  by 
the  operator,  or  by  traction,  with  the  help  of  an  assistant,  will  usually  suffice. 

If  a  general  rule  could  be  formulated  covering  all  cases  it  would  be  of  great  assistance. 
I  have  been  in  the  habit  of  quoting  a  rule  of  this  character,  which  I  first  saw  mentioned 


Keduction    of    iloisal    dislocation    of   the   hip    by   ihe 
wtight  of  the  limb.     (Stimson.) 


542 


SURGICAL  AFFECTIONS  OF   TlIK   TISSUES 


in  the  American  edition  of  Bryant's  *S'?//Y/r/-//,  edited  by  Roberts,  to  the  followiiifj  effect: 
(1)  Flex  tlie  leg  on  the  thigli  and  the  thigh  on  the  Ixxly;  (2)  carry  the  knee  as  far  as  it 
will  go  in  tlie  direction  in  which  it  already  jx)ints;  (3)  carry  the  knee  to  the  extreme 


Fic.  3G1 


Reduction  of  a  dorsal  dislocation  of  the  hip  by  traction.      (l']iichsen.) 

in  the  opj)osite  direction  and  combine  this  movement  with  circumduction  and  traction. 
In  the  backward  dislocations  these  manipulations  should  be  accompanied  by  traction 
made  with  one  of  the  operator's  hands  in  the  popliteal  space.     In  the  anterior  displace- 
ment   backward    pressure    instead  of 
•''"■•  '^^^  traction  can  be  made  by  pressing  uj)on 

the  knee.     I  have    found   this  an  ad- 
mirable working  direction. 

The  aper-lrcatmcni  of  hi])  disloca- 
tions consists  mainly  in  rest  and  quiet. 
These  should  be  enforced,  at  least  by 
a  binder  around  the  pelvis,  and,  if 
necessary,  a  starch  or  plaster-of-Paris 
protection.  The  anterior  suspension 
s})lint  affords  a  comfortable  and  effi- 
cient method  of  treating  these  cases 
after  the  first  few  days.  (See  Fig.  322.) 
Wry  little  liberty  should  be  allowed 
the  patient  until  the  expiration  of  the 
first  month. 

Ancient  and  Unreduced  Dislo- 
cations.— The  longer  a  hip  disloca- 
tion is  allowed  to  go  unreduced  the 
more  difficult  is*  its  replacement.  The 
expiration  of  six  weeks  will  usually 
make  a  hip  reduction  very  difficult, 
while  after  a  lapse  of  three  or  four 
months  it  becomes  wellnigh  impos- 
sible. The  longer  a  limb  is  disused 
the  more  do  its  osseous  structures 
atrophy.  Therefore  a  fracture  of  the 
neck  of  the  femur  or  upper  end  of  the  shaft  may  occur  in  attempting  to  reduce  an  old 
luxation.  The  most  marked  obstacles  are  offered  by  formation  of  adhesions  about 
the   femoral  head  in  its  new  position,  and  the  shrivelling  or  change  in  shape  of  the 


Reduction  of  a  dislocation  by  rotation.  The  thigh  is 
flexed,  slightly  adducted  and  rotated  inward,  as  in  the 
first  stage  of  reduction  of  a  dorsal  dislocation.     (Erichsen.) 


1)ISI.()C.\TH)SS  OF   TlfH   KSF.K  51:} 

(•;i]).siil(',  whose    ()|H'iiiiiij    may    \^v   distoilcd    or  oblitfiatcd,  .so  as  to   jiiakf   roi'iitniiRc 
iinj)ossil)K'  within  it  of  the  head  of  (he  bone. 

Other  thiiifjs  l)ein<;  equal,  then,  more  forec  and  wider  ruiif^e  of  motion  are  neressary 
in  re(hi(in<j  the  ohler  (hsloeations,  while  success  may  he  attained  only  i)y  the  exj)enditure 
of  wellni<;h  all  the  muscular  eiierjfy  of  a  powerfully  hiiill  man.  Attempts  ])rolon<fed 
too  far  produce  serious  laceration,  with  hemorrhaifcs,  whidi  tend  to  encouraj^e  new 
adhesions  in  case  of  failure.  If  a  dislocated  hip  cannot  he  reduced  by  any  apparently 
safe  proccduri>  the  opi-rator  should  decide  whether  to  leave  it,  in  the  hope  of  .securing 
a  fal.se  joint,  or  to  cut  down  tlu>  j)arts  and  make  such  further  division  of  ti.ssues  as  may 
be  neces.sary.  Should  this  be  contemplated  it  implies,  of  course,  that  each  case  should 
be  ailjudi^ed  upon  its  merits. 

DISLOCATIONS  OF  THE  PATELLA. 

By  various  contractions  of  the  (|uadricc|)s  muscles  the  |)atella  may  l)e  displaeed 
oiitiranl,  it  beino;  j)ractically  slipped  over  the  external  condyle.  'I'he  saDie  result  may 
be  producer!  by  a  blow  from  the  inward  direction  and  in  the  extended  j)osition  of  the 
limb.  The.se  dis|)lacements  may  be  complete  or  incomplete;  in  the  former  case  the  fiat 
plane  and  inner  edge  of  the  bone  are  directed  forward  instead  of  sidewise.  Inward 
displacements  are  unusual  and  usually  produced  by  direct  violence.  Such  previous 
disease  as  shall  have  weakened  the  ca])sule,  or  caused  its  distention,  permits  these  dislo- 
cations to  occur  with  a  minimum  of  violence.     In  fresh  ca.ses  the  capsule  is  usually  torn. 

Reduction  is  easily  efTccted  by  lifting  the  liml),  thus  relaxing  the  quadriceps  muscle 
and  making  pressure  and  manipulation  in  the  indicated  direction.  An  anesthetic  may 
be  given  if  thought  admissible. 

When  the  limb  is  j)artially  flexed,  and  a  blow  is  received  on  the  edge  of  the  patella 
directly  from  the  front,  it  is  occasionally  rotated  on  its  tendinous  axis,  -so  that  without 
being  disj)laced  from  its  position  in  front  of  the  condyles  its  articular  surface  looks 
inward  and  it  rides  the  knee  upon  its  edge.  This  is  referred  to  as  vertical  rotation.  It 
is  relieved  and  replaced  by  suitable  manipulation,  a  feature  of  which  may  be  sudden 
and  forcible  flexion  with  external  pressure. 

The  patella  once  displaced  the  joint  structures  are  left  more  or  less  j)ermanently  im- 
paired, and  recurrence  of  the  lesion  is  by  no  means  unc-ommon.  Some  individuals, 
the  young  especially,  have  the  habit  of  "slij:)ping  the  knee-pan,"  this  imj)lying  that  at 
lea.st  partial  dis])lacement  occurs  easily  \\ith  comparatively  slight  ])rovocati(jn.  Some- 
times children  become  so  accustomed  to  this  that  they  learn  how  to  care  for  it  themselves. 

Treatment.^After  every  knee  dislocation  protection  should  be  afforded  for  a 
considerable  period.  In  habitual  dislocations  it  may  be  ju.stifiable  to  make  lateral 
incisions  and  to  excise  an  elliptical  portion  of  the  capsule,  by  which  its  dimensions  may 
be  reduced  and  its  undue  laxity  abolished, 

DISLOCATIONS  OF  THE  KNEE. 

The  head  of  the  tibia  is  occasionally  displaced  as  the  result  of  accident,  though  fre- 
quently this  is  the  result  of  joint  lesions.  A  traumatic  dislocation  can  scarcely  occur 
witiiout  considerable  injury  and  internal  derangement  of  the  joint  structures  proper. 
Anterior  dislocation  may  occur  when  the  femur  is  forced  backward  or  the  leg  forward  in 
severe  accidents.  Here  the  po])liteal  vessels  may  undergo  such  pressure  and  injury  as 
to  con.stitute  a  serious  comijlication.  The  hackicard  dislocations  are  less  common, 
though  likewi.se  the  result  of  violence.  It  matters  not  \\hethcr  the  thigh  be  fixed  and 
the  leg  forced  in  either  dn-ection,  or  whether  the  leg  be  caught  and  fixed  while  the  body 
is  made  to  disj)lace  the  femur;  such  injuries  are  not  likely  to  be  mistaken.  They  are 
likely,  also,  to  be  accompanied  by  displacement  of  the  semilunar  carti/af/e.s.  Lateral 
dislocations  are  practically  the  result  of  force,  often  combined  with  torsion.  Injury 
to  the  lateral  ligaments,  usually  extensive  laceration,  should  accompany  them. 

Dislocations  of  the  knee  are  more  or  less  easily  reduced,  in  theory  at  lea.st,  by  forcible 
traction  and  manipulation,  and  with  the  aid  of  an  anesthetic.  Absolute  rest,  preferably 
in  a  plaster-of-Paris  splint,  is  requisite. 

The  semilunar  cartilages  are  occasionally  torn  loose  and  more  or  less  displaced,  either 
toward  the  notch  or  toward  the  exterior' of  the  joint.     A  cartilage  so  displaced  will 


544  SURGICAL   AFFECTIOXS  OF   THE   TISSCES 

project,  as  a  nilo,  at  the  upper  marprin  of  the  tibia.  These  injuries  may  occur  alone  or 
as  a  com])lication  of  more  serious  forms  described  above. 

Syirptoms. — These  disphiced  cartilages  ])roduce  symptoms  simulatini;  those  of 
movable  bodies  in  the  joint — that  is,  disability  depending  uj)on  the  extent  of  the  original 
iniury  and  the  direction  of  the  displacement.  The  movable  cartilage  may  be  either 
pulled  into  place  by  flexion  or  manipulated  until  it  returns  there,  but  will  frequently 
reappear  when  the  leg  is  straightened.  It  sometimes  becomes  so  entangled  in  the  joint 
as  to  cause  almost  complete  disability.  When  movable  anteriorly  it  may  be  recognized 
along  the  upyx^r  border  of  the  tibia.  The  same  sudden  disability  may  be  produced 
here  as  when  there  are  other  loose  or  movable  bodies  in  the  joint.  The  patient  may 
be  able  to  indicate  that  there  is  something  movable  in  the  joint. 

Treatment. — Xon-operative  treatment  consists  in  sufficient  limitation  in  the  motion 
of  the  joint  with  abstention  from  use  of  it.  In  cases  not  amenable  to  non-oj)erative 
measures  the  joint  may  be  opened  and  the  cartilage  fastened  in  place  to  the  head  of  the 
tibia  either  with  absorbable  or  non-absorbable  sutures. 

The  Fibula. — The  upper  end  of  the  fibula,  although  firmly  boiuid  to  the  tibial 
head,  may  be  dislodged  by  direct  or  indirect  violence.  Forcible  inward  rotation  of  the 
foot,  in  full  extension,  will  sometimes  displace  it  forward,  while  forcible  traction  on  the 
l)iccps  may  dislocate  it  haclcicard.  Displacements  at  this  joint  may  occur  when  the  leg 
bones  are  broken,  while  when  the  tibia  alone  is  broken  and  shortened  upicard  displace- 
ment may  occur  in  consequence.  Should  displacements  be  discoverefl  it  will  not  be 
difficult  by  traction  upon  the  foot  and  leg,  in  the  normal  direction,  and  l)y  pressure  to 
replace  them.  The  backward  displacement  is  the  more  unstable  of  the  two.  The  loicer 
end  of  the  fibula  is  by  itself  rarely  dislocated  or  distorted  except  in  connection  with  violent 
sprains,  accompanied  by  the  laceration  of  ligaments  or  fracture  of  one  or  both  bones. 

DISLOCATIONS  OF  THE  FOOT. 

Backward  and  forward  disj^lacements  of  the  foot  are  j^ossible  without  fracture;  as,  for 
instance,  when  violence  is  applied  to  the  leg  after  the  foot  is  caught  and  fixed.  Even  here, 
however,  the  lateral  ligaments  must  suffer  paitial  or  complete  laceration,  while  one  or 
both  malleoli  ma}  be  broken.  The  most  frequent  disj^lacemcnts  of  the  foot  are  those 
wliich  accompany  and  are  permitted  Ijy  fractures  of  the  lower  jiart  of  the  leg,  notably 
that  originally  descrilied  by  Pott,  with  its  troublesome  form  of  bone  lesions.  An  inward 
dislocation  of  the  foot  is  described  as  produced  by  extreme  supination  and  adduction. 

It  is  necessary  in  studWng  these  injuries  to  the  ankle  region  to  make  out  the  existence 
of  fracture,  if  any  be  present,  as  the  treatment  hinges  largely  upon  such  complication. 

The  astragalus  may  be  dislocated  from  its  relations  with  the  lower  ends  of  the  leg  bones, 
as  the  result  of  wrenches  or  twists  or  of  violent  injuries,  as  falls  or  blows  upon  the  feet. 
When  displaced  it  is  nearly  ah^ays  forward.  A  backward  dislocation  is  exceedingly 
rare.  The  rest  of  the  foot  itself  is  sometimes  dislocated  backward  beneath  the  astrag- 
alus, although  some  portion  of  its  lower  surface  still  remains  in  contact  with  the  upper 
surface  of  the  calcis.  These  displacements  occur  in  consequence  of  combined  torsion 
and  excessive  violence.  The  foot  here  will  be  shortened  anteriorly.  No  matter  in  what 
direction  the  astragalus  may  be  displaced  it  is  easily  recognized. 

Treatment. — Reduction  of  ankle-and-foot  dislocations  accompanied  by  fracture 
is  not  a  difficult  matter,  although  their  retention  may  be;  but  astragalus  dislocations 
which  are  complicated  are  usually  difficult  of  replacement.  They  will  require  relaxa- 
tion of  muscle  tension  by  anesthesia  or  tenotomy  and  forced  manipulations.  ^Ahen 
accomplished  good  function  results.     Better  results  may  be  obtained  by  exsection. 

^lany  of  these  more  serious  forms  of  dislocation  are  compound.  In  such  cases  removal 
of  the  astragalus,  or  a  more  or  less  typical  resection  of  the  ankle-joint,  may  be  judicious. 
In  crushing  injin-ies,  either  primary  or  secondary  amputation  may  be  necessary. 

In  general  it  may  be  said  of  the  bones  of  the  foot  that  one  which  resists  reasonable 
effort  at  reduction,  when  displaced,  should  be  removed.  Various  displacements  of  the 
tarsal  bones,  as  the  result  of  direct  violence,  may  occur,  as  well  as  of  the  metatarsal  and 
phalanges.  Many  of  them  may  be  reduced  by  judicious  pressure  and  manipulation, 
but  the  violence  which  inflicts  the  dis))lacement  will  frequently  make  the  injury  so  com- 
pound that  excision  or  panial  amputation  may  be  necessary. 


PART   VL 
SPECIAL  Oil  liEUlO.XAL  SLIIGERY. 


CHAPTER    XXXVI. 

INJURIES  AND  SURGICAL  DISEASES  OF  THE  HEAD. 

THE  SCALP. 

ERYSIPELAS   AND    CELLULITIS. 

Erysipelas  and  cellulitis  of  the  scalp  are  the  result  of  the  same  infections  and  con- 
ditions as  when  encountered  in  other  regions,  but  are  peculiarly  prone  to  occur  here 
because  of  the  liability  to  infection  from  the  hair  with  the  material  concealed  in  and 
upon  the  surface.  They  frequently  lead  to  suppuration,  in  which  case  abscesses  form 
that  may  extend  inside  the  cranium,  or  into  the  frontal  or  other  sinuses.  "^I'liese  are 
common  about  the  orbit  and  in  the  upper  eyelid,  and  unless  speedily  incised  may  lead 
to  gangrene.  ^Multiple  abscesses  are  also  common.  Disturbances  of  sight  and  hearing 
as  sequels  of  these  infections  occasionally  occur.  The  principal  danger  from  these  puru- 
lent collections  pertains  to  intracranial  infection  or  general  sepsis,  usually  of  pyemic 
type. 

GASEOUS  TUMORS  OF  THE  SCALP. 

The  most  common  of  these  tumors  is  ordinary  emphysema,  which  may  result  from 
injury  to  the  upper  and  lower  air  passages.  Thus  fractures  of  the  nasal  bones  or  of 
the  base  of  the  skull  may  permit  of  distention  of 
the  subcutaneous  cellular  tissue  by  forcible  inspi- 
ration of  air.  Emphysema  of  the  scalp  may  be  a 
valuable  diagnostic  feature  in  certain  instances,  as 
after  fractures  of  the  upper  bones  of  the  face. 
When  connected  with  a  wound  it  should  be  enlarged 
in  order  to  permit  the  escape  of  contained  air. 
Otherwise  these  puffy  swellings  disa])pear  spon- 
taneously l)y  absorption  of  air  into  the  veins.  In 
cases  of  malignant  or  gangrenous  em|)hysema  early 
and  numerous  incisions  are  necessary,  after  which 
antiseptic  solutions,  etc.,  should  be  used. 

Pneumatocele. — A  pneumatocele  is  a  chronic 
gaseous  tmnor,  being  a  cavity  distended  with  air 
which  has  escaped  from  the  cells  of  the  underlying 
bone,  bounded  on  the  outside  by  the  scalp  and 
beneath  by  the  cranium.  They  are  found  about 
the  mastoid  or  the  frontal  regions.  Not  more 
than  three  dozen  cases  are  on  record.  In  consist- 
ency these  tumors  are  elastic,  while  the  escape  of 
air  upon  pressure  is  sometimes  heard  on  ausculta- 
tion. Their  explanation  is  usually  a  defect  of  the  inner  wall  of  the  mastoid  cells, 
through  which  air  may  be  forced  from  the  pharynx  through  the  middle  ear  by  violent 
35  (545) 


Fir..  366 


Pneumatocele  of  cranium. 
Surg.  Obs.,  1867 


(Warren's 


546 


SPICClAf,  OR  RKdlOXAL   Sl'RdERY 


effort,  or  similar  defect  in  the  edmioidai  (clls  by  whicli  air  is  forced  anteriorly. 
Bony  tiefeels  which  might  permit  this  condition  are  seen  in  a  small  ])ercentage  of 
cranimns. 

Treatment. — The  best  results  in  the  way  of  treatment  have  been  achieved  by  })uncturc, 
with  the  injection  of  weak  iodine  solution  (Fig.  366). 


TUMORS  OF  THE  SCALP. 

Tumors  of  the  scalp  may  be  divitled  into  the  coufjcniUil  and  the  acqmrcd,  as  well  as 
into  the  benign  ami  malignant. 

Of  the  congenital  tumors  the  dermoids  are  of  most  interest.  Originally  the  dura 
and  the  skin  were  in  contact,  and  the  cranial  bones  develop  later  between  them.     This 

explains  the  occurrence  of  dermoids  either 
i""^'-  307  beneath  or  outside  of  the  bone  or  their  simul- 

taneous appearance  and  possible  connec- 
tion. Many  of  the  so-called  atheromatous 
cysts  or  wens  are  of  dermoiil  origin.  Those 
which  are  extracranial  need  only  antiseptic 
incision  or  excision.  It  will  often  be  suffi- 
cient to  split  such  a  cyst  with  a  bistoury, 
after  which  each  half  of  the  sac  can  be  de- 
tached from  the  bed  in  which  it  has  lain. 
Should  intracranial  connection  be  discovered 
the  bone  chisel  and  sharp  spoon  will  be 
necessarily  called  into  em])loyment.  Some 
of  these  dermoids  perforate  into  the  orbit, 
and  may  have  to  be  followed  into  that 
location. 

Most  varieties  of  tumors,  benign  or  malig- 
nant, may  be  met  with  in  this  region.  Sub- 
cutaneous collections  of  jat  are  not  so 
common,  nor  are  fibromas.  Various  bcmy 
growths  may  be  met,  while  in  certain  cases 
the  signs  of  brain  pressure  are  to  be  ex- 
plained only  by  their  extension  within  the 
cranium. 

Malignant  turiior.'<  are  common  about  the 
scalp  and  the  cranium;  they  assume,  how- 
ever, no  conventional  appearance,  and  are 
seen  in  any  shape  or  form,  those  of  the  scalp  alone  occurring  either  as  carcinoma  or 
epithelioma  from  its  epithelial  elements,  or  as  sarcoma  from  its  mesoblastic  elements. 
Tumors  primary  in  the  periosteum  or  bone  are  necessarily  of  sarcomatous  nature,  while 
those  of  the  type  which  perforate  to  the  surface  may  be  either  sarcoma  or  possibly 
endothelioma.  The  general  character  of  these  growths  has  been  referred  to  pre- 
viously. In  regard  to  their  extirj)ation  (for  there  is  no  other  treatment  than  this) 
operations  of  varving  degrees  of  severity  may  be  required.  (See  Cysts  and  Tumors 
and  Tumors  of  Bone.) 

The  sujierficial  epithelioma  should  be  attacked  before  it  has  become  adherent,  in  which 
case  everything  should  be  removed  down  to  the  underlying  ])eriosteuni,  after  which  a 
plastic  operation  will  permit  the  repair  of  the  defect,  so  that  primary  union  of  the  whole 
surface  may  be  secured.  Any  malignant  gro^^ih  which  is  adherent  to  the  underlying 
cranial  bone  calls  not  only  for  removal  of  its  own  substance,  but  for  that  of  the  bone  to 
which  it  is  attached.  To  fail  in  this  is  to  invite  recurrence.  This  may  necessitate  more 
or  less  extensive  osteoplastic  resections  of  the  bone,  but  the  condition  permits  of  no 
middle  course.  Extensive  resections  of  bone  have  been  made  with  success,  and  need 
not  be  abstained  from  unless  there  be  good  reason  to  fear  involvement  of  the  dura 
or  cortex.  In  this  case  the  advantages  and  dangers  should  l)e  carefully  weighed  before 
proceeding  to  operation.  During  operations  on  the  bone  great  care  should  be  taken, 
espec-ially  in  certain  regions,  to  avoid  injury  to  the  intracranial  sinuses,  although  it  has 


Osteosarcoma    of   the    temporal    region      Metastatic 
tumor  in  tlie  arm  and  thyroid.     (Parker.) 


.VO.V  ISFL.\M\r.\r(}liy    COXChWITM.   COXDITIOSS  OF    THE  SKl'LL 


17 


ht'cii  Ic'iinicd  llinl  llicsc  iiiav  \w  lii^'iitcd  iiiHi  iiiU'rvciiiiiif  jxirtioiis  rciiKMcd.  lint  tlic 
\V()Uii(liii<;'  (if  llic  sinus  hy  the  j)()iiit  ot"  an  iiisd-iimciit  or  spicule  of  houc  iiuiv  lead  to  a 
hazardous  and  amioyini:;  coinplication,  and  is  (o  he  prevented  when  possihh-.  A  small 
wound  in  a  sinus  may  he  plui:;t;i'd  w  ith  ifanze,  which  may  remain  for  two  or  three  days. 
There  is  always  a  possihility  of  air  emholism  (sec  pp.  38  and  3()li)  wiien  the  sinuses 
are  opened,  as  their  walls  do  not  easily  collapse.  Ilemorrhafje  from  the  soft  parts  may 
he  almost  entirely  controlled  hy  the  use  of  an  elastic  tourni(]Uet  stretched  around  the 
skull.  Oozing  veins  in  the  di|)loe  or  in  the  bone  may  often  be  secured  by  pressin^j;  the 
tables  of  the  skull  toijjether  with  bone  forcej)s,  while  at  other  times  an  antiseptic  wax  can 
be  forced  into  the  interstices  of  the  bone  and  hemorrha<re  thus  checked.  In  certain  cases 
where  it  seems  impracticable  to  slide  (laps  and  cover  defects  the  desired  end  may  be 
obtained  by  skin  fi'rafts,  after  Thiersch's  method. 

A  rare  and  specialized  form  of  blood  tumor,  seen  only  on  or  within  the  cranium,  is 
the  so-called  hernial  dilatation  of  the  superior  lono;itu(linal  sinus.  It  may  present  through 
openings  in  the  bone;  sometimes  pressure  upon  it  will  cause  vertigo  and  perhaps  greater 
prominence  of  adjoining  veins,  even  of  the  jugulars. 


e 


j-^'^i 


H*, 


NON  INFLAMMATORY  DISEASES  AND  CONGENITAL  CONDITIONS  OF  THE  SKULL. 
Incomplete  Formation  of  Bone  (Aplasia   Cranii).— Incom])lete  formation  of 

bone  is  occasionally  met  with.  The  bone  is  a  secondary  formation  in  the  skull,  the  dura 
and  skin  being  originally  in  contact;  consequently  this  condition  can  be  easily  explained 
as  a  failure  to  develop  bone  where  it  is  normally  produced.  These  defects  are  most 
common  in  the  frontal  and  temporal  regions.  The  bone  may  fail  also  to  develoj)  to 
ordinary  thickness,  and  may  be  found  as  thin  as  paper  ot  ossifying  only  in  certain  direc- 
tions.    Supernumerary  bones  may  also 

develop,   apparently  to  take  the  place  ^^^-  ^^^ 

of  those  previously  lacking.  Aplasia 
may  also  be  a  unilateral  defect  and 
contribute  toward  the  formation  of 
meningocele.  Atrophy  or  anostosis — 
i.  e.,  complete  disappearance  of  cranial 
bones — is  occasionally  observed.  It 
may  be  an  interstitial  or  an  eccentric 
process,  and  may  hapj)en  at  any  jjoint 
or  at  several  spots.  Up  to  a  certain 
extent  it  is  the  rule  in  the  skulls  of  th.' 
aged,  wdicji  the  bones  become  reducetl 
to  the  thinness  of  paper  or  may  in 
certain  places  completely  disappear. 
Senile  atrophy,  in  other  words,  is  a 
normal  process,  and  is  to  be  expected 
after  the  sixtieth  year  of  life,  its  possi- 
bility being  not  forgotten  when  opera- 
tions are  undertaken  upon  the  skulls 
of  those  advanced  in  years.  Eccentric 
atrophy  may  also  occur  from  pressure 
of  soft  or  hard  tumors,  among  them  the 
so-called  Pacchionian  bodies.     It  is  also 

stated  that  increasing  hydrocephalus  may  produce  an  internal  andeceentric  anostosis. 
Craniotabes,  or  Cranial  Rickets. — It  is  ])articularly  in  the  skull  that  the  mani- 
festations of  rickets  are  most  common,  the  bone  becoming  unduly  thick  and  the  general 
shape  being  c-hanged.  Usually  there  is  a  flattened  vertex  with  delayed  ossification,  with 
an  abnormally  firm  union  along  the  suture  lines.  In  spite  of  these  changes,  the  bone 
often  becomes  afi'ected  by  pressure  to  such  an  extent  that  a  rachitic  or  hydrocephalic 
child,  confined  to  bed  and  moving  little  or  not  at  all,  will  develop  a  skull  showing  the 
effect  of  such  pressure.  INIany  rachitic  skulls  show  areas  of  atrophic  thinning,  dispersed 
irregularly,  while  the  inner  surface  may  show  the  markings  of  the  convolutions  impressed 
upon  it  by  the  softness  of  the  bone  (Fig.  368).     (See  Rachitis.) 


t 


s 


\ 

\ 


{ 


.f 


xi 


'■.  t.  -) 


Craniotabes   (racliitis).     (Bruns.) 


548 


SPECIAL  OR  RECilONAL  HVRdERY 


SURGICAL  AFFECTIONS  OF  THE  CRANIAL  BONES. 

The  acute  affections  of  l)oncs  have  been  considered  in  Chajjter  XXXII.  Acute 
periostitis  is,  in  the  main,  due  either  to  syphihs  or  to  an  infection  following  injury. 
In  the  latter  case  it  proceeds  from  the  margin  of  the  wound,  and  may  sj)read  to  a  con- 

FiG.  369 


Osteoma  of  skull.     (Mudd.) 

siderable  distance.  It  is  in  some  instances  secondary  to  deeper  infection  extending 
from  the  middle  ear,  and  then  is  found  posteriorly  to  the  ear  and  externally  to  the 
mastoid  cells.  Congenital  openings  or  defects  of  the  sutures  about  the  mastoid  seem  to 
have  much  to  do  with  the  travelling  of  infectious  lesions  in  these  localities. 

Fig.  370 


■^ 


Same  as  Fig.  369,  seen   from   below. 


Acromegaly  and  LeontiasiS  have  been  considered  on  pages  437  and  438. 

Acute  Osteomyelitis. — Acute  osteomyelitis  is  due  to  essentially  the  same  causes  as 
those  just  discussed.  In  this  case  it  is  especially  in  the  diploe  that  the  principal  ravages 
occur.     Unless  promptly  recognized  and  relieved  by  surgical  measures  this  is  likely  to 


/.v./rA7/;.s'  TO  Tiih:  iri:M)  I'Hi'.viors  to  axd  Drnixr;  hirtii 


540 


lead  to  sepsis  of  tlie  |)ycniic  (ypc  aiul  ii(  a  rclalixcly  early  ixiiod,  llic  venous  arraii^eiiienl 
ot"  tlie  (liploe  t'avoriiifi;  such  type  of  disease. 

Necrosis  of  the  Skull.— Necrosis  of  (he  skull  is  ordinarily  tlie  result,  directly  or 
iiidirecth,  of  iiijniy,  in  wliicli  case  it  is  usually  of  tlie  acute  forni,  a  fra<,nnent,  which 
has  heen  too  nincli  se|)araled  from  its  suiroundin^s  to  live,  ^ivinir  evidence  of  early  and 


Syphilitic  caries  of  cranium.     (Brims.) 

easily  recognizable  death.  This  necrosis  is  mainly  confined  to  the  external  table. 
Necrosis  of  slow  origin  is  due  either  to  tuberculosis  or  syphilis,  perhaps  more  often  to 
the  latter.  Under  a  cold  abscess  of  the  scalp  or  subjieriosteal  abscess  will  often  be  found 
a  small  area  of  dead  external  table  which  needs  complete  removal.  Necrosis  has  also 
been  observed  to  follow  severe  burns  of  the  scalp.  It  is  usually  combined  with  caries 
of  adjoining  bone.     The  caries  produced  by  syphilis  is  illustrated  in  Fig.  .371. 


INJURIES  TO  THE  HEAD  PREVIOUS  TO  AND  DURING  BIRTH. 

In  ufew  the  head  is  surrounded  by  amniotic  fluid  and  is  well  guarded  against  injury. 
Nevertheless  as  the  result  of  penetrating  wounds  or  of  falls  on  the  part  of  the  mother 
real  injuries  do  occasionally  occur.  INIost  of  the  cases  of  skull  fracture  reported  as  occur- 
ring before  birth  have  occurred  during  delivery.  Multiple  fractures  of  the  skull  of  either 
character  have  been  observed. 

During  the  process  of  ])arturition  there  nearly  always  appears  a  tumor  of  the  scalp 
in  the  newborn,  known  as  the  rapiif  surrcdaneum,  at  the  point  where  pressure  upon  the 
head  has  been  least.  It  usually  disappears  quickly  after  birth.  It  is  due  to  a  collection 
of  blood,  partly  an  extravasation,  as  the  result  of  com])ressi()n  or  injury.  It  is  c-omposed 
also  of  edematous  soft  tissues  of  the  surface.  If  incised,  blood-stained  serum  is  poured 
out.  When  this  fails  to  rapidly  resorb  during  the  first  days  of  the  infant's  existence,  and 
especially  if  it  fluctuate,  it  may  be  incised  under  antisei)tic  precautions  and  blood  clot 
be  turned  out.  In  rare  cases  it  suppurates,  by  which  is  produced  an  acute  abscess, 
which  should  be  promptly  evacuated. 

A  collection  of  fluid  lilood  between  the  periosteum  and  the  bone  is  known  as  the 
cephalhematoma  nconafonim,  such  a  lesion  occurring  on  an  average  once  in  tw^o  hundred 
cases.     It  is  generally  found  over  the  fissures,  and  api)ears  to  be  produced  by  the  sliding 


550  SPECIAL   OR  REGinXAL  SURGERY 

of  the  bones.  This  collection  also  usually  |m)ni])tly  disaj^pcars.  In  case  of  failure  it 
may  be  aspirated  or  incised.  Before  resorting  to  any  operative  procedure  it  would  be 
well  to  make  a  careful  distinction  between  a  possible  meningocele  or  eneephalocele, 
as  a  congenital  defect,  and  cej^lialhematoina  as  an  accident  of  delivery. 

1  iG.   372 


Frac*(ire  of  right  frontal   bone  in  a  newViorn  infant;   fracture  extendinsc  into  orhit.     (Bruns.) 

A  depression  in  the  skull  of  a  newborn  child  whicli  docs  not  (juickly  right  itself  or 
vield  to  expanding  influences  from  within  should  not  be  allowed  to  go  uncorrected, 
as  serious  lesions  ordinarily  of  paralytic  type  may  result  therefrom.  In  these  days  of 
asejjtic  surgery  there  is  no  reason  why  such  operation  as  may  be  necessary  to  elevate  a 
fragment  or  aii  entire  bone  should  not  be  performed,  with  the  usual  precautions. 

IMPORTANT  POINTS  IN  THE  SURGICAL  ANATOMY  OF  THE  SKULL. 

The  voung  and  the  aged  have  no  distinction  of  tables  of  the  skull,  but  tlie  diploe  which 
separates  the  two  tables  is  an  affair  of  middle  age,  develo})s  slowly,  and  disap])ears  after 
the  same  fashion — sometimes  to  such  an  extent  as  to  leave  the  skull  of  almost  i)apcr-like 
thinness.  In  all  operations,  then,  ui)on  the  young  and  the  old  the  surgeon  should 
proceed  with  extreme  caution,  as  if  expecting  "to  find  the  skull  (juite  thin.  The  lower 
iiiiiit  of  the  squamous  bone  proper  is  the  so-called  mastosquamosal  suture,  and  opera- 
tions confined  to  the  squamous  plate  alone  are  safe  from  injuring  the  sigmoid  sinus  on 
its  inner  side.  The  ridge  at  the  posterior  root  of  the  zygoma  indicates,  by  its  lower  border, 
the  level  of  the  mastoid  antrum.  A  few  lines  above  this  is  the  level  of  the  base  of  the 
brain.  The  viastoid  is  present  at  birth  and  appears  externally  by  the  second  year.  Its 
antrum  is  present  also  at  birth,  though  its  air  cells  do  not  develoj)  until  after  puberty, 
their  location  being  previously  occupied  by  cancellous  tissue.  iSIost  of  these  cells  open 
into  the  antrum,  a  few  directly  into  the  tymj^anum.  They  are  not  always  separated 
from  the  sigmoid  sinus  by  bone.  The  partition  between  them  is  perforated  by  minute 
veins,  forming  an  easy  communication  between  the  sinus  and  the  antrum.  Air  escaj)ing 
from  the  mastoid  cells  into  the  overlying  tissue  may  cause  emjjhysema  from  a  ba.sal 
fracture.  In  all  operations  upon  the  mastoid  antrum  the  operator  should  keep  to  its 
outer  side,  and  the  higher  and  the  more  closely  to  the  posterior  zygomatic  ridge  he  makes 
the  first  opening  the  more  sure  is  he  to  escape  injuring  the  facial  nerve.  The  gromv 
for  flu'  .sigmoid  .sinu.s  extends  to  the  jugular  foramen  from  a  point  on  the  outside  corre- 
sponding to  the  asterion.  The  ktfrral  simi.s  may  be  indicated  externally  by  a  line  from 
the  superior  border  of  the  ma.stoid  to  the  ini(m— l  f.,  from  the  asterion  to  the  inion. 

The  jroiUnl  .s-itiu.s-rs  are  usually  separated  by  a  septum,  which  is  often  incomplete  or 
wanting.  Thev  are  variable  in  size  and  outline,  and  do  not  dcvclo))  until  after  the  seventh 
year.     The  infinuHLvlinn,  by  which  they  t  nipty  into  the  nasal  cavity,  is  often  so  .small 


INJURIES  TO   THE  SOFT  PARTS  OF   THE  (RAX  I  CM  551 

that  wluMi  the  liiiiiio:  nu-nihriuu'  is  involved  if  hccomes  closed,  and  retention,  with  its 
aceonipanyintj  syni|)tonis  pain,  tenderness,  s\veMin<;,  etc. — may  ensue.  I  leeration  and 
erosion,  however,  may  cause  ])eH"ora(ion  internally  throuffh  the  supra-<trl»ital  plates,  so 
that  pus  may  |)enetrate  throu<fl)  the  inner  half  of  the  orhit. 

Aside  from  its  direct  communication  the  superior  lonifitudinal  sinus  coimects  witli 
the  hasal  sinuscvs  throujih  the  middle  cerebral  an<l  the  Sylvian  veins,  while  communi- 
cations with  the  middle  menin<;eal  veins  are  abundant.  Where  the  frontal  and  di|)lo(-tic 
veins  enter  the  lon<ritudinal  sinus  there  frequently  are  dilatations  in  which  marasmic 
thromboses  often  oriij^inate.  This  sinus  is  also  connected  with  the  veins  of  the  nasal 
septum,  so  that  a  septic  phlebitis  may  be  ])ropa<i;ated  from  the  no.se.  So  much  of  the 
lateral  sinus  as  is  contained  in  the  siii:moi(l  groove  is  known  as  the  sicjmoid  sinus,  which 
connects  directly  with  the  exterior  throuijh  the  mastoid  and  the  yiostcrior  condyloid 
veins.  In  siinis  thrombosis  this  mastoid  vein  is  likewise  atVected.  ( )ne  or  more  con- 
dyloi<l  veins  accomjjany  the  hy|)o<rl{)ssal  nerve  throuffh  the  anterior  condyloid  foranu-n, 
and  may  also  serve  for  the  {propagation  of  infection  or  exit  of  j)us. 

While  sejitic  j)articles  may  be  carried  from  any  part  of  the  lateral  or  sifjmoid  sinuses 
— usually  throuji^h  the  internal  jugular — they  may  also  be  carried  by  way  of  the  other 
veins  above  mentioned  or  the  occipital  sinus,  all  of  which  empty  directly  into  the  sub- 
clavian without  pa.ssing  through  the  internal  jugular.  These  sinuses  arc  all  rigid  tubes, 
always  ojkmi,  while  the  veins  are  thin  and  flexible,  their  (aliber  constantly  varying  with 
inspiration  and  expiration.  The  sinu.ses  contain  no  valves,  and  these  are  very  rare  in 
the  cerebral  veins. 

So  far  as  the  li/mphafics  are  concerned  there  is  free  and  easy  communication  l)etween 
the  internal  and  external  plexuses  and  nodes.  Into  the  superficial  nodes,  along  the 
external  jugular,  outside  of  the  deep  fascia,  empty  all  the  external  lymphatics  of  the  head. 
Intracranial  infection  shows  itself  in  swelling  of  the  deep  cervicals  beneath  the  deeji 
fascia.  Lvnnphatics  are  abundant  in  the  dura,  and  pathogenic  organisms,  once  housed 
within  the  dura,  find  it  easily  open  to  invasion.  The  potential  interval  between  the 
dura  and  the  arachnoid  is  termed  the  siilHliiral  space,  when  considerable  efl'usion  may 
occur  without  marked  symptoms,  owing  to  its  easy  difl'usion,  while  blood  here  {K)ured 
out  may  travel  even  to  the  lowest  parts  of  the  spine  and  cause  death  by  pressure  upon 
remote  points. 

The  arachnoid  bridges  over  the  convolutions  and  does  not  extend  into  the  sulci.  It 
is  not  vascular;  at  certain  j:)oints  it  is  adherent  to  the  pia,  at  others  it  does  not  touch  it. 
The  subarachnoid  space  is  formed  in  the  latter  way,  and  within  it  most  of  the  cerebro- 
spinal fluid  is  contained.  This  space  is  unevenly  distributed  over  the  brain  surface, 
most  })r(jminently  beneath  the  posterior  two-thirds  of  the  brain,  where  there  is  a  wide 
interval  between  the  arachnoid  and  the  pia,  extending  forward  around  the  medulla  and 
pons  and  as  far  forward  as  the  oj)tic  nerves.  This  space  connects  with  the  ventricles  by 
the  foramen  of  ]\Iagendie,  as  well  as  with  the  sheaths  of  the  cranial  nerves.  Where 
these  nerves  escape  from  the  l)rain  or  cord  they  are  covered  1)V  all  three  membranes,  the 
layers  being  most  distinct  along  the  optic  nerves.  Fluid  injected  into  the  subdural  sj)ace 
may  pass  along  the  spinal  nerves  as  far  as  the  limbs.  It  is  essential  to  realize  this  in 
order  to  appreciate  how  extensive  is  the  surface  exposed  in  leptomeningitis. 

Internal  hydrocephalus  is  often  the  result  of  closure  of  the  foramen  of  Magendie. 
The  cerebrospinal  fluid  is  rapidly  reproduced  after  traumatic  escape.  External  hydro- 
cephalus or  accumulation  in  the  sul)arachnoid  sjmce,  is  a  condition  frec(uently  due  to 
tul)erculous  infection. 

The  pia  is  the  vascular  coat  of  the  brain,  supplied  with  an  extensive  network  of  fine 
nerve  fibers  derived  from  the  sympathetic  and  the  cranial  nerves,  having  intimate  rela- 
tions with  the  brain,  to  such  an  extent  that  leptomeningtis  and  cnce|)halitis  arc  almost 
inseparable.  The  nerve  supply  to  the  cerebral  membranes  explains  the  .severe  pain  of 
meningitis. 

INJURIES  TO  THE  SOFT  PARTS  OF  THE  CRANIUM. 

In  direct  connection  with  what  has  been  stated  above  it  is  well  to  emphasize  that 
the  venous  communications  between  the  exterior  and  interior  of  the  cranium  are  numer- 
ous, and  that  the  frequency  of  these  anastomoses  explains  the  ea.se  with  which  extra- 


552  SPECIAL  OR  REGIOXAL  SURGERY 

cranial  infections  are  propagated  within;  in  other  words,  these  explain  the  frequency  of 
sejitic  niischit'f  in  the  brain  after  external  injuries. 

Penetrating  and  Incised  Wounds.— PenetratiniT  and  incised  wounds  are  frequent 
about  the  head,  their  jjrugnosis  per  .sr,  as  well  as  their  pro])er  treatment,  varyinor  but 
little  from  tliat  of  such  wounds  in  other  parts,  so  long  as  the  skull  jjroper  and  its  contents 
escape  injury.  Hemorrhage  from  scalj)  wounds  may  be  profuse  and  even  fatal.  The 
most  dangerous  hemorrhages  occur  from  the  temporal  vessels.  Penetrating  wounds  are 
short,  and  the  periosteum  and  underlying  bone  are  usually  also  injured.  Such  small 
articles  as  blades  of  penknives,  particles  of  dirt,  etc.,  will  often  be  founil  when  the  ))arts 
are  carefully  ins|)ecte(l,  a  measure  never  to  be  neglected.  Contusions  of  the  scalp  and 
skull  are  sj)()ken  of  as  subcutaneous,  subaponeurotic,  or  subperiosteal,  and  are  most 
frequent  in  the  frontal  and  lateral  regions.  EccliMiioses  following  them  nuiy  be  extensive 
and  discoloration  may  spread  over  a  large  area.  In  traumatic  hematomas  resulting  from 
various  injuries  incision  should  be  an  early  resort  should  blood  clot  fail  to  resorb. 


INJURIES  TO  THE  CRANIAL  BONES. 

All  conceivable  degrees  of  injury  to  the  bones,  from  a  trifling  division  of  the  perios- 
teum down  to  most  extensive  denudation  or  mangling  of  the  external  tal)le  or  the  entire 
thickness  of  the  bones,  may  be  encountered.  These  lesions  may  be  spread  over  a  large 
area  or  may  be  the  result  of  penetrating  wounds.  In  other  words,  we  may  have  linear, 
penetrating,  or  large  surface  wounds,  with  such  injury  to  the  scalp  as  perhaps  to  amount 
to  a  total  loss  of  covering  for  the  same.  All  of  these,  moreover,  may  be  complicated 
by  fractures  of  the  bone  at  the  point  of  injury,  with  or  without  brain  lesions,  or  by  other 
and  more  remote  lesions. 

In  regard  to  most  of  these,  it  may  be  said  that  7iou-penef rating  injiiric'!,  when  jM'onijitly 
and  properly  attended  to,  have,  in  most  cases,  a  favorable  prognosis.  Every  peiuiraiing 
wound  of  the  cranium  is  a  condition  justifying  grave  prognosis,  on  account  of  the  great 
danger  of  intV'ction  incurred.  Other  features  of  these  wounds,  with  more  in  regard  to 
]>rognosis  and  treatment,  will  be  given  untler  the  head  of  Compound  Fractures  of  the 
Skull,  etc. 

It  is  necessary,  however,  to  say  in  this  place  that  penetrating  wounds  of  the  cranium 
are  often  received  in  a  way  which  does  not  permit  actual  diagnosis,  as,  for  instance,  when 
received  through  the  nose  or  the  orbit.  Every  wound  whose  history  and  ajipearance 
indicate  that  penetration  may  have  occurred  should  be  subjec-ted  to  the  most  rigid  scrutiny 
and  care.  Points  of  fencing  foils,  umbrella  tips,  etc.,  have  been  forced  into  the  brain 
cavity  through  the  orbit  and  elsewhere  in  ways  which  left  little  external  evidence  of 
the  severity  of  the  injury. 

FRACTURES  OF  THE  SKULL. 

Following  the  anatomists,  and  for  general  convenience,  these  are  di^^ded  into  fractures 
of  tJie  vertex,  of  the  lateral  region,  and  of  the  base,  the  former  being  the  most  frequent  as 
the  vertex  is  the  most  exposed.  A  fracture  in  a  given  region  may  be  confined  to  that 
locality  or  may  radiate  widely  or  extend  nearly  around  the  cranium.  Of  all  the  fractures 
of  the  bony  skeleton  those  of  the  skull  constitute  about  2  per  cent. 

Fractures  of  the  Vertex  of  the  Skull. 

Fractures  of  the  vertex  are,  in  most  instances,  due  to  actual  violence,  the  force  being 
often  exjiended  at  the  point  of  apjilication  or  producing  radiating  fractures.  Those 
which  are  limited  to  the  neighborhood  of  the  injury  are  referred  to  as  direct  fractures, 
in  distinction  to  which  we  have  indirect  or  radiating,  often  j^roducing  remarkable  results. 
Fractures  may  vary  between  the  sim|)lest  crack  or  fissure,  accompanied  by  but  trifling 
brain  symptoms  and  never  recognized,  to  the  most  extensive  comminution  and  d(>struction 
of  cranial  bones  which  can  be  imagined. 

Splintered   or  Comminuted   Fractures. — Splintered  or  comminuted   frartnres 

refer  to   the  fornuition    of    numerous   l)()nv  fragments,  which  are   often   more   or  less 


FRACTl'RES  OF   THE  SKILL 


553 


loosened,  .sometim(>s  completely  so,  occjisioiially  dovetiiili-d  too;ether,  and  often  driven 
in  or  depressed.  Such  Inictiires  are  direct,  it  is  possible  to  have  coniniinution  without 
depression;  tiic  latter  makes  it  the  more  trnive  condition. 

Fractures  with  absolute  loss  of  substance  may  be  made  by  <fuusiiot  injuries  or  by 
any  t>xtensive  s|)linterint2;  or  by  a  |)enetraf  in<f  body.  It  is  jjossible  (o  have  jr<icturr  o/  one 
tahlr  iriflioiit  that  of  the  ol/irr,  this  beinjf  often  true  of  the  external  tal)le.  In  isolated 
fractures  ot  the  inner  table  ther(>  is  often  dislddifcment  of  snudl  fra<fment.s  which  may 
injure  the  dura  and  j)ossibly  produce  later  epile|)tic  or  irritative  disturbance.  When  the 
external  table  is  chipped  off  the  diploe  is  ex|)<)sed,  and  this  with  its  wonderfully  fine  venous 
couHuunications  opens  uj)  a  wide  area  to  infection  and  subsequent  pyemia. 

Gunshot  Fractures.  — (Junshot  fractures  are  always  dej)ressed  and  almost  invariably 
conuninuted.  The  bullet  of  the  modern  army  rifle  possesses  a  (^rcat  initial  velocity, 
and  the  cranium  struck  by  it  will  probably  be  disrupted  into  frafjments,  causing  instant 
death.  The  majority  of  <funshot  fraclures  of  the  skull  seen  in  ordiiuiry  civil  practice  are 
due  to  revolver  or  pistol  bullets  from  weaj)ons  of  the  prevailing  ty|)e.  In  these  instances 
there  will  usually  be  |)enctration,  perhaps  with  perforation  of  the  skull,  and  the  formation 


Fic.   373 


Fir..   .374 


Gunshot  fracture  of  skull.      (Helferich.) 


thus  of  one  or  of  two  compound  fractures,  the  wound  of  entrance  being  always  commi- 
nuted and  depressed,  while  fragments  of  bone  may  be  scattered  along  the  course  of  the 
bullet,  which  mav  also  carry  infectious  material  from  without,  such  as  hair,  particles 
of  hat,  and  the  like  (Figs.  373  and  374).     (See  also  Figs.  52,  53  and  54.) 

Whatever  may  be  the  wisdom  of  operating  in  other  cases  where  there  is  room  for  doubt 
as  to  the  proper  course  there  rarely  is  uncertainty  as  to  the  proper  treatment  of  gunshot 
wt)unds  of  the  skull,  which  should  he  invariahlij  subjected  to  operation. 

It  will  thus  be  seen  that  fractures  of  the  skull  may  be  simple  or  compound,  or  compli- 
cated with  other  injuries,  or  depressed,  without  any  reference  to  whether  they  are  simple 
fissures  or  more  extensive  injuries.  On  the  other  hand,  depressed  and  comminuted 
fractures  may  occur  without  being  comjjound  in  a  surgical  sense,  and  wath  each  one  of 
these  injuries  there  may  be  accompanying  disturbance  of  the  brain  of  any  degree  of 
severity,  from  the  mildest  concussion  or  shock  up  to  rapidly  fatal  compression.  Any 
imaginable  comjjiication  of  these  head  injuries  is  not  beyoufl  the  bounds  of  possibility. 

The  essential  features  in  explaining  the  mechanism  of  fractures  of  the  vertex  are  the 
area  involved  and  the  violence  of  the  impact.  The  skull  is  often  surprisingly  elastic, 
even  in  the  oldest  individuals,  and  fractures  occur  ordinarily  when  the  natural  limits 


554  SPECIAL  on  BECJOXAL   SCEnERY 

of  elasticity  have  been  exceeded  and  l)one  cohesion  overcome.  Chihlren  particularlv 
snil'er  from  depression  without  fracture,  wiiich  formerly  was  never  operated  upon,  biit 
whic-ii  is  now  re<;ard(Ml  as  rcfiuiriiiiij  o|)eration.  On  the  other  hand,  certain  skulls  are 
(thn(>rmalli/  fragl/r  (see  Fragility  of  the  Bones,  Chapter  XXXIl),  and  amongthe  insane  may 
he  found  so  porous  and  yielding  as  to  be  easily  pressed  out  of  shape.  In  injuries  of  slight 
extent  it  is  sufficient  that  the  skull  be  regarded  as  compos(>d  of  an  elastic-  substance, 
while  for  injuries  produced  by  greater  violence  the  skull  is  to  be  c-onsidered  rather  as  a 
globe  or  arch  possessed  of  high  resistance  and  elasticity,  whose  shape  will  probal)Iv 
yield  more  or  less  before  a  fracture  results.  Much  may  be  learned  fnmi  such  ex])eriments 
as  those  of  Feliz(>t,  who  filled  skulls  with  ])araffin  and  (lro])ped  tlieni  from  varving  heights, 
and  then  divided  the  bone,  to  note  in  numerous  instances  that,  although  tiie  i)one  had  not 
been  fractured,  it  had  yielded  at  the  point  of  imj^act  to  a  degree  producing  a  marked 
depression  in  the  paraffin  beneath.  After  various  injuries,  especially  to  the  top  of  the 
head,  the  shape  of  the  skull  may  be  altered  and  its  diameters  affected!  Many  fractures, 
then,  are  the  result  of  a  hurstirui  force,  which  may  be  shown  by  the  fact  that  hair  has  been 
found  included  within  aj^parently  closed  fissures,  and  even  on  the  dura.  Moreover, 
particles  of  bullets  have  been  found  within  the  skull  without  any  visii)lc  ojiening  through 
which  they  could  have  entered,  showing  that  the  bone  has  yielded  under  impact  for  a 
fraction  of  a  second.  In  certain  injuries  to  the  head,  as  when  a  man  is  struck  to  the 
ground,  there  is  injury  at  two  points  nearly  opposite. 

Fractures  of  the  skull,  especially  of  the  vertex,  possess  surgical  interest  mainly  as  thev 
are  accomjianied  by  more  or  less  evidence  of  intracranial  complications.  So  long  as  there 
is  no  evidence  of  hemorrhage  or  laceration  within  they  are  ordinarily  regarded  as  a  feature 
of  the  external  wound  with  which  they  are  usually  found,  and  unless  there  be  comminu- 
tion, depression,  or  some  other  good  reason  for  operating  they  are  covered  over  as  the 
wound  is  closed  and  are  left  to  the  natural  process  of  repair  by  formation  of  minute  callus 
or  by  the  ossification  of  granulation  tissue. 

It  is  unfair  to  contrast  the  results  of  the  surgery  of  today  with  those  of  the  pre-antiseptic 
era.  Rules  then  enforced  are  now  abrogated.  One  respect  in  which  we  violate  pre- 
cedent is  in  our  disregard  of  the  periosteum  or  pericranium.  This  is  sacrificed  without 
hesitation  when  found  to  l)e  infected  or  torn  or  lacerated  beyond  repair.  A  flap  of  scalp 
will  adhere  as  readily  to  denuded  bone  as  to  periosteum,  and  skin  grafts  can  be  ap])lied 
and  will  adhere  to  this  same  bone — if  not  upon  the  first  day,  a  little  later  when  granula- 
tions have  appeared.  In  the  various  plastic  operations  necessitated  about  the  head 
we  may  also  transplant  flaps  upon  otherwise  uncovered  bone  wdthout  the  slightest 
hesitation.  Fractures  should  be  treated  mainly  in  accordance  with,  intracranial  c-om- 
jilications,  or  through  what  can  be  seen  either  through  the  wound  or  through  an 
opening  intentionally  made  under  antiseptic  precautions  for  purjioses  of  exploration. 
It  is  conceded  to  be  better  policy  to  remove  fragments  of  bone  whose  vitality  is  uncertain 
and  to  sacrifice  tissue  injm-ed  or  lacerated  to  such  an  extent  that  sloughing  would  .prob- 
ablv  follow  or  be  sd  exi)ose(l  as  to  Iiave  become  infected. 

Diagnosis  of  Fractures  of  the  Vertex.— In  the  absence  of  an  open  wound, 
and  unless  incision  be  made,  diagnosis  of  fractures  of  the  vertex  is  necessarily  conjec- 
tural. In  the  presence  of  a  wound  diagnosis  is  usually  easy.  In  case  of  a  small  puncture 
it  will  be  better  to  enlarge  it  sufficiently  to  permit  the  introduction  at  least  of  the  finger. 
With  the  finger  and  the  eye  we  seek  to  detect  differences  in  level,  depressions,  fissures, 
etc.  ^listakes  arise  from  the  formation  of  an  exudate  or  a  clot,  by  which  a  depression 
of  the  soft  parts  may  be  regarded  as  depression  of  the  bone.  Error  occasionally  arises 
from  the  existence  of  previous  atrophy  of  the  bone  or  any  congenital  defects  in  ossifi- 
cation of  the  skull;  also  in  the  skulls  of  syphilitic  patients  where  disapjiea ranee  of  a 
gumma  is  often  followed  by  absorption  of  the  underlying  bone.  In  case  of  doubt 
exploratory  incisions  should  be  made  under  aseptic  precautions.  These  should  not  be 
made,  however,  unless  the  attendant  is  ready — i.  e.,  has  the  facilities  immediately  at 
hand — for  carrying  out  any  further  operative  procedure  that  may  be  necessary,  as 
elevation  of  fragments,  removal  of  foreign  bodies,  etc.  Error  also  may  arise  from  mis- 
taking for  fracture  a  deceptive  circular  effusion  of  blood  which  frequently  occurs  beneath 
the  scalp  after  injury.  Areas  of  bloody  infiltratifm  often  have  abrupt  margins  which  are 
calculated  to  easily  deceive.  In  children,  more  esjxH'ially,  we  often  have  a  circumscribed 
l)loody  tumor  which  may  contain  cerebrospinal  fluid  rather  than  ])ure  blood.  In  some 
of  these  cases  after  exploration  there  will  be  found  material  resembling  brain  matter, 


FRACTIRFS  OF   TIIF  SKILL  555 

which,  however,  is  not  always  such,  althou<;h  real  hraiii  siihstanee  may  escajH',  caused 
1)V  rupture  of  the  overlyinij  luenihranes.  Should  it  he  noted  that  the  fluid  used  for 
irri>;alint;  and  cleansinjj  such  a  wound  l)e<;ins  to  pulsate,  it  will  iijiply  connection  with 
the  cranial  cavity,  and,  obviously,  fracture.  A  suture  should  not  he  mistaken  for  a  line 
of  fractiiH'.  This  mistake  is  more  easy  when  Wormian  hones  are  present.  Blood  may 
be  wi|K'd  away  from  a  suture  line,  but  not  from  that  indicating  fracture.  It  is  not  often 
possible  to  diajjnostieate  an  isolated  fracture  of  the  inner  table.  It  hap|K'ned,  however, 
once  to  Stroinever  to  notice  that  so  soon  as  an  injured  j)atient  asstimed  the  horizontal 
|)osition  he  In-ijan  to  vomit,  and  that  nausea  subsided  when  he  was  placed  in  the  upright 
position.  On  autopsy  it  was  found  that  there  had  occurrecj  a  depressed  splintering  of 
the  iimer  table  with  j)erforation  of  the  dura — less  irritation  was  produced  in  the 
upright  position  than  when  the  j)atient  was  lying  down,  which  accounted  f«)r  his  vomiting 
when  in  the  horizontal  j)osture.  When  a  c(jmininiition  has  been  produced  it  is  always 
of  j)r()gnostic  value  if  an  unbroken  dura  be  found.  Prolapse  of  brain  substance  i.s  a 
serious  complication.  Escape  of  cerebro.spinal  fluid  is  relatively  rare.  Ri.nvrj  tem- 
prratitir  aftrr  these  injuries  is  ahvays  a  sign  of  danger. 

Treatment. — Treatment  comprises  attention  to  the  local  injury  and  the  suitable 
dealing  with  the  condition  of  the  brain  within  when  injured.  The  treatment  of  simple 
fractures  is  expectant.  In  the  absence  of  indication  for  ojx'ration  it  slunild  be  simple, 
and  should  consist  of  physiological  rest,  a.septic  dressings,  ice  apjjlications  to  the  head, 
the  administration  of  such  laxatives,  diuretics,  antacids,  etc.,  as  may  be  necessary  to 
favor  free  excretion  and  to  guard  again.st  autointoxication.  Whenever  there  is  reason 
to  suspect  a  depres.sion,  exj)loratory  incision  .should  be  made.  Actual  depression,  whether 
the  fracture  be  compound  or  not,  requires  operation.  This  course  is  ju.stified  by  the 
numerous  instances  in  which  later  consequences  have  been  noted,  such  as  traumatic 
ej)ilepsy,  insanity,  etc. 

Compound  injuries  should  always  Ije  operated  uj^on  in  some  manner,  which  includes 
the  removal  of  loosened  sj^linters,  the  elevation  of  depressed  bone,  the  removal  of  foreign 
matter,  the  checking  of  hemorrhage,  the  excision  of  bruised  and  lacerated  tissue,  and 
the  proper  closure  of  the  wound,  with  or  without  drainage. 

In  serious  and  lacerated  cases  it  is  inadvisable  to  close  the  wound  with  the  view  of 
attempting  primary  union.  It  should  be  packed  with  gauze  and  temporarily  closed 
with  secondary  sutures.  These  measures  should  be  seconded  by  pltysiologieal  rest 
(quietude  of  the  head,  which  may  even  be  enforced  by  the  posterior  pla.ster-of-Paris 
splint  to  the  head  and  neck),  attention  to  the  primce  vioe,  the  avoidance  of  transportation, 
the  prevention  of  auto-intoxicatif)n,  etc.  The  surgeon  .should  use  discrimination  as  to 
the  amount  of  bone  to  be  removed,  the  wisdom  of  opening  the  dura  when  not  lacerated, 
of  examination  of  the  brain  with  the  exploring  needle,  the  matter  of  drainage,  and  the 
time  during  which  it  shall  remain.  With  reference  to  all  these  matters  exact  rules  cannot 
be  given.  When  drainage  is  made  in  recent  ca.ses  it  is  usually  sufficient  to  drain  the 
scalp  wound.  Only  in  cases  where  there  is  probability  of  meningeal  infection  is  it 
advisable  to  attempt  to  drain  the  dural  cavity.  This  is  better  accomplished  with  gauze, 
catgut,  or  folded  rubber  tissue  than  with  drainage  tubes. 

Skull  fractures  where  the  injury  is  limited  to  a  .small  area  are  treated  according  to  a 
bolder  method  than  was  in  vogue  a  number  of  years  ago.  There  should  be  careful 
and  judicious  operating  in  every  case  where  di.s-tinct  depression  can  be  made  out,  as  well  as 
in  every  case  where  indications  point  to  injury  of  parts  within  the  bone.  The  statistics 
of  trephining  in  the  pre-antiseptic  era  are  valueless  as  arguments  in  this  consideration. 
If  done  according  to  aseptic  precautions,  and  if  good  surgical  judgment  be  used  in  every 
respect,  the  operation  is  per  se  almost  devoid  of  mortality  and  should  not  be  regarded 
as  a  last  resort,  but  rather  in  such  cases  as  a  first  one.  I  have  seen  so  many  instances 
of  later  untoward  consequences  resulting  from  delay,  which  corroborate  the  experience 
of  others,  that  I  would  not  be  misunderstood  in  this  matter.  My  advice  might  perhaps 
be  summed  up  in  the  following  words:  Where  there  are  no  brain  symptoms  and  no  .fkull 
symptoms,  in  fractures  of  the  vertex,  let  the  ca.fe  alone;  when  either  of  these  are  present, 
especially  the  former,  it  will  always  be  advisable  to  operate. 


556 


SPECIAL  OR  REGIONAL  SURGERY 


Fractures  of  the  Base  of  the  Skull. 

In  the  majority  of  these  fractures  the  violence  is  apj)Hed  at  some  more  or  less  distant 
point,  and,  by  transmission  through  the  arch-Hke  structure  of  the  skull,  expends  itself 
in  Assuring  or  comminuting  the  base.  The  most  frequent  location  of  the  indirect  injury 
is  upon  the  convexity.  The  mechanism  of  these  fractures  has  been  a  prol)lem  for  many 
centuries,  but  has  been  cleared  up  mainl}  within  the  past  three  decades.  Felizet  has 
shown,  for  instance,  how  the  handle  of  a  hammer  may  be  forced  into  its  head  by  strkinq^  it 
in  either  one  of  two  different  ways,  and  has  compared  the  mechanism  of  basal  fractures 
to  this  fact.  The  secret  of  these  fractures  j:)robably  resides  in  the  elasticity  of  the  skull, 
which  varies  within  wide  limits  in  different  individuals,  and  which  breaks,  as  do  the  ribs 
and  the  jjelvis,  at  points  more  or  less  distant  from  that  at  which  the  injury  occurred. 
Were  the  skull  everywhere  equally  thick  and  elastic,  there  would  be  much  less  variation 
in  these  fractures,  but  lacerations  frequently  extend  between  the  most  resistant  parts; 


Fig.  375 


Fig.  376 


Fracture  of  base  of  skull.     (Bruns.) 


Fracture  of  base  by  fall  on  vertex.  Both 
condyles  broken  off  and  driven  in.  Vertex 
was  fissured. 


and  when  violence  is  applied  upon  the  forehead  we  find  that  the  resulting  fissure  extends 
between  the  cri.sta  and  the  wings  of  the  s})henoid,  upon  the  same  side,  in  its  course 
toward  the  base;  that  when  the  lateral  region  of  the  skull  is  injured  the  fissure  extends 
between  the  sphenoitial  wings  and  the  occipital  bone;  and  that  when  the  occipital  region 
receives  the  first  injury  the  fracture  lies  between  the  pyramid  and  the  occipital  crests. 
The  analogy  between  fractures  of  the  skull  and  cracks  made  in  nutshells  (cocoanuts,  etc.) 
when  struck  with  a  hammer  is  too  self-evident  to  be  disregarded.  Many  vears  since  the 
French  introduced  the  term  fracture  by  conire-coup  (counter-stroke) — a  practical  admis- 
sion of  the  occurrence  of  fracture  at  a  point  more  or  less  opposite  to  that  struck. 

There  is,  however,  no  certainty  about  these  fractures.  Extensive  fissures  of  the  vertex 
are  almost  always  extended  to  the  base  of  the  skull,  while  the  reverse  is  seldom  true. 
There  are  doubtless  also  many  cases  in  which  a  bursting  force  compromises  the  bone 
rather  than  mere  radiation  of  unexpended  violence;  but  so  long  as  skulls  conform  to 
no  fixed  mathematical  figures  nor  proportions,  and  are  composed  of  bones  varying  in 
shape,  density,  and  strength,  it  will  be  impossible  to  formulate  any  laws  which  are  sufli- 
ciently  com[)rehensive  to   be  satisfactory.     Fractures  in  the  posterior  fossa  occur  most 


PLATE  XLII 


Fractures  of  the  Base  cf  the  Skull.      Illustrative  lines  of  fissure  or  fracture 

are  printed  in  red. 


FliM'TlUES  OF   TIIli    SKULL  ^r^? 

often  tliroiiffli  violciur  applictl  ijostcriorly  and  Irom  hclow.  Tlicro  is  a  rin<f  form  of 
l)a.sal  fracture  |)r<)(liice<l  mainly  hy  the  impact  of  tlie  verlel)ral  colnmn,  as  wiien  an  indi- 
vidual falls  u|)on  liis  head  the  \vei<:;lit  of  the  hody  forcing''  the  cranial  base  in  U|)on  the 
hrain. 

Fractures  of  tiie  anterior  fossa  may  involve  the  roof  of  the  orbit;  even  facial  bones 
may  participate  in  the  injury.  These  considerations  are  not  without  im|)ortanee, 
for  if  a  patient  j)resents  sym|)toms  of  injury  of  the  petrous  hone,  and  if  these  be  accom- 
panied by  injury  to  the  lateral  rej^ion  of  the  skull,  we  are  in  a  ])osition  to  make  a  diajij- 
nosis  of  fracture  of  the  middle  fossa.     (See  IMate  XLII,  and  Fi<^.s.  .'■J75  and  37().) 

By  all  means  the  majority  of  basal  fractures  are  mer(>  //.swwrr.v  which  open  and  close 
insfanflji  upon  their  production — close  so  (|uickly,  in  fact,  as  .scarcely  even  to  include 
blood  between  the  broken  bony  surface's. 

Prognosis.  The  majority  of  basal  fractures  are  fatal,  cither  because  of  injuries 
to  the  brain,  or  of  hemorrhajije  or  violence  along  the  nerve  trunks,  or  from  infection 
extending  along  the  newly  opened  j)aths.  Other  things  being  ecjual,  the  longer  the 
fissure  the  greater  the  danger,  particularly  so  when  it  takes  its  origin  in  the  vertex,  and 
because  of  greater  ease  of  infection.  -1/V  injection  may  occur  in  any  basal  fracture  by 
fissures  extending  into  the  various  air-containing  cavities — nose,  ears,  sinuses,  etc. 
They  are  then  practically  com))oun(l,  though  invisibly  so.  The  general  prognosis  will 
de|)end,  first,  u])on  the  mjiiri/  to  the  cranial  contents;  second,  upon  the  pos.siht/ttjj  of 
infection.  Statistics  are  absolutely  unreliable,  although  always  possessing  interest. 
NunuM-ous  museum  specimens  show  the  perfection  with  which  bony  repair  may  occur 
and  the  admirable  way  in  which  compensation  is  afi'orded  for  defects.  Supj)uration 
after  basal  fractures  is  mainly  that  due  to  purulent  basal  meningitis,  in  which  case  the 
brain  symptoms  dominate  in  the  clinical  picture,  while  the  appearance  of  a  single  drop 
of  pus  in  the  ear  or  upon  the  surface  is  of  the  greatest  significance.  The  conversion 
of  a  serous  outflow  (e.  g.,  from  the  ear)  into  purulent  fluid  is  also  pathognomonic.  Various 
parali/scs,  jirincijially  of  the  cranial  nerves,  may  follow  this  injury  and  j)rove  temporary 
or  permanent.     Diagnosis  is  often  made  by  a  study  of  these  special  nerve  lesions. 

Diagnosis. — The  most  significant  diagnostic  features  are: 

1.  Spread  of  blood  from  the  point  of  fracture,  until  it  appears  as  an  ecehymosis  at  certain 
points  beneath  the  ski7i:  This  will  occur  early  in  some  cases  and  late  in  others.  It 
may  appear  beneath  the  skin  or  beneath  the  conjunctiva  or  other  mucous  membranes, 
even  in  the  pharynx.  Occurring  about  the  mastoid,  it  implies  fracture  of  the  middle 
or  posterior  fossa;  about  the  eyelids,  of  the  anterior  fossa.  Beneath  the  bulbar  con- 
junctiva it  means  extravasation  along  the  optic  sheath,  probably  from  within  the  dura. 
In  fractures  of  the  posterior  fossa  it  will  come  to  the  surface  of  the  neck,  but  only  after 
two  or  three  days.  The  ecchymoses  about  the  lids  or  orbits  occurring  after  two  or 
three  days  mean  more  than  those  occin-ring  within  these  days,  for  the  latter  may  be 
caused  by  external  bruising.  The  globe  of  the  eye  may  be  pushed  forward  by  blood 
accumulating  within  the  orbit.  Exophthalmos  thus  produced  is  therefore  most  signifi- 
cant, though  not  common. 

2.  Escape  of  serous  fluid,  blood,  or  brain  substance  from  the  cavities  of  the  skull:  Hemor- 
rhages from  this  cause  occur  most  often  from  the  ear,  the  petrous  bone  being  tunnelled 
with  various  canals  through  which  blood  may  thus  cscajie.  The  surgeon  should,  how- 
ever, assure  himself  in  every  instance  that  the  blood  is  escaping  from  the  ear  and  not 
from  some  trifling  woimd  of  the  external  soft  jmrts,  the  soft  walls  of  the  meatus,  or  the 
tym])anum.  Profuse  hemorrhage  can  probably  only  come  from  a  basal  fracture.  Es- 
cape of  serous  fluid  is  usually  noted  as  a  sequel  to  hemorrhage,  although  it  may  begin 
almost  immediately  after  an  injury.  Rarely  more  than  twenty-four  hours  elapse  before 
it  begins  to  flow.  The  quantity  of  fluid  discharged  is  sometimes  considerable.  It 
may  occur  in  frequent  drops  or  during  expulsive  efforts,  like  coughing,  or  may  ooze  in 
such  a  way  as  to  be  insensibly  collected  by  the  absorbent  tiressings.  In  average  cases 
the  amount  in  twenty-four  hours  is  from  100  Cc.  to  200  Cc;  SOO  Cc.  have  been  noted  in 
occasional  instances,  and  in  a  very  few^  still  more.  Occasionally  violent  expiration  will 
increase  the  flow. 

In  some  cases  the  fluid  may  escape  through  the  Eustachian  tube  into  the  pharynx, 
whence  it  may  escape  by  the  nostrils  or  be  swallowed. 

The  escape  of  brain"  substance  is  rarely  noted,  but  obviously  implies  such  serious 
injury  as  to  make  the  prognosis  of  the  worst, 


558  SPECIAL  OR  REGIONAL  SURGERY 

3.  Duiurhancr  of  function  alonxj  particular  cranial  nerves,  paralysis  of  which  is  often 
produced  by  fractures  of  the  base,  especially  those  involviny  the  foramen  of  exit  of  the 
nerve  involved:  The  nerve  may  be  lacerated  or  injured  in  such  case  by  the  fragment 
of  bone. 

In  addition  to  these  distinctive  features  there  will  be  in  the  majority  of  instances  brain 
symptoms,  either  of  contusion,  or  compression,  varying  in  severity  within  all  possible  limits, 
but  adding  their  weight  to  the  value  of  the  testimony. 

Other  and  unusual  signs  of  basal  fracture  may  occur,  such  as  communication  between 
the  cavities  of  the  petrous  bone  and  the  mastoid  cells,  leading  to  the  formation  of 
pneumatocele  (see  page  545),  or  emphysema  of  the  overlying  soft  parts,  observed  mostly 
about  the  orbits,  when  the  nasal  cavity  is  involved. 

Treatment. — The  treatment  of  basal  fractures  is  mainly  symptomatic.  The  first 
effort  should  be  to  make  antiseptic  all  those  parts  of  the  skull  involved,  which  means 
to  shave  the  scalp;  to  thoroughly  cleanse  and  irrigate  the  external  ear  and  the  auditory 
meatus,  using  a  head  mirror  and  ear  speculum  for  this  purpose;  to  tampon  the  meatus 
with  antiseptic  cotton;  to  provide  a  copious  absorbent  dressing  for  such  fluid  as  may 
escape  and  to  change  this  frequently;  to  cleanse  the  nasal  cavity  as  well  as  the  conjunc- 
tival sac,  for  all  of  which  the  peroxide  of  hydrogen  is  serviceable.  All  of  this  should  be 
done  promptly,  while  at  the  same  time  studying  the  ])atient  for  evidence  of  brain  injury 
or  of  involvement  of  special  nerves.  By  the  time  these  measures  are  thoroughly  per- 
formed a  decision  as  to  the  necessity  for  immediate  operation  should  have  been  reached. 
Evidence  of  brain  compression  wanting,  and  in  the  absence  of  external  or  compound 
injury  the  patient  may  be  left  at  rest,  with  cold,  applications  to  the  head  and  active  pur- 
gation. In  many  of  these  instances  benefit  follows  the  application  of  a  number  of  leeches 
to  the  mastoid  region  and  to  the  occiput.  Operation  is  necessary  later  only  when  brain 
symptoms  supervene,  these  consisting  of  evidences  of  compression,  either  from  blood  or 
from  j)us,  as  compression  from  other  causes  should  have  been  acting  at  the  time  of  the 
first  examination,  and  should  have  been  recognized  at  that  time.  When  direct  fractures 
are  evident  the  possibility  of  the  entrance  of  foreign  bodies  should  be  also  remembered. 
Thus  penetrating  fractures  of  the  base  have  occurred  through  the  orbit  as  the  result 
of  accident  or  assault,  and  such  weapons  ,or  implements  as  foils,  ramrods,  drumsticks, 
canes,  umbrella  points,  etc.,  have  been  known  not  only  to  penetrate  into  the  brain,  but 
perhaps  to  leave  some  portion  of  their  substance — e.  g.,  a  foil  tip  or  an  umbrella  tip — 
within  the  cranium  after  their  withdrawal. 

Separation  of  sutures,  known  also  as  diastasis  of  the  same,  is  the  occasional  result  of 
injury  instead  of,  or  complicated  with,  fissures  or  other  fractures.  It  is  the  result  of 
violence,  and  is  virtually  a  specific  form  of  fracture,  from  which  it  differs  in  no  essential 
particular.  Diastasis  can  only  take  place  along  lines  of  previous  suture,  but  it  is  possible 
that  Wormian  bones  may  be  thus  loosened.  Sutures  thus  separated  ordinarily  heal 
by  fibrous  repair  rather  than  osseous  union.  Diagnosis  is  possible  only  as  they  are 
exposed  to  view,  although  displacement  in  the  middle  line  or  along  known  suture  lines 
may  be  regarded  as  diastasis.  The  treatment  differs  in  no  respect  from  that  of  other 
fractures. 

Injuries  to  the  frontal  sinuses  occasionally  complicate  fractures  of  the  skull.  These 
sinuses  vary  in  different  individuals,  are  rarely  truly  symmetrical,  and  are  not  found  in  the 
young.  They  connect  with  the  nose  in  such  a  way  that  emphysema  of  the  frontal  region 
is  quite  possible,  while  air  may  be  blown  beneath  the  periosteum  or  may  comnnmicate 
with  the  interior  of  the  cranium.  In  wounds  of  the  frontal  region  the  sinuses  are  occa- 
sionally opened — a  fact  of  importance,  for  ijifection  of  the  Schneiderian  membrane 
may  occur  and  endanger  life,  mainly  because  of  the  retention  of  infectious  products  within 
its  cavities.  Moreover,  by  such  woimds  the  ethmoid  may  also  be  injured.  Pus  which 
escapes  from  these  sinuses  and  from  the  ethmoidal  cells  is  usually  thin  and  bad-smelling. 
Long  continuation  of  suppuration  after  such  injuries  probal)ly  means  necrosis  and 
formation  of  sequestra. 

INJURIES  TO  THE  BRAIN  AND  ITS  ADNEXA. 

By  better  acquaintance  with  certain  portions  of  the  brain  whose  function  is  now  gener- 
ally recognized  and  described,  as  well  as  with  the  more  exact  knowledge  regarding  the 
entire  encephalon,  the  outcome  of  many  recent  studies,  the  teaching  of  the  past  in  regard 


coxrrsiox  of  riii:  nnwiN 


550 


to  the  iiatiiro  of  various  hraiii  lesions  lias  heeii  essenlialiy  modified.  Ivspeeialiv  is  I  his 
true  ill  reo'ard  to  the  distinction  i'onnerly  emphasized  as' hetweeii  n)ncii.wi(,n  and  n,in- 
prr.s;sioii.  In  diseussiiijr  brain  injuries  we  should,  first  of  all,  distin<;uisli  between  tniu- 
inalie  disturhanees  of  the  entire  endocranium  and  loeali/-ed  injuries  to  the  hraiii  or 
pariKular  vessels  and  nerves  eiiterinu-  into  its  composition.  In  re<i:ard  to  ihc  first 
it  is  possible  that  ihc  ciilirc  blood  or  lyni|)liatic  circulation  within  the  cranium  niav  be 
afiected  in  such  a  wav  as  to  in(ln(>iicc  its  nutrition  and  function,  by  which  means  activity 
aud  function  are  mildly  or  seriously  j)erver(ed.  The  imniedialc CfVect  of  severe  injiirV 
to  any  part  of  the  body  is  refle.x  vasomotor  spasm,  which  constitutes  the  essential  feature 
of  the  condition  known  everywhere  as  .s/iork.  It  is  this  condition,  with  its  niarkerl  local 
expressions,  which  was  forim-rly  known  as  courii.s.s-ion  aj  the  brain.  When  studied  upon 
its  merits  it  is  found  to  be  hulisi'nKjui.sliahlr  from  .shock  j)roduced  by  injuries  to  other  parts. 
The  condition  for  so  many  years  tauj^ht  and  recof^nized  as  concussion  is  but  shock 
following  injury  to  the  head.  This  makes  no  further  demands  upon  the  (|ucslioii  of 
patholo.a^y  than  those  prompted  by  any  traumatic  disturbance. 

Throu(;h  the  mechanism  of  the  eerel)ros])inal  fluid  VA\n(\  alterations  of  pressure  and 
of  tlu>  volume  of  the  brain  are  ])roduce(l.  Ther(>  is  an  (>asy  path  between  (he  inelastic 
cranial  cavity  and  the  exceediiiirly  elastic  and  accommo(latin<!:  spinal  canal,  which  latter 
serves  as  a  reservoir  for  the  ffuid  which  may  be  j)rcsse(l  out  of  the  cranium  when  brain 
pressure  is  increased.  While  the  subdural  and  subarachnoid  sjniees  are  each  of  them 
absolutely  closed  sacs  and  do  not  communicate  one  with  the  other,  there  is  ample 
accommodation  within  each  to  permit  a  constant  equilibrium  of  pressure  under  ordi- 
nary circumstances,  as  between  the  spinal  canal  and  the  cranial  cavity.  The  brain 
expands  in  volume  with  every  systole  of  the  heart,  while  with  every  diastole  it  contracts. 
Its  size  is,  moreover,  modified  by  the  motions  of  respiration.  Under  these  extremely 
.accommodatino;  conditions  it  is  scarcely  credible  that  extenial  injuries  which  leave  no 
internal  evidences  of  violence  should  do  anything  more  than  disturb  the  equilibrium  of 
fluid  distribution. 

"CONCUSSION"  OF  THE  BRAIN. 

We  inherit  this  term  concussion  from  the  earlier  masters  of  our  art,  by  whom,  however, 
it  was  used  in  a  much  broader  sense  than  of  late.  Its  modern  sionifi("anc(>  was  gi\en  to 
it  by  Bf)irel,  who  made  it  apply  to  a  group  of  cerebral  symptoms  the  result  of  injuries 
not  accompanied  by  fracture  or  perceptible  laceration  of  vessels,  symptoms  varyiuo-  in 
intensity  aiul  duration. 

Our  present  j)osition  is  practically  this:  The  possibility  of  pure  concussion  of  the 
brain — i.  e.,  disturbance  of  brain  function  without  gross  mechanical  lesions — is  admitted, 
but  its  general  frequency  is  denied.  When  present  it  should  either  pass  away  quickly, 
the  condition  being  equivalent  to  that  called  "stunning,"  or,  if  it  assume  distinct  form, 
its  signs  and  sympiorns  are  indistinguishable  from  those  of  shock,  consisting  essentially 
of  rapid  and  feeble  pulse,  quick  and  shallow^  respiration,  jiallor  of  the  skin,  coj)ious 
persjjiration,  complete  or  partial  unconsciousness,  muscle  incoordination,  witli  lack  of 
sphincter  control,  occasional  vomiting,  the  pupils  usually  reacting  in  light. 

Treatment. — The  treatment  for  this  condition  is  essentially  that  for  shock,  and 
whatever  may  be  called  for  in  the  way  of  attention  to  injuries  about  the  head — e.  g., 
sewing  up  a  scalp  wound,  etc.     (See  Chapter  XVIII,  on  Blood  Pressure.) 


CONTUSION  OF  THE  BRAIN. 

The  condition  of  sltock  (rrrrbra/  rnnni.s-.sion),  when  of  pure  type,  passes  away  with 
reasonable  promptness,  especially  wIkmi  aided  by  surgical  treatment.  Anijthing  which 
persists  in  the. way  of  muscle  paralysis,  disturbance  of  function  of  nerves  of  special 
sense,  or  other  ,ngn  of  importance,  indicates  something  more  than  mere  vibratory  dis- 
turbance :  it  implies  mechanical  lesion  which  could  be  perceived  by  the  eye  were  the  j)arts 
exposed,  and  constitutes  the  condition  known  as  contusion.  This  imjilies  the  existence 
of  trifling  exudates,  or  hemorrhages,  which  lead  not  only  to  absorption  but  even  cica- 
trization. Contvsion  pure  and  simple  differs  from  ordinary  laceration  as  a  contusion 
elswhere  may  differ  from  a  wound.     It  cannot  be  separated,  however,  from  conditions 


5(50  SPECIAL  OR  REGIOXAL  SURGERY 

in  which  there  are  minute  separations  of  continuity  and  actual  lacerations.  It  may  be 
divided  into  three  postmortem  forms — general  hyperemia,  with  or  without  edema ;  punc- 
tate or  miliary  hemorrhages;  and  thrombosis  of  minute  vessels,  which  may  occur  separately 
or  together.  Moreover,  there  may  exist  similar  lesions  in  the  meninges,  con.stituting 
meningeal  contusion.  Ordinarily  minute  vessels  of  the  pia  are  rujjturcd  and  blood  is 
efTused  in  small  and  thin  patches  over  various  parts  of  the  brain.  The  so-called 
compression  apoplexies  of  certain  authors  are  inse{)arable  from  the  conditions  above 
described.  Such  minute  blood  clots  are  only  to  be  distinguished  u])on  very  careful 
sectioning  of  the  brain,  and  are  found  most  often  in  the  region  of  the  medulla  and  along 
the  floor  of  the  fourth  ventricle.  They  arc  probably  caused  by  the  forcing  into  the  fourth 
from  the  lateral  ventricles  of  the  fluid  contained  in  the  latter. 

Symptoms. — When  the  ordinary  symptoms  of  shock,  which  follow  all  severe  injuries 
to  tlie  head,  especially  when  the  deep  lesions  are  not  too  severe,  fail  to  disa[)pear  in  a 
short  time  under  proper  treatment,  and  when  new  and  irregular  symptoms  are  super- 
added to  those  of  shock  alone,  it  is  reasonable  to  suppose  that  the  intracranial  condition 
is  one  of  contusion  rather  than  of  shock.  When  mental  agitation  changes  into  delirium, 
when  the  rapid,  feeble  ])ulse  becomes  stronger  and  slower,  the  respiration  deeper,  the 
limbs  move  in  incoordinate  ways,  the  speech  disturl)ed  from  muscle  in(;()()rdination, 
the  patient  selects  wrong  words,  or  when  the  mental  ct^ndition  becomes  more  serious  and 
stupor  or  coma  take  place  of  the  delirium,  while  external  irritants  have  less  and  less 
effect,  and  when  the  pupils  gradually  enlarge  while  failing  to  respond  to  light,  it  may  be 
said  that  the  condition  of  contusion  is  making  itself  apparent.  If  along  with  muscle  un- 
certainty there  is  also  muscle  spasm  or  rigidity,  with  fixation  of  the  fingers  in  the  athetoid 
position,  the  evidence  to  this  effect  is  increasing.  If  with  all  this  the  thermometer  fails 
to  show  that  an  active  inflammatory  condition — /.  e.,  meningitis — is  prevailing  the 
diagnosis  may  be  regarded  as  certain.  Error  may  possibly  arise  when  there  are  evidences 
of  alcoholism.  Coma  following  head  injury  ought  not  to  be  ascribed  to  the  alcoholic 
condition  except  by  the  strictest  process  of  exclusion.  Temperature  alone  will  be  of 
the  greatest  service  in  this  direction,  since  in  alcoholism  it  is  usually  subnormal.  In 
apople.vy  and  non-traumatic  hemorrhages  it  is  also  usually  subnormal  at  the  commence- 
mrnf  of  the  attack,  rising  to  normal,  and  remaining  there  if  the  patient  recover,  but  con- 
tinuing to  rise  in  cases  where  the  prognosis  is  bad. 

Treatment. — The  treatment  of  brain  contusion  should  be  managed  largely  in  response 
to  s])ecial  symptoms.  Physi(jlogical  rest,  attention  to  seal])  wounds,  fractures,  etc., 
shaving  of  the  scalp,  application  of  ice  to  the  head,  with  such  stimulation  to  the  heart 
as  may  be  necessary  in  extreme  cases  by  subcutaneous  administration  of  adrenalin, 
atropine,  etc.,  by  local  fomentations  over  the  ejiigastrium,  or  by  immersion  in  a  hot  bath 
when  surroundings  permit  it — these  in  a  general  way  constitute  most  of  the  methods 
of  treatment  in  contusion.  When  only  symptoms  of  diffuse  and  minute  lacerations  can 
be  recognized  the  use  of  the  trephine  is  impracticable  except  when  indicated  by  some 
external  marking — i.  e.,  compoimd  fracture  or  the  like.  When  localizing  symptoms 
are  present  the  trephine  is,  of  course,  indicated.  When  the  skull  injury  is  recognized 
as  a  basal  fracture,  venesection  or  the  ajjplication  of  leeches  l)ehind  the  ears  will  be 
most  serviceable.  In  every  such  case  there  is  the  greatest  necessity  for  regulating  the 
excretions  and  preventing  auto-intoxication.  For  this  purj^ose  diuretics  and  laxatives 
should  be  used,  often  in  conjunction  with  intestinal  antiseptics.  The  catheter  should  be 
employed  whenever  indicated  by  the  condition  of  the  bladder,  which  should  be  carefully 
watched.  As  the  days  go  l)y,  and  patients  lie  more  or  less  hel})less  and  inert,  the  greatest 
care  should  be  exercised  for  the  prevention  of  bed-sores.  When  mental  inertness, 
muscle  rigidity,  etc.,  fail  to  disappear,  potassium  iodide  should  be  used  internally. 


BRAIN  PRESSURE  OR  COMPRESSION. 

That  the  cranial  contents — brain,  blood,  lATiiph,  and  cerebrospinal  fluid — completely 
fill  the  cranial  cavity  has  been  already  am])ly  shown,  as  well  as  that  there  is  no  room 
for  an^-thing  in  the  shape  of  a  foreign  l)ody  without  seriously  affecting  the  equilibrium 
between  the  brain  and  the  contents  of  the  spinal  canal.  When,  however,  any  foreign 
substance  exerts  pressure  upon  the  brain  the  results  are  invariably  the  same,  be  this 
substance  what  it  may,  and  compression  signs  are  always  the  same,  no  matter  what  the 


PLATE   XLIIl 


...  .^. 


Fig.  1.  Compound  Fracture  of  Cranium,  with  Depression  ;   Fracture  of  Bones  ot  Face  ; 

Extradural  Clot  from  Rupture  of  Middle  Meningeal  Artery. 

Fig.  2.   Horizontal  Section  of  same,  showing  Depressed  Fracture  of  Bone.     (Anger.) 

C,  extradural  clot ;    D,  laceration  of  brain  substance,  with  extensive  intracerebral  clot ;    F,  same 
condition  produced  by  contrecoup.     Punctate    hemorrhages  and  minute   lacerations   at   numerous 

points,  characteristic  of  contusion  of  the  brain. 


/.7i'.i/\   I ' h' I : SSI  /,'!■:  oi;  (om i'i:i:ssn>.\  r,(il 

coiiiprc.s.s'iiK/  c(iu.s-c.      Ili'diulioii    in   capacity   of  llic   cranial    ca\ily    (/.   c,   c()iii|)rc.s.si()ii) 
may  lie  producrd — 

1.  By  iv(iiicin<;  the  (linuMisions  of  its  cnclo.siii<,'  walls  (r.  fj.,  dcprcsscMl  fractures  or 
by  direct  pressure); 

2.  Bv  increase  in  the  (iiiaiitily  of  cerel)ros|)iiial  (liiid  or  of  the  voluine  of  the  hiaiii, 
\Yhieh  latter  may  he  produced  hy  ed( ma,  hy  sctous  exudate,  or  hy  actual  hypertrophy; 

'A.   B\'  foreii^n  ltodi(>s,  which  may  (Miter  the  skull   from   without; 

4.  Bv  |)atholo<jical  conditions  collections  of  hlood  or  pus,  tumors,  etc.,  which  may 
be  produced  either  from  the  brain  substance,  its  conlaiiiiiij^  bone  or  membranes,  or  its 
vessels. 

In  every  one  of  these  conditions  the  size  and  tension  of  the  brain  are  aft'eeteth  The 
cerebrospinal  fluid  is  iiiainli/  inrnlrrd  in  acute  not  in  rJironie  conditions.  A  slow  reduction 
of  the  diameters  of  the  skull  produces  such  slow  altci'ations  (jf  ])ressure  as  to  cause  a 
minimum  of  distiu-bauce.  So  far  as  compression  from  trainnatic  influences  is  concerned 
^ve  distiujruish  nuiinly  between  comj)ression — 

1.   By  extravasation  of  blood  (see  Plat(>  XLIII); 

'1.  Bv  fractures  of  the  skull  with  de|)ression,  or  by  foreio;n  bodies  penetrating''  from 
without; 

3.  By  products  of  acute  infectious  iuHammaticjii  due  to  se|)tic  infection  from  without. 
The  result  common  to  all  of  these  is  increase  of  intracranial  tension,  and  its  eonseriuenec 

is  a  less  rapid  flow  of  blood  and  an  altered  blood  suj)j)ly  to  the  brain  and  its  membranes. 

Experiment  has  established  that  in  compression  of  the  brain  cerebrospiiuil  fluid  is 
forced  by  pressure  into  the  spinal  canal,  whose  membranes  are  more  elastic,  and  which 
thus  hel])  to  accommodate  it;  it  has  been  also  established  that  compression  of  the  brain 
bv  one-sixth  of  its  volume,  by  any  material,  is  fatal,  and  that  much  less  is  at  least  serious. 
That  fractures  with  dei)ression  produce  sometimes  serious,  at  other  times  triflino;,  symp- 
toms is  due  to  the  varvino;  accommodation  of  the  sj)inal  canal.  Both  experiment  and 
observation  seem  to  confirm  the  view  that  consciousness  pertains  to  the  cortex  as  a 
whole,  and  that  unconsciousness  is  an  inhibitory  or  paralytic  condition  which  is  produced 
in  compression. 

Temperature  is  a  matter  of  great  importance  in  studying  compression  and  foretelling 
its  consequences.  Elevation  of  temperature  is  an  early,  continuous,  and  constant  symp- 
tom in  these  cases.  If  temperature  be  sul)normal  and  sidisecjuently  rise,  })rognosis  is 
bad.  Variations  of  temperature  are  more  reliable  guides  than  conditions  of  conscious- 
ness. As  Pheljxs  has  remarked,  in  no  condition  excej)t  sunstroke  is  tcmjxTature  so 
uniformly  high  as  in  cases  of  serious  encephalic  lesions. 

Symptoms. — As  indicated  above,  the  sym])toms  and  signs  of  comj^ression  arc 
practically  identical,  no  matter  what  the  compressing  cause.  When  this  cause  acts 
instantly  there  is  no  time  aft'orded  for  differentiation,  but  when  it  occurs  slowly  \ve 
note  the  following  symptoms,  and  about  in  the  order  here  presented:  Irritability  or 
restlessness;  visceral  disturbances;  pain;  intense  cephalalgia;  congestion  of  the  face; 
narrow  pupils;  augmented  {)iilse,  often  seen  in  the  carotids.  If  com])ression  occur 
more  rapidly,  torjior  quickly  succeeds  erethism,  after  which  )«itients  vomit,  have  con- 
vulsions or  at  least  convulsive  motions,  sjjcech  is  disturbed,  and  stupor  con.cs  on,  from 
which  they  neither  awake  nor  can  be  awakened  until  the  compression  is  relieved.  All 
oi  these  indications  refer  to  involvement  of  the  cortex,  which  is  generall}'  regarded  as 
the  seat  of  consciousness  as  well  as  of  projection  and  imagination.  During  the  night, 
of  the  senses  produced  by  pressure  upon  the  cortex  only  the  automatic  basal  apparatus 
and  that  of  the  spinal  cord  continue  in  more  or  less  disturbed  operation.  Of  all  the 
general  functions  consciousness  vanishes  first  and  returns  among  the  last.  \^  heti 
intracranial  jiressure  has  reached  a  certain  point,  e[)ileptiform  convulsions  result, 
varying  in  intensity,  affecting  all  the  limbs,  and  terminating  perhaps  with  rigidity. 
These  form  an  expression  of  high  pressure.  Similar  convulsions  occur  in  various  head 
wounds,  explanation  for  which  is  the  result  of  pressure,  which,  though  not  extensive, 
may  produce  alteration  in  the  circulation,  with  its  disastnnis  cons(>quences.  The  later 
and  constant  evidences  of  compression,  and  those  which  in  af/grarated  cases  supervene 
at  once,  are  reduction  of  pulse  rate,  dwv  to  the  action  of  the  pnemnogastric,  which  suffers 
first  an  irritation  and  later  a  paralysis.  The  pulse  becomes  not  only  slackened  but 
full;  the  respiration  rat(>  is  correspondingly  reduced,  so  that  breathing  during  coma  is 
deep,  slow,  and  often  stertorous.  This  feature  of  stertor  is  an  expression  of  paralvsis 
30 


502  SPECIAL  OR  REGIONAL  SURGERY 

of  the  palatal  and  pharvn<]^eal  muscles,  which  flap,  as  it  were,  in  the  air  current.  Vomit- 
ing, which  may  occur  before  brain  tension  has  risen  high,  does  not  occur  in  the  most 
serious  cases.     Coma  is  absolute. 

Along  with  these  signs  the  most  important  other  indications  are  the  'paralyses,  which 
may  consist  of  monoplegia,  heniij)legia,  or  paralysis  of  individual  muscle  gr()U])s,  accord- 
ing as  j)ressure  is  made  upon  a  limited  area  or  upon  an  entire  hemisphere.  By  the  divi- 
sion of  the  cranial  cavity  by  the  falx  and  the  tentorium  it  is  divid(>d  into  chambers, 
in  any  one  of  which  ])ressure  may  be  more  manifest  than  in  the  others.  Nevertheless 
a  serious  compressing  cause  will  affect  the  tension  of  the  cerebros])inal  fluid  and 
produce  general  expression  of  ]:)ressure.  The  pupils  often  vary,  and  responsiveness 
to  light  is  occasionally  noted.  Nystagmus  and  ocular  rotation  may  be  occasionally 
seen.  Choking  of  the  o])tic  disk  is  also  a  frecjuent  phenomenon,  to  be  recognized  only 
by  ophthalmoscojiic  examination.  This  is  due  to  pressure  in  the  subdural  and  subarach- 
noid prolongations  along  the  optic  nerve.  In  milder  cases  of  chronic  compression  dis- 
turbances of  vision  are  of  very  great  clinical  importance.  These  pertain  especially  to 
diagnosis  of  hydrocephalus  and  of  brain  tumors.  When  they  occur  immediately  after 
injury  and  remain,  they  depend  upon  laceration  or  other  severe  injury  of  the  optic 
nerve.  Those  which  cjuickly  disappear  depend  mainly  upon  pressure  of  blood,  which 
is  reabsorbed,  while  those  which  are  later  in  their  appearance  tlepend  upon  later  intra- 
cranial com])lications.  A  unilateral  lesion  of  the  optic  nerve  depends  most  often  upon 
injuries  to  it  within  the  optic  canal.  When  the  lesion  is  bilateral  the  cause  lies  deep. 
General  paralysis  may  be  of  the  type  of  hemiplegia,  single  or  double — i.  e.,  by  "double" 
I  mean  ])aralysis  of  the  entire  voluntary  musculature  of  the  body,  which  necessarily 
im|)lies  serious  and   often   fatal   hemorrhage. 

Prognosis. — This  depends  in  large  degree  upon  the  nature  of  the  compressing 
cause  and  of  the  possibility  of  its  removal.  While  the  nature  of  the  same  may  ordinarily 
be  determined,  how  much  can  be  accomplished  by  way  of  removal  may  often  not  be 
foretold  before  the  operation  at  which  this  should  be  attempted.  In  every  acute  case  it 
is  desirable  to  make  this  attempt  early,  for  high  pressure,  which  may  be  borne  for  a 
short  time,  is  fatal  if  continued.  Compression  to  any  serious  degree  is  usually  fatal. 
So  soon  as  paralysis  of  circulatory  and  respiratory  centres  is  apparent  the  beginning  of 
the  end  is  at  hand.  Another  reason  for  hastening  operation  is  that  acute  softening  of 
brain  tissue  comes  on  promptly,  as  well  as  general  cerebral  edema,  which  has  destroyed 
many  a  patient  during  the  second  to  the  fourth  day  after  injury. 

Treatment. — The  treatment  of  compression  is  summed  up  in  one  phrase — i.  e., 
to  remove  the  cause  when  possible.  The  only  cases  in  which  this  rule  may  be  safely 
disregarded  are  those  where  the  attempt  to  remove  the  cause  means  more  danger  than  to 
leave  it  unremoved.  This  is  not  true,  however,  in  the  ordinary  cases  of  bone  depression, 
meningeal  hemorrhage,  etc.  Before  operation,  however,  or  as  a  substitute  for  it  in  cases 
of  minor  severity,  it  may  be  well  to  assist  venous  outflow  by  venesection,  by  which  blood 
pressure  is  reduced.  In  these  cases  this  may  be  done  from  the  temporal  veins  or  external 
jugulars,  with  the  patient  in  the  semi-upright  position.  Drastic  purgatives  may  also  be 
em])l()yed  in  order  to  utilize  intestinal  outpour  as  a  stimulation  to  resorption  of  cerebro- 
spitial  fluid.  The  physiological  action  of  cold  (ice-bags)  may  also  be  secured  for  the 
purpose  of  contracting  the  cerebral  arteries.  But  all  these  measures  are  only  to  be 
resorted  to  when  there  is  uncertainty  as  to  the  wisdom  of  operating,  since  when  operation 
is  indicated  it  shcnild  be  done  at  once,  and  shoiild  take  precedence  of  everi/tliitig  else.  This 
operation  means  ordinarily  the  procedure  to  which  the  now  general  term  trepJdning  has 
been,  by  common  consent  applied,  and  comprises  any  measure  by  which  the  skull  is 
opened  at  a  suitable  place  and  the  dura  or  the  underlying  cortex  exposed  to  such  extent 
as  to  permit  removal  of  the  compressing  cause.  Whether  the  opening  be  made  with 
trephine  (annular  saw)  or  with  the  straight  or  revolving  saw,  with  l)()ne  chisel,  with  bone 
forceps,  or  with  anything  else,  is  a  matter  of  choice  on  the  part  of  the  ojjcrator.  So,  too, 
removal  of  the  compressing  cause  should  include  the  elevation  of  de{)ressed  bone,  the 
removal  of  dislodged  particles  as  well  as  of  all  foreign  bodies,  the  cleaning  out  of  blood 
clot,  the  checking  of  hemorrhage,  and  the  closure  of  the  wound,  with  or  without  drainage 
or  counteropening  at  some  other  part  of  the  skull,  as  may  seem  desirable  in  special  cases. 
This  entire  procedure  comes  now  under  the  name  of  trephining,  and  should  in  most 
instances  be  painstakingly  followed. 

The  operative  maneuvers  will  be  discussed  in  another  portion  of  this  chapter. 


/.V./r/i'/yV.S  OF  IXTILU'UAMAL    VFSSIJLS   AM)  SLWdSES 


5G3 


INJURIES  OF  INTRACRANIAL  VESSELS  AND  SINUSES. 


Inlracranial  liciiiorrliai^cs  inav  occur — 

{(i)  From  iii(criial  sources  tliroiiifli  (lie  broken  hone  or  between  it  and  the  (hirji 
(extradural); 

(b)  Beneath  the  (hiru,  between  or  into  the  ineinbranes  (sub(hiral); 

(c)  Into  the  brain  substance  ])roj)er  oi  the  vent  rides  (subcortical  or  intra ventricuhir). 
The  vessels  whose  injuries  are  most  often   under  consideration   are  the  incriiiif/ral 

arferirs,  the  .sv'/fjwr.s",  the  .sinall  vrs.sr/.'i  of  ilir  iiirnihmvr.s-,  and  tlie  infernal  carotid,  'rhe 
arteries,  hke  the  sinus  walls,  may  be  ruptured  either  by  substances  forced  in  from  witluiut 
or  by  sheer  laceration.  The  loiu/ifiidinal  si}n(s  is  most  liable  to  injury  from  without. 
When  this  siiuis  is  exposed,  it  may  be  dealt  with  either  by  suture  if  the  wound  be  small, 
or  by  lipition,  or  by  tamponini;  with  ])repare(l  (jjauze.  llcmorrhaj^c  from  this  source 
is  ordinarily  not  difficult  to  check.  Fatal  air  embolism  has  resulted  through  an  ojxMied 
sinus  not  pr()])erly  j)lu<i<;ed.     The   other 

sinuses  are  more  rarely  injured,  as  by  gun-  ^'"-  ^^'^ 

shot  wound,  fracture  of  the  base,  etc.  The 
sinuses  have  also  been  injured  by  com- 
pression of  the  skull  during  parturition. 
Bleeding  from  a  sinus  is  usually  indis- 
tinguishable from  that  from  a  meningeal 
artery,  except  that  the  former  occurs 
more  slowly. 
Injuries  to  the  Middle  Meningeal 

Artery. — Injuries  to  the  middle  men- 
ingeal artery  naturally  occur  in  the  im- 
mediate neighborhood  of  this  vessel, 
which  is  not  infrequently  rupturctl  by 
contre-coup.  The  artery  runs  sometimes 
in  a  groove  of  the  bone,  somc^timcs  in 
the  dura,  and  sometimes  entirely  in  the 
bone.  The  more  it  lies  within  the  bone 
the  more  likely  it  is  to  be  ruptured  when 
this  part  of  the  skull  is  fissured.  Basal 
fractures  often  follow  the  groove  for  this 
artery.  The  anterior  branch  is  more 
often  injured  than  the  jiosterior.  Extra- 
vasations from  this  source  are  more 
common  than  from  all  others  combined, 
the  amount  of  blood  varying  within 
wide  limits.  240  Gm.  of  blood  clot 
have   been    known   to    collect   and   the 

dura  to  be  separated  down  to  the  base  of  the  skull.  I  have  repeatedly  taken  away 
a  small  teacupful  of  blood  clot  in  such  cases  (Fig.  377  and  Plate  XLllI). 

Symptoms. — The  symptoms  of  this  hemorrhage  are  those  of  compression,  while 
extravasation  may  be  ra])id  antl  quickly  fatal,  delayed  for  some  time,  or  may  take  place 
in  two  stages,  the  first  but  slight  and  producing  no  coma.  New  clots  are  always  dark 
and  disk-shaped,  thick  in  the  middle,  with  a  definite  margin.  As  the  clots  become 
older  they  become  more  adherent  and  difficailt  to  remove.  The  symptoms  of  meningeal 
hemorrhage  consist  of  an  interval  of  consciousness  or  lucidity  after  injury,  followed  by 
epileptic  or  spastic  symptoms,  alterations  in  the  pupils  and  pulse,  unconsciousness  pass- 
ing into  coma,  and  stertorous  respiration.  There  may  or  may  not  be  external  evidence 
of  head  injury.  The  character  of  the  paralysis  (hemiplegia)  may  indicate  that  the  clot 
is  really  upon  the  side  opposite  to  that  of  the  skull  which  shows  evidence  of  injury.  In 
this  case  arterial  laceration  is  the  result  of  contrc-cnup.  According  to  the  rapidity  of  the 
S}Tnptoms  is  the  extent  of  the  primary  lesion.  I\I(Miingeal  hemorrhages  involve  imme- 
diately the  motor  area,  which  makes  diagnosis  all  the  easier. 

Injuries  to  the  Carotid.— Injuries  to  the  carotid  within  the  cranium  are  exceed- 
ingly rare.     Still,  it  has  been  injured  in  basal  fractures  and  penetrating  wounds. 


Compression  following  hemorrhage    from  the  middle 
meningeal  artery.      (Helferich.) 


564  SPECIAL  on  rfahos'al  surgery 

Arteriovenous  Aneurysm.— IX-vclopiiKiit  of  arU'riovcnous  aneurysms  after  basal 
injuries  is  occasiunully  noted.  'I'liey  will  occasionally  jrive  rise  to  pulsatin<^  e.\o[)litlial- 
mos.  Pulsating  tumors  within  the  obrit  which  push  the  eye  forward  not  infrecjueiitly 
occur  after  serious  head  injury.  Of  77  eases  collected  by  Rivington,  41  had  a  traumatic 
origin. 

Subdural  Hemorrhages. — Subdural  hemorrhages  are  not  infrequent  in  the  skulls 
of  tile  newborn,  and  constitute  the  so-called  (ipop/c.ria  neonatorum.  They  may  occasion 
convulsions  and  paralyses  of  irregular  type,  while  if  the  extravasations  become  infected 
multiple  abscess  may  result. 

In  adults  subdural  hemorrhages  are  most  commonly  coimected  with  brain  lesions 
which  have  been  already  spok(;n  of  as  contusions.  They  may  be  the  starting  j)oints  for 
pachymeningitis.  Their  ihost  common  results  are  disturbances  of  consciousness  and 
mentality.  Paralytic  dementia  follows  in  some  of  these  cases.  Plxtensive  subdural 
hemorrhage  may  give  a  clinical  picture  corresponding  to  extradural.  Disseminated 
miinite  eechymoses  constitute  minute  focal  lesions,  which  are,  however,  usually  so  dis- 
tributed as  to  confuse  and  prevent  accurate  diagnosis.  Apoplexy  or  intraventricular 
hemorrhages,  especially  from  the  lenticulostriate  artery  (Charcot's  "artery  of  hemor- 
rhage"), have  until  very  recently  never  been  regarded  as  wan-anting  surgical  int(>rfer- 
ence.  Of  late,  however,  especially  in  the  ingravescent  or  ])rogressive  forms,  ligature 
of  the  connnon  carotid  has  been  of  some  service,  though  in  order  to  render  this  effective 
ligation  should  be  done  early. 

Traumatic  Intraventricular  Hemorrhage. — Traumatic  intraventricular  hemor- 
rhage occurs  in  much  the  same  way  as  meningeal,  by  contre-coup.  Individuality  of 
sym])toms  is  lost  in  the  general  comatose  condition  of  the  patient,  but  when  operation 
is  performed,  as  it  is  usually  best  to  perform  it,  if  no  extradural  clot  be  found  and  if  brain 
tension  be  evidently  increased,  the  dura  should  be  opened;  after  which,  if  no  subdural 
clot  be  seen,  the  ventricles  should  be  tapped  with  an  exploring  instrument.  In  this 
case,  if  l>lood  be  removed  by  aspiration,  a  knife  should  be  passed  directly  into  the  ven- 
tricle, after  which  blood,  if  ])r(>sent,  will  ])romptly  escape.  Dennis  was  the  first  to 
diagnosticate  the  presence  of  intraventricular  clot  and  to  deliberately  incise  into  it, 
and  I  have  myself  repeatedly  imitated  this  procedure,  both  with  and  without  success. 

In  every  case  in  which  superficial  or  cortical  hemorrhage  can  be  recognized — or  even 
suspected — or  intraventricular  hemorrhage  as  well,  one  should  insist  upon  exploration. 
This  means  trephining,  with  perliaps  asj)iration  of  the  ventricular  contents.  Tapjiing 
of  the  ventricle  is  described  mider  Treatment  for  Hydrocephalus,  while  trephining  is 
described  at  the  end  of  this  chapter. 


LACERATIONS  AND  INJURIES  TO  THE  BRAIN  SUBSTANCE. 

These  have  been  mentioned  under  contimon  of  the  brain.  They  may  be  divided  into 
those  which  occur  with  or  without  fracture  of  the  cranial  bones.  The  term  contusion 
was  first  suggested  by  Dupuytren.  The  condition  comprises  all  degrees  of  injury,  from 
the  most  minute  local  disturbances  to  lesions  involving  the  entire  hemisphere.  The 
milder  forms  show  a  sprinkling  of  punctate  hemorrhages,  numerous  in  the  centre  of  the 
injured  area,  the  surrounding  tissue  taking  on  a  more  or  less  diffuse  tint,  which  fades 
out  toward  the  perij)hery,  discoloration  being  due  to  the  imbibition  of  the  coloring 
matter  of  the  blood.  In  more  extensive  injuries  clots  as  large  as  peas,  or  larger,  are 
embedded  at  various  ])oints,  each  surrounded  by  its  area  of  discoloration.  WIumi  foreign 
bcxlics  have  been  driven  into  the  brain  the  tissue  is  also  discoloi'cd,  while  various  foreign 
materials  may  be  met.  In  instances  of  great  violence  there  may  occur  absolute  rupture 
of  brain  tissue  extending  from  cortex  to  ventricle. 

Prognosis. — Prognosis  depends  in  large  degree  upon  escape  from  or  occiu-rence 
of  infection.  In  infected  cases  the  principal  dangers  are  from  blood  pressure  and  from 
later  edema  or  acute  softening  as  well  as  from  meningitis.  Brain  lacerations  mav  heal 
by  cicatricial  rc])air,  but  usually  with  some  perversion  of  function. 

The  possibility  of  ci/.siic  degeneraiion  of  larf/r  or  .s-ma/l  clots-  is  one  of  great  importance. 
(See  Cysts  of  New  Formation  in  Chapter  XXVI,  ])age  2(')4.)  A  blood  clot  within  the 
cranium  which  fails  to  resorb  is  essentially  a  hematoma,  in  whose  interior  softening 
and  conversion  into  a  cyst  may  easily  occur.     These  cysts  make  room  for  themselves  at 


GUXsjfoT  wnrxDs  OF  Tin-:  iii:m) 


nco 


the  c'X|)('iis('  of  siirrouiKliii^  hniiii  (issue,  ;iihI  when  loealed  in  tlie  iiiolor  ;ire;i  inve  rise 
to  locali/iiii;-  sviiiptoins  as  well  as  (o  e|)ile|>lie  eoiiviilsioiis.  'J'liev  iiiav  he  ofleii 
tlia<,niostieatecl  with  eertaiuty  after  an  {uriirate  liistory  of  the  ease  and  a  study  of  (he 
j)henoin(Mia  which  it  pnvseiits.  As  tliey  (>;row  older  tlieir  walls  heeonie  firmer,  and  it 
is  often    j)ossil)l(>   to  dissect   them   out. 

That  joirujii  hodirs  mail  he  riirap.^ii/dtfd  and  remain  without  prodncinj;  dis(ui'f)anee  is 
now  well  known.  This  is  particularly  true  of  bullets.  As  a  rule,  however,  ihouj^h 
enca|)siilated,  they  ])roduce  sym|)toms  like  headache,  vertio;o,  etc.     (See  Plate  XLIIl.) 

Symptoms.  The  jfctieral  features  of  hrain  lacerations  are  those  of  cotitiisiuii.  So 
lonij  as  the  disturhanees  are  minute,  even  if  multiple,  or  the  foreio;n  hodv  small,  com 
pression  .symptoms  are  not  produced,  or  at  least  in  very  incomi)lete  detrree.  Minute 
diagnosis  is  not  easily  obtained.  The  most  essentia!  thing  is  to  decide  upon  the  ((uestion 
of  operative  interference.  In  the  absence  of  distinctly  localizing  symptoms  or  other 
external     markings    it     is    not 

usually  performed.     I'pon   the  i'""^-  '•^''^ 

other  hand  a  l(\sion  which  can 
b(>  localized  is  j)r()bal)ly  due  to 
extravasation  sufficiently  large 
to  be  easily  reached  by  opening 
the  skull;  and,  unless  there  be 
other  and  sufficient  reason  to 
the  contrary,  this  should  l)e 
done  (Fig.  378). 

In  many  instances,  however, 
contractures  or  paralyses  of 
muscle  groups  occur  later,  and 
are  followed  by  spastic  condi- 
tions which  may  be  permanent. 
More  can  be  done  in  these 
cases  by  massage,  by  internal 
medication,  perhaps  with  ex- 
ternal counterirritation,  than  by  distinctly  surgical  procedures.  Tendoplastic  or  neuro- 
plastic  measures  for  their  relief  may  also  be  considered.  Both  albuminuria  and 
glycosuria  are  known  to  be  the  result  of  injuries  herein  described,  as  well  as  bulbar 
paralysis  and  disturbances  of  special  senses.  More  immediate  dangers  after  these  head 
injuries  are  those  of  bronchopneumonia  or  hemorrhagic  or  edematous  infiltration  of 
the  lower  lobes  of  the  lungs — conditions  often  spoken  of  as  hypnsfatic  pneumonia, 
much  resembling  those  produced  experimentally  in  bilateral  division  of  the  j^neumo- 
gastrics.  Some  of  them  are  produced  by  paralysis  of  the  glottis,  the  result  of  which  is 
incomplete  closure,  with  aspiration  of  fluids  and  solids  from  the  mouth,  whose  decom- 
position sets  up  an  infection  within  the  lungs,  and  is  often  referred  to  as  aspiration 
pneinnonia.  Some  form  of  pulmonary  disturbance  follows  in  perhaps  one-third  of  the 
ca.ses  of  the  injuries  above  alluded  to,  antl  should  be  anticijxited  and  prevented. 


Bullet  embedded  in  anterior  fussa.      (U.  S.  Army  Meii.  Museum.) 


GUNSHOT  WOUNDS  OF  THE  HEAD. 

These  have  already  been  extensively  considered  in  a  previous  chapter,  so  that  but  little 
more  need  be  said  of  them  here.  Such  wounds  in  the  scalp  are  likely  to  be  followed  by 
sloughing.  So  far  as  gunshot  fractures  of  the  skull  are  concerned,  there  is  frequently 
a  marked  discrepancy  between  the  wounds  of  the  inner  and  outer  tables,  that  last  per- 
forated by  the  bullet"  being  almost  splintered.  Penetrating  wounds  of  the  cranium  by 
Mauser  and  similar  bullets  are  not  necessarily  fatal.  Many  men  were  shot  through 
the  head  tluring  the  Cul)an  and  South  African  wars  and  yet  did  not  die  as  a  result 
of  tlie  wound.      (See  Chapter  XXII.) 

Treatment. — So  far  as  treatment  is  concerned,  gunshot  injuries  of  the  skull  necessi- 
tate trephining  or  exi)loration,  for  checking  of  hemorrhage,  disinfection  of  the  bullet 
track  w^hen  possil)le,  often  for  a  counterdrainage  opening  with  through  drainage  either 
by  tube  or  gauze.  The  huUet.  if  it  can  be  found,  should  be  removed.  In  searc-hing  for 
it' the  old  porcelain-tipped  probe  of  Nelaton  has  almost  completely  given  way  to  Fluhrer's 


566 


SPECIAL  OR  REGIONAL   SURGERY 


alumimim  probe,  wliich  is  \nr}i;vv  and  I()ii<i;cr  an«l  wlicii  riji-lilly  directed  will  \>y  slight 
weight  usually  glide  gently  along  a  bullet  track,  thus  leading  often  to  the  missile^  and  at 
the  same  time  indicating  by  its  direction  where  the  counteroi)ening  should  be  made.  Two 
other  methods  of  detecting  bullets  are  now  in  vogue.  (Jirdner,  some  years  ago,  invented 
a  telephone  prol)e,  by  which,  so  soon  as  the  instrument  touches  the  missile,  a  telephone 
circuit  is  completed  and  the  o])erator  with  a  tele])honc  receiver  applied  over  his  own  ear 
hears  the  tell-tale  "click"  indicating  the  fact.  This  has  been  further  improved  by  the 
substitution  of  a  bell  or  "buzzer,"  which  tells  its  own  tale  when  the  probe  touches  the 
bullet. 

A  still  more  ingenious  application  of  electricity  for  the  purpose  is  that  afforded  by 
Rontgen's  discovery,  and  during  the  American  and  P^nglish  campaigns  of  the  past 
few  years  skiagrams  of  skulls  showing  bullets  in  various  locations  have  become  quite 
common.     (See  Plate  XIII.,  p.  229.) 


Fig.  379 


PROLAPSUS  AND  HERNIA  CEREBRI. 

Escape  of  brain  matter  beyond  its  normal  level  is  not  uncommon  in  connection  with 
compound  fractures  or  their  sequels.  It  may  be  primary,  escaping  with  the  blood 
at  the  time  of  the  accident,  or  secondary,  occurring  during  the  ensuing  days.  Any 
lesion  of  this  kind  in  which  the  brain  appears  or  can  be  handled  is  entitled  to  the  term 
'prolapsus,  in  contradistinction  to  hernia,  which  implies  that,  though  escaping  from  the 
proper  cavity,  it  is  nevertheless  covered  by  other  textures — e.  g.,  the  dura  or  scalp. 

The  jirotrusion  may  vary  in  size  from  a  small  tumor  to  one  the  size  of  a  fist.  It  is 
always  the  result  of  uncontrolled  intracranial  tension,  and  may  be  produced  by  hemor- 
rhage, by  serous  imbibition,  or  as  the  result  of  brain  al)scess.     When  immediate  it  is 

of  the  first  variety;  when  later,  of  the  second 
or  thirrl.  When  abscess  is  present  it  usually 
delays  protrusion,  which  is  produced  by 
degrees.  Prolapse  occurs  through  large 
openings,  such  as  those  made  by  gunshot 
wounds,  the  trephine,  etc.  Prolapse  proper 
iin])lies  laceration  of  the  dura.  It  pertains 
obviously  to  the  convexity  of  the  skull,  occur- 
ring, however,  in  exceedinglv  rare  cases  into 
the"  orbit  (Fig.  379). 

Prognosis.  —  The  prognosis  is  generally 
inifavorable.  There  is  always  risk  of  edema 
or  infection,  either  of  which  may  prove 
fatal. 

Infiltration,  gangrene,  suppuration,  or  re- 
pair by  granulation  may  so  disfigure  and 
disguise  the  real  brain  substance  as  to  lead  to 
error  of  diar/nosis.  It  by  no  means  follows 
that  every  tumor  presenting  through  an  opening  in  the  skull  is  of  this  character.  When 
gangrene  and  spontaneous  se]iaration  occur,  spontaneous  recovery  may  follow,  the 
stump  being  covered  by  granulations  and  finally  roofed  over  by  connective  tissue. 

Treatment. — Treatment  in  the  primary  cases  should  include  the  most  rigid  asepsis 
with  reuKnal  of  all  foreign  particles.  Localized  pressure  does  some  good,  especially 
in  those  cases  where  it  can  be  tolerated.  Signs  of  abscess  should  always  be  watched 
for,  and  deep  exploration  is  often  justified  or  indicated.  While  excision  or  cauteriza- 
tion are  often  heralded  as  successful,  they  are  by  no  means  without  their  dangers. 
Nevertheless  in  selected  and  suitable  cases  excision  may  be  freely  practised.  Cases  that 
admit  of  it  should  wear  a  protective  shield  properly  molded  to  the  jxart.  Skin  transplan- 
tation, or  even  osteoplastic  rei)air  of  the  defect,  may  give  good  results  in  favorable  cases. 


Prolapsus  cerebri.      (Bryant.) 


SEPTIC  ISFECTIOSS    11 7 77//. \    Till-:   CliAMUM  5G7 


SEPTIC  INFECTIONS  WITHIN  THE  CRANIUM. 

Under  tlir  fjciu'ral  (criii  septic  injection  arc  iiicliidcd: 
.1.  Ahstvss; 
li.  Tlir()nd)()sis; 

C.  Siinis  ])liU'l)iti.s; 

D.  ]\I(>niii^itis; 

E.  F/iu'cphalitis. 

'riicsf  arc  dillcrcn;  maiiircstalioiis  of  infection,  tlic  clinical  |)iclnrc  (lid'crin^  ac'cordinp; 
to  tile  tissues  and  localities  involved.  For  the  |)r()duction  of  these  infectious  conditions 
no  s]K>eial  l)a('teria  other  than  those  already  catalotfued  in  ('liapter  III  are  conij)rehended. 
Their  method  of  activity  is  there  discussed  at  sullicient  len<^th,  and  we  iieed  here  only 
consider  tlu'  various  paths  oj  injection.  ']''hese  may  lie  alonjji:  the  hioodres.seJ.s,  the  lymph- 
vr.s.sel.s,  nerve  slicat/i.s,  and  ])r()ion<i;ations  of  the  membranous  sacs  which  extend  from  the 
cranial  cavity  proj)er. 

The  most  common  of  all  the  paths  of  infection  is  afforded  by  the  middle  ear,  especially 
when  in\()lved  in  a  chronic  suj)purative  lesion,  which  is  by  no  means  necessarily  con- 
nectetl  with  a  patulous  tympanic  membrane,  and  which  may  consequently  be  undis- 
covered, thou<;'h  in  more  or  less  constant  activity. 

A.  Abscess  of  the  Brain. — This  may  be  traumatic  or  non-iraumatic.  The  former 
variety  is  most  often  due  to  the  direct  result  of  injury,  infection  displayinjjj  its  con- 
sequences prom])tly  or  sometimes  not  imtil  long  periods  have  ela])sed.  The  ordinary 
form  occurs  within  the  first  two  weeks,  usually  as  an  acute  cortical  abscess  beneath 
a  more  or  less  comjiromisetl  membrane,  surroundefl  by  a  zone  of  red  softening,  and 
this  by  another  of  brain  edema.  The  chronic  traumatic  abscesses  are  less  often 
cortical,  but  are  deeper.  They  are  marked  by  prolonged  suppuration  of  the  external 
wound,  but  may  occur  through  some  mechanism  not  understood.  ^)nly  the  chronic 
abscesses  show  encapsulation,  the  capsule  ]xirtakng  of  the  character  of  the  pyophylactic 
membrane,  elsewhere  described.  (See  Chajjter  VIII.)  It  may  cover  a  long  period — to  my 
personal  knowledge  at  least  nine  years,  while  others  have  mentioned  twenty  and  more. 
The  non-traumatic  abscesses  are  in  the  main  due  to  middJe-ear  disease.  When  the 
roof  of  the  tympanum  breaks  down  it  is  the  middle  fossa  of  the  skull  which  is  infected; 
when  the  posterior  wall,  naturally  the  posterior  fo.'Jsa.  The  most  common  result  of  per- 
foration of  the  tympanic  roof  is  involvement  of  the  mastoid  antrum  or  the  sigmoid  groove 
and  sinus.  In  the  former  case  we  have  temporosphenoidal  abscess;  in  the  latter,  cere- 
bellar, if  any.  Previous  to  actual  perforation  there  is  thinning  of  bone  with  thrombosis 
along  the  minute  veins  connected  with  the  sinuses.  When  the  dura  is  exposed  by  the 
carious  process,  granulation  tissue  often  protects  it  against  further  inroads,  while  masses 
of  the  same  projecting  into  the  tym):)anum  have  been  mistaken  for  ]irola])se.  If  the  sig- 
moid groove  be  the  site  of  the  first  disturbance,  extradural  abscess  may  form  between 
the  sinus  and  the  remaining  bone,  the  granulating  process  then  involving  the  whole  bony 
groove.  Its  later  consequence  is  sinus  pJdebitis,  »inus  thrombosvi,  or  intradiiral  injec- 
tion. If  there  be  adhesion  between  the  dura  and  the  cortex  we  have  actual  brain  ulcera- 
tion ^^  ithout  formation  of  a  true  al)scess;  Init  if  once  the  perivascular  sheaths  have  carried 
infection  to  the  substance  of  the  brain  there  is  a  rapid  purulent  disintegration  of  the 
same,  and  formation  of  a  true  subj^ial  or  deep  abscess,  which  latter  is  in  effect  a  purulent 
encephalitis.  INIacewen  has  shoA\n  how  imjiortant  it  is  not  merely  to  evfxcuate  such 
abscesses,  but  to  eradicate  the  path  of  infection  from  the  point  of  origin,  which  is  i-arely 
easy. 

Extradural  jnis  may  escape  into  the  mastoid  cells  by  erosion  of  their  inner  walls. 
Such  pus  may  escape  suddenly,  and  .serious  s^niiptoms  thus  be  mitigated.  Even 
abscess  of  the  bone  may  thus  em])ty  itself  by  the  process  of  adhesion  and  jwintingtoward 
the  surface.  Pus  from  the  mastoid  cells  may  perforate  the  temporomaxillary  joint  or 
escape  along  the  digastric  groove  and  form  deeji  cervical  abscesses. 

When  the  arachnoidal  tissue  is  involved,  both  sulxlural  and  subarachnoidal  spaces 
participate  in  the  infection,  and  the  brain  floats  upon  a  pus-bed  rather  than  a  water-bed. 
Leptomeninqiiis  under  these  circumstances  becomes  quickly  diffused  and  fatal.  Serous 
fluid  may  accumulate  so  quickly  as  to  produce  death  by  mere  obstruction  to  the  cerebral 
bloodvessels,  while  distention  of  the  ventricles  and  an  acute  infectious  internal  hydro- 


568  SPECIAL  OR  REGIONAL  SURGERY 

ceplialiis  is  possible.  Lcploiiiciiinjfilis  may  he  pr()))a<;iit('(l  wlici-cvcf  iiiiatoiiiical  i)atl)s 
may  carry  it,  cv(mi  to  (he  cauda  ('(luiiia  and  aloiif^;  the  sj)iiial  nerve  slicallis. 

The  i)us  within  cerebral  abscesses  is  often  discolored,  sometimes  oit'ensive.  A  i^jreenisli 
color  is  usually  imparted  by  the  Bacillus  ])yocyaneus,  while  the  offensive  odor  comes 
mostly  from  the  Bacillus  coli.  Around  such  an  abscess  is  a  zone  of  infiauied  cerebral 
tissue.  If  within  this  zone  a  iiyo|)hylactic  membrane  is  f)roduced  by  condensation  the 
abscess  may  become  encapsulated  and  life  be  prolonged.  When  a  capsule  fails  to  form, 
the  process  being  too  acute  or  rapid,  death  is  the  speedy  termination  of  such  a  case. 
Thes(>  abscesses  are  generally  single,  but  m*ay  be  multij^le.  There  is  also  a  metastatic 
expression  of  abscess  formation,  seen  in  typical  cases  of  pyemia,  where  numerous  miliary 
abscesses  are  found  within  the  brain.  Pressure  symptoms  are  less  likely  from  abscess 
than  from  a  tumor  of  the  same  bulk,  while  there  is  much  greater  liability  to  edema  and 
sudden  infection.  Gradually  extending  paralysis  implies  pathological  activity  around 
the  abscess.  Large  collections  of  pus  are  often  met  in  the  least  vital  jmrts  of  the  brain, 
as  in  the  frontal  or  temporosphenoidal  lol)es. 

Symptoms. — Aside  from  causal  indications  {e.  g.,  injury  to  the  head,  middle-ear 
disease,  recent  operations  upon  the  air-containing  cavities,  etc.)  the  first  symptoms 
may  be  slight.  They  consist  usually  of  headache,  often  ascribed  to  cold  or  trifling 
injury,  becoming  exaggerated,  rarely  definitely  located,  radiating  widely.  In  time  it  is 
spoken  of  as  "excruciating,"  and  may  be  continuous  or  intermittent.  Vomiting  is  not 
infrequent,  rarely  accompanied  by  nausea.  Chills  come  on  early  in  the  history  of 
the  case,  varying  in  intensity,  duration,  and  frequency.  The  more  frequent,  the  more 
likely  is  it  that  the  abscess  results  from  some  general  infection.  Temperature  is  seldom 
much  elevated;  it  is  often  subnormal.  When  exalted  it  is  in  pro])ortion  to  the  degre(!  of 
meningeal  involvement.  If  pressure  symptoms  become  marked  we  get  the  usual  slow 
|)uLse  due  to  increased  tension.  After  evacuation  of  ]nis  ])ressure  symptoms  may  subside, 
but  temperature  rise.  Such  discharge  from  the  middle  ear  as  may  have  been  previously 
noted  usually  diminishes.  A  history  of  cessation  of  discharge  and  of  increased  pain  and 
fever  occurring  at  irregular  intervals  is  very  characteristic. 

These  patients  seldom  come  under  the  surgeon's  notice  until  the  condition  is  serious. 
If  they  are  still  conscious,  pain  is  the  dominating  complaint.  This  may  be  aggravated 
by  percussion  over  the  affected  region.  Rigitlity  of  the  sternomastoid  on  the  aft'ected  side 
is  a  sign  of  lesion  of  the  sigmoid  sinus.  Pain  elicited  by  deep  j^ressurc  in  the  posterior 
cervical  triangle  is  also  significant.  There  is  mental  hebetude,  with  progressive  failure 
of  mental  and  physical  power,  as  the  stuj)or  increases,  or  coma  becom(\s  marked. 

Ab.iccs.s-  may  be  often  distinguished  from  infectious  thrombosis,  as  in  the  latter  respira- 
tions ai"e  ({uickened  and  vomiting  occurs  when  the  patient  is  in  the  upright  position. 

Vomiting  arrompanird  hg  crphalah/ia  is  always  indimtivf'  of  .intracranial  mischief. 
If  it  be  a  special  feature  throughout  the  case  it  may  indicate  cerebellar  lesion.  Convul- 
sions are  also  frequent,  but  rarely  distinctive.  They  are  the  result  in  most  cases  of  sec- 
ondary irritation  of  motor  areas.  Paralysis  is  the  consequence  of  destructive  rather 
than  of  irritative  lesions. 

The  ear  should  be  examined,  and  the  use  of  a  probe  may  give  much  information. 

Brain  abscess  connected  with  middle-ear  disease  will  usually  be  found  in  the  tem})oro- 
sphenoidal  lobe,  but  occasionally  occurs  beneath  the  tentorium,  in  the  cerebellum. 
Many  of  these  cases  are  connected  with  self-evident  indications  of  purulent  otitis  media 
and  mastoid  disease,  and  operation  for  the  latter  has  often  to  be  combined  with  the  recog- 
nition of  and  suitable  treatment  for  brain  abscess.  The  surgical  treatment  of  mastoid 
disease  will  be  discussed  in  separate  paragraphs  and  under  a  separate  heading.  When- 
ever there  is  any  reason  to  suspect  the  existence  of  pus  within  the  cranium  the 
operator  should  expose  the  dura  by  opening  above  the  mastoid;  or  his  operation  may 
already  have  taken  him  as  far  as  the  sigmoid  sinus,  in  which  case,  with  the  dental  engine 
or  with  other  bone-cutting  instrunu'uts,  he  may  much  enlarge  the  field  of  ojxM-ation  and 
thus  make  access  both  to  the  simis  and  to  the  brain  itself.  An  extradural  collection  of 
pus  may  be  found  within  the  sinus  or  above  it.  Drops  of  ])us  may  escap(>  as  the  operator 
cleans  away  or  even  ))resses  apart  the  granulations.  He  has  often  to  decide  uj)on  further 
e\i)loration,  either  to  open  the  sinus  expecting  to  find  it  filled  with  disintegrated  blood 
clot  and  products  of  decom])osition,  or  to  open  the  dura  ])ro|)er,  expose  the  cortex,  and 
perhaps  explore  here  with  the  aspirating  needle  for  pus  located  more  d(M'])ly.  In  those 
cases  where  evidences  of  brain  abscess  are  more  pronounced,  and  those  of  mastoiditis 


SEPTIC  IXFh'CTIOXS    11777// \     77//;   Ch'AXllWf  569 

less  so,  llic  hilciiil  region  of  llic  skull  may  he  cxiioscd  niid  llic  <  riiiiiiiin  i)|)cnc(|  wiili  ;i 
livpliiiic  hct'oi*'  woikiiijj;  (lowinvard  and  exposing-  I  lie  inasloid  ic^iioii.  In  not  a  iVw 
instances  hotli  operations  are  eoinhined  and  the  area  of  hone  to  Itc  cut  a\\a\  is  relatively 
larjje.  Thus  complete  fi/iii panic  rvnitrafion,  with  removal  of  nuicli  of  the  masttnd, 
may  he  comhined  with  tfc|)hiiiinfr  and  opening  of  a  brain  abscess,  or  o])enin<f  of  the  sinus, 
in  which  latter  there  may  be  found  such  a  condition  as  to  make  it  advisable  l-o  li<ratc 
the  conunon  jugular  low  in  the  neck,  and  irriirate  from  the  sinus  to  the  location  of  the 
ligature,  where  the  vein  is  laid  open,  or  even  to  pass  a  small  swab  upon  the  end  of 
a  licxible  j)robe.  Nothinij^  cati  more  j)redisjK)se  to  typical  pyemia  than  a  bi-cakiiij^-down 
eU)t  within  a  sinus  or  vein  involved  in  throml)()|)hlebitis. 

Tciiiporo.s'plirnoidal  ahficcus  will  often  be  indicated  by  the  escape  of  pus  throu^di  the 
flura,  above  the  roof  of  the  tymj)anum.  Although  such  an  abscess  might  be  evacuated 
by  enlaro:ini;  the  tympanic  aj)i)roach  to  it,  it  would  ordinarily  be  much  better  to 
oj)cn  the  skull  above  the  ear,  and  thus  make  free  access  and  j)rovision  for  drainage. 
In  any  ])art  of  such  an  o])eration  when  the  dura  has  once  been  exposed  its  a])pearance 
should  be  carefully  noted.  The  coiu'sc  of  the  j)ial  vessels  can  usually  l;e  traced  thnHigh 
it.  'J'herefore  when  it  is  sufficiently  o])a(|ue  to  prevent  any  api)re(  iation  of  conditions 
beneath,  or  sufHci(>ntly  distended,  it  may  be  opened. 

When  cerebellar  abscess  is  suspected  the  tre))hine  should  be  applied  about  midway 
between  the  tip  of  the  mastoid  and  the  external  occipital  protuberance  (inion),  ?'.  e., 
one  inch  beneath  Reed's  base-line  and  one  and  a  half  inches  l)ack  of  the  mastoid..  The 
instrument  should  here  be  used  with  care,  as  the  occi})ital  bone  is  of  irregular  and  variaV)le 
thinness.  In  a  brain  abscess  which  can  be  freely  opened  gauze  packing  will  be  found 
seiviceable,  even  though  its  use  necessitates  the  emjjloymcnt  of  secondary  sutures  or 
|)erliaps  leaving  the  wound  open  in  order  to  permit  of  its  removal. 

Localizing  symptoms  are  only  occasional  in  comiection  with  cerebral  abscess,  Itecause 
the  majority  of  these  lesions  are  located  without  the  motor  area.  Pu])illarv  alterations 
are  indefinite.  As  an  abscess  enlarges  the  size  of  the  pupil  may  increase.  Infective 
thrombosis  rarely  affects  the  pupils,  save  that  when  located  in  the  cavernous  sinus  it 
may  produce  ptosis.  In  tempo rosphenoidal  abscess  pain  is  usually  localized  in  or  near 
the  ear  upon  the  same  side.  As  the  motor  area  becomes  involved  there  is  a  gradual 
development  of  localizing  phenomena,  referred  to  the  oj^posite  side.  Facial  paralysis 
is  common  in  advanced  destructive  lesions  in  the  mastoid  and  tympanum.  When  pro- 
duced by  coitical  lesion  it  is  rar(>ly  so  pronounced  as  when  by  direct  ])aralysis  of  the  nerve. 
In  frontal  abscess  thi-re  are  few  localizing  ])henomena.  A.bscess  in  the  parietal  region 
is  most  commonly  of  traumatic  origin,  and  is  to  be  suspected  in  accordance  with  external 
surface  markings.  Occijrital  abscess  is  exceedingly  rare,  and  ceiebellar  abscess  fur- 
nishes few  localizing  symptoms.  Its  most  prominent  clinical  features  are  retraction  of 
the  head  and  neck;  slow,  feeble  pulse  and  respiration;  subnormal  temperature;  violent 
yawning;  rigidity  of  the  masseters;  slow  speech;  ojrtic  neuritis;  vertigo  and  vomiting. 
If  accom])anied  by  thiombosis  there  is  pain  upon  pressure  in  the  ujiper  jiart  of  the  neck. 
In  all  of  these  cases  tvhen  abscess  is  near  the  surface  there  is  more  or  less  leptonieningitvi, 
which  becomes  diffuse  at  once  when  the  abscess  biu'sts.  If  meningitis  be  pr(\sent  we 
have  high  tempi-rature  without  marked  remissions,  rapid  ])ulse,  and  general  irritability, 
rapidity  of  pulse  indicating  i>redominance  of  leptomeningitis  over  ence[)halitis,  since  the 
more  marked  the  latter  the  slower  the  pulse.  As  distinguished  from  sinus  thrombosis 
we  have  in  the  latter  high  temperature  with  marked  remission,  raj^id  and  weak  pulse, 
frequent  chills,  profuse  sweats,  and  often  sym])toms  of  pulmonary  infarct  or  diarrhea, 
with  cervical  and  submastoid  tenderness  and  involvement  along  the  jugular  vein  upon 
the  afl'ected  side.  //  all  three  conditions  he  associated  the  si/mptoms  of  tJirombosls  vsnally 
prevail,  although  there  may  be  retraction  of  the  head  due  to  basilar  meningitis.  As 
between  tumor  and  abscess  we  have  in  the  former  absence  of  explanation  of  infection,  slow 
progress  of  symptoms,  more  definite  localizing  i)heiiomena,  ))rogr<\ssive  involvement  of 
nerves,  pronounced  optic  neuritis,  absence"  of  chill,  and  alternating  periods  (/f  mitigation 
of  symptoms.  Temi)erature  and  ])ulse  afford  little  help,  save  that  subnormal  tempera- 
ture ])oints  rather  to  abscess. 

Prognosis. — Fi-om  every  direction  come  statements  that  the  tendency  of  cerebral 
abscess  is  invariably  toward  fatality.  No  matter  what  the  cause,  imless  relief  be 
promi)tly  afforded,  death  is  the  sure  result.  Of  the  acute  cases  those  not  promptly  oper- 
ated usiiallv  die  within  a  few  weeks.    The  more  chronic  or  prolonged  ca.ses  rarely  come 


570  SPECIAL  OR  REGIONAL  SURGERY 

under  surgical  treatment ;  most  of  those  wliicli  do  are  the  result  of  (Hscasc  in  or  ahout  the 
middle  ear.  Were  it  possible  to  early  diagnosticate  formation  of  llicse  abscesses  |)rognosis 
would  he  much  more  favorable.  When  seen  before  necessarily  fatal  complications  have 
arisen,  in  instances  where  the  position  can  be  reasonably  well  determined,  surgical 
attack  is  likely  to  give  good  results.  After  proper  evacuation  even  complete  mental  and 
bodily  recovery  is  ])ossible.  Anchoring  of  the  brain  by  adhesions  may  leave  a  train  of 
dis(iuieting  symptoms,  which,  however,  are  not  so  bad  as  fatality.  Abscesses  may 
remain  for  a  long  time  encysted,  and  yet  be  a  fruitful  source  of  danger.  ]Multij)le 
abscesses  may  complicate  both  the  diagnosis  and  the  treatment  and  produce  a  condition 
beyond  help. 

The  operative  treatment  of  these  cases  will  be  discussed  by  itself. 

B.  Sinus  Thrombosis. — The  sinuses  are  predisposed  to  thrombosis  by  virtue  of 
their  size,  inflexibility,  shape,  and  the  fact  that  they  are  not  emptied  during  respiration, 
all  of  which  tend  to  retard  blood  flow.  If  to  these  be  added  defect  in  the  blood  supply, 
then  everything  predis])()ses  toward  mam.wiir  tliwmhosis.  Tins  occurs  much  less  fre- 
quently than  the  infective  form,  is  mostly  confined  to  the  longitudinal  sinus,  is  noted 
mainly  at  the  two  extremes  of  life,  and  is  often  seen  in  cases  of  death  following  exhausting 
diarrliea  in  children.  In  the  marasmic  form  the  clots  are  dense,  firm,  stratified,  and 
non-adherent;  they  rarely  occupy  the  whole  cali})er.  In  old  cases  the  clots  may  be 
tunnelled  sufficiently  to  permit  reestal)lishment  of  circulation.  Their  principal  evil  conse- 
quences are  edema  of  the  frontal  lobes  and  serosanguineous  effusion  into  the  ventricles 
or  orbits — in  the  latter  case  producing  exoj)hthalmos.  Sometimes  epistaxis  is  produced. 
Stra!)ismus,  tremor,  muscle  rigidity,  or  contractures  are  more  often  seen  conjoined, 
es])ecially  in  children,  with  convulsions,  sometimes  unilateral,  and  choked  disk. 

Diagnosis. — I'lie  diagnosis  in  adults  is  difficult,  but  in  chihlren,  when  convidsions 
occur  after  exhausting  illness,  with  the  signs  just  noted,  marasmic  thrombosis  may  ordi- 
narily be  diagnosticated. 

Injeciive  throvihosis,  the  other  variety,  is  due  exclusively  to  the  invasion  of  pyogenic 
organisms.  It  is  observed  mostly  in  the  basal  sinuses;  its  origin  is  local,  and  it  is  always 
secondary  to  some  external  infection.  Its  most  frequent  cause  is  middle-ear  disease; 
consecjuently  the  sigmoid  sinus  is  the  one  most  often  involved.  It  may  follow  carbuncle, 
erysipelas,  or  cellulitis  of  the  external  parts,  or  nasal  ulceration,  as  well  as  dental  caries, 
su|)puration  of  the  tonsils,  etc.  Infection  may  be  propagated  by  tissue  continuity,  or 
through  the  circulation. 

Symptoms. — Infective  thrombosis  presents  few  distinctive  symj^toms.  Ix)cal  ischemia, 
perversion  of  function,  extracranial  edema  are  too  vague.  Headache  is  nearly  always 
constant  and  vomiting  is  frequent;  temperature  runs  high,  with  marked  remissions;  the 
pulse  is  small  and  rapid,  and  remains  so  even  under  an  anesthetic.  ChiJh  are  frequent, 
of  the  pyemic  type,  and  are  followed  by  copious  sweats.  Should  pulmonary  infarct 
occur  there  will  be  typical  thoracic  signs,  although  at  first  physical  examination  may  give 
negative  results.  Later,  however,  we  get  prune-juice  expectoration,  putrid  simtum, 
etc.  Cerebral  function  is  disturbed  late  rather  than  early.  The  duration  of  the  disease 
ordinarily  is  from  two  to  four  weeks.  Should  mrniuf/iti.s-  comjjlicate  the  case  there  is 
more  violent  headache,  persistent  high  temperature,  great  excitement,  muscle  spasm, 
strabismus,  delirium,  and  coma;  if  the  sigmoid  sinus  be  involved  there  is  usually 
retraction  of  the  head.  Should  leptomeningitis  extend  down  the  spine,  complaint  of 
girdle  pains  will  l)e  made. 

Differential  Diagnosis. — The  two  conditions  which  are  most  likely  to  be  confused  with 
sinus  thromlxjsis  are  meningitis  and  brain  abscess.  In  thrombosis  there  are  pain  and 
tenderness  over  the  mastoid,  extending  down  the  neck.  Fever  is  high,  ])ulse  rapid, 
respiration  not  affected,  rigidity  not  usually  present.  Chills  are  frequently  followed 
by  {)rofuse  pers])iration.  The  general  picture  is  one  of  sepsis  and  the  typhoid  state. 
There  are  no  special  eye  symptoms.  Death  is  finally  due  to  pyemic  ])rocesses.  In 
menincjitis  pain  is  an  early,  constant,  and  severe  symptom.  Headache  is  frontal  or 
general,  fever  is  not  characteristic,  pulse  is  rapid  until  the  accumulation  of  pus  causes 
slowness  by  pressure,  breathing  is  short  and  rapid,  and  finally  of  the  Cheyne-Stokes 
variety.  Rigidity  of  the  neck  and  back,  with  retraction  of  the  head,  is  nearly  always 
present,  with  spasmodic  contractions  or  convulsions  about  the  neck.  Chills  are  not  so 
pronounced,  vomiting  is  almost  invariably  of  the  projectile  type,  optic  neuritis  is  fre- 
quent, and  the  intellect  is  early  impaired.     In  hrain  abscess  pain  is  at  first  localized  and 


SEPTIC  INFKCriOSS   WITIIIS    Tlfh'  CRASIVM  571 

S(>V('rc,  cxlciHlinu;  ;iiul  hccominj;  »'\cnici;itiii<::.  This  increases  on  pressure,  and  does 
not  disappear  until  relief  is  obtained  or  llie  |)atieiU  hecoines  unconscious.  'i\'ni|)eialure 
is  normal  or  subnornud  until  the  abscess  ruptures.  The  pulse  is  slow,  as  in  coin|)ression 
from  other  causes;  breathing  is  slow  and  stertorous.  Ki^idity  and  vomitinjf  are  like 
those  of  menintjitis.  Eve  .symj)toms  are  almost  always  present,  photophobia  at  first, 
later  in(>(|uality  of  j)Upils,  with  dilatation  on  the  all'eeted  side,  o|)lic  neuritis  and  irregular 
movements  of  the  eye  and  lids.  Drowsiness,  dizziness,  and  impaired  intellect  are  features 
when  the  abscess  is  in  the  cerebellum.  Death  occurs  in  coma  unless  the  case  be  com- 
plicated by  meninjjitis. 

\Vi'  may  also  have  exophthalmos'  on  one  side  or  both,  with  conjunctival  injection, 
edema  of  the  lids,  and  disturbauces  of  vision,  due  to  thrombosis  of  the  cavernous  sinus 
and  stasis  in  the  o])hthalmic  vein.  In  thrombosis  of  one  transverse  sinus  only  the 
internal  jui^ular  on  that  side  will  curry  less  blood.  So  long  as  that  on  the  other  side  is 
free  it  will  take  that  which  cannot  pass  throu<>;h  the  obstructed  one.  ('onseciuently 
the  ju<i;ular  on  the  other  side  will  carry  more.  But  if  the  contained  clot  extend  so  far 
that  direct  eonunmiication  with  the  internal  jufijular  is  interfered  with  then  the  internal 
juyular  of  the  affected  side  will  be  almost  empty,  while  the  external  of  the  same  side 
will  be  the  more  distended.  When  the  eye  is  protruded  and  the  frontal  vein  distended 
it  is  evident  that  the  cavernous  sinus  on  that  side  is  involved.  If  the  superficial  veins 
of  the  scalp  be  distended  it  is  the  superior  longjitudinal  sinus  which  is  at  fault.  When 
the  veins  of  the  mastoid  region  are  involved,  we  may  locate  the  thrombus  in  the  transverse 
sinus;  when  there  are  no  localizing  symptoms,  it  can  only  be  said  in  a  general  way  that 
thrombosis  has  occurred. 

Prognosis. — Prognosis  is  always  unfavorable,  though  recovery  is  not  impossible.  The 
therapeutics  arc  in  the  main  prophylactic.  By  actual  physiological  rest  the  possibility 
of  i)ulmonarv  complications  can  be  diminished.  The  treatment,  aside  from  this,  is 
])urcly  <)]ierative,  and  will  be  discussed  elsewhere. 

C.  Sinus  Phlebitis. — This  may  be  the  result — 

(a)  Of  thrombosis;  or, 

(h)  The  continuation  of  suppurative  processes  from  neighboring  tissues. 

Symptoms. — The  symptoms  are  seldom  diagnostic.  Sinus  phlebitis  is  often  accom- 
panied by  meningitis,  even  encephalitis.  The  first  symptom  is  usually  severe  headache, 
often  localized,  made  worse  by  pressure.  Anorexia  with  early  mental  disturbance  and 
often  delirium  follows,  with  vomiting,  restlessness,  and  mania,  changing  to  stupor  and 
coma.  Riqidity  or  spasm  of  cervical  muscles,  or  of  those  of  the  extremities,  followed 
by  paralyses,  is  often  seen.  Evidences  of  irritation  of  special  nerves,  particularly  the 
oculomotor  or  the  vagus,  are  not  rare.  When  pyemic  symptoms  occur  they  are  vague 
and  are  most  conspicuous  in  the  lungs  and  liver.  Taken  in  conjunction  with  aggra- 
vating brain  symptoms  they  make  prognosis  unfavorable. 

Symjitoms  will  in  large  measure  depend  upon  the  sinus  most  involved.  They  are 
characteristic  if  this  be  the  cavernous  sinus.  There  are  disturbances  in  the  eye  on 
the  same  side,  congestion  of  orbital  veins,  pain  and  photo})hobia,  and,  later,  cloudiness 
of  the  cornea  and  edema  with  exophthalmos.  Finally  the  pupil  becomes  paralyzed 
and  dilated,  the  cornea  loses  its  polish,  the  upper  lid  cannot  be  raised,  and,  if  the  case 
persists,  the  cornea  ulcerates.  Along  with  these  local  evidences  there  will  be  com- 
plaint of  frontal  pain,  usually  with  paralysis  of  the  hypoglossal  nerve  and  consequent 
thickness  of  speech.  When  the  transverse  sinus  is  involved  there  are,  first,  vagus  irrita- 
tion, then  paralysis  with  paralytic  sequences  in  the  muscles  of  the  jaw,  the  tongue,  palate, 
pharynx,  etc.  Diaphragmatic  motions  are  interfered  with  and  the  character  of  the 
respiration  altered.  As  the  trouble  extends  to  the  internal  jugular  we  have  further 
paralysis  of  accompanying  nerves,  especially  of  the  hypoglossal.  As  the  irritation  ex- 
tends down  the  vein  there  w-ill  be  tenderness,  rigidity,  and  often  swelling.  The  local 
signs  and  symptoms  vary  obviously  as  the  lesion  extends  from  one  sinus  to  the  other, 
for  Avhen  one  cavernous  sinus  is  involved  the  trouble  nearly  always  extends  to  the 
other,  and  local  symptoms  are  repeated  upon  the  opposite  side. 

D.  Meningitis. — The  dura  has  a  duplicate  anatomical  character.  Its  outer  sur- 
face, having  the  structure  of  periosteum,  functionates  as  such;  its  inner  surface,  being 
lined  with  endothelium,  partakes  of  the  nature  of  a  true  serous  membrane.  When  the 
former  texture  is  mainly  at  fault  we  have  pach\Tiieningitis  exi:erna,  or  endocranitis,  which 
is  rarely  a  primary,  but  usually  a  propagated  lesion  met  with  after  injury  or  external 


572  SPECIAL  OR  REGIONAL  SURGERY 

infection.  It  may  lead  to  infiltralioii  with  piinilcnt  prodiicls,  and,  it"  speedy  exit  for  pus 
be  not  ])rovi(led,  to  involvement  of  the  j)ia  within.  Exiradural  .sii / )])vr citing i  without 
external  injury  is  very  rare,  but  should  there  have  been  a  subdural  hemorrhage  with 
external  lesion  the  blood  clot  may  become  infected  and  break  down.  Paclnjniniiu- 
gitis  r.rfcrna  is  most  common  after  chronic  lesions  of  the  cranial  bones — i.  c,  caries  and 
necrosis.  Sj/mpfom.'^  are  ncjt  characteristic  and  often  not  distiu<^uishable.  When  chnjnic 
there  will  be  local  tenderness,  evidence  of  the  presence  of  pus,  with  focal  symptoms. 

Treatment. — The  treatment  is  always  surgical,  save  possibly  in  certain  cases  due  to 
syphilis,  where  delay  may  be  justifiable  for  the  purpose  of  testing  the  action  of  antispecific 
drugs. 

Pachymeningitis  Interna. — Pachvineningitis  interna  is  often  confounded  with 
chronic  hydrocephalus.  It  is  fretiuently  the  occasion  of  a  firm,  membranous  exudate  upon 
the  internal  surface  of  the  dura,  which  forms  in  time  a  new  membrane  rich  in  small  and 
extremely  friable  vessels,  from  which  hemorrhages  easily  occur,  thus  giving  rise  to  the 
contlition  of  ])achymeningitis  hiemorrhagica.  Trifling  hemorrhages  will  ])roduce  little 
or  no  disturbance ;  when  of  greater  extent  they  may  give  rise  to  localizing  brain  symj)toms. 
These  extravasations  may  absorb  or  undergo  fluidification — i.  e.,  produce  localized 
or  cystic  collections  of  fluid.  The  condition  sometimes  occurs  after  other  acute  infec- 
tions, especially  pneumonia,  pleurisy,  typhoid,  whoo])ing-cough,  etc.  Recovery  is  pos- 
sible, but  usually  at  the  expense  of  adhesions,  which  lead  to  subsequent  complications. 

The  symptoms  of  pachymemngitis  hwmorrhagica  are  headaclie,  whicli  will  increase 
in  intensity  with  every  new  escape  of  blood,  usually  localized  in  the  vertex,  with  more 
or  less  ])aralysis  following  each  new  extravasation.  The  final  residt  may  be  atrophy. 
Absence  of  disturbance  in  the  cranial  nerves  points  to  lesions  in  the  convexity  rather 
than  basal  or  ventricular.  In  chronic  cases  there  is  optic  neuritis,  and  toward  the  end 
coma,  usually  coming  on  slowly.  Dennis  has  recommended  tre])hining  under  these 
circumstances,  and  has  practised  it  with  great  benefit. 

Treatment. — The  treatment  should  be  in  a  large  degree  surgical,  for  little  short  of 
eradication  will  bring  about  the  desired  result. 

Leptomeningitis. — This  term  refers  to  inflammation  (i.  c,  infection)  of  the  pia 
mater,  in  whose  texture  we  encounter  tissue  quite  different  from  that  composing  the 
dura,  and  in  which,  when  inflamed,  distinction  as  between  the  arachnoid  and  pia  has 
disa]))ieared.  Leptomeningitis  suppurativa  is  an  exceedingly  c(nnmon  expression  of 
intracranial  infection,  and  may  result  n(jt  merely  by  extension,  but  as  a  j)rimarv  infection. 
When  begun  it  sjjreads  rapidly,  the  fluid  contained  within  the  meningeal  cavities,  mixed 
with  |)yogenic  agents,  helping  to  disseminate  the  active  agents  to  the  ultimate  limits  of 
the  membranous  involvement.  Consequently  basilar  meningitis  usually  extends  down 
the  spinal  canal.  Next  to  injury  the  most  frequent  cause  is  middle-ear  disease,  with 
its  infectious  comjilications  and  extensions.  Next  to  this  come  sinus  phlebitis  and  endo- 
cranitis.  Infection  from  the  teeth  and  the  nasal  cavity  may  occur.  It  is  also  known  to 
result. from  panophthalmitis:  in  traumatic  cases,  w^ien  primary,  it  sets  in  early,  even  from 
four  to  thirty-six  hours  after  injury.  So  rich  is  the  pia  in  loose  connective  tissue  that  even 
from  the  outset  the  inflammation  may  assume  the  phlegmonous  type.  The  cerebro- 
spinal fluid,  as  well  as  that  of  the  ventricles,  becomes  cloudy,  contains  numerous 
flocculi,  and  is  often  blood-stained. 

Symptoms. — When  the  disease  is  limited  to  the  vertex  and  follows  several  days  after 
injury  it  usually  begins  with  chills  and  malaise,  with  increasing  temperature;  after  which 
the  symptoms  assume  the  pyemic  type,  distinguished  from  true  pyemia  l>y  their  compara- 
tively early  onset.  The  pulse  becomes  frequent,  first  full  and  then  small;  patients  are 
disturbed,  restless,  or  uncontrollable,  and  complain  of  headache,  moan,  grate  the  teeth, 
become  delirious,  with  glistening  eyes  and  congested  face.  After  a  while  delirium  sub- 
sides into  stupor  and  restlessness  into  insensibility.  The  pupils  contract  and  remain 
inactive  to  light.  Paralyses  and  cram])s  are  not  infrequent.  Traumatic  basilar  lepto- 
meningitis occurs  often  with  fracture  of  the  base.  Signs  and  symj^toms  are  less  dis- 
tinctive here;  paralyses  occur  more  easily  and  are  less  distinctive,  save  those  which 
involve  the  special  cranial  nerves.  When  ptosis  occurs  with  dilatation  of  the  ])npils 
and  glosso])haryngeal  paralysis  we  should  be  quick  to  susjx'ct  extension  of  the  process 
along  the  brain.  Cramp  or  stift'ness  of  cervical  muscles  mean  the  same  thing,  and  are 
signs  of  grave  import  which  may  be  considered  pathognomonic.  Albuminuria  is 
frequent,  with  marked  increase  of  phosphates  in  the  urine. 


()i'i:u.\ri\i-:  Tui:.\TMi:\r  ()i<  i\rir\cH.\.\i.\L  si  I'ln  uatioss       57.'] 

hi  the  iion-lniiiiiKilic  ra.sr.s  (lie  .si/iiiploins  of  /r/t/diiicninc/ili.s-  tire  lliosr  of  inrrcns'inq 
bruin  prcssiin  and  tcmprraturr.  The  disease  usiuilly  eoiiiineiices  with  lieadaclie  rollowiMJ 
In  \(rli<:(),  liy|K>restlu>sia,  restlessness,  (leliriiiiii,  insonmia  folldwed  hy  soiniioleiice, 
iiiiis(l(>  spasm,  |)aralysi's,  coma,  and  d(>a(li.  IT  llie  disease  extends  from  tlie  middle 
ear  there  is  rre(|uently  facial  paralysis  before  the  nienini;'eal  symptoms  appear. 

'I'he  type  of  fever  is  one  of  <>;radnal  increase,  thonjrli  before  death  temperature  often 
falls  even  below  th(>  normal.  Palho^'iiomonic  fever  shonid  not  be  mistaken  for  ihe 
elevation  of  teni|)erature  which  oft-n  accompanies  absorption  of  intracranial  hemor- 
rha>j;es.  In  the.se  latter  eases  temperatnre  may  moinit  to  '.V.)°  C,  but  if  risin<^  hiirjier 
than  this  meniiifjeal  e()mj)lieations  should  be  suspected. 

Diagnosis. — The  diagnosis  as  between  sinus  phlebitis  and  lcp(onicnin<,nlis  depends 
principally  upon  the  existence  of  pyemic  .symptoms.  WIkmi  the  latter  are  entirely 
wantini:;  we  may  at  least  say  that  the  predominating^  .symptoms  of  sinus  phlebitis  are 
ab.sent. 

Prognosis.  The  prooiiosis  is  unsatisfactory.  Many  cases  end  in  forty-eiirht  hour.s; 
others  may  live  for  two  weeks  or  more. 

Treatment. — Tn^atment  .seems  almost  futile,  thon<fh  one  should  endeavor  by  enerj^etie 
purgation,  vene.sc-clion,  etc.,  to  do  what  h(>  can.  The  only  prosjun-t  or  hope  comes  from 
tile  po.ssibility  of  relieving  the  conii)re.ssion  from  efi'usion  of  purulent  fluid,  and  of  irri- 
gating and  draining  what  is  now  an  enlarged  abscess  cavity.  Since  we  do  not  hesitate 
to  o])(>n  and  wash  out  other  serous  cavities  when  thus  affected — e.  g.,  peritoneum, 
l)ericardium,  joints,  pleura — we  should  no  longer  hesitate  to  o|)en  the  dura  and  wash 
out  the  subdural  sjiace,  even  though  this  necessitate  more  than  one  trephine  oj)ening. 
The  measure  was  suggested  by  S.  W.  Gro.ss,  in  1873,  when  he  reported  cases  thus  treated 
with  success,  and  has  since  been  practi.sed  l)y  other  surgeons,  among  them  by  Souchon, 
who  has  advised  multiple  puncture  with  the  small  drill  ami  irrigation  and  disinfection 
througli  numerous  small  openings.  Of  11  cases  collected  by  Gross  more  than  twenty- 
five  years  ago,  45  per  cent,  recovered. 

E.  Encephalitis. — The  etiology  of  this  condition  is  practically  that  of  leptomenin- 
gitis. It  may  ])roceed  from  sinus  phlebitis  or  from  the  veins  em])tying  into  the  sinus, 
infection  travelling  backward  rather  than  forward.  In  many  cases  the  primary  infection 
occurs  from  without,  as  in  gunshot  fractures.  It  is  also  transmitted  along  the  Ivmpliatic 
channels,  since  I  have  operated  on  abscess  in  the  frontal  lobe  following  intranasal 
operation.  It  assumes  practically  always  the  suji))nrative  type,  and  may  run  either  an 
acute  or  a  chronic  course.  When  acute  the  lesion  is  usually  limited  in  area,  and  the 
result  is  an  acute  abscess  with  irregular  boundaries.  It  may  be  distinguished  from  uremic 
coma  by  examination  of  the  blood  (leukocyi^osis)  as  well  as  that  of  the  urine. 


OPERATIVE  TREATMENT  OF  INTRACRANIAL  SUPPURATIONS. 

In  dealing  with  pus  the  surgeon  can  never  follow  a  safer  rule  than  to  go  according  to 
this  dictum:  i.  c,  that  pus  left  alone  is  a  greater  source  of  danger  than  the  surgeon's 
knife  judiciously  used.  Consec{uently  ubi  pn.s;  ibi  cvacua,  applies  to  intracranial  col- 
lections as  well  as  others.  For  its  detection  and  evacuation  operations  are  now  regarded 
as  not  merely  justifiable,  but  indicated  whenever  there  is  presumption  of  its  presence. 
Discussion  now  hinges  entirely  upon  the  wisdom  of  ex[)loration  when  absolutely  no 
diagnosis  can  be  made.  Save  where  an  opening  already  exists,  trephining  is  a  neces.sary 
preliminary.  Among  other  indications  is  .spnnfanroii.s'  escape  of  pus  through  a  previous 
opening  or  any  of  the  natural  outlets  of  the  cranium,  with  or  without  localizing  {phe- 
nomena. Fvrtftcr  indications  are  those  pertaining  to  the  bone — i.  r.,  loosening  of  peri- 
cranium ;  or  to  the  scalp — i.  e.,  edema,  puffy  tumor,  etc.;  and  certain  other  indications  are 
tho.se  of  a  more  general  character,  chills  and  pyrexia.  When  the  dura  is  exposed  much 
can  be  determined  by  the  existing  brain  tension,  it  being  now  well  established  th.it  brain 
pulsation  is  often  intensified  by  the  presence  of  pus  beneath  the  dura.  The  most 
feasible  method  for  detection  of  sid^dural  or  deep  collections  is  the  use  of  the  aspirating 
needle — a  method  now  generally  in  vogue  and  everywhere  accepted. 


574  SPECIAL  OB  REGIONAL  SURGERY 


MASTOID  DISEASE  AND  THE  MASTOID  OPERATION. 

In  all  cases  of  infection  and  suppuration  of  the  middle  ear  the  adjoining  portions  of 
the  cellular  structure  of  the  mastoid  undoubtedly  participate.  Fortunatc^ly  morbid 
activity  is  usually  so  limited  that  the  clinical  evidences  of  what  is  calhnl  masiuiditis 
occur  in  a  relatively  small  proportion  of  cases,  but  otitis  media  purulenta  is  so  common 
that  mastoiditis  is  consequently  a  complication  of  sufficient  frequency,  and  occasionally 
of  such  severity,  that  it  is  as  likely  to  come  untler  the  su})ervision  of  the  general  surgeon 
as  that  of  the  specialist.  Moreover,  the  region  affected  is  such  common  ground,  as  it 
Avere,  between  the  broad  field  of  the  former  and  the  restricted  field  of  the  latter  that 
it  seems  to  me  that  every  general  surgeon  or  student  of  general  surgery  should  be  familiar 
with  the  condition  and  its  surgical  treatment. 

Several  of  the  specific  germs,  of  diseases  like  pneumonia,  la  grippe,  etc.,  are  known  to 
set  up  acute  mischief  within  the  tympanum  as  well  as  the  commonly  known  pyogenic 
organisms.  They  have  easy  access  to  the  middle  ear  through  the  Eustachian  tube, 
as  well  as  by  the  deeper  blood  and  lymph  channels.  The  naso{)harynx  is  never  free 
from  the  presence  of  organisms,  while  the  specific  fevers,  like  scarlatina,  and  notably 
such  infections  as  diphtheria,  predispose  to  germ  activity  in  the  region  into  which  the 
inner  end  of  the  Eustachian  tube  opens.  The  Schneiderian  membrane,  which  is  prac- 
tically continuous  from  the  ethmoid  cells  to  the  membrana  tympani,  affords  easy  travel- 
ling, and  in  all  directions,  for  infecting  organisms.  The  violence  of  reaction  will  depend 
upon  two  uncertain  and  indeterminable  factors,  the  virulence  of  the  organism  and  the 
susceptil)i]ity  of  the  patient.  To  what  extent  the  mastoid  cells  and  antrum,  around  an 
infected  tympanum,  shall  participate  may  be,  to  a  considerable  degree,  a  matter  of  their 
anatomical  arrangement.  When,  however,  they  do  participate  to  any  great  extent  the 
fact  is  made  known  by  symptoms  of  unmistakable  character.  These  constitute  the 
added  features  of  what  is  known  as  viastoidiils. 

The  cavity  in  the  mastoid  known  as  the  viastoid  antrum,  no  matter  what  may  be  the 
arrangement  of  the  other  cells,  is  always  present,  and  in  the  presence  of  deep  disease  the 
antrum  should  be  first  opened.  In  close  proximity  to  the  antrum  are  cavities  like  the 
sigmoid  sinus,  the  horizontal  semicircular  canal,  the  facial  canal,  and  the  interior  of 
the  cranium.  ^Vhile  opening  the  antrum  care  should  be  taken  to  avoid  encroachment 
upon  the  other  cavities  or  structures,  except  in  those  instances  where  there  is  evidence 
of  intracraniid  mischief,  in  which  case  it  may  be  desirous  to  expose  the  sinus  wall,  or  even 
a  considerable  area  of  brain  surface.  The  mastoid  prominence  varies  in  different  indi- 
viduals, extending  outward  to  accommodate  the  sigmoid  groove  for  the  lateral  sinus. 

According  to  the  intensity  of  the  process  the  pathological  condition  of  the  mastoid 
may  vary  between  an  empyema  of  its  cavities,  an  osteomyelitis  of  its  osseous  structure,  or 
osteoperiostitis  of  its  external  surface.  Nevertheless  all  three  of  these  may  be  combined 
in  the  same  case. 

Symptoms. — The  symptoms  of  mastoiditis  are  'pain,  referred  to  the  mastoid,  as  well 
as  to  the  region  around  it,  although  when  pressure  is  not  made  by  retained  pus  pain 
may  not  be  intense;  local  tenderness  is  present  in  nearly  all  cases,  and  will  depend  u))on 
the  proximity  of  the  trouble  to  the  surface.  This  tentlerness  is  evoked  by  gentle  |)ressure, 
which  will  sometimes  produce  pitting,  or  by  tapping  lightly  with  the  fiiiger.  When  the 
trouble  is  suj^erficial  there  will  often  be  edema,  with  all  the  local  evidences  of  su|)pura- 
tion.  In  addition  to  this  there  will  be  coincident  SMiiptoms  of  disease  of  the  middle 
mr,  with  discharge,  earache,  etc.,  and  frequently  edema  or  actual  phlegmon  of  the 
auditory  canal. 

The  different  directions  in  which  destructive  processes  may  extend,  and  their  conse- 
quences, are  as  follows:  (a)  Externally,  with  well-marked  local  evidences  of  the 
proximity  of  pus;  (b)  anteriorly  into  the  meatus,  with  phlegmonous  apjjearances  in 
that  canal;  (c)  upwarcl,  through  the  roof  of  the  tympanum  or  the  antrum,  with  disastrous 
cerebral  sym])toms  or  extradural  abscess;  (d)  inward,  toward  the  sinus,  with  consequent 
thrombophlebitis,  extradural  abscess,  and  perhaps  cerebellar  abscess;  (e)  downward, 
and  away  from  the  mastoid,  with  phlegmon  deep  in  the  neck. 

The  first  appearance  of  s^anptoms  of  any  of  these  complications  should  awaken  appre- 
hension and  demand  scrupulous  attention.  Any  collection  of  pus  along  the  auditory 
canal  should  be  promptly  incised,  and  the  first  indication  of  mastoid  tenderness  or 


MASTOID   niShWSi:    AM)    Till:   MASTOID   ol'l-.h'ATIOS  r,7r) 

iiillainnialioii  should  cause  a  prouipl  a|)|)rKati()u  of  Iccclics,  followed  hy  auliscptif 
irrio-atioiis.  In  this  way  it  may  Ix"  |)()ssil)ir  to  avert  serious  syiuploins,  |)i'o\  ided  these 
measures  be  instituted  early. 

But  with  either  the  access  of  local  symptoms  indicating  the  i)rescnce  of  ])us,  or  of  more 
ijeneral  symptoms,  elevation  of  tem])erature,  acceleration  of  pulse,  headache,  or  any- 
thin*:;  els(>  suu<i'es!ive  of  dural  irritation  or  cerebral  complication,  no  time  should  be 
lost  in  nuikiuj;-  free  and  radical  operation.  The  ma.sloid  oprrafioti,  so  called,  is  then 
demanded  in  these  cases.  When  thus  indicated  the  first  objective  point  should  be  llu; 
onfnnii.  In  order  to  reach  this  the  customary  incision  of  many  writers,  back  of  and 
|)arallcl  to  the  posterior  convex  border  of  the  car,  is  insuflicient  and  uncertain.  The 
antrum  lies  within  what  INIacewen  has  described  as  the  .suprcoiiriitcil  frianglr,  and  is  to 
be  regarded  as  the  key  to  the  situation.  It  is  necessary  to  recognize  the  posterior  zygo- 
matic root,  which  projects  behind  and  above  the  ear,  as  well  as  the  tip  of  the  mastoid 
])rocess,  and  then  to  make  a  perpendicular  linear  incision,  about  a  quarter  of  an  inch 
behind  the  ])osterior  border  of  the  external  osseous  meatus,  extending  from  this  posterior 
root  down  to  or  nearly  to  the  mastoid  tij).  The  surgeon  should  cut  down  directly  U])on 
the  bone,  without  disscc-ting  or  scratching  his  way  through  the  difiercnt  tissue  layc-rs. 
The  posterior  auricular  attachments  are  thus  fully  exposed,  and  should  be  reflected 
forward,  so  that  the  posterior  aspect  of  the  external  meatus  is  fully  cx])osed.  After  thus 
exposing  the  bone  the  surgeon  notes  the  position  of  the  su})erior  mcatal  triangle,  which 
is  formed  by  the  jHJSterior  zygomatic  root,  the  upp(>r  posterior  segment  of  the  external 
osseous  meatus,  and  an  imaginary  line  uniting  these  two,  extending  from  the  most  posterior 
portion  of  the  osseous  meatus  to  the  zygomatic  root.  Within  this  triangle  the  mastoid 
antrum  may  be  entered,  its  dejith  being  proportionate  to  the  depth  of  the  middle  ear 
from  the  surface.  So  long  as  care  is  exercised  the  sigmoid  groove  will  not  be  injured. 
The  depth'  at  which  it  lies  from  the  surface  varies.  It  is  more  superficial  in  children, 
while  in  adults  with  chronic  ostitis  of  the  region  it  may  have  a  thick  covering.  When 
opened  it  should  be  thoroughly  cleansed,  for  it  may  contain  not  only  \ms  but  granulation 
tissue  or  masses  of  cholesterin.  After  cleansing  the  antrum  the  jmssage  between  it  and 
the  middle  ear  should  be  noted,  as  well  as  the  position  of  the  facial  canal,  which 
traverses  its  inner  side  obliquely  from  without  inward  as  it  passes  into  the  inner  wall 
and  roof  of  the  tym]ianum.  It  is  recognizable  by  a  ridge  of  harder  osseous  tissue.  If 
changes  have  occamvd  in  the  surrounding  bone  it  may  not  be  recognized.  If  the  opera- 
tor kee])s  to  the  upper  and  outer  part  of  the  antrum  he  will  avoid  the  nerve.  Any  injury 
to  it  will  produce  facial  twitching.  The  bony  canal  may  be  eroded  by  granulations, 
so  that  the  nerve  itself  may  be  exposed  when  the  antrum  is  being  cleansed. 

The  mastoid  cells  lie  posteriorly  and  below  this  antrum,  and  should  be  exjiosed,  when 
cleaning  out  their  morbid  contents,  by  removing  the  external  mastoid  wall.  In  this 
part  of  the  o]jeration  the  sigmoid  groove  should  not  be  forgotten,  as  it  may  have  been 
disintegrated  by  granulations  which  have  extended  into  the  fossa  and  separated  the  dura 
from  the  bone"^  When  granulations  have  thus  formed  there  is  usually  more  or  less 
thrombosis  of  the  sigmoid  sinus  in  addition  to  the  localized  pachymeningitis. 

The  instruments  w-hich  may  be  emi)loyed  during  this  work  are  a  matter  of  choice. 
It  can  be  done  with  the  ordinary  bone  instruments  of  the  genera!  surgeon,  which  should, 
however,  include  gouges  and  curettes  of  small  size  as  well  as  delicate  chisels  and  majlet. 
A  dental  or  surgical  engine  is  advisable,  which  will  serve  julmirably  and  for  the  desu'ed 
purpose.  Just  what  instrument  should  be  used  and  how  manipulated  will  depend  upon 
the  more  or  less  pneumatic  {i.  e.,  cellular)  character  of  the  bone.  Some  mastoids  are 
richly  cellular.  Pus  or  granulation  tissue  should  be  followed  wherever  it  may  lead. 
When  both  mastoid  cells  and  tympanum  participate  in  the  morbid  process,  and  are 
practicallv  filled  with  pus,  de])ris,  or  granulations,  there  may  then  be  added  to  the  opera- 
tion those  features  which  entitle  it  to  be  called  ij/mpauomasioid  e. rente  ration,  as  devised 
bv  Schwartze,  Zaufal,  Stacke,  and  others,  and  fre(iu(Mitly  described  under  their  names. 
It  is  an  extension  of  the  measures  already  described,  and  results  in  converting  the  mas- 
toid cells  and  antnim,  the  tympanic  cavity,  and  the  auditory  canal  into  one  common 
cavity.  Not  only  is  the  bonv  barrier  between  the  antrum  and  the  tympanum  removed, 
but  the  ossicles  as  well.  This  leaves  a  large  cavity,  which  should  be  partially  closed  and 
lined  by  granulation  and  cicatricial  tissue,  epithelial  lining  being  furnished  so  far  as  it 
mav  extend  from  the  exterior.  ,  . 

The  operation  may  be  begun  practically  as  already  described,  the  incisions  bemg  more 


576  SPECIAL   OR   RKCIOXAL   SmaKNY 

extensive  anil  the  auriele  more  freely  detaelied,  so  as  to  be  refleetetl  forward.  There 
need  he  no  partieular  effort  to  save  the  periosteum  over  the  area  of  the  attaek,  although 
there  is  no  objeetion  to  reffeeting  it  with  the  softer  tissues.  Some  operators  jjrefer  to 
detaeh  the  cartilaginous  meatus  and  the  ear  from  its  osseous  insertion  and  to  shift  them 
all  farther  forward.  The  antrum  and  the  mastoid  cells  having  been  exposed,  ojx-ned, 
and  cleaned  out,  the  surgeon  next  jiasses  forward  and  upward  to  the  external  wall  of  the 
e])itymjianum,  and  the  dividing  barrier  of  bone  between  the  tympanum  and  the  mastoid. 
This  cavity  being  uncovered,  the  incus,  if  present,  may  be  lifted  out  of  its  position,  or 
all  of  the  ossicles  removed  in  as  gentle  a  manner  as  circumstances  will  permit.  All  the 
bony  jjrominences  and  partitions  between  the  tip  of  the  mastoid  and  the  anterior 
wall  of  the  tympanum  are  then  smoothed  off  with  a  curette,  or  surgical  engine,  while 
granulation  tissue  is  followed  in  to  any  recesses  which  may  be  occupied  by  it,  or  along 
any  of  the  cranial  outlets  which  it  may  be  seen  to  traverse.  One  gives  the  greatest 
care  to  avoidance  of  injury  to  the  horizontal  semicircular  canal,  to  the  ac|ueduct  of 
Fallopius,  or  to  inadvertent  puncture  of  the  sigmoid  groove.  The  Fallopian  aqueduct, 
or  canal,  lies  in  the  ridge  between  the  mastoid  and  the  meatus,  along  the  floor  of  the 
aditus,  antl  it  should  be  sj^ared  in  the  process  of  cutting  away  the  bone. 

If  the  membranous  portion  of  the  meatus  has  been  split,  as  advised  by  some  ojxTators, 
its  margins  may  be  brought  together  with  chromic  gut.  At  all  events  the  auricle  should 
be  brought  back  into  place  after  the  cleansing  is  finished,  where  it  should  be  fastened 
and  retained  by  sutures  as  well  as  by  the  dressings.  Should  there  be  insufficient  skin 
to  cover  the  opening  thus  made,  slide  a  flap,  or  even  cover  the  exposed  raw  area  with 
a  skin  graft.  The  former  will  usually  be  the  better  plan.  The  cavity  left  after  such 
closure  should  be  packed  with  gauze,  on  which  balsam  of  Peru  should  be  used.  This 
may  be  left  for  two  or  three  days,  after  which  a  daily  dressing,  with  irrigation  or 
suitable  cleansing,  will  suffice. 

]Most  of  the  mechanism  of  the  middle  ear  is  apparently  destroyed,  but  loss  of  hearing 
is  not  complete. 

CEPHALOCELE. 

The  term  cephalocele  is  applied  to  tmnor  of.  the  endocranium,  presenting  through 
defects  in  the  cranial  bones,  of  essentially  congenital  origin,  and  containing  more  or 
less  of  intracranial  contents.     It  comprises — 

A.  Mcningocrlc,  which  means  a  tumor  consisting  of  a  membranous  jjrotrusion  and 
containing  cerebrospinal  fluid;  and, 

B.  Eurrphalocclc,  referring  to  tumors  which  contain  also  more  or  less  of  actual  brain 
substance. 

Such  tumors  of  non-traumatic  origin  can  only  be  explained  by  the  existence  of  con- 
genital defects  which  permit  the  escape  of  that  which  the  normal  bone  retains  within 


Fig.  380 


Uccipital   cephalocele. 


normal  limits.  In  most  instances  the  defect  is  in  the  middle  line,  at  either  one  or  the 
other  extremity  of  the  skull.  In  some  instances  the  arches  of  the  atlas,  or  even  of  other 
cervical  vertebni^,  are  lacking.  The  most  connnon  ce])haloceIes  are  the  occi]:>ital,  which 
are  known  as  inferior  when  below  the  ()cci])ital  s])ine,  or  suj^erior  when  above  it.  Those 
appearing  anteriorly  are  known  as  sincipital,  and  are  met  with  most  often  at  the  root  of 


Ch'I'Jf.\//>('/:LE 


577 


the  nose,  where  tliev  may  eoniintiiiiciite  with  the  ()rl)it  or  the  nasal  cavity.     Other  and 
irre<;hir  lornis  are  hiterally  or  iiiisyininelrieally  located  (I''ii;s.  .']S(),  ,'iSl  aii«l  .■iS2). 

CrphalorrlcN  have  an  ehi.stic  feelin<r,  many  of  them  an  e.\(|ui.site  fluctuation.  Some- 
times by  toucl)  alone  we  reco<rnize  both  their  fluid  and  solid  contents.  A  meninf^ocele 
with  thin  walls  is  /m//.s///cr///.  IJy  |)ressure  they  can  he  reduced  in  size,  such  pressure 
usually  j)roilucin<5  brain  symptoms,    often    |)aralysis   or   convulsions.     Many   children 


Fio.   381 


A 


Sincipital  meningocele. 

thus  afTected  cannot  lie  upon  the  tumor  without  becoming  restless.  When  the  |)atients 
cry  or  make  violent  straining  efforts  it  becomes  larger  and  its  covering  more  vascular, 
while  during  quiet  sleep  it  is  usually  reduced  in  size  or  tension. 

A  large  proportion  of  patients  with  these  congenital  defects  die  shortly  after  birth. 
The  tumor,  when  large,  may  be  ru{)tured  during  delivery.  Occasionally  the  sac  ruptures 
spontaneously,  which  accident  is  usually  followed  by  purulent  meningitis  from  infec- 

Fi.:.   382 


Sincipital  hydrencephalocele;  two  views. 


(All  of  these  from  the  Buffalo  Clinic.) 

The  principal  danger  is 


tion,  though  it  may  possibly  lead  to  spontaneous  recovery 
the  liability  to  such  accident. 

The  eneepha/occle.s  are  divided  into  the  cenencephnloceles,  containing  solid  brain  sub- 
stance, and  hydrencephaloreles,  consisting  of  the  protrusion  of  a  dilated  brain  cavity — 
i.  e.,  a  thin  area  of  brain  enclosing  fluid  communicating  with  one  of  the  ventricles.     INIost 
of  the  large  tumors  pertain  to  the  latter  class.     The  more  brain  material  such  a  tumor 
37 


578  SPE'CIAL  cm  REGinXAL   SURGERY 

contains  the  more  it  |)ul.sate,s,  e.sjx'cially  if  tlic  ])ati('nt  rrv  or  strain;  the  smaller,  too,  is 
the  skull — /.  ('.,  the  fjreater  the  tendency  toward  niicroce|>halus. 

Concjcnital  ri/.ft.s-  of  luaiii  iiiid  iii(iiil)i;ni(>,  in  a  measure  traumatic,  are  classified  bv 
Rawling,  as  follows: 

1.  According  to  situation:  (o)  witiiin  the  calvarium,  suhostcal.  subdural,  subarachnoid 
or  intracerebral;  (h)  projec-ting  through  an  opening  in  the  skull,  with  or  without  ven- 
tricular communication. 

2.  According  to  origin,  /.  e.,  whether  they  arise  from  Ijlotjd  clot  or  other  causes. 

3.  According  to  contents,  whetiier  they  contain  clear  fluid,  altered  clot,  or  brain 
sul)stance. 

Cysts  of  this  character  arc  to  l)e  differentiated  from  the  cephaloceles  already  considered 
because  there  is  about  most  of  them  the  element  of  traumatism,  although  this  may  have 
been  intra-uterine  or  produced  during  paiturition.  Those  which  are  associated  with 
premature  synostosis  and  microcephaly,  with  hydrocephalus,  with  marked  deformity, 
or  situated  below  the  external  occipital  protuberance,  are  generally  considered 
inojierable,  while  these  considered  ofx-rable  consist  of  limited  protrusions  without  any 
of  the  above  defects.  This  practically  excludes  the  greater  prof)ortion  of  the.se  cases 
from  operation,  which  is  always  dangerous.  Nevertheless  if  success  is  to  be  achieved 
the  risks  should  be  taken.  CXsteoj)lastic  methods  of  closing  cranial  openings  may  be 
perliaps  of  value  in  rare  cases,  although  in  the  young  the  skull  is  t(j(j  thin  to  furnish  an 
external  tal)le  which  can  of  itself  be  detached.  In  inojx-rable  cvsts  of  this  kind,  with  a 
tendency  to  increase,  while  the  rest  of  the  brain  lags  behind  in  the  rate  of  growth,  the  edges 
of  the  <  ipiniiig  become  everted,  and  o]>eration  is  thus  made  more  difficult  and  less  desirable. 

Treatment. — Treatment  should,  first  of  all,  be  protective,  by  a  shield  of  some 
device  held  in  place  by  a  suitable  bandage  or  dressing.  Compression,  with  or  without 
puncture,  has  given  at  times  satisfactory  results,  but  not  much  should  be  expected  from  . 
any  method  or  combination.  Most  of  the  cases  are  such  that  extirpation  would  seem 
api)li(al)le,  but  the  impossibility  of  absolute  asepsis  in  young  infants  and  the  liability 
to  fatal  shock  preclude  many  of  these  attempts.  In  some  instances  ligature  of  a  menin- 
gocele has  been  successfully  apj^licd.  Oprraiion  may  be  attem])ted  in  young  children 
in  selected  cases.  Plastic  operations  may  l)e  resorted  to,  or  plastic  maneuvers  combined 
with  extirpation.  It  may  be  possible  by  the  insertion  of  a  celluloid  plate  to  atone  for 
a  small  defect  in  the  skull  after  extirj)ation  of  a  tumor  of  this  kind.  1  have  successfully 
practised  this  method  in  spina  bifida. 

HYDROCEPHALUS. 

This  term  is  applied  to  abnormal  collections  of  cerebrospinal  fluid  wirhiii  tlic  <raiiial 
cavity.     We  sjx'ak  of — 

A.  Hydrocephalus  venirinilonnn  or  infcrnus,  when  the  lliiiil  i-  iiMitiiicd  to  the  dilated 
ventricles  of  the  brain;  or  of — 

B.  Hi/drorrpliahis  meningrus  or  cxtcrnu-s,  when  the  iluiJ  collect.^  Ijctwccn  the  brain 
and  the  dura. 

The  former  condition  is  much  the  more  common.  The  cause  of  hydrocephalus  in 
the  young  is  essentially  congenital,  aiul  inseparable  from  imf)erfect  development  within 
the  cranium.  The  forms  are  occasionally  combined.  At  the  time  of  commencing 
trouble  the  skull  may  be  of  natural  size,  but  yields  to  the  accumulation  of  fluid  within 
until  it  attains  relatively  enormous  dimensions.  ^lost  children  thus  affected  die  early, 
some  shortly  after  birth.  It  is  most  common  in  rachitic  children.  Hydrocephalus 
developing  in  the  adult  is  the  result  almost  solely  of  atro])hy  of  the  brain.  Pachi/mcnin- 
rjitis  interna  (see  p.  572)  may  also  produce  subdural  exudate  leading  to  liijdrorrphalu-s 
e.riernus.  Encapsulated  collections  of  cerebrospinal  fluid  due  to  pachymeningitis  interna 
are  known  as  hi/gromas  of  the  dura.  A  ventricular  form  of  hydroce})halus  may  also 
result  from  meningitis  and  tuberculous  disease.  The  condition  is  essentially  chronic, 
the  fluid  collecting  in  the  dilated  lateral  ventricles,  though  the  third  or  forth  are  .some-: 
times  also  distended:  40)0  Cc.  of  cerebrospinal  fluid  have  been  f(jund  in  more  than  one 
instance.  As  the  result  of  the  presence  of  the  fluid  there  is  atrophy  of  brain,  with  arrest 
of  development,  to  such  an  extent  even  that  the  hemispheres  are  changed  into  great  sacs, 
being  merely  spread  out  upon  the  outer  wall  of  cystic  cavities;  all  the  surface  markings 
are  lost,  and  gray  and  white  substances  are  scarcely  to  be  differentiated. 


iiyi)i{()('i:i'ii.\u's  fijo 

111  the  cranimii  ifscit"  llic  Ixuks  of  the  vt-rtcx  scpanih',  and  instead  ol"  siitnrcs  tlitrc 
is  a  li^lillv  strc'tclu'd  nicnihranc.  Tlicrc  is  also  con^fcnital  or  accpiircd  njihi-sKi  i.  r., 
jil)Solu((>  dct'cct  of  hone  hctwccn  tlic  dura  and  |)('ricraniuni.  All  thcst'  clian^es  jrivc  to 
liydr()fe|)luilic  heads  a  distinftivc  apixaranc'c.  Other  dev(loj)inental  defects — hare-lij), 
club-foot,  etc. — are  eoiumon  in  these  patients.  Many  infants  thus  affected  die  duiini^f 
deliverv  unless  skilful  help  is  at  hand,  "^riie  result  ins;  disi)roportion  between  tiie 
eniartji'd  head  and  the  suudi  face  is  most  distincti\'<>.  ('hildren  in  this  condition  suffer 
from  disturbed  digestion,  are  emaciated,  with  raciiitic  curvatures  of  the  loni;  bones; 
special  senses  are  seldom  developed  perfectly;  strabisnuis  and  nystagmus  arc  frc(|Ucnt, 
while  cramps  and  stupor  arc  by  no  means  infrc(|ucnt. 

Prognosis.  \\'i!ii(>  spontaneous  recovery  is  |)ossiblc,  as  already  stated,  the  tendency 
is  always  toward  fatality. 

Treatment.  -Treatm'.Mit  by  compression  of  the  cnlartfiiio' skull,  with  elastic  bandaj^cs 
or  their  e(|ui\alcnt,  is  an  abandoned  method  since  compression  which  can  be  effective; 
is  too  ifrcat  to  be  toU^rated.  Treatnu'ut  by  mere  aspiration  is  also  useless.  Ta])pin<;  is 
an  old  eiperation  lon<:;  discontinued,  recently  reviv(>d,  but  again  proved  disappointing. 
The  esta!)lishment  of  j)cniianciif  drainage  is  a  more  recent  suggestion.  It  depends  upon 
the  demonstration  of  the  fact  that  the  tension  of  the  cerebrospinal  fluid  and  of  the  blood 
in  the  cerebellar  veins  is  the  same,  and  that  intracranial  pressure  forces  fluid  into  the 
veins  and  away  from  the  skull.  Thus  subdural  or  aiifodrainagc  was  suggested.  Suther- 
land and  Cheyne,  in  lcS*.)S,  were  the  first  to  o])erate  in  this  uuunier.  They  opened  the 
dura  near  the  lower  angle  of  the  anterior  fontanelle,  through  the  opening  carried  a  strand 
of  catgut  into  the  ventricle,  and  jiassed  the  outer  end  beneath  the  dura;  but  the  method 
again  proved  disappointing.  Mikulicz  passed  a  gold  tul)e  into  the  right  ventricle, 
leaving  its  outer  end  in  the  subcutaneous  tissues  about  5  Cm.  from  the  middle  line. 
After  being  three  weeks  in  this  j)osition  it  ceased  to  drain,  and  was  then  inserted  into 
the  other  ventricle.  The  child  died,  unbenefited,  in  six  weeks.  In  another  case  he 
used  a  glass-wool  drain,  making  it  subdural  rather  than  subcutaneous.  This  case 
seemed  to  be  benefited.  Senn  has  modified  the  method  by  making  a  large  pocket  in 
the  subcutaneous  tissues  of  the  cervical  region,  inserting  one  end  of  a  rubber  tube 
into  it  and  carrying  the  other  into  the  ventricle  between  the  temporal  and  frontal  bones. 
Even  this  proved  disa])|)ointing.  I  have  twice  tried  conducting  fluid  by  a  small  rubber 
tube  from  the  ventricle  into  the  cellular  tissue  in  the  neck,  passing  the  tube  beneath  the 
skin  by  suitably  curved  forceps.  This  method,  however,  showed  no  advantage  over  the 
others  mentioned  above.  Taylor  has  endeavored  to  make  a  jjcrmanent  fistula  between 
the  ventricles  and  the  subdural  space  by  jjassing  chromicized  catgut  into  the  ventricle 
and  letting  it  drain  into  the  latter.  His  results,  however,  were  not  encouraging,  in  spite  of 
the  jjlausibility  of  the  theory  upon  which  they  were  based.  Drainage  through  the  spinal 
canal  into  the  abdominal  cavity  has  also  been  prac-tised  by  a  very  few  surgeons.  The 
ingenuity  and  theory  of  the  method  are  most  attractive,  though  but  very  few  little  patients 
are  in  condition  to  bear  the  abdominal  section  which  is  necessitated  for  the  purpose.' 

Permanent  drainage,  then,  has  been  a  most  disappointing  procedure,  although  th(>re 
need  be  no  hesitation  in  tapping  the  lateral  ventricles  when  there  is  indication  for  it. 
This  can  easily  be  done  at  any  time  by  an  opening  about  3  Cm.  behind  tlie  external 
autlitory  meatiis  and  tlu;  same  distance  above  the  base-line  of  the  skull.  By  directing 
the  i)uncturing  instrument  to  a  point  on  the  opposite  side,  0  Cm.  above  the  meatus,  the 
lateral  ventricle  will  be  entered.  (This  same  general  direction  will  serve  for  opening 
an  abscess  in  the  tem]x)rosphenoi(lal  lobe.)  The  best  results  in  hydrocephalus  seem 
to  have  been  obtained  by  lumbar  puncture,  as  first  suggested  by  Quincke,  the  method 
being  the  same  as  that  now  in  general  use  for  intraspinal  cocainization.  As  directions 
for  entering  the  spinal  canal  with  the  aspirating  instrument  would  be  identical  with 
those  mentioned  in  the  chajiter  on  Anesthesia,  when  describing  intraspinal  cocainization, 
the  reader  is  referred  to  that  section  for  further  direction  (p.  208).  The  only  case  of  well- 
marked  hydrocephalus  which  I  have  ever  ai)})arently  cured  was  one  repeatedly  tajjped 
in  this  fashion,  a  considerable  amount  of  fluid  being  withdrawn  at  each  little  operation. 

>  In  March,  1906,  Cvishing  informed  me  that  his  present  routine  in  effecting  such  drainage  was  to  make  a 
laminectomy  and  expose  the  spinal  canal  from  the  rear,  then  to  do  a  laparotomy,  and,  exposing  the  bodies  rf 
the,  vertebra;,  pass  through  from  in  front  backward  a  silver  tube,  wliose  end  should  reach  into  the  spinal  canal, 
draining  it  into  the  abdominal  cavity,  the  posterior  wound  being  always  snugly  closed.  The  spinal  canal  is 
thus  exposed  in  order  to  ensure  the  accurate  performance  of  the  other  part  of  tlie  operation. 


580 


SPECIAL  OR  REGIONAL  SURGERY 


SURGICAL    TREATMENT    OF   DEFECTS   OF    INTRACRANIAL    DEVELOPMENT. 

There  are  numerous  causes  which  produce  imbecility  and  kindred  condition.^  in  the 
young.  Some  are  in  effect  congenital,  some  are  postnatah  Within  the  j)ast  few  years  a 
numl)er  of  these  cases  have  been  subjected  to  surgical  o])cration,  in  many  instances  with 
more  or  less  success.  Mental  defect  may  occur  from  injuries  at  the  period  of  l)irth — 
mainly  hemorrhages,  more  commonly  cortical,  though  sometimes  dee]).     In  either  case 

Fig.  383 


Fig.  384 


Lines  of  removal  of  bone  as  practised  by  the  author,  by  Lannelongue,  and  by  others. 

the  clots  thus  formed  frequently  undergo  cystic  alterations.  The  term  jiorenccphalon 
is  modern,  and  applied  to  changes  comprising  disappearance  of  real  nerve  tissue  with 
partial  su!)stitution  by  connective  tissue,  often  with  other  degenerations,  the  result 
being  atrophic  alterations  which  apparently  permit  of  no  remedy.  In  a  ease  of  true 
uorencephalon  the  outlook  for  operation   is  not  at   all  encouraging,  nor  is  it  in  any 

cases  which  are  accom]mnied  or  caused  by  a  genuine 
arrest  of  cerebral  development.  On  the  other  hand, 
when  the  mental  condition  can  l)e  ascribed  to  the 
result  of  injuries,  to  hemorrhages,  to  meningeal 
irritation,  to  premature  ossification,  or  too  early 
closure  of  the  fontanelles,  or  when  it  is  accompa- 
nied by  evidence  of  meningeal  irritation  or  symp- 
toms which  point  to  a  definite  area  of  the  brain 
as  being  the  site  of  the  principal  disturbance, 
operation  as  a  legifimatc  experiment  may  be  con- 
scientiously suggested  and  performed. 

The  operation  is  usually  desc-ribed  as  craniotomy 
or  craniectomy,  and  is  apt  to  be  successful  in  many 
cases  of  microcephaly  combined  with  idiocy.  An 
acquired  form  will  give  a  better  ])rognosis  than  will 
the  congenital  condition.  The  danger  of  the  opera- 
tion is  often  great,  and  especially  so  since  it  is 
called  for  in  puny,  ill-nourished,  and  badly  cared- 
for  children.  To  be  successful  it  ought  to  be  exten- 
sive. It  should  vary  in  character  and  degree — from 
simple  division  of  the  skull  along  the  middle  line, 
from  near  the  root  of  the  nose  to  the  occiput  on 
one  or  both  sides,  to  the  formation  of  large  bone 
flaps  by  cutting  away  a  wide  groove  of  bone  so  as 
to  relieve  pressure  u|)on  the  hemispheres.  Fig.  383  presents  the  various  ways  of 
performing  the  operation. 

It  can  usually  be  made  bloodless,  or  nearly  so,  by  an  elastic  tourniquet  around  the 
skull.     The  incision  in  the  skin  should  not  correspond  to  the  groove  in  the  bone,  but 


Defective  cerebral  development.    (Buffalo 
Clinic.) 


SURGICAL    TRi:.\TMi:\T  OF  l-PILFPSY   AM)    Till-:   I'SYCllOSKH  581 

should  ovcrhii)  ''  ^"""'  '''l'<'  <li.st;iii(c.  For  niv  own  part  1  pn  fcr  to  do  most  of  tlicsr 
()|)cralioiis  in  two  sitliii<:s.  I  would  advise,  as  a  rule,  to  j)i-<'|)arc  tlic  scalp  carcfullv  for 
ojKTatioii,  to  divide  the  skin  alon<r  tlic  proposed  line,  separate  it  from  the  pericranium 
and  <heck  all  oozin<r;  then,  after  openin<r  the  skull  with  the  trephine,  to  cut  away  with 
l^roper  forceps  (roiiireur)  along  the  desired  line,  or,  if  provided  with  it,  to  remove  the 
bone  by  some  surgical  engine  or  revolving  saw  operated  by  electricitv.  The  strip  of 
bone  thus  removed  should  be  at  least  half  an  inch  wide,  and  tiie  overfving  |)eriostenm 
should  be  removed  with  it,  as  only  in  this  way  can  the  undesirably  rajjitrregencration 
of  bone  be  prevented.  By  this  means  the  dura  is  exposed,  but  not  opened.^  In  some 
cases  this  will  be  sufficient.   ' 

In  many  otluTs,  however,  it  will  be  insufficient;  and,  could  this  be  foreseen,  it  would 
be  well  to  combine  the  above  measures  in  one  as  a  first  o|K'rati(jn,  and  then,  a  few  days 
later,  to  open  the  dura  as  the  .second  procedure — this,  however,  only  on  the  discovery 
by  careful  insj)ection  that  the  wound  is  absolutely  free  from  possibility  of  infection. 
Conid  infection  be  prevented,  this  is  certainly  the  safer  procedure,  since  in  weak,  puny 
youiig  children  to  make  a  long  scalp  incision,  to  remove  a  long  strip  of  bone,  and  then 
to  widely  open  the  dura  is  more  than  can  safely  be  done  in  the  majority  of  instances. 

It  should  have  l)een  carefully  explained  to  those  interested  in  the  case  that  improve- 
meiit  will  in  all  prol)ability  be  extremely  slow,  and  that  little  or  nothing  is  to  l)e  exjx'cted 
at  first,  even  if  })rom])t  recovery  from  the  operation  ensue.  Neither  would  I  advise  any 
one  to  perform  the  operation  unless  parents  are  wilUng  to  assume  all  risks  and  abide 
by  the  results. 

SURGICAL  TREATMENT  OF  EPILEPSY  AND  THE  PSYCHOSES. 

Operations  for  relief  of  epilepsy  seem  to  date  back  even  to  the  prehistoric  era,  and  were 
for  centuries  done  as  a  purely  empirical  measure;  later,  to  have  been  practised  with 
more  or  less  plausible  reason ;  then  to  have  fallen  into  discredit  for  long  periods  of  time, 
with  occasional  revivals  of  the  practice,  until  within  the  past  twenty-five  years  the 
operation  has  been  again  revived  upon  its  merits  and  upon  the  recognition  of  more  or 
less  accurate  indications. 

Operations  of  tiiis  character  are  based  upon  two  fundamental  facts:  the  first,  the 
widespread  experience  that  after  various  operati(jns  epileptic  patients  have  been  bene- 
fited; and,  second,  that  a  certain  proportion  of  these  cases,  especially  those  of  traumatic 
origin,  are  characterized  by  a  localized  and  definite  aura,  and  by  a  sV.stematic  and  prac- 
tically invariable  order  of  muscle  involvement,  according,  it  would  seem,  to  .some  fixed 
law,  and  pointing  definitely  to  a  certain  area  of  the  brain  from  which  apparently  the  irri- 
tation arises  and  spreads.  This  form  of  epileptic  .seizure  is  that  generally  known  as  the 
Jarksonian,  and  is  that  in  which  operation  is  most  often  of  real  service.  The  statements 
of  patients  regarding  these  i)henomena  should  never  be  accepted;  only  those  made  by  a 
trained  observer  (nurse  or  physician)  are  reliable. 

In  spasms  of  the  Jarksonian  type  there  is  a  certain  order  of  progression  which  is  scarcely 
ever  violated.  Thus,  irritation  beginning  in  the  leg  centre  can  hardly  reach  the  face  centre 
without  traversing  that  of  the  arm.  It  is  possible  also  to  have  sensory  equivalents  for 
Jacksonian  attacks,  as  when  they  commence  with  peculiar  sounds  indicating  irritation 
in  the  centre  of  hearing,  or  with  optical  phenomena,  or  with  disturbances  of  smell  or 
taste,  the  former  indicating  occipital  irritation,  the  latter  irritation  in  the  temporo- 
sphenoidal  region. 

The  surgeon  will  often  be  consulted  as  to  the  wisdom  of  operation  in  the  presence  of 
this  condition.  In  brief,  and  in  a  general  way,  the  following  statements  may  be  made: 
It  is  necessary,  first  of  all,  to  establish  a  traumatic  origin,  and  ejiilepsy  which  has 
preceded  a  severe  head  injury  can  in  no  sense  be  ascribed  to  it.  If  it  can  be  clearly 
established  that  it  has  followed  injury,  and  if  a  distinct  scar — especially  a  scar  which  is 
adherent — or  depression  can  be  discovered,  or  any  area  which  is  always  irritable  and 
which  seems  epileptogenic  when  irritated;  or  if,  again,  by  close  study  of  the  case  it  can 
be  determined  that  the  aura  and  the  initial  muscle  .sMiiptoms  ari.se  always  in  the  same 
part — as,  for  instance,  a  finger,  thumb,  foot,  etc. — and  proceed  according  to  a  con.stant 
program — then  it  may  be  said  that  operation  is  not  merely  justifiable,  but  advisable. 
On  the  other  hand,  when  neither  distinct  scar  nor  history  of  localizing  phenomena  can 
be  obtained  operation  should  rarely  be  attempted. 


582  SPECIAL   OR  REGIOXAL  SURGERY 

Again,  in  epilepsy  of  the  non-traumatic  type,  operation  may  Ije  advised  when  it  assumes 
the  distinctly  Jacknonian  form — i.  e.,  when  everything  points  to  irritation  proceeding 
from  a  localized  portion  of  the  brain.  In  the  absence  of  Jacksonian  symptoms  operation 
is  even  more  of  an  experiment  than  in  the  traumatic  form.  Such  cases  should  be  studied 
a  long  time  on  their  merits  before  a  decision  is  made  to  trephine. 

The  operation  itself  is  directed  to  excision  of  irritable  scars,  to  exposure  of  the  dura 
at  the  point  of  o{)ening,  to  the  detection  and  suitable  treatment  of  depressed  fragments, 
dural  adhesions,  tumors,  foreign  bodies,  etc.  It  is  essential  in  every  case  that  it  be 
represented  to  those  interested  that  the  operation  itself  removes  the  cause,  but  cannot 
be,  per  se,  expected  to  complete  the  cure,  especially  in  cases  of  long  standing,  and  that  the 
final  cure  must  depend  in  large  measure  upon  the  avoidance  of  subsequent  irritation, 
upon  the  estaljlishment  of  perfect  hal)its  of  diet  and  excretion,  which  are  often  perverted, 
and  perhaps  upon  the  long-continued  administration  of  drugs,  of  which  the  bromides 
are  those  most  constantly  given.  The  reader  need  not  be  reminded  that  old  cases 
are  the  least  favorable,  and  that  recent  cases  are  the  most  so  for  operation,  antl  that  the 
longer  the  diseased  condition  has  existed  the  harder  it  will  be  to  cure  by  any  method. 

Besides  these  direct  operative  attacks  it  has  been  suggested  by  Alexander  to  tie  the 
vertebral  arteries  (now  practically  abandoned)  and  by  Jonnesco  to  excise  the  superior 
and  middle  cervical  s^Tnpathetic  ganglia.  This  seems  to  me  particularly  indicated  in 
those  cases  where  a  convulsion  can  be  aborted  by  prompt  administration  (by  inhalation) 
of  amyl  nitrite  as  soon  as  the  preliminary  aura  is  recognized.  The  operation  is  described 
in  the  chapter  on  Surgery  of  the  Cranial  and  Cervical  Nerves.  ]\Iany  encouraging 
results  of  this  treatment  have  been  reported. 

I  heheve  thoroiir/hlij  in  operating  in  selected  cases.  I  am  equally  confident  that  indis- 
criminate operation  must  lead  only  to  disappointment  and  to  occasional  disaster.  In 
the  presence  of  long-standing  lesions,  like  bone  depressions,  cystic  degeneration  of  old 
clots,  etc.,  the  brain  may  have  been  so  long  pressed  upon  as  to  have  become  atrophied. 

The  whole  subject  of  the  modern  surgical  treatment  of  epilepsy  is  inseparal)le  from 
the  topic  of  promjit  and  efficient  treatment  of  all  head  injuries.  Were  tlie  indications 
in  these  always  met  at  the  time  of  the  accident  we  should  have  a  much  smaller  propor- 
tion of  cases  of  traumatic  epilepsy. 

Inasmuch  as  one  object  of  many  of  these  operations  is  to  break  up  adhesions  between 
the  dura  and  the  pia,  there  is  generally  anxiety  to  know  the  result  after  such  operations 
as  to  whether  they  do  not  speedily  form  anew.  There  is  always  this  theoretical  danger, 
and  it  is  my  custom  in  such  cases  to  insert  beneath  the  dura,  at  the  point  where  such 
adhesions  have  been  divided  or  torn,  a  piece  of  delicate  gold-foil,  duly  sterilized,  in 
order  that  it  may  separate  these  surfaces  and  prevent  the  recurrence  of  the  old  condition. 
Foil  used  for  this  purpose  is  harmless,  and  I  have  numerous  patients  in  whom  it  has 
been  used,  apparently  without  producing  the  slightest  disturbance.  (Foils  of  silver  or 
aluminuiu  answer  as  well  or  better.) 

Mental  and  psychic  disturbances  after  head  injuries  have  been  long  known  and  the 
suggestion  to  operate  upon  the  skull  in  cases  of  so-called  trcmmatic  insanity  is  not  new. 
In  a  general  way  it  may  be  said  that  whenever  distinct  mania  follows  a  recognized  lesion 
of  the  vertex  of  the  skull,  and  fails  to  subside  within  a  reasonable  time  and  under  proper 
treatment,  there  are  the  best  of  reasons  for  raising  the  scalp,  trephining,  and  exj)loring 
as  to  the  deeper  conditions.  Patients  might  be  released  from  asylums  who  have  long 
been  inmates  had  this  measure  been  practised  at  the  beginning  of  their  mental  alienation. 

The  same  measure  will  give  relief  in  certain  cases  of  cephalalgia,  or  headache,  where 
the  pain  is  always  ascribed  to  a  particular  region,  and  especially  wIkmi  there  is  tenderness 
over  this  region.  These  operations  are,  of  course,  empirical,  yet,  as  the  result  of  altered 
nutrition  and  allayed  irritation,  relief  follows  in  a  fair  proportion  of  instances. 

INTRACRANIAL  TUMORS. 

Until  within  recent  years  these  were  regarded  as  having  interest  mainly  for  the  path- 
ologist and  clinician,  but  as  essentially  hopeless  so  far  as  surgical  help  is  concerned. 
Recent  discoveries  in  the  field  of  cerebral  localization  and  recent  experience  with  exten- 
sive openings  into  the  cranium  have  shown,  however,  that  a  small  projiortion  of  intra- 
cranial tinnors  are  of  such  a  character  and  so  located  as  to  make  them  amenable  to 


L\ Th'.  1  ( 'h'.  I  .\7. 1  /.    Tl  MOh'S  r,s;j 

surt^ical  relict',  'riicsc  tuiiidis  occur  willi  altout  c(|iiiil  trc(|uciicy  in  cliildliood  and  adult 
life.  Ill  the  order  oi"  frequeney  they  stand  about  us  follows:  Tuberculous  pruninia, 
glioma,  sarcoma,  cysts,  carcinoma,  and  syj)liilitic  fj^nnima,  with  a  small  jjroportion  of 
fibroma,  etc. 

Of  UK)  cases  of  brain  tumor  sel(>cted  at  random  not  more  than  5  to  7  per  cent,  are  so 
placed  us  to  justify  sur<;ical  attack.  In  as  many  more,  at  least,  the  tumors  are  .s<)  located 
as  to  justify  o])eninii;  the  cranium  for  mere  relief  of  pressure  without  any  notion  or  en- 
deavor to  attack  tiic  tumor  itself.  Hcjorc  opcninf/  the  (■rmiiuiii  (lia<^nosis  should  he  made 
as  carefully  as  |)()ssil)le — first,  as  to  locatixni;  second,  as  to  whether  roriiml  or  siihroiilca/; 
third,  as  to  the  iitinihrr  of  tmnor.s  prr.sntf;  fourth,  as  to  their  f/rnrral  r/iamrfrr.  Location 
is  determined  in  the  main  by  study  of  j)ain  complained  of,  by  watchinj;  patients  during 
convulsive  seizures,  by  determining  the  extent  of  local  or  general  paralysis,  by  careful 
history  which  shall  reveal  the  m(>thod  and  rate  of  extension  of  the.se  symptoms,  and  by 
the  study  of  the  ojitic  disks,  of  vision,  and  by  noting  the  presence  or  absence  of  stu|)or, 
nau.sea,  coma,  slow  |)ulse,  or  othei  compression  symptoms. 

Symptoms. — A  brief  epitome  of  the  j)rincipal  features  attending  cases  of  brain  tumor 
will  include: 

1.  Pftiii  (tiid  lirndnrJir,  rarely  localized  with  much  accuracy;  the  former  .sometimes 
increa.sed  by  percussion  or  pressure,  occasionally  periodical  and  usually  intense.  The 
location  of  the  j)ain  .sometimes  corres])onds  with  that  of  the  tumor. 

2.  Vomiting,  usually  without  pain  or  nausea,  and  often  projectile.  I  have  repeatedly 
seen  obstinate  constijiation  in  brain-tumor  cas(>s  which  has  gone  almost  to  a  degree  of 
acute  obstruction,  and  which  has  caused  serious  error  in  diagnosis. 

3.  Vertigo,  inde))endent  of  indigestion  or  the  condition  of  the  stomach  or  bowels. 
It  is  most  frequent  in  cerebellar  tumors,  but  occurs  in  about  50  per  cent,  of  all  cases. 
It  is  som(>timcs  (juite  severe. 

4.  I\i/r  .sijiit})fo)iis  such  as  optic  n(>uritis,  choked  disk,  usually  double,  indicating 
pressure,  but  telling  little  or  nothing  as  to  the  location  of  the  tumor  causing  blindness. 
Ophthalmo|)legias  are  of  little  value  by  themselves  as  symptoms.  Hemianoj)sia, 
when  homonymous,  usually  indicates  a  lesion  of  the  cuneus  of  the  same  side,  the  blind 
half,  according  to  the  patient,  indicating  the  side. 

5.  Localizing  symptoms  which  may  be  due  to  the  destruction  of  brain  tissue  or  to 
indirect  pressure.  Those  of  im])ortance  comprise  paralysis  or  spasms,  indicating 
involvement  of  the  motor  area;  sensory  aj)hasia,  indicating  troul)le  in  Broca's  area, 
ataxia  or  staggering,  due  to  cerebellar  lesions;  loss  of  sense  of  position,  sometimes  seen  in 
lesions  of  the  i)arietal  regions;  anesthesia,  which  is  rare  uidess  the  internal  capsule  is 
involved.  Other  symptoms  are:  word-deafness,  which  indicates  a  lesion  of  the  j)ost(>rior 
part  of  the  first  temporal  convolution;  agraphia,  indicating  deep  lesions  under  Broca's 
speech  centre,  and  alexia,  usually  produced  by  lesions  of  the  lower  left  parietal  lobe. 
Tumors  in  the  .sen.sory  zone  affect,  vision  and  sjiecch,  and  reveal  themselves  by  irritative 
symptoms.  For  instance,  a  patient  with  verbal  deafness  and  marked  hemiplegia  prob- 
ably has  tumor  involving  the  left  superior  or  dor.sotemporal  gyrus,  which,  as  it  grows, 
would  involve  loss  of  muscle  sense  and  anesthesia  on  the  opposite  side  of  the  body.  A 
patient  with  headache,  vomiting,  choked  disk,  stu])or,  increasing  hemianesthesia,  lateral 
hemiano])sia,  without  spasm  or  hemiplegia,  |)robably  has  a  tumor  in  the  white  substance 
of  the  occipital  lobe.  If  hemianopsia  alone  be  present  then^  is  almost  always  a  tumor 
upon  the  inner  aspect  of  the  occipital  lobe,  on  the  side  opposite  to  the  dark  half-fields, 
which  by  downward  growth  may  cause  cerebellar  symptoms.  P.sychic  and  mental 
disturbances  are  present  in  many  cases,  but  not  in  all ;  most  frequently  in  frontal  lesions. 
They  are  met  with  in  about  one-third  of  the  cerebellar  tumors  and  two-thirds  of  the 
temporal  tumors;  they  assume  the  epileptic  type,  with  hallucination,  mania,  or  .sometimes 
convulsions  of  Jacksonian  tyjie,  the  latter,  of  course,  indicating  lesions  of  the  motor 
area. 

6.  Finally  there  are  frecjuent  const  it  utional  disturl)ances,  including  anomalies  of  thirst 
and  appetite,  and  disturbances  of  heart  and  respiration.  In  two  or  three  instances  the 
writer  has  seen  such  serious  obstruction  of  the  bowel  as  to  lead  to  mistake  in  diagnosis, 
the  obstruction  in  each  case  being  finally  fatal,  but  apparently  not  justifying  operation. 

The  above  s>Tnptoms  pertain  to  the  brain  tumors  in  general.  When  it  comes  to 
tumors  of  the  cerebellum  these  constitute,  in  a  measure,  a  cla.ss  by  them.selves.  Those 
which  are  operable  comprise  tumors  located  in  one  lateral  lobe,  or  invading  the  vermis 


584  SPECIAL  OR  REOIOXAL  SURGERY 

or  middle  lol)e,  or  those  found  at  the  jiinetion  |)oint  of  tlie  cerebelhim,  mefhilla,  and 
pons,  those  first  mentioned  Ix'int;  l)y  far  the  more  favorable  for  attack.  It  is  not  rela- 
tively diffieult  to  decide  u])on  the  ])resence  of  a  tumor  in  the  cerchellum,  but  to  minutelv 
lo<-ate  it  is  extremely  difficult.  In  addition  to  the  symptoms  aln-ady  rehearsed  above  the 
following  features  may  I)e  mentioned:  Headache  is  often  intense,  sometimes  agonizing. 
While  usually  referred  to  the  back  of  the  head  it  is  occasionally  frontal.  Nausea  and 
vomiting  are  generally  present,  at  least  for  a  time.  Sometimes  they  sul)side  to  recur 
later.  Optic  neuritis  and  choking  of  the  disk  occur  earlier  and  oftener  than  in  other 
tumors.  Blindness  sometimes  comes  on  promptly.  Vertigo,  as  in  other  brain  tumors, 
is  connnonly  due  to  irritation  of  those  branches  of  the  fifth  nerve  which  suj)plv  the  inner 
surface  of  the  dura,  this  irritation  being  reflected  to  the  bulbar  nuclei  of  the  fifth,  and 
thence  to  the  nuclei  of  the  {ineumogastric.  This  is  partly  true  of  those  growths  which 
are  in  relation  with  the  dura,  though  sometimes  it  is  true  of  tumors  which  make  pressure 
at  the  base  of  the  brain.  It  is  imj)ortant  to  distinguish,  if  possible,  between  mere  vertigo 
and  cerel)ellar  ataxia.  The  more  directly  focal  symptoms  are:  nystagmus,  which  may 
be  present  when  the  eyes  are  quiet  or  only  when  they  are  in  use;  paralysis,  when  the 
pyramidal  tracts  are  involved;  muscle  weakness,  seen  more  often  in  the  legs,  which  is 
nearly  always  a  cerebellar  s^-mptom;  and  sometimes  a  peculiar  posture  of  the  head, 
where  the  spinal  column  becomes  concaved  toward  the  affected  side,  the  face  looking 
almost  l)ackward.  Incoordination  is  a  common  indication;  in  about  four-fifths  of  the 
cases  patients  stagger  in  their  gait. 

To  determine  whether  a  given  tumor  is  an  irritative  or  destructive  lesion  special  study 
should  be  made  of  the  spastic  or  non-spastic  condition  of  the  limbs,  and  note  to  which 
side  the  eyes  are  turned.  Tonic  spasms  and  contractures  are  rare  in  cerebellar  tumors. 
A  tremor  of  the  head  and  upper  part  of  the  body  is  not  infrequent,  and  muscle  sense  is 
rarely  lost. 

Between  cerebellar  tumors  and  those  of  the  parietal  region  the  chief  diagnostic  points 
are  muscular  and  cutaneous  sensibility  in  the  former,  with  nystagmus  and  peculiar 
and  extreme  vertigo.  From  frontal  growths  they  may  sometimes  be  differentiated  by 
the  clearness  of  the  mental  processes  and  the  absence  of  those  symptoms  which  point 
especially  to  involvement  of  the  temporocortical  region,  e.  rj.,  aphasia.  In  cere- 
bellar tumors  convulsions,  one-sided  or  general,  are  not  infrec|uent,  and  incontinence  of 
urine  and  feces  is  often  noted.  The  convulsions  are  accompanied  l)y  subjective  sensa- 
tions and  noises,  vertigo,  and  by  sudden  blindness,  with  loss  of  consciousness,  while  such 
tonic  sjxasms  as  occur  are  generally  of  the  extensor  type,  and  last  from  one  to  ten 
minutes. 

Basal  tumors  of  the  cerebrum  produce  a  collection  of  s^Tnptoms  which  sometimes 
arc  significant.  Owing  to  their  location  they  involve  the  functions  of  several  of  the 
special  nerves.  In  tumors  in  the  anterior  fossa  there  is  involvement  of  the  optic,  the 
oculomotor,  and  the  first  branch  of  the  fifth.  In  tumors  of  the  pituitarij  bodi/  there  is 
invohement  of  the  optic,  the  chiasm,  the  oculomotor,  and  the  first  branch  of  the  fifth, 
as  well  as  the  abducens.  In  tumors  resting  on  the  middle  fossa  and  situated  above  the 
dura  the  oculomotor,  the  patheticus,  and  the  chiasm  are  involved.  If  situated  beneath 
the  dura  there  is  paralysis  of  the  three  ocular  nerves  and  also  the  fifth  nerve.  In  tumors 
of  the  posterior  fossa  there  is  involvement  of  the  facial,  the  trigeminus,  the  auditory, 
the  glossopharyngeal,  the  vagus,  th(>  accessorius,  and  the  abducens. 

Neurofibroina  of  the  Acoustic  Nerve,— Frankel  and  Hunt  have  recently  shown  that 
basal  tumors  spring  from  the  acoustic  nerve,  which  are  essentially  neitrofihromas.  They 
have  their  site  upon  the  nerve  at  the  point  where  it  merges  fnjm  the  junction  of  the  pons 
and  the  medulla  ;  in  other  words,  where  the  function  of  the  nerve  is  more  or  less  disturbed, 
and  the  patient  thereby  made  to  complain  of  deafness,  tinnitus,  and  vertigo.  They  slowly 
displace  surroimding  tissues.  They  vary  in  size  from  a  cherry  to  that  of  a  robin's  e^^:,, 
are  loosely  attached,  and  when  exposed  easily  enucleated.  Their  general  s^Tnj)toms 
are  those  common  to  all  brain  tumors,  but  focal  sMuptoms  may  include  ataxia,  paralyses 
(especially  of  the  fifth,  sixth,  and  seventh  nerves),  inequality  of  the  pupils,  and  loss  of 
coordinate  movements  of  the  eyes;  these  s^Tnptoms  are  in  addition  to  those  of  the  auditory 
already  mentioned. 

Access  to  these  tumors  is  a  serious  matter.  It  should  be  undertaken  in  two  stages: 
the  first  including  a  large  lateral  exposure,  with  or  without  an  osteoj^lastic  flap,  compris- 
ing the  lower  portion  of  the  squamous,  a  part  of  the  occipital,  and  perhaps  even  the 


IXTRACRAXIAL   TUMORR  5^5 

posterior  aspect  of  tlie  iiiasto'ul.      DraiiKi^^e  will  l)e  r((|iiir((l  for  a  lew  hours  as  in  other 
similar  operations. 

As  to  dcpih  and  iiiiiiihrr  tiie  former  may  only  he  learned  hy  stndviii<;  the  nature  and 
location  of  the  signal  syin|)tonis,  the  presence  and  order  of  appearance  of  the  same, 
pres(Mice  or  absence  of  headache,  and  local  chan<i-es  in  leni|)erafMre.  Tumors  occurring 
in  tuherculous  individuals  are  prohahly  multiple.  When  dill'ercnt  centres  or  systems 
are  involved  nniltiple  lesions  are  usually  present. 

It  has  been  lu>ld  that  the  three  cardinal  .symptoms  of  brain  tumor  are  opiic  nntritis, 
li((ul(trlir,  and  raiiufitK/;  and  while  each  of  these  is  sifrnificant,  and  all  of  them  are 
corroborative,  they  are  not  necessarily  |)resent  nor  does  their  absence  exclude  po.ssibility 
of  tunu)r.  Other  .ngufi  indicating  the  presence  of  tumor,  it  is  a  mistake  to  wait  for  the 
development  of  these  three.  The  most  distinctive  feature  of  intraeranial  neoplasms  is 
the  progressive  character  of  such  symptoms  as  are  present. 

There  is  but  one  form  of  brain  tumor  wliich  is  amenal)le  to  internal  treatment — 
namely,  st/pliilific  gumma;  and  in  case  of  doubt  it  may  be  justifialjle  to  keep  the  |)atient 
actively  under  the  infiuence  of  iodides  for  a  reasonable  Icufjlli  of  time.  This,  however, 
neetl  never  be  |)rolonged  beyond  si.\  weeks,  after  which  time,  should  no  improvement 
occur,  operation  should  not  be  delayecl. 

Operation.  Brain  tumors  are  operated  for  two  purposes:  First,  for  relief  of  pain 
and  other  distressing  symptoms  in  incurable  cases;  second,  for  radical  cure.  Operation 
is  justifial)le  in  any  case  when  pressure  symptoms  become  severe,  particularly  so  when 
pain  is  localized  to  a  reasonable  extent.  Choking  of  the  optic  disks  is  not  inirecjuently 
relieved  and  threatened  disability  postponed.  The  complete  operation  consists  in  the 
exposure  of  the  timior  and  in  its  removal. 

The  osteoplastic  method  should  be  used  in  exposing  the  tumor,  by  which  a  bone  flaj) 
is  raised,  along  with  the  overlying  scalp,  from  which  it  is  not  detached.  The  centre  of 
this  flap  is  supposeil  to  be  calculated  to  overlie  the  centre  of  the  tleep  lesion  which  it  is 
proposed  to  attack.  In  many  instances  the  operation  should  be  divided  into  two  dis- 
tinct procedures,  the  first  consisting  in  removal  of  the  bone  and  exposure  of  the  dura; 
this  exposure  should  be  ample,  including  the  whole  lateral  region  if  necessary,  as  Horsley 
has  showm;  the  second,  a  week  or  two  later,  comprising  the  balance  of  that  which  is  to 
be  done.  But  comparatively  little  shock  attends  removal  of  the  tumor  in  the  second 
stage  of  such  a  divided  operation.  After  removal  of  the  growth  its  cavity  is  best  packed 
with  a  gauze  tamj)on,  after  promj:)t  ligation  of  all  l)leeding  vessels  within  the  field  of  opera- 
tion, although  it  is  usually  required  merely  on  account  of  venous  oozing,  as  it  is  often 
])ossible  to  cut  to  the  depth  of  an  inch  in  the  brain  without  a  single  artery  sj)urting 
except  those  in  the  pia.  The  tampon  is  of  value  if  allowed  to  remain  for  forty-eight 
hours,  as  preventing  filling  of  the  cavity  with  clot  or  excessive  bleeding  during  the 
vomiting  Avhich  may  follow  the  administration  of  the  anesthetic.  The  vasoconstricting 
])roi)erties  of  adrenalin  may  prove  of  great  service  here;  it  should  be  used  in  the  standard 
1  to  1000  solution,  diluted  1  to  3.  I  have  no  hesitation  in  spraying  this  upon  the  brain 
or  in  saturating  tampons  with  it,  which  may  he  left  in  situ  so  long  as  necessary.  A 
number  of  the  old-fashioned  small  .serrefines,  properly  sterilized,  can  also  be  resorted 
to,  if  needed,  for  securing  vessels,  which  may  not  be  easily  tied.  They  can  be  left  in 
place  along  with  the  tampon  and  all  may  be  removed  together. 

Next  to  the  danger  from  hemorrhage  is  that  of  rapid  edema  of  the  brain,  which  may 
result  from  increased  tension  in  the  arteries  or  through  venous  stasis,  which  later  pro- 
duces lymph  stasis,  by  which  fluid  collection  in  the  tissues  is  still  further  facilitated. 
Another  reason  for  using  tampons  is  to  prevent  such  relaxation  of  veins  as  may  predis- 
pose to  this  edema.  In  most  respects  the  operations  for  removal  of  brain  tumors  differ 
slightly  from  tho.se  who.se  general  principles  are  elsewhere  mentioned  in  this  work.  I 
am  greatly  in  favor  of  using  secondary  sutures  (/.  e.,  those  tied  with  l)ow-knots),  which 
may  be  loosened  on  the  second  or  third  day,  permitting  the  raising  of  the  flap,  removal 
of  tampon,  etc.,  and  I  employ  them  largely  after  all  sorts  of  operations  upon  the  cranium. 
If  we  desire  to  prevent  any  attempt  at  union  of  wound  margins  we  may  employ  the 
green  silk  protective  introduced  by  Lister,  which  should  have  been  previously  carefully 
sterilized  by  boiling. 

The  operative  treatment  of  cerebellar  tumors  is  made  doubly  difficult  by  their  protected 
position  and  the  large  sinuses  with  which  this  part  of  the  brain  is  surrounded.  The  cavity 
is  restricted  in  size,  intradural  tension  is  greater  than  above  the  tentorium,  and  there  is 


58G  SPECLIL  OR  REGIONAL  SURGERY 

no  room  for  easy  displaconient  or  retraction  of  ])art.s.  The  occipital  bone  varies  much 
in  thickness  and  at  j^oints  is  somewliat  thin.  (Operation  which  is  begun  either  as  an 
exjiloration  or  with  a  fixed  pur])ose  nuiy  prove  palhative,  even  should  the  original  ))urpose 
fail  of  accomj)lishment,  as  relief  may  be  afforded  by  reducing  tension,  such  relief  con- 
sisting perhaps  in  freedom  from  headache,  vomiting,  and  vertigcx  Incision  should  extend 
from  the  tip  of  the  mastoid  process,  a  little  above  the  su})erior  curved  line,  to  beyond 
the  median  line,  with  a  vertical  median  incision  by  which  a  flap  sufficiently  large  may  be 
reflected  downward.  It  is  best  to  reflect  the  periosteum  with  the  other  soft  tissues  in 
order  to  expose  the  bone.  The  bone  shoukl  be  bitten  away  with  forceps  or  removed  with 
a  reliable  engine  as  rapidly  as  possible,  hemorrhage  being  controlled  with  Horsley's  wax. 

The  operation  may  be  divided  into  two  stages,  confining  the  first  stage  to  the  exposure 
of  the  cerebellar  surface,  or  the  operator  may  attempt  all  at  one  time. 

The  second  stage  consists  in  raising  a  dural  fiap,  l)y  which  the  cerebellar  surface 
is  exposed  for  inspection.  It  will  protrude  promjitly  through  the  opening,  so  that,  with 
the  finger,  it  may  be  po.ssible  to  detect  a  tumor  by  the  sense  of  touch.  If  no  tumor 
ap])ear  on  or  near  the  surface  deeper  exploration  should  be  made,  with  the  aid  of  a 
retractor  and  by  removal  of  a  portion  of  the  cerebellar  hemisphere.  This  may  require 
furtiier  exposure  of  the  lateral  region  of  the  skull.  Tumors  situated  deeply  or  at  the 
jiniction  of  the  cerebelhun  and  ])ons  require  all  the  room  that  can  l)e  afforded  from  the 
outside,  and  are  better  aj:)proac-lied  from  the  lateral  region  than  from  above  or  below. 
It  is  comforting  to  realize  what  considerable  portions  of  the  cerebelhun  can  be  removed 
without  serious  or  extensive  disturbance,  but  as  the  medulla  and  pons  are  approached 
there  is  need  of  great  care.  The  opening  may  be  extended  across  the  middle  line,  and 
either  the  lateral  or  the  longitudinal  sinus,  or  both,  may  be  doubly  ligated  and  divided. 
The  tentorium  may  also  be  divided  nearly  to  the  petrous  portion,  after  the  lateral  sinus 
has  been  thus  dvided,  and  so  better  access  given  to  the  deep  location. 

These  remarks  apply  especially  to  operations  for  tumors  of  the  cerebellum.  The 
other  features  of  such  operative  attack  are  those  common  to  brain  tumors  in  any  location. 

In  all  operations  for  l)rain  tumor,  but  particidarly  for  ceiebellar  tiunor,  it  will  prove 
of  the  greatest  advantage  to  have  the  operating  table  so  inclined  that  the  jiatient's  head 
will  l)e  three  or  four  feet  above  his  heels.  In  this  position  the  veins  are  drained  by 
gravity,  and  the  operation  is  complicated  by  l)ut  little  venous  oozing.  Crile's  pneumatic 
suit,  or  at  least  the  lower  part  of  it,  should  be  worn,  and  an  assistant  should  watch  and 
report  on  the  blood  pressure.  These  two  precautions  permit  such  an  operation  to  be 
conducted  with  an  ease  aufl  safety  hitherto  unknown.' 

Gushing,  dealing  especially  with  a  group  <jf  brain  tumors  in  which  radical  procedures 
are  im])ossible,  where  nevertheless  relief  from  symptoms  -would  jirove  a  therapeutic 
desideratum,  has  proposed  to  afi'ord  this  by  removal  of  a  ]M)rtion  of  their  bony  covering, 
in  order  to  allow  a  part  of  the  brain  to  protrude,  and  thus  provide  a  means  of  relief 
for  the  constantly  increasing  pressure.  The  incomplete  union  of  the  bones  in  infancy 
permits  sf)mething  of  this  kind  to  occur  through  natural  causes,  but  after  fusion  of 
the  elements  of  the  cranial  vault  it  is  no  longer  possible,  save  in  those  rare  cases  where 
an  opening  results  from  the  process  of  slow  pressure  absorption,  Avhich  comes  only  when 
the  tumor  is  in  actual  contact  with  the  bone. 

It  would  be  mechanically  ideal  if,  during  adult  life,  a  dislocation  of  cranial  sutures 
could  be  produced  similar  to  that  observed  in  very  small  children.  The  dangers  of 
such  operation  are  many,  among  them  being  the  po.ssible  injury  to  the  functions  of  that 
portion  of  the  cortex  which  protrudes  through  the  o]:>ening  thus  made,  by  which,  for 
example,  preexisting  paralysers  might  be  aggravated.  For  this  reason  it  is  preferable 
to  establish  the  hernia  over  some  "silent"  or  unimportant  ]:>art  of  the  cortex  and  to  avoid 
making  it  unnecessarily  large.  Gushing,  after  various  trials,  recommends  to  make  the 
bone  defect  under  the  temporal  muscle,  which  not  only  affords  a  certain  degree  of  pro- 
tection, Init  exposes  an  area  where  few  important  motor  centres  are  involved.  He  has 
reported  several  cases,  with  gratifying  results,  with  a  minimum  of  undesirable  sequels. 

Obviously  in  tumors  below  the  tentorium  the  opening  would  l^est  be  made  in  the  sub- 
occipital region.  Nevertheless,  Gushing  Ix-lieves  that  even  here  the  final  result  would 
be  no  more  effectual  than  were  the  defect  placed  elsewhere. 

Beck  has  called  attention  to  the  value  of  the  temporal  fascia  as  a  substitute  for  the 

»  New  York  xMedical  Journal.  February  11  and  18,  1905. 


PLATE  XLIV 


FIG.    1 


I'i.ssura  cuulralis.     (Kcjlaiido.) 


pitalU. 


Topographical  Anatomy  of  Cortex.      Localization  of  Functions.      ("Ziehen.) 


FIG.  2 


/  Piss,  occipitalis. 


Nerv.  oV^      Hypopli'ysi.s. 

Corpora  caudicantia. 
Apertura  canalis  centralis.' 

AntiTior  coliiinii  ol'  cord. 


Fissura  c. 


Posterior  column  of  cord. 
■Canalis  centralis. 


Topographical  Anatomy  of  Inner  Surface  of  Right  Hemisphere.      Localization 

of  Functions.      (Ziehen.) 


OPERATIONS  Vl'OS   THE  CRANIUM  fiS? 

otlicr  firm  covcriiiiiis,  by  wliicli  the  hraiii  should  In-  left  enclosed  alter  fxposiiri-,  and 
wln'ii  these  hitter  are  not  avaihihle.  For  the  purpose  he  would  fold  over  a  flap  made 
from  the  temporal  muscle  and  the  adjoining  periosteum  in  such  a  manner  that  fascia 
originally  external  sliouKl  now  be  ])laced  deeply  and  in  contact  with  the  cortex. 

OPERATIONS  UPON  THE  CRANIUM. 

The  //.s'.s'//;v  oj  Rolando  is  the  aiiatoMiical  landmark  whose  j)ositioii  it  is  important  to 
determine  with  reference  to  a  number  of  modern  surj^'ical  procedures,  for  around  it 
cluster  most  of  the  motor  ar(>as  or  centres.  It  commences  at  the  middle  line  about 
5()  j)er  cent,  of  the  distance  backward  from  the  glabella  (root  of  the  no.se)  to  the  ituon 
(occipital  ])rotul)erance),  and,  passing  downward  and  forward,  makes  with  the  middle  line 
an  angle  of  ()7  to  ()9  degrees.  For  most  purposes  it  begins  half  an  inch  back  of  a  })oint 
midway  between  the  glabella  and  inion.  It  may  be  easily  found  by  Cliinir'.s  tnrfliod, 
which  consists  in  folding  a  s(|nare  ])iccc  of  paper  diagonally  and  folding  this  again; 
after  which  it  is  thrcc-{|uartcrs  unfoldccl,  the  acute  angle  then  rej)resenting  (17'.  degrees. 
If  this  i)e  properly  ap|)lic<l  to  the  skull,  one  edge  of  its  surface  can  be  made  to  fall  directly 
over  the  Rolandic  fissure.  The  fissure  may  also  be  located  by  a  sinijilc  instrnmcnt 
known  as  the  cyrtometer — a  gauged  metal  striji  having  a  sliding  arm  uj)on  it,  which, 
when  the  long  stri])  is  ])laced  over  the  longitudinal  sinus  (?'.  c,  the  middle  line  of  the  skull), 
can  be  made  to  fall  directly  over  the  fi.ssure.  While  neither  of  these  methods  is  invariably 
and  minutely  exact,  either  of  them  is  sufficiently  accurate  for  all  practical  pin-poses. 

The  fissure  of  Sijlrius  may  be  incHcated  by  a  line  drawn  from  a  pcnnt  3  Cm.  Ijehind 
the  external  angular  jjrocess  to  a  point  2  Cm.  below  the  most  prominent  part  of  the 
parietal  eminence.  The  short  and  ascending  limb  of  this  fissure  is  of  relatively  small 
imjiortancc  in  this  connection. 

Rrifl's  hasr-linr,  so  called,  is  a  line  drawn  from  the  inferior  margin  of  tlie  orbit  back- 
ward through  the  centre  of  the  external  auditory  meatus.  It  is  a  line  often  alluded  to 
in  cranial  tojiography.  The  colored  plate  (see  Plate  XLIV)  will  indicate  with  reliable 
accuracy  the  relations  of  the  motor  centres  to  each  other  and  to  the  principal  fissures  and 
convolutions.  It  pertains  merely  to  the  left  hemisphere  of  the  brain,  in  whose  third 
frontal  convolution  is  [)laced  Broca's  centre  for  spc^ech,  the  corresponding  area  u])on  the 
right  side  having  no  exactly  corresponding  function.  The  centre  for  vision,  it  will  be 
seen,  is  located  in  the  cuneus,  the  most  basal  ])()rtions  of  the  hemispheres  l)eing  the  seat 
of  the  sj^ecial  senises  of  taste,  .smell,  and  hearing. 

Operation. — The  word  trephine  is  at  present  used  lioth  as  a  noun  and  as  a  verb, 
the  older  term  trepan  being  now  wellnigh  discarded.  The  instrument  consists  of  a 
section  of  a  tube,  one  of  whose  extremities  is  arranged  Avith  shar])ly  cut  saw  teeth,  the 
whole  provided  with  a  grip  or  handle,  which  revolves  in  a  plane  jDarallel  to  that  in  which 
the  saw  teeth  cut.  The  best  instrument  is  that  arranged  in  a  slightly  conical  manner, 
so  that  it  may  less  easily  burst  through  the  skull  and  do  harm  to  ])arts  within.  The 
trej)hine  })roper  is  manipulated  by  the  hand.  A  variety  of  substitutes  have  resulted 
from  applications  of  human  ingenuity  to  the  prol)lem  of  o])cning  the  cranial  bones. 
Some  of  these  are  operated  by  foot  or  hand  power,  with  reduplicated  mechanisms,  and 
others  by  electricity.  The  more  com])licated  the  mechanism  the  more  likely  it  is  to  get 
out  of  order,  and  there  are  but  few  of  these  substitutes  which  give  anything  like  lasting 
satisfaction. 

The  operation  of  trephining  is  made  to  include  any  method  by  which  an  opening  is 
made  in  the  uninjured  cranium  or  by  which  an  opening  already  existing  is  enlarged 
and  made  to  sul)serve  the  surgeon's  purpose.  Aside  from  the  saws  already  alluded  to, 
there  are  in  use  a  variety  of  cutting  bone  forceps,  rongeurs  of  various  device,  and  a 
variety  of  chisels,  which  are  to  be  used  in  connection  with  the  mallet  or  hammer.  In 
order  to  use  any  of  the  latter  instruments  to  advantage  the  first  attack  should  be  made 
with  a  trephine  of  rea.sonable  size,  say  2  to  3  Cm.  in  diameter,  after  which  forceps,  c-lii.sel, 
or  saAV  may  be  used.  Straight  saws  also  are  of  occasional  usefulness.  I  do  not  favor 
the  use  of  the  chisel  and  mallet,  feeling  that  the  concussions  resulting  from  blows  of  the 
hammer  add  to  the  shock  of  the  operation.  The  common  trephine  is  provided  with  a 
centre  pin,  which  can  be  withdrawn  after  a  shallow  groove  has  been  cut.  To  prevent 
slipj)ing  of  the  centre  pin  the  point  to  which  it  is  to  be  applied  should  be  marked  by 
cutting  a  nick  with  the  |)oint  of  a  chisel. 


588 


SPECIAL   OR  REGIOXAL   SURGERY 


The  Gigli  saiv  should  be  in  everv  surgeon's  (Uitfit.  It  consists  of  a  piece  of  steel  wire 
having  a  thread  cut  around  and  along  it  by  a  die,  by  ■which  it  is  made  as  effective  as  a 
series  of  saw  teeth.  Two  small  trephine  o[)enings  are  made,  and  it  is  then  passed  into 
one  and  out  of  the  other,  the  dura  jirotected  by  depressing  it,  and  the  wire  then  handled 
as  though  it  were  a  chain  saw.  It  can  thus  be  madv  to  cut  its  way  (luickly  through  the 
bones  of  the  skull. 

( )ther  aids  in  mechanical  procedures  are  revolving  small  saws  and  the  surgical  engine. 

In  tiie  absence  of  a  wound  a  flaj)  of  scalp  is  rai.sed  before  applying  the  instrument. 
This  flap  is  ordinarily  t)f  horseshoe  shaj>e,  and  should  be  made  with  its  convexity  pointing 
toward  the  occiput,  as  drainage  is  best  afforded  later  by  this  arrangement.  The  old 
crucial  incisions  are  now  wellnigh  abandoned.  The  pericranium  is  detached,  after 
incision,  with  the  periosteum  elevator,  and  it  should  be  turned  up  with  its  overlying 
scalp  without  comjiletely  separating  it.  The  scalp  flap  can  be  held  out  of  the  way  by 
temporarily  sewing  it  to  some  other  ])art  of  the  scalp,  every  portion  of  which  should  be 
previously  shaved  closely  and  thoroughly  scrubbed.  The  operator  has  his  choice — to  seize 
vessels  as  they  lileed  or  to  make  the  oj^eration  in  large  degree  bloodless  by  applying  an 
elastic  tourniciuet  tightly  around  the  scalp  al)ove  the  eyebrows  and  beneath  the  occiput, 
the  ears  preventing  it  from  sliding.     If  the  tourniquet  be  used  the  vessels  will  often  bleed 

Fig.  3S5 


The  Powell  ek-etric  saw  cutting  a  "trap-ilMnr"  in  the  skull,      f Illustrating  the  operation  upon  a  catlaver.) 


in  an  annoying  way  after  the  wound  is  closed.  If  the  operation  be  performed  for  fracture 
of  the  skull,  should  there  be  an  opening  already  made  by  the  depression  of  fragments, 
it  may  not  be  necessary  to  use  the  trej^hine,  but  with  suitable  bone  forceps  fragments 
may  be  removed  or  detached.  In  this  case,  however,  there  are  often  sharp  points  of 
bone  which  will  require  removal  by  cutting  bone  forceps,  for  the  surgeon  should  leave 
the  margin  of  the  bone  opening  comfortably  round  and  smooth.  Should  there  be  no 
opening  into  which  the  point  of  an  elevator  or  of  bone  forceps  can  be  inserted,  then 
one  should  be  made ;  it  is  for  this  purpose  that  the  tre])hine  is  mainly  used  in  cases  of 
fracture  of  the  skull.  It  should  now  be  applied  upon  a  firm  and  undetached  surface  of 
bone,  one  which  will  bear  the  pressure  necessary  in  the  process  of  perforation.  As  used 
for  this  purpose  it  should  be  so  applied  that  at  least  two-thirds  of  the  circle  cut  by  its 
teeth  will  be  upon  unbroken  skull ;  the  remaining  segment  of  the  circle  may  be  over  the 
fractured  area.  After  it  has  begun  to  cut  a  distinct  groove  the  centre  pin  should  be  with- 
drawn and  the  instrument  maintained  in  its  position  during  its  work  by  a  firm  and  steady 
hand,  which  will  force  it  evenly  through  the  bone  and  not  exercise  undue  pressure. 
As  the  diploe  is  jierf orated  the  bone-dust  becomes  soft  and  bloody  and  the  resistance  is 
diminished.  As  the  instrument  sinks  deejDer  the  ojx'rator  should  frequently  intermit 
its  use,  and  determine  his  position  by  means  of  the  irrigator  and  of  the  })robe  or  other 


()i'i:ii.\Ti().\s  ri'os  Tin:  cuamim 


589 


instrunnMit.  Tho  nearer  the  inner  surface  is  ajjproaclied  the  nK)re  eantion  must  Ix'  exer- 
cised, reinemherini;  that  the  l)<)ne  is  hkely  to  he  of  nne(|ual  thickness.  When  the  skull 
has  been  completely  perforated  at  one  or  two  ])oints  aroun<l  the  little  circle  the  o|M'rator 
should  introduce  the  j)oint  of  an  elevator  and  prv  up  the  disk  of  hone,  or  hv  rockini;  the 
handle  of  the  trephine  he  may  he  ahle  to  remove  the  hutton  with  that  instrument.  \\'hcn 
the  operation  is  performed  in  the  ideal  maimer  the  dura  is  scarcely  touched,  certainK- 
not  rafii^edly  injured  by  the  teeth  of  the  instrument  (Fifijs.  3S(),  387  and  .^SS). 

Before  o|HMnn<j  the  dura  every  loo.se  particle  of  bone  and  every  .sj)linter  should  be 
removed,  (lepres.s<>d  fra<];mcnts  should  be  j)icked  out,  and  those  which  are  .semidetached 
should  be  raised  to  their  jiroper  level.  Through  the  openinf^  thus  made  the  dura  is 
carefully  examined;  extradural  collections  of  Ijlood  are  reco<i;nized  instantly,  while  some 
itlea  as  to  the  amount  of  intracranial  tension  may  l)e  secured,  even  throufjjh  a  small 
o|XMun<i;.  .Vbsence  of  ])ulsati()n  means  probably  the  presence  of  cyst,  tumor,  or  abscess 
dee])er.  Edema  of  the  mcmbran(\s  usually  subsides  after  nicking  or  opening  them. 
A  yellowish  discoloration  of  the  dura  often  indicates  the  existence  of  a  tumor  beneath. 
Nothing  abnormal  being  discovered  outside  of  the  dura,  should  brain  tension  be  great 


Fig.  386 


Fig.  387 


Construction  of  an  osteoplastic  flap;  bone  is  exposed; 
first  openings  are  made  with  a  hand  trephine  or  burr. 
(Marion.) 


Division  of  bone  by  use  of  hammer  and  chisel. 
(Marion.) 


or  should  the  dura  be  discolored,  as  by  blood  beneath,  the  membrane  should  be  oj)ened, 
by  a  triangular  or  horseshoe  flaji,  and  the  subdural  condition  accurately  estimated. 
In  some  cases  of  meningeal  hemorrhage  clots  will  be  ejected  with  some  force  the 
instant  the  dura  is  opened.  In  other  cases  of  intracranial  pressure,  either  from  tumt)r 
or  from  intraventricular  hemorrhage,  the  brain  will  instantly  jirotrude  to  such  an  ext(Mit 
as  to  make  its  reposition  difficult  or  even  impo-ssible.  Horsley's  dural  .separator  is 
exceedingly  useful,  both  outside  and  inside  the  dura,  for  detecting  and  separating 
adhesions,  and  as  a  retractor. 

Incisions  in  the  dura  should  be  made,  so  far  as  possible,  parallel  with  its  vessels  rather 
than  across  them.  When  accessible,  dural  vessels  can  always  be  secured  and  tied. 
Vessels  of  the  pia  can  also  be  picked  up  and  secured  with  fine  catgut  ligatures.  When 
the  brain  tissue  itself  is  diseased  it  should  l)e  carefidly  excised.  The  cortex  itself  is  not 
so  vascular  as  to  afford  much  trouble.  Upon  any  |)ortion  of  the  membranes  or  cerebral 
.surface  a  sterilized  solution  of  adrenalin  can  be  sprayed  or  ai)i)licd  without  hesitation. 
In  all  deliberate  operations  sinuses  are  avoided.  When  exposed  or  when  necessary  to 
attack  them  they  may  be  ligated  and  divided,  or  may  be  packed  with  tampons  of  sterilized 


590 


SPECIAL  OR  REGIOXAL  SURGERY 


gauze,  or  may  be  seized  with  serrefiiies  or  liglit  henio.statie  foreeps,  which  may  he  left 
for  a  day  or  two  ineluded  within  the  dressings. 

Any  of  the  exposed  motor  areas  or  centres  can  l)e  stiiinilated,  wlien  desired,  if  the 
j)atient  be  not  too  dee|)ly  anesthetized,  by  the  faraiHc  current  of  mild  degree,  a])plied  to 
surfaces  which  have  not  been  l)athed  with  antiseptics,  nor  long  exposed  to  the  vaj)or  of 
the  anesthetic,  through  a  douI)le  brain  electrode  made  for  the  pur|)ose,  or  by  sterilized 
probes   connected   with   the   battery. 

Buttons  of  bone  or  chips  (jf  the  skull  may  be  replaced  after  suture  of  the  dura,  when 
desired,  though  this  is  seldom  ailvisable.  When  fragments  are  thus  to  be  replaced 
they  slK)uld  be  placed  in  warm  sterile  salt  solution  at  once  after  removal,  and  kept  warm. 
When  a  button  is  thus  put  l)ack  the  j)eriosteum  may  be  sewed  over  it  with  Ijuried  catgut 
sutures. 

The  dura  should  l)e  stitched  with  fine  catgut  as  closely  as  possil)le.  I  have  often 
placed  beneath  the  dural  o])eiiing  a  piece  of  gold,  silver,  or  aluminum-foil,  carefully 
sterilized,  with  a  view  to  preventing  (lense  adhesions  between  the  dura  and  the  mem- 
brane or  cortex  beneath.     I  have  never  known  it  to  do  hami. 


Fig.  388 


Fig.  389 


Exposure  of  cortex  or  of  cerebellum  after  division 
of  dura.      (Marion.) 


Osteoplastic  resection  after  Wagner. 
(Chipault.) 


Drains  and  drainage  are  to  be  avoided  when  possible,  and  should  be  removed  early, 
except  in  cases  of  abscess.  They  may  lie  made  of  catgut,  horse-hair,  gauze,  rubber,  or 
even  of  glass,  like  those  short  ones  which  Kocher  inserts  after  extensive  operations, 
their  outer  ends  flanged  to  prevent  their  slijiping  l)eyond  control. 

Opcniiuj  fhe  skull,  or,  in  general  terms,  trephining,  is  at  present  resorted  to  for  the 
folio irnn/  purposes: 

1.  For  relief  of  com pression — 

(a)  By  depressed  bone,  as  in  comminuted  or  gunshot  fracture; 

(b)  By  removal  of  clot  or  ligation  of  vessels; 

(r)  By  evacuation  of  pus,  either  from  the  meningeal  cavity  or  from  a  deeper 

abscess ; 
{(I)  By  the  removal  of  serous  eflfusions,  either  extra  ventricular  or  intraventricular. 

2.  For  removal  of  foreign  bodies. 

3.  For  relief  of  ititracranial  irritation — e.  g.,  epilepsy,  the  psychoses,  etc. 

4.  For  removal  of  tumors. 

5.  To  compensate  for  defective  development. 

G.  For  exploratory  or  purely  empirical  reasons,  including  the  making  of  "relief 
openings"  for  relief  of  pain,  etc. 

Aside  from  the  ordinary  methods  of  trephining  as  applied  for  common  conditions, 
modern  surgery  comprises  the  resort  to  essentially  new  methods  for  raising  areas  of  skull 
of  considerable  size  and  then  restoring  them  to  their  previous  jiosition.  These  are  ordin- 
arily spoken  of  as  osteoplastic  resections,  and  have  added  very  materially  to  the  art  and 
resources  of  the  surgeon.     These  consist,  in  a  general  way,  of  the  formation  of  a  window, 


OI'Kh'ATloXS    Ul'<)\    Till:'   Ch'.WIIM  591 

as  it  were,  In  llic  xcrtcx  or  lateral  rcy'ioii  of  tiic  skull  \i\  ((iillinin^f  a  <|iia<lraii;^ular  or  liorsc- 
slioc  (lap  ot"  scal|),  wliicli  is  (Iclaclicti  only  for  a  slight  dislaiicc  around  tlir  incision, 
alter  which,  hy  use  of  the  revolvinif  saw  or  by  chisel  and  mallet,  a  <jroove  is  cut  throuj^li 
the  l)()ne  runninfj;  parallel  with  the  niar<^in  of  the  scalp-Hap,  hut  |)erhap.s  a  centimeter 
within  it.  Alter  this  hone  area  is  completely  eut  through  on  three  sides  it  is  then  sprung 
up  or  elevated  in  such  a  way  as  to  be  broken  across  the  base  ot"  the  bone-dap.  It  is  not 
at  all  detached  nor  sc|)arated  from  the  scalj),  and  so  when  subse(|uently  lowered  into 
|)()sition  retains  its  vitality  by  virtue  of  its  vascular  comiections. 

\\  hen  some  |)articular  measure  seems  indicated  in  order  to  atone  for  a  larjfe  defect 
in  bone  it  has  become  (juite  custoniary  to  itisert  some  artijicial  .substitute,  mairdy  cither 
(rlhiloid  or  a  thin  aluminum  |)latc,  prcxiously  absolutely  sterilized  and  cut  at  the  time 
into  such  sha|)e  as  may  be  called  for,  but  a  trifle  larijer  than  the  real  defect,  beinjf  let  in 
or  sprung  in,  as  it  were,  either  completely  beneath  the  bone  or  into  the  bony  o]«'iiing, 
so  as  not  to  be  easily  detached  or  slip  out  of  the  way.  By  this  Itcteropla.siic  method 
most  admirable  results  have  been  achieved.  I  have  used  celluloid  for  this  purj)ose  in 
the  sj>inal  cohnnn  also,  closing  with  it  the  defect  which  remained  after  the  extirpation 
of  the  sac  of  a  spina  bifida.  It  is  rarely  nrcrs.sari/  to  resort  to  this  practice  in  the  skull, 
as  dense  fibrous  tissue  in  (hw  time  finnly  jn'otects  tlie  endocranial  contents  from  external 
harm  (Figs.  oSb,  ;i<S7,  088  and  389). 


CHAPTER  XXXVII. 

THE  ORBIT  AND  ITS  ADNEXA;  THE  EXTERNAL  AUDITORY  APPARATUS; 

THE  ACCESSORY  SINUSES;  THE  CRANIAL  AND  CERVICAL 

NERVES;  THE  ORBITAL  CONTENTS  AND  ADNEXA. 

INJURIES  OF  THE  ORBIT. 

lufra-orhifal  hemorrhage  is  not  uncommon  after  injuries  to  the  head.  It  may  result 
from  ru])ture  of  orl)ital  vessels  proper  or  by  escape  of  blood  from  Avithin  the  cranium, 
either  outside  or  beneath  the  dural  prolongation  which  constitutes  the  sheath  of  the  optic 
nerve.  When  extensive  it  may  produce  a  pulsating  tumor,  and  this  may,  in  time,  become 
practically  a  traumatic  aneurysm.  After  basal  fractures  blood  frequently  will  escape 
forward  so  as  to  appear  beneath  the  conjunctiva.  Collections  of  blood  in  the  orbit  may 
also  interfere  with  the  return  circulation  in  such  a  way  as  to  lead  to  extensive  chemosis 
of  the  conjunctiva  or  edema  of  the  lids  and  orbital  contents.  Pressure  may  cause 
temporary  disturbance  of  vision.  Should  there  be  absolute  blindness  it  may  be  inferred 
that  there  has  been  injury  to  some  part  of  the  optic  tract.  Protrusion  of  the  globe  is 
an  indication  of  the  degree  and  amount  of  extra-ocular  hemorrhage,  which  may  be 
verv  pronounced.  "When  visual  symptoms  are  bilateral,  while  external  evidences  are 
confined  to  one  orbital  region,  it  may  be  assumed  that  there  has  been  intracranial  dis- 
turbance as  well,  with  laceration  along  the  optic  tract.  Such  immediate  damage  will 
in  time  be  followed  by  the  ordinary  s}Tnptoms  of  neuro retinitis  and  atrophy. 

The  more  external  the  injury  the  more  cjuickly  Avill  it  yield  to  ice-cold  applications. 
There  are  times  when  incisions  for  relief  of  tension  may  be  desirable.  An  extensive 
clot  in  the  orbit  which  seriously  displaces  the  eyeball,  and  which  does  not  quickly  absorb, 
should  be  evacuated  by  an  incision,  either  directly  through  the  lid  or  beneath  the  lid 
and  outside  of  the  globe. 

Penetrating  injuries,  like  gunshot  wounds,  are  usually  easy  of  recognition.  If  vision 
be  instantly  and  completely  lost  the  harm  done  to  the  o]:)tic  nerve  or  the  globe  will  j)rob- 
ably  prove  irre])aral)le.  Foreign  bodies  penetrate  from  various  directions,  and  sometimes 
to  such  a  depth  that  they  are  difficult  to  find.  I  have  seen  a  large  chip  of  wood  com- 
pletelv  lf)st  within  the  orbit,  and  such  bodies  may  enter  either  from  outside  or  from  within 
the  nasal  cavities.  A  foreign  body  will  nearly  always  limit  the  motility  of  the  globe  and 
usually  disjjlace  it.  If  its  presence  can  be  ascertained  or  revealed  before  operation  it 
should  be  sought  and  removed  at  the  expense  of  almost  any  and  every  other  indication. 
If  its  presence  be  suspected  it  may  be  sought  for,  even  though  a  skiagram  fail  to  reveal 
it.  When  the  usefulness  of  the  eye  is  destroyed  it  will  be  advisable  in  such  case  to 
remove  it  in  the  progress  of  this  search. 

Aside  from  the  traumatic  hematomas  above  mentioned  extravasation  occurs,  due  to 
constitutional  or  vascular  disease,  as  atheroma,  especially  when  coupled  with  violent 
straining  efforts.  Subconjunctival  effusion  and  exophthalmos,  with  limitation  of 
motion,  will  be  unfailing  expressions  of  such  damage.  Orbital  aneurysms,  sponta- 
neous or  tramnatic,  are  occasionally  seen.  They  will  cause  a  more  or  less  pulsating 
exo])hthalmos,  while,  in  some  instances,  a  bruit  may  be  detected  with  the  stethoscope. 
Cases  may  be  imagined  where  it  would  be  suitable  to  cut  away  the  external  wall  of  the 
orbit  and  expose  such  a  tumor.  Ordinarily,  however,  ligature  of  the  internal  or  common 
carotid  will  be  required.  Angiomas  occur  also  in  the  orbit,  producing  exojihthalmos, 
usually  without  pidsation.  Such  tumors  will  prove  com])ressil)le  and  the  globe  may  be 
gently  pressed  backward  into  the  orbit  to  immediately  ])rotrude  again  when  pressure 
is  removed.  These  lesions  will  prove  very  difficult,  usually  impossible  of  treatment, 
and  no  general  rule  can  be  made  therefor. 

Orbital  cellulitis,  i.  e.,  infection  of  the  cellular  and  other  tissues  in  the  orbit,  may  occur, 
either  from  without  or  from  within,  but  usually  in  connection  with  some  traumatism, 
(592) 


TCMOh'S  (>!•'   Till':  oh'IIIT  5f);j 

Somrliiiit's  lliis  involves  (irst  llic  conira  or  (lie  .stnidiircs  of  llic  }f|ol)c;iit  other  times 
infection  is  l>y  a  more  direct  method,  thronj^h  the  conjnnctival  sjic  or  the  orl)ital  coverings. 
It  varies  in  intensity  between  extreme  hmits.  It  may  even  he  bilateral.  While  cjises 
occasionally  nndert^o  resolntion  it  usnaily  tenniriatcs  by  formation  of  alwcess.  It  is  met 
with  in  the  infi'ctions  fevers,  in  facial  erysipelas,  by  extension  npward  of  infection  from 
tliseased  teeth,  after  primary  infection  of  the  ethmoidal  or  sphenoidal  sinuses,  or  by 
extension  from  external  phle<fmons.  There  will  be  edema  of  the  lids,  usually  with 
chemosis,  fixation  and  protrusion  of  the  eyeball,  conimonly  with  diverfi;enc(\  In  pro|)or- 
tion  to  the  severity  of  the  lesion  there  will  be  present  septic  symptoms,  with  deep-seated 
pain  and  headache.  X'ision  is  disturbed  in  j)roportion  to  the  j)ressure  upon  the  nerve 
and  <flobe,  as  well  as  the  involvement  of  the  ocular  structures  proper.  When  the  disease 
is  be<,nni  within  the  eye  it  will  usually  terminate  by  a  cond)ination  of  |)anophthalmitis 
with  ()rl)ilal  abscess. 

Treatment,  'Vhv  a|)plication  of  the  compound  ichthyol  or  Crede's  silver  ointment, 
with  ice,  preceded  pcrliaps  by  the  use  of  leeches,  will  be  suitable  local  treatment  unless 
the  presente  of  pus  bi'  ilistinctly  made  out  or  until  tension  threaten  serious  harm.  In 
either  of  these  events,  however,  free  incisions  are  re(juired  at  |)oints  of  greatest  tension, 
the  knife  beinif  so  directed  as  to  avoid  the  <jlobe.  'i'hese  incisions  should  be  free  aiul 
sutficiently  dee|).  Should  there  be  accom])anyin<j  j)an()phthalmitis  the  eyeball  itself 
should  be  freely  incised  through  its  anterior  aspect  and  its  contents  completely  evacu- 
ated. Such  onptying  of  the  contents  of  the  sclerotic  is  called  rvuccratlon  of  the  globe. 
While  theoretically  indicated,  experience  has  shown  that  it  is  a  disastrous  practice  to 
enucleate  the  eye  at  such  a  time;  evisceration  first  and  enucleation  later,  should  it  j)rove 
desirable. 

TUMORS  OF  THE  ORBIT. 

The  orbit  is  the  site  of  many  primary  tumors  which  originate  within  its  proper  tissues 
as  well  as  those  which  encroach  upon  it  from  neighboring  cavities  or  from  the  face. 
Prognosis  is  better  in  the  former  than  in  the  latter,  but  unfavorable  in  all  malignant  cases. 

()f  the  primary  cystic  tumors  there  may  be  nearly  all  the  known  varieties,  including 
those  of  parasitic  origin.  The  pseudocysts  of  the  cranial  cavity  sometimes  project 
into  the  orbit,  forming  orbital  encepholacele.  Dermoid  cysts  are  not  at  all  uncommon. 
Around  the  l)urs{e  of  the  orbital  muscles  exudation  cysts  occur,  while  the  retention  cysts, 
including  the  cholesteatomas,  are  not  infretjuent.  The  true  dermoid  cysts  may  contain 
all  the  ordinary  epithelial  products,  just  as  in  any  other  part  of  the  body.  Parasitic 
cysts  include  the  echinococcus  and  the  eysticercus,  the  latter  being  rare,  while  the  former 
may  extend  into  the  frontal  sinus  or  cranial  cavity.  It  produces  almost  constant  ciliary 
neuralgia.  Vascular  tumors  of  all  types  are  found  in  the  orbit  and  the  various  expressions 
of  telangiectasia  of  the  litis  and  orbit  are  often  seen.  These  are  always  of  congenital 
origin.  Of  the  more  simple  tyjjes  of  mesoblastic  tumors  tlie  osteomas  are  perhaps  as 
conunon  as  any.  These  assume  all  the  tyj)es  described  in  the  chapter  on  Tumors,  and 
are  of  all  degrees  of  hardness.  Sarcoma  and  osteosarcoma,  originating  within  the 
orbit,  are  unfortunately  too  common.  Naturally  they  spread  to  and  involve  all  the 
adjoining  structures.  True  e7idothelioma  is  rarely  recognized  as  such  until  after  removal 
and  microscopic  examination.  Epithelioma  commencing  upon  the  surface  of  the  eye, 
or  about  the  skin  and  spreading  inward,  is  also  quite  common. 

Exophthalmos  is  an  expression  of  intra-orbital  tension  common  to  all  forms,  while  by 
the  extent  of  |)rotrusion  and  its  direction  the  site  of  the  tumor  may  to  some  extent  be 
determined.  ( )ther  disturl)ances  of  position,  with  limitation  of  motion  and  c{)nse(iuent 
dijMopia,  are  further  exj)ressions  of  pressure  and  dislocation.  Ptosis,  or  dnK)ping  of  the 
upper  lid,  is  a  feature  of  tumors  which  proceed  from  the  upper  |)art  of  the  orbit.  The 
vascular  tumors,  as  already  mentioned,  produce  more  or  less  j)ulsation.  Ocular  tension 
is  usually  increased,  and  when  circulation  and  enervation  have  been  seriously  affec-ted 
necrosis  and  even  perforation  of  the  cornea  may  occur.  Pain  is  a  variable  feature,  but 
is  sometimes  pronounced.  An  exploring  needle  may  be  passed  into  a  tumor  which 
seems  to  be  cystic,  but  it  should  be  done  with  ever\'  precaution,  both  against  infection  and 
injury  to  the  eye. 

Tumors  of  the  optic  nerve  proper  originate  more  often  in  its  sheath  than  in  its  true  neural 
tissue.  They  may  occur  at  any  point,  but  usuallv  within  the  orbit.  These  tumors 
38 


594  SPECIAL  OR  RECnoXAL   SfRGERY 

are  usually  of  the  sarcomatous,  ^lioniatous,  or  eiidotliclioiuatous  type.  Cystic  changes 
are  not  int're({uent ;  they  occur  usually  in  the  yovuij;.  AH  of  these  tumors  will  involve 
the  optic  nerve  in  such  a  way  as  to  produce  signs  easily  recognizable  with  the  ophthalmo- 
scope, such  as  optic  neuritis  and  nerve  atrophy.  Moreover,  they  afi'ect  or  com])letely 
destroy  vision.  They  are  not  so  painful  as  most  of  the  other  intra-orhital  tuuKjrs,  and, 
while  causing  a  direct  forward  j)rotrusion  of  the  eye,  affect  its  motility  less  than  other 
forms.  Nevertheless  they  grow  with  great  rapidity  and  evince  destructive  tendencies. 
In  theory  the  treatment  for  all  tvmiors  of  the  orbit  is  complete  extirpation,  while  the 
malignant  tumors  reciuire  emj:)tying  of  the  orbital  contents.  Benign  tumors  and  cysts 
are  usually  successfully  treated  by  this  method.  ( )f  most  malignant  tumors  it  may  be  said 
that  the  j)rognosis  is  unfavorable.  I'he  lymjjliatic  and  vascular  connections  are  so  free, 
and  extension  into  surroiuiding  cavities  so  ea.sy,  that  recurrence  takes  ])lace  in  the  larger 
j)roportion  of  cases.  Too  often  l)y  the  time  a  patient  is  willing  to  sacrifice  the  eye  and  the 
orbital  contents  it  is  too  late  to  effect  a  radical  cure. 


EXOPHTHALMOS. 

The  term  r.rnphthalmos  simj)ly  implies  protrusion  of  the  eyeball  beneath  and  even 
between  the  lids.  Usually  it  is  in  a  downward  and  outward  direction.  In  some  cases  the 
disj)lacement  is  accompanied  by  an  easily  recognizable  jnilsation,  and  occasionally  by  a 
bruit  or  audible  sound.  The  latter  instances  are  spoken  of  as  ])ulsating  exophthalmos. 
They  are  connected  in  most  cases  with  vascular  tumors  or  intra-orbital  aneurysms, 
although  sometimes  the  aneurysm  may  be  primarily  intracranial.  For  instance,  arterio- 
venous aneurysms,  by  communication  of  the  internal  carotid  artery  with  the  cavernous 
sinus,  will  produce  pulsating  exophthalmos.  Whatever  be  its  cause  exophthalmos 
is  an  expression  of  pressure  from  behind.  This  is  true  even  of  the  ocular  symptoms 
accompanying  Graves'  disease  or  exophthalmic  goitre,  only  here  the  protrusion  is 
permitted  by  general  fulness  of  the  vessels  and  undue  vascularity  of  the  orl)ital  tissues. 

In  proportion  to  the  amount  of  projection  there  will  be  swelling  and  edema  of  the 
upjier  lid,  the  skin  being  more  or  less  shiny  and  the  veins  distended.  In  extreme  cases 
the  lids  are  everted  and  the  conjunctiva  extremely  chemotic,  while  Ijy  exposure  of  the 
cornea  it  becomes  vascular,  infected,  and  often  necrotic.  Should  it  be  possible  to 
replace  the  globe  by  pressure  it  will  protrude  so  soon  as  pressure  is  removed.  In  vascu- 
lar cases  a  bruit  may  be  heard  and  pulsation  detected  with  the  finger.  Audible  sounds 
are  lost  by  making  firm  compression  on  the  common  carotid  of  the  same  side,  and  return 
instantly  when  this  pressure  is  removed.  By  the  ophthalmoscope  both  arterial  and  even 
venous  pulsation  may  be  |:)erceived  at  the  fimdus.  Vision  is  only  slightly  aftecied  by  a 
well-marked  protrusion,  especially  when  the  latter  has  occurred  slowly.  The  pulsating 
forms  will  frequently  give  subjective  sym])toms  of  soimd  and  sense,  e.  g.,  vertigo. 

A  history  of  injury,  coui^led  with  external  evidences,  may  give  a  clue  to  some  of  these 
cases  as  an  indication  of  traumatic  aneurysm  or  communicating  vascular  tumor.  Soft 
and  vascular  tumors,  without  history  of  injury,  are  usually  malignant,  this  being  true 
also  of  multiple  growths. 

Treatment. — The  treatment  of  exophthalmos  should  depend  entirely  on  its 
nature.  ^YIlen  due  to  arteriovenous  aneurysms,  or  to  the  consequences  of  injury  alone, 
a  ligation  of  the  common  or  of  the  internal  carotid  will  give  the  best  result.  When  com- 
pression of  the  carotid  gives  temporary  relief  to  at  least  some  of  the  features  of  the  case  its 
permanent  ligation  is  indicated.  Bilateral  exophthalmos  implies  a  more  serious  con- 
dition, especially  in  CJraves'  disease.  When  thyroid  symptoms  are  prominent  a 
thyroidectomy  is  indicated.  When  the  thyroid  participates  but  slightly  such  a  case  may 
be  treated  by  excision  of  the  cervical  s^onpathetic  on  both  sides. 


INTRA-OCULAR  TUMORS. 

The.se  tumors  may  assume  most  of  the  known  ty])es  and  may  spring  from  practically 
all  f)f  the  ti.ssues  of  the  eye. 

From  the  iri.s  there  may  develop  r/y.v/.s  of  traumatic  or  even  of  congenital  origin.  In 
the  former  such  a  foreign  body  as  an  eyelash  may  be  found,  having  entered  through  an 


sYMiwTiiirric  oi'iiriiALMiris  595 

txlcnial  wound  of  (lie  coriua.  \'a.s(iilar  (iiiiiors  an-  occasionally  met  with,  many  of 
which  arc  fnll  of  piffnicnt,  while  melanomas,  with  a  mininmin  of  vsiscular  strnctnrc,  are 
also  observed.  The  actively  malijinaiit  tnmors  of  the  iris  nsually  assume  the  sarcoma- 
tous or  endodieliomatous  type,  and  when  melanotic  assume  an  e.\c(-cdinfjlv  rapid  and 
serious  |)hase  and  course.  In  the  iris,  also,  tul)crcuIous  or  syphilitic  ifraiiulomas  an; 
occasionally  encountered. 

In  the  rhoroid  are  seen  expressions  of  tuberculosis,  cspeciallly  th(;  more  acute,  as  a 
complication  of  tuberculous  meninifitis.  The  most  common  malignant  tumor  here  is 
sarcoma  of  the  melanotic  variety.  Of  the  rrliua,  <r|ioma  is  the  mo.st  common  as  well 
as  the  most  mali<;nant  tumor,  occurrinfj;  usually  in  the  youn^.  All  of  these  tumors  when 
malifjnant  spread  from  their  primary  site  to  the  adjoiniiif];  ti.ssues.  When  extremely 
malijinant  they  kill  too  (piickly  to  show  many  metastatic  expressions.  At  other  times 
they  will  appear  in  other  parts  of  the  body. 

All  intra-ocular  tumors  tend  to  imj)air,  and  the  maliffiiant  to  (|uickly  destrov  vision. 
Tension  is  increased  and  the  natural  contour  of  the  <jlobc  may  be  lost.  Fixation  to 
and  involvement  of  the  surrounding;  orbital  tissues  depend  in  some  measure  on  the 
ra|)i(lity  of  (growth  and  its  location.      I'hey  occur  sooner  or  later  in  malij:;nant  cases. 

A  mali<;nant  (j^rowth  of  any  j)art  of  tlu-  ^lobe  calls  for  enucleation  of  the  eye,  as  well 
as  removal  of  the  orl)ital  contents.  When  the  orbital  tissues  are  thus  involved  it  is  too 
late  to  secure  more  than  temf)orary  benefit.  If  the  eyelids  are  involved  they  should 
also  be  sacrificed  and  the  orbital  opening  covered  by  some  plastic  procedure. 

PANOPHTHALMITIS. 

The  term  panophthalmitis  implies  a  phlegmonous  proc-ess  involving  the  entire  contents 
of  the  sclerotic,  by  which  the  eye  is  destroyed.  It  is  usually  traumatic  in  origin,  but 
may  occur  as  an  extension  of  infection  from  ulcer  and  abscess  of  the  cornea,  or  from 
thrombotic  or  metastatic  processes.  Its  course  is  usually  rapidly  destructive,  while  it 
is  accompanied  by  more  or  less  orbital  cellulitis.  These  signs,  therefore,  are  not  con- 
fined to  the  orbit  proper,  for  the  lids  become  edematous,  the  conjunctiva  chemotic,  and 
there  is  more  or  less  jiurulent  discharge  from  the  entire  conjunctival  sac,  which  will 
esca[)e  beneath  the  lids.  If  the  cornea  is  at  first  clear  it  rapidly  becomes  cloudy,  and 
to  the  signs  of  intra-orbital  mischief  are  added  all  those  above  described  under  the 
heading  of  intra-orbital  cellulitis.  The  sclerotic  is  an  unyielding  membrane;  hence  j)ain 
in  these  cases  is  usually  intense,  while  septic  features  are  added  according  to  the  nature 
of  the  cause.  When  the  lesion  has  begun  in  the  cornea  it  usually  ruptures  early  and 
the  ocular  contents  may  escape  in  this  way. 

Treatment. — Panophthalmitis  is  dangerous  to  life  as  well  as  to  the  eye  when  not 
promptly  treated.  The  same  rule  prevails  here  as  well  as  elsewhere  in  the  j)resence  of 
pus.  Prompt  evacuation  offers  the  greatest  safety  and  relief.  Evacuation  of  the  entire 
contents  of  the  eye  through  a  free  incision  and  by  means  of  a  sharp  spoon,  with  antiseptic 
irrigation,  affords  the  only  safe  measure  in  these  cases. 

As  previously  remarked,  the  general  consensus  of  opinion  among  oculists  and  surgeons 
is  that,  under  these  circumstances,  enucleation  should  never  be  done,  the  danger  being 
that  of  a  purulent  meningitis  or  thrombosis  by  extension  backward  along  the  sheath  of 
the  optic  nerve. 

SYMPATHETIC  OPHTHALMITIS. 

This,  too,  is  a  matter  of  interest  common  to  the  eye  specialist  and  the  general  surgeon. 
The  term  refers  to  lesions  of  one  eye  which  follow  sooner  or  later  upon  injuries  or  infec- 
tions of  the  (jther.  These  expressions  of  so-called  sym[)athy  occur  in  irritative  or  inflam- 
matory lesions.  The  former  are  more  or  less  neurotic  and  include  pain,  often  referred 
to  the  region  beyond  the  orbit,  })hotophobia,  blepharosj)asm,  too  free  lacrymation,  and 
various  subjective  phenomena  of  impaired  \ision.  These  features  will  be  accompanied 
by  more  or  le.ss  tenderness  of  the  globe,  with  ciliary  neuralgia  and  injection.  These 
may  subside  under  treatment,  but  will  recur  when  the  eye  is  again  used. 

Contrasted  with  these  lesions  is  another  form  whose  features  are  most  pronounced 
along  the  uveal  tract,  though  the  retina  may  also  suffer.     Its  subjective  features  are  those 


506  SPECIAL  OR  REGIOXAL  SURGERY 

of  uvrith,  to  which  are  added  actual  exudates  in  various  parts  of  tlie  fjlohe,  some  of  which 
may  l)e  seeu  with  the  o])hthahiioseo])e,  with  intra-ocular  tension,  which  re(hices  the  ante- 
rior chamber,  and  with  j)artial  or  complete  loss  of  sight  that  may  end  in  total  atrophy.' 
In  some  instances  these  lesions  occur  rapidly ;  in  others  the  course  of  the  disease  is  chronic. 

The  oculopathologists  have  striven  hard  to  ex])lain  these  phenomena.  Most  of 
them  believe  in  the  continuity  of  the  subilural  or  subvaginal  sheath  of  the  nerve  from 
one  orbit  around  into  the  other,  and  believe  that  the  germs  passed  along  this  subway. 
Involvement  of  the  yet  unaffected  eye  may  f(jllow  the  entrance  of  foreign  bodies,  occur- 
rence of  traumatisms,  punctures,  existence  of  corneal  lesions  as  minute  ulcers,  constant 
irritation  of  the  presence  of  an  artifical  eye  upon  the  stump,  the  performance  of  some 
of  the  connnon  operations  upon  the  globe,  and  even  the  much  less  frequent  conditions  of 
pathological  changes  in  the  choroid,  the  ciliary  Ixxly,  the  optic  nerve,  or  the  existence 
of  intra-ocular  tumors.  A  recognition  of  the  possibilities  in  these  cases  will  lead  to 
more  radical  treatment  of  the  lesions  which  may  produce  them.  Even  a  minute  foreign 
body  should  be  promptly  removed  and  an  ulcer  of  the  cornea  should  not  be  regarded  as 
a  trifling  lesion.  Under  all  circumstances  the  surgeon,  as  well  as  the  general  practi- 
tioner, should  be  alert  to  the  possibilities  of  these  lesions,  quick  to  recognize  the  sMTiptoms, 
and  prompt  in  urging  the  only  satisfactory  relief.  It  will  be  seen  that  the  earliest  sug- 
gestive features  are  those  of  involvement  of  the  uveal  tract. 

Treatment. — There  is  usually  but  on(^  efficient  method  of  treatment  for  these 
cases,  and  this  consists  of  removal  of  the  injured  or  di.ieased  other  ei/e,  more  j)articularly  if  it 
be  more  or  less  already  impaired  by  the  conseciuences  of  the  original  lesion.  The  excep- 
tions to  this  statement  occur  in  the  event  of  well-marked  symj)athetic  inflammation, 
as  it  may  be  possible  that  there  will  be  better  vision  in  the  originally  injured  eye  than  in 
that  secondarily  infected;  but  so  long  as  it  is  a  matter  of  simple  sympathetic  irritation 
enucleation  is  the  proper  course.  While  this  is  extremely  radical  there  is  no  satis- 
factory substitute  for  it.  The  only  excuse  for  delay  should  be  threatening  j^hlegmonous 
processes  by  which  communication  jiosteriorly  might  be  afforded.  Bull  has  laid 
down  the  following  indications  for  enucleation  of  the  first  eye  before  the  outbreak  of 
sympathetic  inflammation  in  the  other  eye: 

1.  When  the  wound  is  in  the  ciliary  region,  and  so  extensive  as  to  greatly  damage 
or  entirely  destroy  vision; 

2.  When  the  wound  is  in  the  ciliary  region,  and  is  already  accompanied  by  iritis  and 
cyclitis; 

3.  When  the  eve  contains  a  foreign  bodv,  and  attempts  at  its  removal  have  proved 
futile; 

4.  When  the  eye  is  atrophied  or  shrunken  and  tender  on  pressure,  or  is  continually 
irritated. 

ENUCLEATION  OF  THE  GLOBE  OF  THE  EYE. 

The  conditions  which  justify  enucleation  of  the  eye  have  been  pointed  out.  For 
the  operation,  which  is  usually  done  under  general  anesthesia,  the  lids  should  be  widely 
separated  with  the  ordinary  eye  speculum  or  by  suital)le  retractors.  A  circiflar  incision 
is  then  made  through  the  conjunctiva,  around  the  margin  of  the  cornea.  This  is  carried 
down  to  the  sclerotic  at  a  little  flistance  from  the  corneal  margin,  by  which  Tenon's 
capsule  is  opened;  then  a  strabismus  hook  is  inserted  in  each  direction  and  the  tendon 
of  each  muscle  raise<l  upon  it  and  divided  close  to  its  insertion.  By  pressure  upon 
the  surrounding  tissues  the  eye  is  now  made  to  protrude.  Should  the  globe  have  been 
already  collapsed  it  should  be  drawn  forward  with  forceps,  one  blade  of  which  may  be 
thrust  within  it.  After  thus  firmly  withdrawing  it  a  blunt-pointefl,  curved  scissors  is 
passed  behind  and  around  it,  the  blades  being  made  to  open  in  such  a  way  as  when 
closed  to  divide  the  optic  nerve  at  a  little  distance  from  the  globe.  After  this  enucleation 
by  pressure  is  easy,  and  any  further  tissues  recjuiring  division  may  be  readily  cut.  The 
principal  source  of  hemorrhage  is  the  artery  extending  through  the  nerve,  but  this  is 
readily  controlled  by  pressure. 

Shoidd  there  have  been  any  inflammatory  or  septic  condition  about  the  orbit  or  the 
conjunctival  sac  the  parts  should  be  cleansed  with  hy(ln)gen  peroxide  or  other  anti- 
septic. Sutures  are  seldom  required.  A  compress  should  be  apj)lied  outside  the  eyelids, 
removing  it  sufficiently  often  to  be  certain  there  is  no  retention  of  fluid  or  blood. 


Uccovcn-  is  iisuiillv  rapid.  ( iraiuilalion  tissue  sonu'tiincs  loniis  a(  llic  hotloin  (jI' the 
eonjuiietival  sac  and  lu'coiiies  exuheraiil.  In  (liis  ease  it  should  he  removed  with  scissors 
and  eanterizi'd,  alter  which  it  rarely  reenrs. 


SYPHILITIC  AFFECTIONS  OF  THE  EYE  AND  THE  ORBIT. 

As  already  descrihed,  nianv  expressions  of  the  \arions  sta<fes  of  syphilis  |)ertain  to 
the  eye.  Thns  there  may  he  clianctr  u\Hn\  the  eyelid  or  eon juiieti\a,  or  ideeration  of 
the  same;  syphilitic  iritis  as  a  secondary  expression;  syphilitic  retinitis,  ncurorctinitis, 
choroiditis,  as  tertiary  lesions;  and  the  formation  of  irmnmas  in  the  later  stages  (jf  the 
disease,  and  in  almost  any  imaginable  locality,  especially  the  uveal  tract.  Syphilitic 
tumon'  are  seen  upon  the  iris  more  often  than  anywhere  else  within  the  eye.  Outside 
of  the  glohc  and  within  the  orbit  the  ordinary  exj)ressions  of  syj)hilitic  |)criostitis  and 
of  gummatous  tumors  occur.  These  constitute  also  the  more  conunon  intra-orbital 
expressions  of  th's  disease. 

The  .s-i/)ii})/(»iis  of  syphilitic  lesions  in  this  location  do  not  vary  from  similar  lesions 
elsewhere,  save  so  far  as  th(>y  involve  special  tissues  or  disturb  the  special  sense  of  sight. 
The  prognosis  in  nearly  all  of  tlu-m  is  relatively  good  if  suitable  and  active  treatment  be 
promptly  instituted.  It  is,  however,  too  much  to  expect  that  annular  destruction  of 
areas  of  the  retina  or  choroid  can  be  com])letely  repaired. 


CATARACT. 

Cataract  is  a  subject  of  primary  interest  to  the  general  surgeon  only  so  far  as  it  pertains 
to  the  consec|uences  of  injury  to  the  orbital  region.  The  term  implies  oj^acity  of  the  lens 
or  of  its  capsule,  or  both,  which  may  be  partial  or  complete.  Its  pathognomonic  feature 
is  slow  and  progressive  failure  of  vision.  Examination  by  direct  as  well  as  bilateral 
illumination  will  show  the  opacity  to  be  located  behind  the  iris.  Everyone  should  be 
able  to  recognize  it;  its  excision  should  be  relegated  to  the  trained  specialist,  since  it  is 
one  of  the  most  delicate  special  operations. 


GLAUCOMA. 

The  term  glaucoma  \\w\A\es  a  collection  of  more  or  less  variable  pathological  conditions 
within  the  eyeball  which  lead  to  increased  intra-ocular  tension.  Because  of  this  in- 
creased pressure,  with  its  disturbance  of  circulation  and  the  peculiar  coloration  often 
given  to  the  cornea  or  the  pupil,  the  disease  has  received  this  name.  Among  its  symp- 
toms are  pu])illarv  changes,  including  both  size  and  mobility  of  the  iris;  turbidity  of  the 
cornea,  as  well  as  the  fluid  humors  of  the  eye;  pain,  corneal  anesthesia,  impairment  or 
final  loss  of  vision,  engogement  of  the  visible  vessels  of  the  globe,  and  a  peculiar  cupping 
or  excavation  of  the  ojjtic  disk.  Unless  checked  by  operative  intervention  the  course  of 
the  disease  is  steadily  toward  blindness.  It  varies  in  acuteness,  the  favorable  cases 
being  the  acute  ones,  in  which  early  operation  can  be  practised.  It  admits  of  no  other 
treatment. 

Treatment. — The  operation  almost  universally  practised  by  the  oculist  is  either 
iridectomy  or  sclerotomy.  The  condition  is  briefly  mentioned  in  this  place  for  the 
double  reason  that  the  student  may  be  made  aware  that  the  condition  may  follow 
certain  injuries  to  the  eyeball  or  the  head,  and  that  the  more  chronic  forms  have  been 
successfully  treated  by  excision  of  the  cervical  sjpnpathetic,  on  one  side  or  both,  the 
oj)erati()n  being  based  ii])on  anatomical  and  physiological  facts  pertaining  to  the  dis- 
tribution and  function  of  tho.se  sympathetic  fibers  which  pass  to  the  orbit  from  the  cervical 
trunk.     The  operation  is  described  in  the  section  on  the  Cranial  and  Cervical  Nerves. 


598  SPECIAL  OR  REGIONAL  SURGERY 

AFFECTIONS  OF  THE  IRIS  AND  THE  CILIARY  BODY. 

These  lesions  are  frequently  the  result  of  blows  and  of  penetrating  injuries,  as  well 
as  of  sypliilis.  Moreover,  motility  of  the  iris  is  so  essential  to  the  normal  function  of  the 
eye  that  where  it  may  possibly  be  effected  the  surjijeon  should  protect  ai^ainst  those 
adhesions  between  the  iris  and  the  lens  or  cornea,  which  are  very  likely  to  occur,  by 
instillation  of  a  sufhciently  stronif  solution  of  atroj)ine,  a  ^  to  1  per  cent,  solution  being 
usually  sufficient  for  this  pur])ose.  These  adhesions  are  referred  to  as  synechice,  and 
are  anterior  when  the  iris  becomes  affixed  to  the  cornea,  or  posterior  when  affixed  to 
the  lens.  They  occur  easily  after  minute  punctures  of  the  cornea,  the  result  being  a 
limited  mobility  or  a  dislocation  of  the  |)upil,  along  with  opacity  of  the  cornea,  all  of 
which  work  to  the  detriment  of  vision. 

The  iris  is  so  visible  that  the  meclianism  of  an  exudate  on  or  in  it  can  be  observed 
almost  from  begimiing  to  end  when  it  occurs  in  the  form  of  iritis.  Occasionally  an 
exudate  will  merge  into  an  actual  collection  of  pus  which  will  gradually  fill  up  the  anterior 
chamber,  and  which  is  then  spoken  of  as  hypopyon.  Under  the  most  favorable  circum- 
stances a  disappearance  of  this  pus  by  absorption  may  be  noted.  It  may  prove 
destructive  or  may  necessitate  evacuation. 

The  iris  and  the  ciliary  body  are  intimately  connected,  and  inflammation  beginning  in 
one  point  may  easily  s])read  to  and  involve  other  tissues.  These  structures  with  the 
choroid  constitute  the  so-called  uveal  tract,  and  when  they  participate  in  infiammation 
it  is  called  uvriti'i. 

The  s-yniptoms  of  iritis  consist  of  pain,  lacrymatif)n,  photojihobia,  which  is  often 
intense;  increasing  turbidity  of  the  aqueous  humor,  as  well  as  of  the  cornea,  by  which 
vision  is  impaired;  visible  discoloration;  irregularity  and  sluggishness  in  movements  of 
the  iris,  and  circumcorneal  injection.  A  congestion  which  assumes  an  annular  form 
about  the  cornea  and  does  not  involve  the  conjunctival  sac  indicates  trouble  in  the 
ciliary  region,  while  a  true  conjunctivitis  is  limited  only  by  the  extent  of  the  membrane 
itself." 

Iritis  due  to  syphilis,  whether  assuming  the  plastic  or  the  gummatous  form,  requires 
the  most  active  antisyphilitic  medication,  in  addition  to  local  treatment.  The  non- 
sj)ecific  and  traumatic  forms  need  absolute  rest  in  a  dark  room,  with  cold  applications 
about  the  eye  and  the  free  use  of  atropine,  to  completely  dilate  the  pupil  and  prevent  the 
formation  of  synechiee. 

THE  CORNEA. 

The  cornea  being  the  most  exposed  part  of  the  eyeball  will  be  frequently  subjected 
to  minor  or  serious  injury  in  connection  with  violence  to  the  orbital  region.  It  is  an 
exceedingly  sensitive  membrane,  whose  reflex  excitability  is  heightened  by  the  presence 
of  a  small  foreign  body,  this  accident  being  one  of  frequent  occurrence.  It  is  a  lesson 
in  neurophysiology  to  watch  the  relatively  k)cal  and  general  disturbances  which  the 
presence  of  a  mimite  speck  of  foreign  material  embedded  in  the  cornea  may  cause. 
Every  extraneous  body  should  be  removed  at  once,  the  procedure  being  now  facilitated 
by  the  local  use  of  cocaine,  for  any  abrasion  or  serious  injury  of  the  cornea  occurring 
in  surgical  cases  offers  a  possible  source  of  infection  to  the  deeper  ocular  structures. 
Careful  attention  should  be  given  to  the  use  of  antiseptics  of  suitable  strength  in  the 
conjunctival  sac,  whenever  this  region  is  involved.  This  statement  cannot  be  made 
too  positive.  There  is  danger  both  to  the  cornea  and  to  the  iris  in  perforating  ulcer  or 
traumatism  of  the  cornea,  and  there  is  as  much  occasion  for  the  use  of  atropine  in  these 
instances  as  in  those  pertaining  to  the  iris  proper.  To  the  protrusion  of  the  cornea, 
which  is  j)roduced  by  weakening  of  its  structure  and  tension  from  within,  is  given  the 
name  staphyloma.  It  is  frecjnently  combined  with  adhesions  of  the  iris  and  dislocatitm 
of  the  pu])il.  It  constitutes  not  only  a  cosmetic  disfigurement,  but  a  serious  imj)ediment 
to  vision. 


PLATE   XLV 


FIG.    1 


Lacrymal  Fistula  on  the  Right  Side  ;   Ectasia  of  the  Lacrymal  Sac  on  the  Left 
Bilateral  Epicanthus.     (Haab.; 


FIG.  2 


:@V 


Dacrocystitis.      (Haab.j 


THE  LACRYMAL    TRACT  599 

Till-:  CONJUNCTIVAL  SAC. 

TIh-  iiiucoiis  membrane  liiiiiit;  llic  coiijiiiictixal  sac  is  iMi-haps  tlic  most  exposed 
to  irritation  and  even  infection  of  all  nnicons  snrfaces.  It  is  not  strange  then  that 
conjunctivitis  is  the  most  common  of  all  eve  affections.  Wlu-ther  irritated  hv  constant 
exposure  to  dust  and  dirt,  or  raw  and  cold  winds,  or  hy  the  heat  of  a  hiast  furnace,  hy 
the  dazzlinj;  hrilliancy  of  ele<tric  li^dits,  or  contact  with  l)a<teria,  it  dis|)lavs  a  surprising 
(le»;ree  of  accommodation  and  resistance.  It  has  |H'euliar  snsceptiliilities,  particidarlv  to 
the  iferms  of  (jonorr/itd  and  dij)hthiria.  'J'o  these  it  is  |)eculiarly  sensitive,  and  uiider 
their  influenee  it  may  (juiekly  .snccmnl).  The  harm  done  in  eitiier  of  the.se  conditions 
is  by  no  means  limited  to  the  eonjmictiva,  l)ut  may  extend  in  such  a  way  as  to  eventually 
cause  loss  of  vision. 

Nowhere  else  may  the  ])henomenon  of  hyjx'remia  be  .so  easily  studied  as  by  watchin<^ 
the  ocular  con jimctiva  for  a  few  moments  after  the  occurrence  of  irritation.  The  rapidity 
with  which  the  vessels  dilate  and  become  visible,  the  occurrence  of  the  consccinent 
redness  and  swellinj;,  and  the  reflex  |)henomena  attending,'  it  become  a|)|)reciable  within 
a  short  time.  In  the  chronic  contlitions  the  ti.ssues  become  thickened  and  less  mobile. 
A  chronic  conjunctivitis  is  the  constant  condition  in  certain  laborers  who.se  eyes  are 
exposed  in  their  occuj)ati()n. 

A  |x*culiar  granulomatous  conditicm  of  the  conjunctiva,  especially  the  palpebral,  i.s 
that  known  as  trachoma,  which  apjwars  to  be  due  to  a  specific  form  of  infection  that 
leads  to  exudation,  organization  and  thickening,  intensified  in  j)unctate  areas,  and 
giving  the  surface  the  a])))earance  of  an  ordinary  gramdation.  This  condition  has 
assumed  such  im|)ortance  as  to  be  sufficient  for  the  exclusion  of  aliens  and  immigrants. 

The  milder  conditions  of  acute  or  subacute  conjunctivitis  subside  under  cold  a|)pli- 
cations  and  mild  antisej)tic  and  astringent  eye-washes  or  collyria.  These  should  Ix* 
frecjuently  instilled,  beneath  the  lid  whenever  this  area  is  involved  as  a  complication  of 
injuries  to  the  head  or  face.  In  acute  cases  of  the  infectious  type,  sucli  as  the  gonorrheal 
or  diphtheritic,  atropine  should  be  lused  locally,  so  that  the  iris  may  be  drawn  out  of 
liarm's  way  and  the  pupil  left  free  should  resolution  and  recovery  ensue.  Individuals 
suffering  from  either  gonorrhea  or  diphtheria  should  be  cautioned  and  protected  from 
possibility  of  conjunctival  infection.  The  eyes  of  the  newborn  are  not  infre(|ucntly 
infected  during  the  process  of  parturition.  The  parturient  canal  of  women  suspected 
of  having  an  infectious  lesion  of  this  kind  should  Ije  cleansed  before  the  passage  of  the 
fetal  head,  and  in  all  susj)icious  cases  instant  and  constant  attention  should  be  given  to 
the  eyes  of  the  newborn  infant. 


THE  LACRYMAL  TRACT. 

The  larrymal  gland,  though  situated  in  the  anterior  and  upper  part  of  the  orbit,  and 
beneath  the  upper  lid,  where  it  is  ordinarily  well  protected,  is  nevertheless  liable  to  both 
acute  infections  and  chronic  irritations.  When  acutely  inflamed  it  usually  goes  on  to 
abscess  formation.  We  have  then  acute  dacrijo-adeniti.s-,  which  will  produce  the  ordinary 
sjTnptoms  of  phlegmon,  with  the  adtled  ocular  features  of  vascularity  and  chemosis  of 
the  conjunctiva  and  more  or  less  edema  and  immobility  of  the  upper  lid.  Displacement 
of  the  eyeball  may  be  produced  by  great  inflammatory  swelling.  These  absces.ses  tend 
to  discharge  either  through  the  skin  near  the  external  angle  or  sometimes  through  the 
conjunctiva.  WHiile  in  the  former  case  a  scar  results,  it  nevertheless  is  a  jireferable  point 
either  for  spontaneous  opening  (jr  for  incision.  If  the  case  be  seen  in  time  it  will  be  advis- 
able to  make  this  incision  early  and  so  limit  destruction.     (See  Plate  XLV,  Fig.  1.) 

The  lacrymal  gland  suffers  occasionally  in  instances  of  constitutional  .syphilis,  imder- 
going  chronic  and  obstinate  enlargement.  It  may  also  be  the  site  of  tumors  either  nor- 
malignant,  usually  adenoma,  or  cancerous,  most  instances  of  the  latter  being  expressions 
of  extension. 

The  tear  passages  proper  are  composed  of  the  canalicidi,  the  lacrATnal  sac,  and  the 
duct.  These  are  altered,  occasionally,  in  their  relaticMis,  or  absent,  as  the  result  of 
congenital  tlefects.  The  passages  j)roper  frecjuently  become  obstructed,  as  the  result 
of  any  chronic  irritation  which  produces  thickening  of  the  conjunctiva,  and  in  many 


(iOO  SPECIAL  OR  Ri:(;i()\AL  SURGERY 

laborers  and  others  who  are  exposed  to  (hist,  dirt,  or  cold  winds  there  will  he  a  more  or 
less  constant  stillieidium  or  overflow  of  tears.  Li  some  of  these  cases  it  is  sufficient  to 
slit  up  one  or  both  eanalicnli  with  a  fine  prohe-pointed  l)istoiiry. 


DACRYOCYSTITIS. 

The  larri/mal  .mc  proper  is  frequently  the  site  of  both  acute  and  chronic  disease, 
known  as  dacrijocystitu,  which  is  the  result  of  infection  sf)reading  from  the  conjinictival 
sac,  rarely  from  the  nose,  or  the  exaggeration  of  conjunctival  thickenings,  like  those 
mentioned  above.  The  first  s^inptonis  are  overflow  of  tears,  accompanied  by  swelling 
or  enlargement  in  the  region  of  the  sac.  By  pressure  upon  this  a  mixture  of  water, 
mucus,  and  sometimes  pus  may  be  expressed.  As  the  disease  goes  on  the  fluid  becomes 
purulent.  If  the  sac,  by  pressure,  can  be  emptied  into  the  nose  the  nasal  duct  may  be 
regarded  as  patulous  and  the  treatment  is  simplified.  If  not  there  is  stricture,  usually 
at  the  U])per  end  of  the  duct,  which  re(|uires  division  and  dilatation.  The  more  chronic 
forms  of  troul)le  in  this  region  are  fretjuently  intensified  into  acute  phlegmonous  lesions 
which,  if  neglected,  will  lead  to  spontaneous  perforation  and  the  formation  of  a  lacrymal 
fistula  at  a  point  below  the  inner  angle  of  the  eye,     (See  Plate  XLV,  Fig.  2.) 

Treatment. — The  treatment  should  consist  of  exposure  of  the  sac  by  incision  of  the 
canaliculi  and  its  irrigation  l)y  means  of  a  syringe  and  antiseptic  fluid.  Unless  this  fluid 
passes  easily  into  the  nose  the  stricture  should  be  divided  and  Bowman's  probes  passed, 
the  ])rinciple  of  treatment  being  the  same  as  that  in  treating  lU'cthral  stricture.  This 
part  of  the  treatment  should  l)e  referred  to  an  oculist. 

In  acute  dacryocystitis  with  sup])uration  the  sac  along  the  natural  passages  slujuld 
be  opened.  When  a  diagnosis  of  an  acute  lesion  of  this  kind  is  made  nothing  but  the 
most  radical  treatment  is  advisable. 


THE  LIDS. 
Congenital  deformities  of  mild  degree  are  not  infrequent  about  the  eyelids. 

EPICANTHIS. 

Ejiicanthis  is  a  term  implying  folds  of  redundant  skin  extending  from  the  internal 
end  of  each  eyebrow  to  the  inner  canthus  and  over  the  lacrymal  sac.  It  varies  much  in 
degree,  is  a  more  or  less  hereditary  feature  in  certain  families,  and  is  not  infretjuenUy 
associated  with  other  defects.  The  ])al])ebral  fissure  varies  in  length  in  different  indi- 
viduals, giving  a  longer  or  shorter  window  through  which  the  eye  proper  shall  appear. 
Sometimes  the  fissure  is  much  too  short  and  requires  division  or  extension,  which  is 
easily  made  by  incision  at  the  outer  angle. 

COLOBOMA. 

Coloboma  is  a  term  applied  to  various  lesions  of  the  eyelid,  the  iris,  and  the  choroid, 
implying  a  defect  in  structure,  which,  in  the  eyelid,  leaves  a  V-sliaped  deficiency,  corre- 
sponding to  harelip,  whose  edges  may  be  brought  together  by  a  simple  operation. 

STYE;   HORDEOLUM. 

The  eyelids  are  subject  to  certain  painful  or  disfiguring  lesions,  which  frequently  come 
under  the  notice  of  the  general  surgeon.  Of  these  the  most  common  is  siije,  or  hordeolum. 
This  is  a  phlegmon  of  one  of  the  minute  glands  along  the  margin  of  the  lid,  which  has 
become  infected  and  violently  reacted.  It  forms  a  miniature  furuncle,  often  associated 
with  conjunctivitis,  and  giving  a  disproportionate  reaction.     So  soon  as  the  presence  of 


i:sTW)i'i()\'  gOl 

pus  run  he  (Ictcctcd  ;i  |)Uii(tiirf  should  he  made  and  (lie  containrd  dro|)of  pus  exvacuated. 
Tiiiratcninfi:  suppuration  may  sometimes  be  aborted  by  local  use  of  1  or  2  per  cent. 
nuMTUiial  (yellow)  oxide  ointment. 

CHALAZION. 

A  somewhat  similar  but  non-inflanunatory  cystic  distention  of  one  of  the  Meibomian 
glands,  which  jjursues  a  slow  and  jjainless  course,  is  called  clialazion.  It  j)resents 
rather  beneath  the  mucous  surface,  but  is  often  visible  through  the  skin.  Its  contents 
are  mucoid  or  dermoid.  When  it  attains  troublesome  dimensions  it  should  be  exposed 
through  a  small  incision,  usually  external,  and  thoroughly  extirpated. 


XANTHELASMA. 

Small,  elevated  areas  of  dirty-yellow  color  are  met  with  in  the  skin  about  the  eyelids, 
more  often  near  the  inner  angle.  Such  a  lesion  is  called  xaniJiela.wia,  the  lesion  being 
a  fatty  metamorphosis  of  a  portion  of  the  skin  structure.  While  harmless,  it  is  amen- 
able to  excision  for  cosmetic  eifect. 

Any  of  the  ordinary  tumors  which  afiFect  similar  tissues  elsewhere  may  be  seen  about 
the  eyelids.  The  more  conunon  are  the  vascidar  tumors,  esj^ecially  small  nevi.  Epi- 
thelioma occasionally  commences  along  the  palpebral  margin,  but  Is  more  often  an 
extension  from  neio-hborinir  tissues. 


BLEPHARITIS. 

The  margins  of  the  lids  are  frequently  involved  in  a  mildly  infectious  inflammatory 
condition  called  blepharitis,  in  which  nearly  all  the  structures  {participate;  when  the 
borders  alone  are  involved  it  is  referred  to  as  blepharitis  inarginalis.  The  condition 
is  largely  due  to  dirt,  and  to  irritation  in  which  the  Meibomian  ducts  seem  to  share.  It 
is  accompanied  l)y  chronic  conjunctivitis.  The  condition  is  seen  more  often  in  the  ill- 
nourished,  the  rickety,  and  the  tuberculous.  The  best  local  treatment  consists  in  the 
use  of  an  ointment  of  yellow  oxide  or  yellow  sulphate  of  mercury.  The  former  may  be 
used  in  2  per  cent,  strength,  and  the  latter  not  stronger  than  1  per  cent.  This  should  be 
applied  along  the  lid  margins  at  night,  and  thoroughly  rubbed  in.  A  commencing 
phlegmon  and  stye  may  be  aborted  by  one  of  these  preparations. 


TRICHIASIS. 

Another  very  annoying  complication,  and  usually  the  sequel  of  the  condition  already 
mentioned,  is  trichiasis,  or  turning  inward  of  the  eyelashes.  Chronic  irritation  and 
cicatricial  contraction  on  the  inner  aspect  of  the  eyelids,  or  a  chronic  blepharospasm, 
which  may  be  the  result  of  corneal  infections,  serve  to  draw^  the  lids  inward,  especially  with 
the  margins  of  the  hair  follicles,  so  that  the  eye-winkers  grow  toward  the  ocular  surfaces, 
which  tliey  constantly  irritate.  The  result  is  a  vicious  circle,  each  morbid  condition 
intensifying  the  other.  In  time  there  is  produced  a  condition  of  entropion,  which  is  to 
be  remedied  only  by  operation.  It  is  not  sufficient  to  treat  trichiasis  by  epilation,  as 
the  hairs  will  grow  again  and  continuously  cause  trouble.  The  cause  should  be  removed 
and  the  etfect  treated. 

ENTROPION. 

By  this  term  is  meant  a  condition  of  inversion  of  the  margin  of  one  or  both  lids,  by 
which  the  external  surface  is  brought  into  actual  contact  with  the  surface  of  the  eyeball. 
It  is  a  chronic  condition  brought  about  through  the  action  of  several  contributing  causes. 
Any  condition  of  the  cornea  or  deeper  portion  of  the  eye  which  leads  to  photophobia 
and  spasmodic  closure  f)f  the  eyelids  will  produce  in  time  hypertrophy  of  the  orbicularis, 
with  corresponding  strengthening  of  the  muscle  and  exaggeration  of  its  activity.     Chronic 


602  SPECIAL  OR  REGIOXAL  SURGERY 

l)lf|)harospasm  will  thus  in  time  lead  to  a  mild  degree  of  cntroj)ion,  while  any  affection 
of  the  inner  palpebral  surfaces  which  leads  to  cicatricial  contraction  will  still  more 
intensify  it.  So  soon  as  trichiasis  or  irritation  by  the  eyelashes  is  added  to  what  has 
gone  before,  every  feature  is  exaggerated  and  the  cornea  is  made  to  lie  practically  in 
contact  with  the  skin  surface  of  the  eyelid.  A  further  consecjuence  is  corneal  disease, 
often  with  ulceration  and  oj)acity,  with  even  worse  structural  changes. 

The  condition  is  really  a  serious  one  and  is  to  be  treated  not  alone  by  operation  upon 
the  lid,  l)ut  care  should  be  given  to  all  the  contributing  features.  So  far  as  the  lid  con- 
dition alone  is  concerned,  I  have  found  the  operation  suggested  by  Hotz  the  most  satis- 
factory of  any,  at  least  in  average  cases.  An  incision  is  made  from  one  end  of  the  lid 
to  the  other,  along  the  distal  border  of  the  tarsal  cartilage,  and  down  to  it.  Through 
this  a  bundle  of  those  orbicularis  fibers  which  run  parallel  with  the  incision  is  dis.sected 
away.  In  extreme  cases  the  tarsal  cartilage,  which  is  incurved  as  the  result  of  the  old 
condition,  may  be  either  incised  or  a  strip  excised  from  its  structure.  Sutures  are  then 
inserted  which  include  not  only  the  borders  of  the  skin  incision,  but  the  exposed  border 
of  the  tarsus  and  the  tarsoor])ital  fascia.  By  applying  the  central  suture  first,  and  then 
one  on  either  side,  it  will  usually  be  found  that  as  the  sutures  are  tightened  the  edge  of 
the  lid  is  drawn  outward  and  the  desired  effect  obtained. 

The  large  number  of  operative  methods  which  have  been  suggested  for  the  cure  of 
entropion  bespeak  the  variety  of  causes  which  may  produce  it  and  the  many  devices  to 
which  different  ingenious  ophthalmic  surgeons  have  resorted. 

ECTROPION. 

This  condition  is  the  reverse  of  entropion,  and  implies  eversion  of  the  margin,  or  of  a 
considerable  portion  of  a  lid,  with  consequent  exposure  of  its  conjunctival  surface, 
which  imdergoes  changes  in  consequence  of  which  it  becomes  thickened,  contracted, 

and  irritated.     Ectropion  may  possibly  be  produced  by 
^i°-  -^90  violent  orbicular  spasm,  especially  in  children,  the  lids 

being  so  tightly  shut  as  to  be  everted.  Ordinarily  it  is 
the  result  of  external  lesions  which  produce  cicatricial 
contraction,  like  burns,  or  of  chronic  ulcerative  lesions 
along  the  paljx-ljral  border,  such  as  are  met  with  in 
tuberculous  and  syphilitic  disease.  The  lower  lid  is 
much  more  frequently  involved  than  the  upper. 

For  the   relief  of  ectropion    plastic    operations   are 

practised,  usually  on  the   lower  lid.     The  milder  cases 

require  a   V-shaped  incision,  its  apex  downward,  with 

free    dissection   of   the    integument   up   or   near   to   the 

Arit's  operation  forectropion.         margin  of  the  lid,  by  which  it  is  released  from  the  scar 

(Arlt.)  tissue  which  has  bound  it  down.     Fig.   390  illustrates 

the  general  principle  of  such  an  operation.     The   lower 

portion  of  the  V-shaped  defect  is  then  brought  together  with  sutures,   the  triangular 

fiap  being  fastened  in  a  position  much  higher  than  that  in  which  it  originally  rested. 

All  of  these  operations  upon  the  eyelids  are  included  under  the  term  blepharoplasty, 
of  which  the  above  is  the  most  simple.  When  necessary  new  flaps  may  be  raised  from 
the  temporal  region,  from  the  forehead  or  from  the  cheek,  as  may  be  required,  and  turned 
into  |)lace,  their  pedicles  being  so  planned  as  to  carry  a  sufficient  blood  supjjly  for  nourish- 
ment of  the  same.  If  this  supply  be  properly  provided  these  operations  are  jjractically 
always  successful.  It  is  necessary  f)nly  to  make  the  transjjlanted  flap  at  least  one-third 
larger  than  appears  to  be  necessary,  judging  from  mere  size  of  the  defect,  for  experience 
shows  the  necessity  of  allowing  at  least  one-third  for  primary  and  cicatricial  shrinkage. 
A  hrteroplastic  operation  is  occasionally  performed  for  this  purpose,  by  which  the  flap 
of  skin  is  detached  from  an  entirely  different  part  of  the  body,  or  from  the  body  of 
another  individual.  Skin  thus  transplanted  should  be  prepared  by  removal  of  all  of  the 
fat  upon  its  raw  surfaces,  skin  alone  being  desired  and  not  other  tissue.  Figs.  391,  392, 
393  and  394  illustrate  blepharoplastic  operations  of  various  types,  which  may  be  modi- 
fied or  made  more  extensive.  These  are  but  a  few  of  the  various  plastic  devices,  and 
are  intended  to  serve  merely  as  suggestions  or  examples  rather  than  methods  to  which 
one  is  limited. 


INJURIKS  OF   Tin-:  FA'EIiALL   A\D   ADXKXA   I.\   (IFSERAL 


003 


INJURIES  OF  THE  EYEBALL  AND  ADNEXA  IN  GENERAL. 

Tliis  t<)[)i<'  liiis  alrciidy  hccii  coiisidcrrd.      It  seems  advisahle,  however,  to  siiiiiinarize 
some  of  (lie  results  of  such  injuries  in  order  to  call  atteiiliou  to  tlieir  danj^^ers  and  methods 

Vm.  391 


Richet's  operation  for  ectropion.     (Arlt.) 


of  treatment.     Burns  of  the  orbital  regions,  for  instance,  are  liable  to  cause  not  only 
opacity  of  the  cornea  followng  ulceration,  but  adhesions  between  the  conjunctival  sur- 

Fio.  392 


Fricke's  method  of  blepliaroplasty.      (Arlt.) 


faces  and  the  palpebral  margins.      The  term  symhlepharon  is  applied  to  those  lesions 
where  the  lids  are  more  or  less  fixed  upon  the  globe  and  their  motility  i)artly  or  com]iletely 


Fig.  393 


Fig.  394 


Dieffenbach's  method  of  blepharoplasty, 

(.Arlt.) 


Arlt's  method  wlien  a  portion  of  the  eyelid  is 
to  be  sacrificed.     (Arlt.) 


impaired.  When  the  edges  alone  of  the  lids  have  grown  together  the  condition  is  known 
as  ankyloblepharon.  Both  of  these  conditions  are  the  result  of  adhesion  of  granulating 
surfaces  and  of  cicatricial  contraction,  and  should  be  avoided. 


004  SPECIAL  OR  REGIOSAL  SURGERY 

By  a  connission  of  the  orbital  rcfjion,  and  esixrially  of  the  eyeball,  all  sorts  of  injuries 
may  he  inflicted,  from  those  involvini;  the  cornea  to  deep  lesic^ns  which  leave  little  or 
no  superficial  evidences,  but  cause  j>artial  or  complete  blindness.  Detachriwnt  of  the 
retina,  for  instance,  is  one  of  the  possibilities  cjf  such  ccjnditions.  Intra-ocvlar  hemor- 
rhages or  (li'ilorafion  of  the  kus,  with  traumatic  ctitaract,  may  also  occur. 

The  sclerotic  may  be  ruptured  with  or  witlujut  the  presence  of  a  foreign  body,  in  which 
case  the  contents  of  the  eye  may  have  partially  or  comj>letely  escaped.  An  eye  which 
has  collapsed  from  these  causes  offers  an  almost  hofx-less  field  for  the  general  or  special 
surgeon,  and  little  can  be  done,  save  possibly  for  cosmetic  purposes.  There  is  danger 
of  svm pathetic  ophthalmia,  and  it  may  Ix;  a  question  whether  evisceration,  i.  e.,  com- 
[)letion  of  the  evacuation,  may  not  be  the  wiser  course. 

Perforating  wounds,  even  when  inflicted  by  minute  bodies,  have  dangers  of  their 
own,  including  the  possibilities  of  infection.  The  interior  mechanism  of  the  eye  Is  so 
easily  disturbed,  and  its  transparent  media  so  easily  clouded,  by  the  results  of  accident 
or  hemorrhage,  that  even  apparently  trivial  injuries  may  be  followed  by  disturbances 
of  vision. 

Treatment. — The  general  principles  of  treatment  of  all  such  injuric-^  ^lujuld  include, 
first,  the  removal  of  every  detectable  foreign  body,  followed  by  the  application  of  cold, 
and  the  use  of  anti-septic  eye-washes,  which,  however,  must  not  be  used  too  strong 
lest  they  irritate.  Saturated  boric-acid  solution  is  perhaps  a.s  strong  as  anything  which 
is  jjermitted,  while  even  this  may  occasionally  require  dilution.  In  afldition  to  this  the 
use  of  atroj)ine  solution  is  always  indicated.  It  has  the  double  effect  of  soothing  and 
allaving  pain  and  of  dilating  the  iris  into  a  narrow  ring.  AYith  such  measures  as  these 
it  may  be  possible  to  save  vision;  at  all  events  it  will  limit  reaction  and  prevent  harm. 


DISTURBANCES  OF  INNERVATION. 

The  nerves  which  supply  the  eye  and  its  adnexa  may  undergo  injury,  either  witliiii  the 
orbit  or  within  the  cranium,  or  in  their  course  from  one  to  the  other.  Tlic  para/i/ses 
may  be  caused  by  syphilis,  by  intracranial  tumors,  or  by  injury.  A  careful  study  of  the 
areas  and  nerves  involved  will  sometimes  lend  consideraljle  help  in  diagnosis,  both  in 
traumatic  and  pathological  cases.  Thus  diplopia,  or  double  vision,  may  be  caused  by 
paralysis  of  the  external  rectus  on  one  side,  by  which  its  antagonistic  internal  rectus  is 
permitted  to  swerve  the  eye  too  much  to  the  inner  side  and  away  from  the  normal  axis 
of  vision  required  for  single  sight.  When  there  Ls  complete  paralysis  of  the  third  nerve 
there  may  be  drooping  of  the  eyelid,  called  pto.n-s,  with  imyjaired  motion  of  the  eye,  upward, 
inward,  or  downward.  The  eye  will  roll  outward  because  the  external  rectus  is  supplied 
by  the  sixth  nerve.  There  will  also  be  dilatation  of  the  pupil,  with  loss  of  accommodation. 
When  the  upper  lid  is  raised  there  is  also  double  vision.  This  third-nerve  paralysis, 
however,  is  not  always  complete,  and  diplopia  may  result  only  when  the  eye  is  directed  in 
a  certain  way.  When  the  sixth  nerve  is  paralyzed  the  eye  is  rolled  inward,  and  again 
there  is  diplopia.  When  the  fourth  nerve  is  paralyzed  the  eye  is  but  slightly  displaced 
upward  and  inward.  When  the  sympathetic  nerve  is  involved  there  will  be  protrusion 
of  the  globe  with  dilatation  of  the  pupil.  This  will  Ix;  accompanied  by  flushing  of  the 
face. 


MUSCULAR  AND  ACCOMMODATIVE  DEFECTS. 

Detection  of  errors  of  accommodation  is  practically  a  specialty  within  a  specialty, 
while  the  various  forms  of  strabismus,  or  deviation  of  the  eyes  from  their  normal  axes, 
depend  largely  upon  regulation  of  accommodative  errors. 

REGION  OF  THE  EXTERNAL  AND  MIDDLE  EAR. 

The  region  of  the  ear  is  subject  to  congenital  malformation.s,  deviations,  and  defects, 
which  include  anomalous  shapes  of  the  auricle,  malpositions  of  the  organ,  defects  in 
the  cartilaginous  structure  with  resulting  deformity,  and  congenital  excesses  or  redund- 


REGION  OF   Tflh-   h'XTERXAL  AXD   Ml  1)1)1. F.    I-AR 


fiOfi 


aiuics  In  wliicli  there  are  made  to  a|)|)ear  supeniimierarv  auricles  or  jjortioiis  thereof. 
'I'liese  latter  have  been  deserihed  by  Sutton  and  treated  in  his  work  on  Comparative 
]*atli()l(>f/i/.  They  bear  relation  as  well  to  the  branchial  clefts,  and  are  of  ^reat  interest 
from  a  phylojijenetie  |)oint  of  view.  Some  of  these  defects  result  from  absolute  arrest 
or  excess  of  development,  others  from  injurv  durin<r  intra-uterine  life;  some  are  accentu- 
ated by  lack  of  care  durin«f  the  early  months  of  infanc  y.  'I'he  most  common  deformity 
of  the  ("ar  is  that  by  which  it  is  made  unduly  prominent  and  deflected  outward  or  forward, 
the  eartilaji;e  beini:;  thick  and  abnormally  curved.  Such  orrr/nppliir/  or  ovrrproinincnl 
cars  can  be  made  to  assmne  their  proper  position  on  tin-  side  of  (he  head  bv  the  excision 
of  an  elliptical  piece,  either  of  skin  or  of  skin  and  cartilafj;e,  at  the  point  of  junction  of 
the  ear  and  the  scalp.  The  amoimt  to  be  removed  should  be  projjortionate  to  the 
desired  effect.  The  parts  may  be  brought  together  by  sutures,  and  the  auricle  sliould 
then  be  boimd  upon  the  head. 

Fii^.  895  illustrates  a  common  form  of  defect,  iidierently  of  the  cartilaj^c  and  of  the 
overlyin},'  skin.  This  is  but  one  illustration  of  many,  two  eases  bein<,^  rarily  found 
exactly  alike.    Not  infrecpiently  these 

arrests  of  development    include   the  ^"■-  ^^^ 

structures  of  the  middle  ear  as 
well.  The  auditory  meatus  niay 
be  entirely  covered  and  conceal(Ml, 
or  may  be  absent,  having  failed  to 
develoj). 

Supcrnumerarii  auricles  are  usually 
found  as  small  tags  of  skin  and 
cartilage  in  front  of  or  below  the 
car.  They  are  easily  removed  and 
leave  no  disfiguring  scar. 

The  external  ear  is  also  exposed 
to  injury,  which  it  frequently  re- 
ceives in  the  way  of  contusions  and 
lacerations.  It  is  occasionally  de- 
tached. The  ordinary  wounds  of 
these  parts  require  only  the  conven- 
tional treatment,  while  it  may  be 
possible,  by  replacement  and  ap- 
l)roximation  of  a  completely  detached 
|K)rtion,  to  see  it  re-adhere.  This 
hap{)ened  to  the  writer  after  his 
horse  had  completely  bitten  a  piece 
out  of  the  ear  of  his  groom.  Here, 
as  with  detached  finger-tips,  cleanli- 
ness   is  necessary,    and    the    parts 

must  be  kept  warm  and  protected  after  dressing.  The  cartilage  of  the  ear  is  covered 
by  a  perichondrium  which  corresponds  to  the  periosteum.  Beneath  it,  or  beneath 
the  skin  alone,  l)lood  may  be  extravasated  as  the  result  of  contusions.  When  such 
collections  fail  to  promptly  resorb  they  should  be  incised  and  the  contained  blood 
released.     Such  lesions  are  referred  to  as  tratimatic  othematomas. 

A  peculiar  lesion  of  this  general  character  occurs  occasionally  in  the  insane.  If  due 
to  injury  the  latter  is  but  trifling.  It  makes  a  conspicuous  tumor,  involving  usually 
the  lower  end  of  the  auricle,  and  is  known  as  the  othematoma  of  the  insane.  It  is  scarcely 
amenable  to  surgery,  nor  does  it  often  need  it,  but  it  constitutes  a  disfigurement  which 
is  not  only  easily  ap])arent,  l)iit  diagnostic  as  to  the  cerebral  or  mental  condition. 

The  ear  is  the  site  of  many  neoplasms,  both  innocent  and  malignant  Small  papillomas 
are  common,  while  fibrous  tumors  are  likely  to  develop,  especially  about  the  fibrocar- 
tilaginous lower  end  of  the  auricle,  where  the  ear  has  been  pierced  for  ear-rings.  Keloid 
tumors,  of  still  more  conspicuously  fibrous  nature,  are  common  about  the  ear,  especially 
among  negroes.  All  innocent  tumors  may  be  excised,  through  incisions  which  should 
be  so  planned  as  to  leave  a  minimum  of  disfigurement.     (See  Fig.  397.) 

Of  the  malignant  tumors  epithelioma  is  perhaps  the  most  frequent.  It  pursues  a 
course  here  similar  to  that  which  characterizes  it  elsewhere,  save  that  the  dense  structures 


■H 

■ 

^^^' '  ''''-'' 

Wm 

j^W^^I 

jf  ■■. ' ,                            ""*« 

*  ^^'  1 

Developmental  defect  of  external  ear.      (BruomeJ 


m(\ 


SPECIAL  OR   REGIOSAL   S(  RdERY 


of  the  t;irtila<,nii()U.s  rar  yirkl  but  slowly  to  its  cntToaclimciit.  Tlie  form  known  as 
"rodent  ulcer"  is  slower  here  than  elsewhere.  Fij;.  iilXl  illustrates  a  ease  under  the 
writer's  care,  showing  complete  destruction  of  the  external  ear  by  a  growth  of  this  kind. 


Fig.  390 


Fig.  397 


Complete  destruction  of  auricle  by  rodent  ulcer. 
(Buffalo  Clinic.) 


Congenital  lymphangioma  of  ear. 
(Lexer.) 


which  had  attained  a  degree  and  extent  that  did  not  permit  of  successful  treatment,  and 
which  eventually  |)roved  fatal.  \Yhen  growths  of  this  character  have  not  progres.sed 
too  far  they  should  be  radically  removed,  the  question  of  cosmetic  effect  being  secondary 
to  that  of  their  eradication.  By  a  well-planned  plastic  operation  much  can  be  done  to 
atone  for  disfigurement  resulting  from  radical  operation. 


FOREIGN  BODIES  IN  THE  EAR. 


All  sorts  and  descriptions  of  foreign  bodies  may  enter  the  ear.  Young  children  have 
a  tendency  to  introduce  all  kinds  of  bodies  into  the  ear,  as  into  the  nose,  and  sometimes 
intrude  them  to  such  a  distance  that  their  removal  is  made  difficult.  Living  insects 
make  their  Avay  into  the  meatus  auditorius  and  even  deposit  their  larvse,  which  may 
sulxsequently  go  through  their  developmental  phases  and  fill  the  passage-way  with 
young  insects.  Among  the  inanimate  materials  which  children  introduce  are  small 
buttons,  pebbles,  l)eans,  peas,  beads,  etc.  Such  a  foreign  body  may  not  be  at  once 
discovered,  and  some  of  those  which  easily  undergo  deconij^osition,  like  fresh  vegetabk 
substances,  may  not  be  detected  until  they  have  set  up  trouble  by  decomposition. 
Therefore  it  may  be  hours  or  days  before  its  presence  is  recognized.  Sometimes 
it  may  be  easily  seen,  again  it  may  be  concealed.  When  the  auricle  is  drawn  upward 
and  backward  the  external  meatus  is  somewhat  straightened,  and  bodies  within  it 
are  more  easily  made  visible,  especially  l)y  reflectefl  light.  Therefore  the  head  mirror 
is  usually  required  for  their  detection  and  removal.  The  substance  may  be  one  which 
is  easily  seized  and  withdrawn,  after  certain  turning  or  shifting  motions  have  been 
attempted,  or  it  may  be  im])acted  so  as  to  offer  considerable  difficulties.  It  should  never 
l)e  pushed  farther  in,  for  injury  might  thus  be  done  to  the  membrana  tynipani,  and 
the  effort  should  be  to  remove  it  with  the  least  possible  damage  to  the  lining  of  the 
canal.  So  essential  is  it  to  have  the  head  kept  perfectly  still  fluring  these  maneuvers 
that  it  will  be  advisable,  with  young  children,  to  administer  an  anesthetic.  Instances 
occasionally  occur  which  necessitate  incision  and  liberation  of  the  auricle,  with  its 
deflection  forward,  and  the  consequent  more  complete  exposure  of  the  auditory  canal. 


Tin:  Ml  1)1)1. i:  i:Mi  ^-j 

F<)rcf|)s  (if  various  fasliioiis  may  he  used,  or  occasionally  a  l»liiiit  liook  inav  he  made 
with  a  prohc,  wliicli  may  Ix'  used  to  a<lvaiita};c. 

( )f  liviiii;  f()rci<;ii  liodics  iiit'ormatioii  can  he  ohtaincd  more  pminptlv ,  as  tlic  aiiiioxaiicc 
caused  l)y  tlicir  movements  will  at  once  distiirl*  the  |)atient. 

lleiief  has  often  heen  |)rom|ttly  afforded  hy  filling  the  meatus  with  water  or  j^ivcerin 
as  warm  as  can  he  home,  l)y  wliich  the  insect  is  kille^l,  after  which  it  mav  he  removed 
hy  irrijxalion  or  hy  force|)s,  assisted  l)y  <;ood  illumination. 

That  which  is  essentially  a  forei<;n  hody  may  he  produced  hy  an  arniiiiu/dlioii  of 
cerumen  in  wax-like  form  within  the  auditory  canal.  Xe^k-ctful  j)atients  sometimes 
allow  this  to  accumulate  until  it  constittites  not  only  a  source  of  irritation  hut  an  ohstacle 
to  hearing.  Its  removal  is  not  ordinarily  accompanied  hy  difliculty,  hut  recjuires 
patience  and  often  considerahle  effort,  not  only  with  instruments,  hut  with  irri^ati(»n, 
es|)ecially  with  an  alkaline  solution,  hy  which  the  waxy  suhslance  is  softened. 

A  phenomenon  noted  in  n)any  of  these  cases,  where  instrumentation  has  to  l)c 
|)ractised  within  the  vicinity  of  the  middle  ear,  is  coufjhing  or  snee/in<^,  sometimes  to  a 
detjrce  which  interfen-s  with  the  work  to  he  done.  This  is  a  reflex  to  be  explained  through 
coimectioii  with  the  pneumogastric  nerve. 


THE  EXTERNAL  AI'DITORY  CANAL. 

In  the  fihrocartilaginous  as  well  as  in  the  more  richly  cellular  ptjrlions  of  this  passage- 
way small  phlegmonous  processes  frecjuently  occur.  They  give  rise  to  an  amoimt  of 
suti'ering,  and  even  of  sympathetic  reaction,  disjiroportionate  to  the  extent  of  the  tliffi- 
culty.  They  are  called  furuncles,  or  boils,  sometimes  occurring  singly,  often  in  groups. 
A  commencing  jirocess  of  this  kind  may  he  cut  short  by  the  use  of  an  ointment  of  1  to 
2  per  cent,  yellow  sulphate  of  mercury,  but  after  the  furuncle  is  well  develo})ed  it  is 
best  treated  by  free  incision,  which  can  be  made  with  the  freezing  spray,  and  without 
much  pain  to  the  patient. 

More  extensive  ])hlegmonous  destruction,  assuming  even  carbimcular  form,  is  occasion- 
ally met  witli  in  this  region.  There  will  be  more  or  less  necrosis  of  tissue  in  such  cases, 
which  will  require  removal,  usually  with  the  sharp  spoon.  These  cases  are  not  without 
their  danger,  since  the  veins  connect  so  freely  with  the  interior  of  the  cranium. 

Hifperostosis  and  exostosis  produce  either  a  narrowing  of  the  auditory  canal  or  its 
complete  obstruction,  and  sometimes  even  the  formation  of  an  osseous  tumor  of  con- 
siderable size.  A  thickening  and  even  new  formation  of  bone  may  be  the  result  of  the 
chronic  irritative  processes  which  frequently  occur  in  the  middle  ear,  but  many  of  these 
conditions  occur  in  the  newborn,  in  whom  they  are  to  be  regarded  as  congenital  excesses 
antl  in  whtjm  they  frequently  cause  permanent  impairment  or  loss  of  hearing.  Some 
of  the  osteomas  in  this  region  are  of  bone-like  hardness,  their  density  Ijeing  sufficient 
to  dull  or  even  to  break  the  finest  temj:)ered  steel  instruments. 

A  small  exostosis  may  be  removed  with  the  ordinary  instruments  of  the  surgeon  or 
the  dental  engine,  but  the  larger  and  more  dense  growths  offer  formidable  difficulties 
for  the  operator  and  uncertain  results  for  the  patient.  When  growths  of  this  kind  attain 
considerable  size  they  should  not  Ix"  attacked  through  the  natural  passages,  but  the 
auricle  should  be  separated  and  pushed  forward  and  the  auditory  canai  opened. 


THE  MIDDLE  EAR. 

The  middle  ear  has  for  its  external  boundary  the  membrana  tMnpani,  which,  for 
clinical  purposes,  constitutes  a  limit  beyond  which  the  general  surgeon  should  not 
trespass,  the  structures  within  being  those  within  the  field  of  the  aural  surgeon.  Never- 
theless the  student  of  surgery  should  realize  that  the  membrane  of  the  drum  may  be 
ruj)tured  in  consequence  of  a  blow  upon  the  external  ear,  or  perhaps  by  the  suflden 
condensation  of  air  produced  by  explosions,  etc.  It  may,  moreover,  Ije  lacerated  in  con- 
sequence of  various  injuries  to  the  head,  basal  fractures,  etc.,  even  those  involving  the 
opposite  side  of  the  head;  it  may  also  be  injured  by  foreign  bodies,  introduced  usually 
from  without  and  through  the  canal.     While  this  membrane  has  normally  an  opening 


608  SPECIAL  OR  RKGIO.XAL  SCRGKRY 

by  vvliicli  air  prcsKuri"  is  iHjiializcd  on  citlicr  side,  tlii ;  sccins  to  play  hiit  a  small  part  in  the 
lial)ility  to  or  ('xemj)tion  from  injury  such  as  just  (lescrihcd.  'J'lic  mcmhranc  has  its 
own  blood  supply,  which  can  become  congested  to  a  degree  permitting  considerable 
escape  of  blood  after  laceration.  It  (lo(>s  not  follow  that  l)leediiig  from  the  ear  is  neces- 
sarily an  indication  of  basal  fracture,  after  injuries  of  the  head,  unless  the  hemorrhage  is 
continuous  and  considerable,  in  which  case  it  may  be  stated  that  the  injury  must  be 
dee]>er  and  more  extensive  than  one  of  the  membrane  alone.  If,  however,  cerebrospinal 
fluid  can  be  detected  as  esca])ing  with  and  diluting  the  blood,  or  escaping  intlependently, 
then  the  diagnosis  of  basal  fracture  may  be  regarded  as  certain. 

After  such  injuries  as  lead  to  hemorrhages  from  the  ear  th<>  external  auditory  canal, 
should  be  irrigated  and  ])r()tected  against  infection  by  light  tam])oning,  etc. 

It  is  the  writer's  opinion  that  the  general  surgeon  should  abstain  from  operative 
intervention  in  the  ordinary  diseases  of  the  middle  ear,  save  in  the  presence  of  symptoms 
which  accompany  mastoiditis,  acute  infections  of  the  sinuses,  or  even  of  the  brain  itself. 
When  it  comes  to  an  extensive  operation,  such  as  is  often  requin^d  in  such  instances, 
including  not  men^ly  oj^ening  of  the  mastoid  antrum  and  cells,  but  exi)()sing  the  dura 
and  judging  of  the  condition  of  the  siniis,  with  })erhaj)s  the  simultaneous  ligation  of  the 
jugular  in  the  neck  and  washing  out  of  the  intervening  portion,  then  these  are  measures 
requiring  such  surgical  judgment  and  operative  skill  that  it  would  seem  that  tlie  general 
surgeon  should  be  ])eculiarly  equi{)ped  for  this  task.  But  the  ordinary  office  operations 
should  be  left  to  those  who  make  a  sjH'cialty  of  these  diseases. 

When  the  cavity  of  the  tympanum  is  involved  in  a  suj)purative  condition,  with  caries 
of  the  surrounding  bone  and  extension  into  the  spongy  tissue  of  the  adjoining  mastoid,  this 
abscess  cavity  shoidd  be  cleaned  out.  Therefore  the  more  radical  operations  of  the 
aurist,  by  which  the  membrana  tympani  is  destroyed,  the  ossicles  of  the  ear  removed, 
etc.,  are  but  api)li(ations  of  broad  surgical  })rinciples  to  a  limited  region  of  the  body, 
but  made  justifiable  by  their  results.  Moreover,  in  a  more  chronic  type  of  cases,  where 
the  tympaninn  is  filled  by  redundant  granulation  tissue  and  by  ])olypoid  formations, 
which  are  jiroducing  more  or  less  circumscribed  caries  or  necrotic  ])roce.sses  in  the  bone, 
by  which  bony  ]>artitions  between  the  cranial  cavity  antl  the  ear  ])rop(>r  are  gradually 
thinned  or  lost,  and  by  which  encroachment  on  the  intracranial  simis(\s  with  all  its  dangers 
is  incurred,  they  are  still  to  be  subjected  to  the  same  general  radical  methods  of  treat- 
ment, no  matter  whether  it  be  carried  out  by  a  specialist  or  a  general  operator. 

THE  ACCESSORY  CRANIOFACIAL  SINUSES. 

While  these  cranial  cavities  are  connected  with  the  respiratory  tract  there  are,  never- 
theless, good  topographical  and  physiological  reasons  for  considering  their  lesions  in 
this  j)lace.  There  is  free  venous  communication  between  each  of  them  and  the  cranial 
cavity,  and  free  lymphatic  communication  as  well  from  at  least  three  of  them.  Infection, 
therefore,  may  and  often  does  travel  from  the  smaller  to  the  greater  cavity,  and  thrombo- 
phlebitis, brain  abscess,  or  jjurulent  meningitis  may  be  the  ultimate  result  of  apparently 
trifling  infection  of  one  of  the  sinuses. 

They  are  four  in  number — the /roH/a/,  the  ethmoidal,  the  sphenoidal,  and  the  mamillary, 
or  antrum  of  Highmore.  They  are  all  connected  with  the  nasal  cavity,  and  all  lined 
with  the  same  Schneiderian  membrane,  which  affords  a  continuous  ])athway  of  infection. 
At  least  two  of  them  are  cellular  in  character,  much  resembling  the  mastoid  cells.  Their 
means  of  communication  with  the  nasal  cavity  are  small,  and  often  obstructed  by 
catarrhal  swelling  and  inspissated  discharge.  If  thus  plugged  their  retained  contents 
may  undergo  decomjjosition  and  intensify  the  trouble.  It  has  been  shown  that  the 
effect  of  inward  currents  of  air  through  the  nostrils  is  to  suck  out  from  these  sinuses 
more  or  less  of  their  secretion.  In  this  way  perhaps  may  be  accounted  for  the  strings 
of  tenacious  mucopus  which  slowly  make  their  way  out  of  especially  the  anterior  sinus 
openings.  Some  surgeons  believe  that  if  one  sinus  is  affected  all  the  others  on  that 
side  of  the  head  are  more  or  less  involved;  while  this  may  be  true  in  many  cases,  and 
is  easily  explained  on  anatomical  grounds,  it  is  not  strictly  true  of  all  instances,  lea.st  of 
all  in  cases  of  chronic  empyema  of  the  antnnn,  which  often  long  remains  simple  and 
uncomplicated. 

Surgical  lesions  within  the  accessory  sinuses  result  from  infective  processes,  proceed 


THE   AC('i:SS<)lxY    CHASIOFACIAL   SIXCSKS  0()9 

ot'ttMi  to  sii|)|»iii';iti(Hi,  ol'tfii,  ((to,  willi  caries  of  (lie  siirroiiiidiiij,'  si>oiij;y  Itoiic  as  well. 
Those  coiiditioiis  may  result  from  the  onliiiarv  acute  cati'rrhs,  or  follow  the  more  spccilic 
fevers,  like  iuHueiizu  aud  thi"  exanthenis,  aud  fre(|ueiitly  follow  di])htheria.  Traumatic 
causes  may  also  eouspire  to  produce  the  same  eilVct.  lu  the  maxillary  sinus  disease  is 
often  ihw  to  extension  upward  from  carious  teeth.  In  syphilitic  aud  tuberculous  patients 
these  alVections  will  i)artake  to  a  }j;reater  or  less  degree  of  the  specific  nature  of  these 
dist-ascs. 

Si/>ii pfdiiis  (hllei"  aecordin*;  to  location  and  arc  often  obscure  en(»n(i;h  to  make  diajf- 
nosis  diilicult.  Perhaps  the  most  prominent  symptom  is  jxiin,  either  dee|)-seate(l, 
vaijue,  or  disciuii'tinjj;,  located  in  the  nci<;hl)orhood  of  the  diseased  simis;  or  intense  and 
neuralijic  in  cliaract(>r,  ra(liatin<j  from  the  sourc(>  of  the  trouble.  Its  severity  is  propor- 
tionate to  the  acnteness  of  the  case.  When  tlu>  frontal  and  maxillary  sinuses  are  in- 
volved there  occur  i-xternal  swclliiif^  and  tendt>rness.  If  the  sinus  opiMiings  be  patulous 
ther(>  will  b(>  more  or  less  purulent  dischar<!;e  into  the  nasal  cavity,  that  which  comes 
down  fnun  the  upper  sinuses  ap])earing  beneath  the  middle  turbinate  body.  Trans- 
illumination by  means  of  a  small  electric  light,  passed  into  the  nostril,  will  demonstrate 
an  opacity  in  the  region  of  the  ailVcti'd  sinus  which  docs  not  ap])car  on  the  healthy  side. 
The  coiuiition  is  fre(}uently  associat(-d  with  nasal  polyj)!,  small  or  large;  while  granula- 
tions in  time  sj^ring  up  within  these  cavities  and  may  even  esca])e  therefrom  as  these 
become  filled.  'I'lie  giMicral  clinical  picture  is  one  of  nasal  obstruction,  with  more  or 
less  constant  discharge,  sometimes  mucopurulent,  sometimes  offensive,  which  ])erhaps 
may  be  favored  by  certain  positions  of  the  head,  this  being  especially  true  of  the  maxil- 
larv  antrum.  Along  with  tluvse  features  go  a  degree  of  headache,  of  local  pain,  and  even 
(jf  mild  or  severe  febrile  disturbances,  proportionate  to  the  severity  of  the  lesions  which 
produce  them. 

When  the  anterior  ethmoid  cells  are  involved  pain  is  usually  referred  to  the  temj)les 
rather  than  the  forehead,  though  both  may  sufi'er  alike. 

Treatment  should  be  bas(Hl  upon  the  fact  that  we  have  affected  and  infected  cavities 
whose  interiors  an-  diseased,  and  whose  outlets  are  blocked.  The  more  free  and  thorough 
the  drainage  and  the  cleansing  which  can  be  given,  the  more  prom])t  the  results.  In 
all  well-marked  cases,  then,  radical  treatment  is  indicated.  The  ordinary  treatment  by 
sprays,  inhalations,  etc.,  is  useless,  as  the  source  of  the  trouble  is  not  reached. 

Special  treatment  for  each  sinus  will  now  be  considered. 

Frontal  Sinus. — Most  of  the  symptoms  of  affection  of  the  frontal  sinus  are  objective, 
and  there  is  frequently  external  swelling,  with  tenderness  and  edema.  P'or  its  relief 
intranasal  methods  will  often  suffice.  In  almost  all  cases  we  may  expect  to  find  hyper- 
tro])hic  conditions  within  the  nose.  When  empyema  exists  there  is  often  a  deviated 
septum.  It  is  impossible  to  avoid  the  conclusion  that  there  is  a  strong  relation  between 
hypertrophic  lesions  and  sinus  retention.  The  difficulty  may  arise  from  many  causes, 
most  of  which  lead  to  sneezing,  coughing,  and  hacking,  by  which  the  mucous  membrane 
of  the  nasopharynx  is  both  thickened,  loosened,  and  predisposed  to  polypoid  changes. 
The  irregularities  thus  produced  harbor  more  germs  than  usual  and  their  effect  is,  in 
a  measure,  proportionate  to  their  numbers.  For  the  examination  of  the  upper  part 
of  the  nasal  cavity  Killian's  speculum  is  of  great  help. 

The  frontal  sinus  differs  very  much  in  shape  and  size,  not  only  in  different  individuals 
but  on  opi)osite  sides  of  the  same  individual.  It  may  be  rudimentary  upon  one  side 
and  large  upon  the  other.  It  is  usually  more  capacious  in  those  individuals  who  have 
prominent  foreheads  and  resonant  voices.  Here,  as  elsewhere,  it  will  usually  be  found 
that  the  most  radical  operation  is  the  best,  although  one  endeavors  naturally  to  preserve 
cosmetic  features  of  the  nose,  so  far  as  he  can,  without  sacrificing  the  patient's  interests. 
The  nasopharyngeal  duct  is  so  often  connected  with  the  ethmoidal  cells,  as  well  as  the 
frontal,  that  the  form(>r  may  be  easily  affected  when  the  frontal  sinus  is  diseased. 

In  case  of  sinus  disease,  especially  when  the  frontal  sinus  is  involved,  it  is  better  to 
encourage  patients  to  snuff  materials  back  into  the  throat  rather  than  to  forcibly  blow 
the  nose  or  expectorate  them,  as  the  latter  would  tend  to  force  into  the  sinus  that  which 
it  would  be  better  to  have  aspirated  out  of  it. 

The  frontal  sinuses  may  be  attacked  from  within  the  nose  or  externally.     It  is  perhaps 

the  least  open  to  mild  and  conservative  treatment,  as  it  is  the  most  difficult  of  access  by 

non-operative  methods.     The  anterior  ethmoid  cells  are  usually  connected  with  it  and 

infection  rarely  spares  one  part  to  involve  the  other  alone.     Therefore  if  it  be  necessary 

39 


010  SPECIAL  OR  RKGIOSAL  SURGERY 

to  ojKTate  oil  tlic  frontal  sinus  the  anterior  and  ui)|)cr  (•ells  >Ih)ii1(I  he  e.\])osr(l  at  the 
same  time.  Thus  o|)erations  which  have  for  their  ohject  continuous  (]rainaf;e  have 
usually  as  an  ol)jection  the  necessity  for  wearing;  the  (lrairui<je  tulje  for  months.  After 
opening  the  sinus  from  without  the  nasal  duct  may  he  enlarged  to  any  size  and  desired 
degree,  and  a  tube  inserted  which  .shall  afford  amj)le  drainage  downward.  This  may 
be  covered  with  a  flaj)  and  allowed  to  remain  for  a  number  of  weeks.  Nevertheless  it 
is  a  foreign  body  which  has  to  be  subsequently  removed  from  the  no.se.  Killian's 
method  is  doubtless  the  best  for  most  ca.ses,  as  the  most  anterior  of  the  ethmoid  cells, 
and  tho.se  which  extend  over  the  orbits,  cannot  be  easily  reached  through  the  no.se,  and 
if  disea.se  involve  the  posterior  ethmoid  cells  its  extension  to  the  sphenoid  may  be  ex- 
pected. The  operation  includes  an  incision  from  the  tem})oral  end  of  the  shaved  eye- 
brow, along  its  curve  to  the  side  of  the  nose,  and  down  to  the  middle  of  the  nasal  processes. 
The  ])eriosteum  is  divided  along  a  line  a  little  higher,  and  again  in  the  centre  of  the  frontal 
process,  the  intent  being  to  so  remove  it  that  a  bony  bridge  may  be  left  after  removal  of 
the  anterior  lower  wall  of  the  sinus.  The  first  periosteal  incision  should  correspond  to 
the  upper  border  of  this  bridge,  either  above  or  below  it.  The  sinus  is  opened  at  first 
Avith  a  chisel,  afterward  with  bone  forceps  or  surgical  engine.  It  is  then  completely 
scra])ed  out,  leaving  the  supra -orbital  ridge  for  a  Ijridge.  Its  floor  is  resected  along  with 
the  fnjntal  process  of  the  superior  maxilla.  Through  this  opening  the  anterior  and 
middle  ethmoid  cells  may  be  reached  and  cleaned  out  to  the  middle  turbinate.  The 
ethmoid  cells  may  then  be  attacked,  the  sphenoidal  cells  inspected,  and  also  attacked  if 
necessary.  The  opening  into  the  nose  should  be  made  free,  and  a  fla])  shoukl  be  formed 
from  the  nasal  mucojx'riosteum,  .so  that  there  may  remain  a  permanent  opening  of 
sufficient  size.  This  method  may  be  modified  to  suit  various  needs.  After  doing  all 
the  work  necessary  the  external  wound  is  closed,  with  a  tube  for  drainage,  while  the 
formation  of  the  bridge  above  alluded  to  prevents  much  of  the  sinking  in  of  the  anterior 
wall  of  the  sinus,  which  would  otherwise  occur.  If  the  little  pulley  over  the  superior 
obli(jue  muscle  has  been  interfered  with  in  the  operation  or  loo.sened  from  its  attach- 
ment there  will  be  at  least  temporary  and  perhaps  permanent  diplopia.  This  should 
be  carefully  avoided.  There  is  also  danger  of  injury  to  the  contents  of  the  orbit.  For 
some  time  after  the  operation  there  will  be  some  drooping  of  the  upper  lid.  Nevertheless 
the  results  are  usually  satisfactory.  After  the  operation  the  patient  should  be  permitted 
to  lie  upon  the  healthy  side  and  be  forbidden  to  blow  his  nose ;  he  should  rather  attempt 
to  aspirate  the  fluid  from  the  wound.  If  necessary  both  sinuses  can  be  attacked  at  the 
same  time  and  after  the  same  fashion,  the  septum  being  removed. 

Here  as  with  the  other  sinuses  the  test  of  the  efficacy  of  the  treatment  will  be  furnished 
by  relief  of  the  headache,  pressure,  and  pain.  Should  carious  or  necrotic  bone  be  ex- 
posed, or  should  there  be  indications  of  malignancy,  much  more  radical  surgery  would 
be  indicated. 

The  Ethmoidal  and  Sphnioidal  Cells. — For  the  exposure  of  these,  especially  the  latter, 
it  is  necessary  t(j  make  ro(jm  for  work.  This  would  be  true  even  in  normal  cases,  and 
is  still  more  so  when  the  parts  are  hypertroj)hied  and  the  passage-way  is  obstructed. 
It  is  necessary  at  least  to  remove  all  deviated  portions  of  the  nasal  septum,  and  to  clear 
away  not  only  all  hypertrophies  of  the  turbinates,  but  to  remove  more  or  less  of  these 
bones.  With  a  free  passage-way  it  is  possible  to  expose  the  opening  of  the  sphenoidal 
cells,  whose  anterior  wall  may  then  be  broken  down,  after  which  granulations  may  be 
removed  with  an  appropriate  small  spoon,  or  the  purulent  contents  cleaned  out  with 
swabs. 

In  dealing  with  the  ethmoidal  cells  by  intranasal  methods  it  is  necessary  to  break 
down  the  sUglit  com})artments  between  them,  one  after  another,  because  of  the  fact 
that  they  all  constitute  foci  of  disea.se.  An  o{)ening  at  least  2  Cm.  in  length  will  usually 
Ije  recjuired,  and  can  be  comfortably  made,  under  suitable  illumination,  if  all  obstruc- 
tions have  been  removed;  after  this  a  probe  is  gently  pas.sed  upward  and  alongside  of 
the  nasal  .septum  until  it  rests  against  the  ethmoid,  then  passed  backward  until  it  meets 
the  posterior  wall,  which  will  be  in  the  immediate  neighborhood  of  the  sphenoidal 
opening,  through  which,  by  gentle  mani{)ulation,  it  may  he  passed.  At  this  point  the 
presence  of  ])oly])S  or  a  greatly  thickened  mucosa  may  Ix"  detected  by  palpation  with 
the  finger  within  the  na.sopharvnx,  while  should  pus  be  removed  by  the  end  of  the  probe  it 
would  indicate  empyema  of  this  cavity. 

In  all  these  accessory  nasal  sinus  examinations  and  operations  the  greatest  aid  will  be 


Till-:   ACCESSORY    Ch'AMOFACf AL   SIXCSES  Oil 

iilVonlcd  hy  cocaiiU'  Sdhitioii,  which  has  the  doiihlc  a(lvaiita<j('  of  not  merely  aholishiiij^ 
sensation,  hut  of  ( ontraetinj;  and  reiiderinji;  anemic  the  mucous  memhraiies,  and  thus 
to  a  certain  extent  shrinkinj,'  them.  \Vhen  necessary  for  this  latter  purjjose,  or  for  the 
control  of  hemorrha<:e,  adrenalin  may  he  added  to  the  cocaine.  For  all  these  purposes 
a  spray  of  a  mild  solution  may  he  first  used,  for  its  general  henumhing  ell'ect,  after 
which  it  would  he  advisable  to  use  a  str()n<;  solution,  even  saturated,  very  s|)ariiigly, 
ap])lyinf;  it  hy  the  aid  of  illumination  just  to  the  area  where  the  effect  is  desired,  and 
not  allowino;  it  to  come  in  contact  witii  other  parts  of  the  nasal  cavity;  this  i.S  done  to 
avoid  unj)leasant  sym|)toms  from  cocaine  al)sorption.  Another  henefit  obtained  from 
the  use  of  cocaine  is  in  thus  ai)olishin<;  sensation  to  an  extent  which  does  away  with  reffex 
vasomotor  symptoms,  shock,  etc.  Therefore  even  when  a  <ieneral  anesthetic  is  used 
it  will  he  Well  to  use  at  least  a  small  amount  of  it  for  this  latter  j)ur|)ose. 

The  c|uestion  of  instruments  and  of  methods  will  depend  nuich  on  the  equipment  of 
the  operator  anil  his  exjx'rtness  in  the  necessary  techni(|ne. 

21tc  Ma.villarij  Aiitnini  of  JJIgltmore. — This  is  the  lartjest  of  the  accessory  sinuses, 
the  most  easily  approached,  and  the  one  w'hose  tlisturhance  is  mtxst  quickly  and  easily 
appreeiatcd.  It  may  he  infected  by  continuity,  along  the  Schneiderian  membrane 
which  lines  it,  or  by  extension  upward  of  disease  from  carious  teeth,  as  well  as  after  a 
variety  of  injuries  involving  its  integrity.  So  long  as  its  opening  into  the  nose  be  not 
plugged  it  will,  when  involved  in  catarrhal  or  supjnirative  inflammation,  discharge 
into  the  latter  a  characteristic  fluid,  which  is  especially  likely  to  escape  when  the  head 
is  held  downward  and  to  the  opj)osite  side.  Any  statement  of  this  fact,  couf)led  with 
evidences  of  local  inflammation,  should  enable  an  easy  recognition  of  antral  disease. 
In  more  chronic  cases  it  becomes  blocked  by  thickening  of  its  membrane,  the  production 
of  granulations  or  of  polypi,  which  sometimes  completely  fill  it.  AVhen  thus  plugged  and 
filled  there  is  a  tendency  to  protrusion  of  its  anterior  outer  wall  and  floor,  while  the 
overlying  cheek  may  become  somewhat  edematous,  the  parts  at  the  same  time  being 
tender.  The  pain  from  a  diseased  antrum  will  often  induce  the  patient  to  go  to  the  dentist 
for  extraction  of  a  molar  tooth,  which,  however,  afl'ords  little  relief. 

The  relief  for  chronic  antral  disease  is  surgical,  as  in  the  case  of  the  other  sinuses. 
Opening  the  antrum  through  a  tooth  socket  would  seem  judicious  only  when  a  diseased 
tooth  is  the  cause  of  the  lesion.  It  is  useful  only  for  such  otherwise  uncom|)licated 
cases.  The  argument  usually  used  in  its  favor  is  that  it  affords  better  drainage.  This, 
however,  is  not  the  case,  since  the  position  assumed  by  the  head  for  the  greater  part 
of  the  time  does  not  locate  such  an  opening  in  the  most  dependent  part  of  the  caAity. 
Moreover,  the  discharge  is  not  always  fluid,  nor  does  it  flow  freely;  on  the  contrary  it 
is  often  thick,  and  so  adherent  to  the  wall  or  roof  of  the  cavity  that  it  takes  a  strong 
irrigating  stream  or  swab  to  dislodge  it.  If  the  antrum  is  to  be  opened  through  the 
mouth  it  would  seem  more  surgical  to  open  it  wiflely,  cleanse  it,  and  then  either  drain 
it  or  close  it  again.  Other  things  being  equal,  the  best  method  is  that  which  permits  of 
both  examination  and  subsequent  treatment.  Jansen's  method  is  frequently  most 
serviceable.  It  includes  careful  cleansing  of  the  teeth,  with  disinfection  of  the  mouth, 
and  walling  off  the  area  to  be  exposed  by  gauze  strips  in  order  to  prevent  hemorrhage 
into  the  throat.  An  incision  is  made  through  the  anterior  mucoperiosteum,  beneath 
the  floor  of  the  antrum,  from  the  first  incisor  to  the  first  molar.  Its  edges  are  then 
separated  and  the  entire  front  wall  of  the  antrum  removed.  Through  such  an  opening 
its  interior  can  be  carefully  inspected  and  cleansed.  Should  it  seem  desirable  to  go 
farther  the  inner  wall  may  be  removed  by  forceps,  and  through  this  oi>ening  the  eth- 
moid cells  can  be  seen  and  curetted  up  to  the  insertion  of  the  middle  turl)inate.  Then 
the  sphenoid  surface  can  be  inspected  and  the  lower  portion  of  the  sphenoid  cells  resected. 
Finally  a  good-sized  counteropening  is  made  inward,  onto  the  floor  of  the  nose,  the 
antrum  is  loosely  packed,  the  ends  of  the  gauze  extending  into  the  nose,  and  the  muco- 
periosteal  wound  closed,  in  order  to  secure  primary  union.  All  bone  edges  should 
be  made  smooth  and  non -irritating;  the  sphenoidal  cells  should  not  be  packed,  but 
left  open  for  subsequent  treatment. 

In  the  presence  of  bone  disease,  malignant  growth,  etc.,  it  may  not  be  possible  to 
shut  oft"  the  mouth  again  from  the  antral  cavity.  In  such  cases  the  packing  may  be  made 
more  snug  and  the  granulation  process  will  have  to  be  sul)stitute(l  for  sutures. 

Sjjecial  flaps  or  plastic  methods  should  be  devised  for  sj^ecial  cases,  as,  for  instance, 
the  formation  of  a  mucoperiosteal  flap  from  the  outer  side  of  the  antral  wall  and  its 


612  SPECIAL  OR  RKaiONAL  SURGERY 

union  posteriorly  within  the  eavity  of  the  antrum  with  another  made  from  the  antral 
floor.  By  tin-ning  the  latter  in  the  necessary  direction  a  line  of  suture  may  be  made 
thr()U<i;h  the  mouth.  Any  such  cavity,  Vmg  diseased,  will  call  for  a  radical  method  of 
attack  and  opcninjr,  which  latter  can  be  maintained  to  ])ermit  of  subse<|uent  treatment, 
as  an  early  closure  would  sometimes  be  undesirable.  Antral  cavities  thus  left  more  or 
less  op(Mi  should  l)c  treated  with  clcansino;  sj)rays  or  a])j)lications,  and  with  such  stimu- 
lating'; applications  as  silver  nitrate  in  various  strengths  of  solution,  or  similar  antiseptic- 
stimulants. 

THE  CRANIAL  NERVES. 

While  most  of  the  affections  of  tlie  nerves  are  considered  to  be  non-operative,  and  to 
belong  rather  to  the  internist  than  to  the  surgeon,  there  are,  nevertheless,  some  nerve 
lesions  which  are  only  to  be  relieved  l)y  surgical  intervention.  These  may  be  divided 
into:  (1)  Wounds  and  irt juries.  (2)  Morbid  condilions,  such  as  (a)  neuralgia,  and 
{h)  muscle  spasm. 

WOUNDS  OF  THE  NERVES. 

Wounds  of  nerves  have  been  considered  in  the  chapter  on  Wounds,  and  the  possibility 
of  nerve  regeneration  and  repair  therein  discussed.  In  every  division  of  a  nerve  trunk  of 
importance  or  size  the  nerve  ends  should  be  trimmed  and  reunited  by  a  suture,  passed 
either  through  the  sheaths  or  through  the  nerve  itself.  The  ends  should  l)e  brought 
together  securely  and  the  tension  should  not  be  too  great.  If  this  be  promptly  done 
the  best  of  results  may  be  expected.  This  is  equally  true  of  cranial  antl  peripheral 
nerves.  Clinical  experience  has  long  since  established  the  necessity  of  this  procedure 
after  all  such  injuries,  and  nerve  suture,  or  neurorrhapliy,  is  now  a  standard  operation. 
Later  there  was  added  to  this  measure  the  analogous  one  of  nerve  (/raffing,  and  it  has 
been  found  that  nerves  can  be  juggled  with  just  as  can  tendons,  as  tlescribed  in  the 
section  on  Tendon  Suture.  Indeed  the  methods  of  nerve  suture  and  nerve  grafting  are 
strikingly  similar  to  thos(»  emjiloyed  with  tendons,  where  can  be  made  either  end-to-end 
juncti(jn,  lateral  implantation,  or  a  more  properly  termed  grafting,  a  trimmed  end  of  one 
nerve  being  inscrttMl  into  another.  In  the  arm,  when  the  ulnar  nerve  has  been  caught 
in  callus  and  completely  destroyed,  l)otli  the  upi)er  and  lower  portions  may  be  grafted 
into  one  of  the  adjoining  nerves,  e.  g.,  the  median;  this  procedure  seems  to  reestablish 
conununication  and  serve  the  double  ])ur])ose,  in  a  manner  corrcsi)onding  to  duplex 
or  cjiuulruplex  telegraphy  over  one  wire.  Nerves  which  have  been  divitk'd  and  en- 
tangled in  scars  may  be  disengaged,  their  ends  trimmed  off  and  apjiroximated,  success 
being  ])roportionate  to  the  length  of  time  tluring  which  nerve  degeneration  may  have 
been  taking  place. 

Another  operation  is  practised  on  nerves,  solely  for  the  n  lief  of  ])aiiifr.l  or  disturbing 
symptoms,  i.e.,  neurertoniy.  In  cases  of  intractable  and  hojxlcss  neural";ia,  where 
other  measures  fail,  sensory  or  complex  nerve  trimks  are  t!ivid(-d,  a.  ])ortion  of  the  con- 
tinuity being  resected.  This  operation  is  practised  more  often  upon  the  trifacial  nerve 
than  upon  all  others.  It  is  generally  successfid,  but  in  those  cases  where  ])ain  is  due  to 
some  central  lesion  it  is  often  palliative  rather  than  curative.  In  the  case  of  the  trifacial 
nerve  the  operator  endeavors  to  be  as  radical  as  possible  in  its  practice,  and  to  remove 
the  Gasserian  ganglion  rather  than  portions  of  any  of  its  branches. 

The  neuralgia  for  which  these  operations  are  performed  may  be  due  either  to  central 
or  constitutional  causes,  as  well  as  to  local  irritations,  compressions,  or  degenerations. 
The  term  neuralgia  itself  is  so  vague  and  covers  such  widely  differing  changes  that 
nothing  which  can  be  said  in  this  ])lace  woidd  clear  u))  the  problems  of  its  ]:)athology; 
conse(|uently  attention  will  be  directed  here  solely  to  its  surgical  relief  in  connection 
with  the  various  nerve  trunks  which  are  usiuilly  attacked. 

One  other  operation  is  practised  u])on  nerves  for  the  relief  of  pain  and  spasmodic 
affections — namely,  nerve  stretching,  or  nerve  elongation.  This  is  practised  nion^  often 
upon  the  sciatic  than  up^on  any  other  nerve,  but  has  been  done  for  the  reli(4'  of  choreic 
spasm  of  the  arm  and  shoulder,  by  exposing  and  stretching  the  various  cords  of  the 
brachial  plexus,  for  the  relief  of  spasmodic  torticollis,  and  in  various  other  places. 


WOIWDS  OF  Tlfh   .V /•;/.' i7;,s 


G13 


Fig.  398 


Nusshaiiiu    was    the    first  to   note  tluii  ohsliiiatc  intercostal   neuralgia  was  rclicvi  d   hv 
accidental  stretchinjj  of  an  intercostal  nerve,  and  introduced  tlie  procednre. 

Operations  upon  nerves,  then,  include  mifuir,  (jrajfiiu/,  .stnlrhiiuj,  (livi.sion,  and 
rcsrriio)!.  Al'ttM-  any  operation  upon  a  nerve  trunk  the  ])arls  pertaininj^  to  it  slu.uld  he 
placed  in  a  |)osition  ol"  rest;  and,  furtlicnnore,  such  position  as  will  prevent  stretchiiifj 
and  favor  relaxation  of  the  sutured  trunk  should  he  maintained.  The  writer  is  credited 
with  tlu>  first  |)riinarv  suture  of  the  sciatic  nerve,  which  was  done  inunediately  after  its 
accidental  division,  duriiitj;  the  course  of  an  extensive  operation,  iiecoverv  was  prompt 
and  eoni])lete.  The  liuih  was  iiuinohilized  in  the  extended  position  and  physioloi^ical 
rest  thus  maintained. 

Nerves  can  be  stretched,  it  has  hceii  found,  to  one-twenlielh  of  tli(  ir  Icnjrth.  Nerve 
trunks  hav(>  much  more  strnigth  than  has  been  <i;encrally  ap|)i-c(iale<l.  'I'he  s(  iatic  trunk 
of  a  full-iirown  individual  will  l)ear  a  stress  of  more  than  eii^hty  ])()unds,  while  even  six 
pounds'  pull  are  nec(\ssary  to  tear  the  suj)ra-orl)ital  nerve.  'I'he  benefit  which  follows 
nerve  ( lonontion  is  ascribed  to  the  improvement  in  its  nutrition  produced  by  the  damaj^e 
done  to  its  substance,  and  the  consc-ciuently  enhanced  blood  supply,  as  well  as  to  the 
severin<i'  of  adhesions  between  tlu>  sheath  and  its  surroundin<rs  an(l  betwei'u  the  nerve 
bundles  within  the  sheath. 

The  ojieration  of  nerve  stretchino"  consists  simj)ly  in  exposin<r  the  nerve  at  a  site  of 
election,  detaching  it  from  its  surroundings,  and  then  hooking  either  the  finger  or  some 
smaller  instrument  beneath  it  and  pulling 
firmly,  yet  gi-ntly,  in  both  directions;  in  the 
case  of  the  sciatic,  for  instance,  the  entire 
limb  should  be  lifted  from  the  table,  and  even 
this  does  not  entail  u])on  the  nerve  trunk 
anywhere  near  a  breaking  force. 

The  cranial  nerves  are  sought,  found,  and 
treated  as  follows,  in  their  respective  cases : 

Tlie  supra-orhital  nerve  is  attacked  at  its 
exit  from  the  supra-orbital  notch,  which  can 
usually  l)e  felt,  or  foramen,  when  such  exists, 
either  by  a  straight  incision  made  directly 
over  it,  where  it  can  be  felt,  or  by  a  curved 
incision  through  the  region  of  the  eyebrow, 
which  should  have  been  shaved  for  the  pur- 
pose, the  resulting  scar  being  hidden  by  the 
hair  as  it  grows  again. 

The  infra-orbifal  nerve  is  similarly  treated 
at  the  infra -orbital  foramen,  where  it  lies 
under  the  levator  labii  superioris.  It  may  be 
exposed  by  either  a  curA^ecl  incision,  parallel 
to  the  orbital  margin,  or  by  a  vertical  inci- 
sion, which  will  leave  a  more  disfiguring  scar. 
Tlie  second  branch  of  the  fiftJi  nerve  may 
be  attacked  from  the  front  by  Chavasse's 
modification  of  Carnochan's  original  method,  consisting  of  a  T-shaped  incision  from 
one  corner  of  the  eye  to  the  other,  the  vertical  branch  extending  from  its  middle  well 
down  to  the  mouth.  After  the  infra-orl  ital  nerve  is  identified  it  is  secured  with  a 
piece  of  silk.  The  anterior  wall  of  the  antrum  is  then  removed,  the  cavity  opened,  and 
a  small  trejihine  applied  to  its  posterior  wall.  The  nerve,  being  exposed  in  its  canal  or 
groove,  is  divided  anteriorly,  j)ulled  down  into  the  cavity  by  means  of  a  ligature  pre- 
viously ap])lied  to  it,  and  now  made  to  serve  as  a  guide  into  the  sphenomaxillary  fo.ssa. 
Here  it  may  be  followed  directly  into  its  connection  with  JNIeckel's  ganglion,  which  may 
also  be  extirpated.  The  nerve  trunk  is  forcibly  pulled  out  of  the  foramen  rotundum, 
through  which  it  escapes  from  the  Gasserian  ganglion. 

Horsley  does  not  open  the  antrum  but  lifts  the  orbital  contents,  including  the  peri- 
osteum, follows  the  nerve  along  the  canal  by  means  of  sharp-pointed  bone  forceps,  and 
thus  follows  it  up  to  the  foramen  rotundum,  where  it  is  evulsed  as  above.    (See  Fig.  399.) 
Lueeke  years  ago  devised  a  method  of  lateral  approach,  attacking  the  ganglion  and 
the  nerve  from  the  temporal  region.     An  incision  is  made  from  the  external  angle  of 


Various  incisions  for  reaching  different  branches 
of  tlie  trifacial  nerve:  a,  supia-orbital;  h,  external 
nasal;  c,  Bruns'  incision;  d,  inf.  dent,  at  mental 
foramen;  p,  internal  nasal;/,  infra-orbital;  £7,  Carno- 
chan's incision.      (.Marion.) 


614  SPECIAL  OR  REGIONAL  SURGERY 

the  orbit  straight  downward  in  the  direction  of  the  moUir  teeth,  where  it  is  met  by 
another  exteniHng  from  the  middle  root  of  the  zygoma,  downward  and  forward  Through 
these  incisions  the  zvgoma  is  exposed  and  divided  Thus  an  osteoplastic  flap  is  formed 
which  is  laid  up  ovt-r  the  temporal  region,  the  divided  ])iece  of  bone  being  raised  with 
the  overlying  skin  and  not  detached.  This  exj){)ses  the  temjMjral  and  zygomatic  fossse. 
The  temjioral  muscle  is  then  drawn  backward  with  a  hook,  the  fatty  tissue  which  fills 
these  fossfe  cleaned  out,  and  the  nerve  sought  for  in  the  s})henomaxillary  fossa,  where 
both  it  and  Meckel's  ganglion  may  be  extirpated.  The  flap  is  then  turned  down  and 
fastened  in  place  (Fig.  400). 

The  inferior  denial,  or  third  dividon  of  the  fifth  nerve,  may  be  reached  in  .several  ways: 
Its  terminal  portion  where  it  escapes  at  the  mental  foramen;  its  upper  portion  by  an 
incision  two  inches  along  the  lower  border  of  the  jaw  and  above  the  angle,  the  masseter 


Fig.  399 


Fig.  400 


Branches  of  the  inferior  maxillary  nerve  which 
most  concern  the  surgeon:  a,  auriculo-temporal;  b, 
inf.  dental;  c,  buccal.      (Marion.) 


Exposure  of  Meckel's  and  the  Gasserian  ganglia 
by  temporary  resection  of  the  zygoma;  Luecke's 
method.   (Marion.) 


muscle  being  separated  from  the  jaw,  and  the  ascending  ramus  opened  with  a  f-inch 
trephine  at  a  point  \\  inches  above  the  angle,  its  upper  edge  ^  inch  below  the  sigmoid 
notch.  The  nerve  is  here  exposed  before  it  enters  the  canal.  The  lingual  nerve  may 
also  be  found  resting  upon  the  internal  pterygoid  muscle.  A  ligature  tied  annind  each 
nerve,  for  traction  purposes,  permits  easy  tracing  of  their  trunks  to  the  foramen  ovale, 
where,  after  vigorous  stretching,  they  are  divided.  They  should  then  be  traced  down- 
ward and  at  least  one  inch  of  their  trunks  removed. 

The  Gasserian  Ganglion. — When  all  three  branches  of  the  trifiacial  nerve  are 
involved  in  painful  tic,  or  when  operation  has  already  been  practised  upon  one  or  more 
of  them  and  the  tic  has  recurred,  it  becomes  necessary  to  attack  the  Gas.serian  ganglion 
itself.^    This  may  be  approached  by  either  one  of  two  methods.     Both  are  difficult  and 

1  Osmic  Acid  and  Other  Treatment  of  Trigeminal  Neuralgia. — While  it  hardly  pertains  to  operative  surgery, 
it  may  be  worth  while  to  say  that  it  .«eems  to  me  that  no  case  of  trifacial  neuralgia  i^hould  be  subjected  to 
radical  operation  until  at  least  two  or  three  remedies  have  been  given  a  fair  trial.  One  of  these  is  castor  oil 
its  use  being  based  upon  the  theory  that  such  neuralgia  is  of  toxic  origin  and  that  a  prolonged  evacuant 
treatment  should  benefit  it.  This  would  mean  the  administration  of  two  or  three  good-sized  doses  of  castor  oil 
every  day  for  a  period  of  two  to  three  weeks.  It  is  not  such  a  drastic  remedy,  thus  given,  as  would  appear. 
for  after  the  oil  lias  once  thoroughly  i)roduce<l  its  laxative  effect  it  ceases  to  distress,  but  serves  as  a  very 
effective  eliminant.  The  second  remedy  is  Qclseminm,  the  best  preparation  being  the  tincture  of  the  green  root. 
It  seems  to  exercise  a  selective  affinity  for  the  trifacial  nerve.  It  should  be  given  in  large  doses,  pu.shed  to  the 
physiological  limit,  i.  p.,  until  the  patient  begins  to  see  everything  in  yellow  colors.  Its  effect  on  the  heart 
must  also  be  guarded.  Fifteen  drops  of  the  green  tincture  given  every  two  hours,  and  for  a  few  da.vs,  will 
usually  suffice  to  thoroughly  test  its  efficacy. 

Osmic  acid  is  used  cmly  for  intraneural  injection,  its  efficiency  now  being  under  trial.  Ten  to  twelve  drops 
of  a  2  per  cent.,  freshly  prepared  aqueous  solution  are  directly  injected  into  the  nerve  trunk  after  its  exposure. 
Murphy  has   been  its   particular  advocate,  and  has   reported  relief  of  pain  in  a  number  of  cases  thus  treated. 


WOT'XDS  OF  THE  SERVES  G15 

serious,  liavinj;  a  mortality  of  from  1")  to  20  per  cent.  As  Cushinfj  has  pointed  out, 
however,  its  mortality  rate  is  scarcely  as  f^reat  as  the  death  rate  hy  suicide  in  neuralj^ic 
eases  of  this  kind.  The  attack  from  helow  was  first  carefully  worked  (Hit  hy  Rose  and 
then  by  Antlrews,  and  is  begun  in  much  the  same  way  as  the  operation  for  the  removal 
of  Meckel's  fi;angli<jn  by  resection  of  the  zygoma,  described  above.  A  flap  is  laid  up, 
larger  and  wider,  incluciing  the  zygoma,  with  the  most  complete  possible  exposure  of  the 
zygomatic  fossa.  The  coronoid  process  is  drilled  in  two  |)lace.s,  divided  between  the 
o"|HMiings,  which  are  to  be  used  for  subsequent  suture,  and  the  temporal  muscle  pushed 
uj)ward  and  forward,  out  of  the  way,  with  tlie  upper  fragment.  The  foramen  ovale  is  tlu-n 
identified  bv  following  into  it  the  inferior  nuixillary  nerve,  the  l)ase  of  the  skull  being 
cleaned  awav  in  that  neighborhood,  and  a  small  trephine  opening  made  between  it 
and  the  foramen  rotundum,  connecting  these  two  openings  by  a  much  larger  one. 
Through  this  oin-ning  the  ganglion  is  exposed  and  destroyed  piecemeal  or  extracted  as 
completely  as  possible.  The  ojieration  is  exceedingly  difficult,  and  hemorrhage,  espe- 
cially froiii  the  middle  meningeal  artery  at  the  foramen  spincsum,  maybe  so  troublesome 
as  to  make  it  imprac-ticable  unless  the  carotid  be  tied.  I  have  preferred  in  (loing  this 
operation  to  make  j)reliminary  ligation  of  the  common  carotid,  which  facilitates  the 
balance  of  the  procedure.  The  exposure  by  this  method,  however,  is  not  as  satis- 
factory as  by  that  next  to  be  described. 

Hartley  and  Krause,  about  the  same  time  and  independently,  devised  a  method  of 
attacking  the  ganglion,  after  raising  an  osteoplastic  flap  from  the  side  of  the  skull,  which 
affords  a  better  exposure  and  a  more  satisfactory  method. 

Within  reason  the  larger  the  osteoplastic  flap  the  easier  the  balance  of  the  o|x>ration. 
Whether  it  be  square  or  horseshoe  in  shape,  whether  it  be  made  by  chisel,  by  Gigli  saw, 
or  by  surgical  engine,  matters  little.  In  fact  experience  has  shown  that  the  conserva- 
tion of  the  bone  is  not  a  matter  of  serious  import,  and  there  is  no  good  reason  why 
there  sliould  be  any  hesitancy  to  remove  the  bone  should  the  formation  of  such  an 
osteal  flap  present  too  many  difficulties.  After  the  dura  is  completely  exposed  it  is  to 
be  separated  from  the  base  "of  the  skull  until  the  foramen  spinosum  and  middle  menin- 
geal artery  are  reached.  It  is  better  to  do  this  quickly  and  with  the  finger  than  slowly 
with  instruments.  After  this  separation  the  brain  with  its  dural  covering  is  lifted  by 
a  spatula  or  retractor,  so  as  to  afford  a  good  view  of  the  region  of  the  ganglion.  It  will 
be  necessary  to  double  ligate  the  middle  meningeal  artery  unless  preference  has  been  given 
to  make  a  preliminary  temporarv  or  permanent  ligation  of  the  carotid.  Should  this 
artery  have  been  injured  in  raising  the  flap  it  should  be  secured  before  going  any  farther, 
either  bv  plugging  the  opening  or  canal  with  gauze  or  with  antiseptic  wax  (Fig.  401). 

The  upper  surface  of  the  ganglion  is  adherent  to  the  dura,  and  these  adhesions  should 
be  separated.  The  second  and  third  branches  should  be  identified  and  divided  near 
their  exit.  The  first  branch  is  in  too  close  relation  with  the  cavernous  sinus 
to  justifv  much  interference.  The  ganglion  itself  is  then  seized,  after  complete  isola- 
tion, with  forceps  and  CA-ulsed,  with  as  much  of  its  longer  and  shorter  roots  as 
possible.  Hemorrhage  is  checked  by  adrenalin  or  by  pressure  with  gauze,  as  may  be 
required.  If  gauze  be  used  for  the  purpose  it  may  also  be  utilized  for  drainage  The 
brain  is  restored  to  position  and  the  fiap  sutured  in  its  proper  place. 

Before  doing  either  of  these  operations  I  should  prefer  to  place  the  patient  within  the 
Crile  pneumatic  suit  and  then  tilt  the  body  to  an  angle  of  at  least  -45  degrees,  thus  prompt- 
ing empt}-ing  of  the  cranial  and  cervical  veins  by  gravity,  while  at  the  same  time  blood 
pressure  is  maintained  by  the  pneumatic  pressure  (see  p.  180). 

Abbe  has  endeavored  to  lessen  the  shock  of  the  operation  by  not  formally  tearing  out 
the  ganglion,  but  bv  taking  out  a  section  of  the  nene  trunks  between  it  and  their  foramen 
of  exit,  and  then  interposing  a  piece  of  thin,  sterile,  rubber  tissue,  inserting  it  in  such  a 
way  that  it  shall  effectually  prevent  regeneration  of  nen-e  trunks  acrcss  the  interwil, 
this  rubber  being  intended  to  remain  and  become  encapsulated.     This  method  of  Abbe 

It  seems  to  depend  for  its  effect  upon  two  factors— the  destruction  of  nerve  filaments  and  their  substitution  by 
connective  tissue.  All  the  nerve  branches  that  can  be  exposed  should  be  injected;  the  palatine  and  lingual 
through  the  mouth;  the  intra-orbital  and  supra-orbital  by  incisions  upon  the  face;  orbicular  branches,  as  well, 
should  be  injected,  if  possible.  Mo.st  of  those  who  have  used  it  advise  also  to  inject  a  few  drops  into  the 
foramina  of  exit,  around  the  trunks,  which  are  thus  infiltrated  with  the  solution.  The  procedure  is  painful  and 
usuallv  requires  a  general  anesthetic,  but  it  seems  to  be  free  from  danger.  While  the  treatment  has  been 
successful  in  some  cases  it  has  been  equally  disappointing  in  others,  and  the  method  will  scarcely  supplant  the 
more  radical  method  of  ganglion  exsection. 


GIG 


SPECIAL  OR  REGIONAL  SURGERY 


seems  to  have  made  operative  attaek  upon  the  Gasserian  <i;an<);Hon  less  formi(Uihle  and 
less  dangerous.  It  remains  to  be  seen  whether  it  is  jjernianently  as  effective  as  more 
complete  extir])ati()n 

The  Lingual  Nerve. — In  some  cases  of  cancer  of  the  tongue  there  is  such  intense  pain 
that  not  only  has  the  lingual  artery  been  tied  but  the  lingual  nerve  been  stretched  or 
exsected.  It  can  ordinarily  be  reached  where  it  lies  on  the  floor  of  the  mouth  beneath 
the  mucous  membrane,  at  the  fold  between  it  and  the  tongue,  where  it  can  be  felt  if  the 
tongue  be  forcibly  stretched.  Through  a  small  incision  a  blunt  hook  may  be  passed  and 
the  ners'e  thus  secured.  Close  to  the  first  lower  molar  the  nerve  lies  in  the  tongue  near 
the  surface,  where  it  can  also  be  found. 

The  Seventh  or  Facial  Nerve.— This  nerve  has  sometimes  to  be  stretched  for  spas- 
modic afl'ections.  ^Yhen  the  desire  is  simply  to  reach  its  trunk  it  may  be  sought  through 
an  incision  behind  the  ear,  by  which  the  posterior  border  of  the  })arotid  is  exposed,  the 
sternocleidal  insertion  identified,  the  nerve  lying  in  the  interval  between  these  two 
landmarks.  A  more  easy  method  of  reaching  it  would  pr<)bal)ly  be  by  an  incision  in 
front  of  the  ear  just  l)efore  its  main  branch  divides  as  it  enters  the  parotid  gland.  If 
necessary  this  ma}'  be  followed  backward  until  the  main  trunk  is  reached. 


Fir..  401 


Fio.  402 


Intracranial  exsection  of  Gasserian  ganglion;  dura 
open,  brain  lifted  ui>.  Ilartley-Krause  method. 
(Marion.) 


Relations  of  the  facial  and  .sijinal  accessory 
nerves:  n,  carotid;  h,  int.  jug.;  r,  facial  nerve;  d, 
transv.  proc.  atlas;  e,  spinal  acces.;  /,  stern,  mast, 
muscle.     (Marion.) 


Neuro-anastomosis  for  Facial  Palsy.— In  view  of  the  ho])ele.ssness  of  facial  jiaralysis, 
when  resulting  from  destructive  injuries  to  the  nerve  trunk,  the  introduction  of  anasto- 
motic methods  has  marked  a  very  distinct  advance.  Ballance,  in  1895,  was  the  first  to 
apply  neuro-anastomotic  methods  to  the  facial  nerve.  He  attached  the  facial  to  the 
spinal  accessory.  His  own  experience,  as  well  as  that  of  half-a-dozen  later  o[)erators, 
jiroved  that  nerve  regeneration  is  possible,  but  that  in  this  particular  instance  voluntary 
movements  of  the  face  were  often  accomjianied  by  distressing  and  unsightly  associated 
movements  of  the  shoulder,  and  vicr  versa.  Hence,  Taylor  and  others  suggested  the 
use  of  the  hypoglossal  instead  of  the  s])iiial  accessory,  the  former  being  a  purely  motor 
nerve  running  near  the  facial,  intimately  associated  with  it  in  function,  and  arising  by 
nuclei,  whic-h  tire  eqiudly  closely  associated  in  the  cranial  centres.  The  operation  is 
indicated  in  all  cases  of  paralysis  caused  by  lesion  of  the  nucleus  within  the  brain,  or 
the  nerve  trunk  at  the  base  of  the  brain,  or  along  its  course.  It  is  justifiable  in  Bell's 
palsy,  when  there  is  complete  reaction  of  degeneration  in  the  facial  nerve  after  several 
months  of  treatment  (Fig.  402). 

The  steps  of  the  operation  are  practically  as  follows:  Incision  is  made  along  the 
anterior  margin  of  th(>  mastoid  and  the  sternomastoid  muscle,  and  the  parotid  gland  is 
retracted  forward  anil  the  posterior  belly  of  the  digastric  is  exposed.     It  should  then  be 


WOfrXDS  OF    THE   SFJiVES 


617 


|)ull('<l  downward  and  backward  and  di\idcd  if  necessary.  The  styloid  process  is 
identified,  and  tiie  facial  nerve  whicii  enicrj^es  I'idni  tiie  stylomastoid  foramen  near 
its  base  is  then  sonj^ht  and  isohited.  It  siiould  be  se|)aruted  as  hi^h  us  possible  and 
divided  close  to  its  exit,  so  that  one-half  inch  of  its  free  trunk  may  be  secured  before 
it  enters  the  <2;land.  Two  fine  silk  sutures  ar(>  then  passed,  one  on  either  side,  throuirh 
the  j)eriplieral  end  of  its  sheatii  and  tied,  tlu'  ends  remainin<^  lo'i^,  to  be  snbse(|nently 
used.  This  nerve  end  should  be  trimmed  to  a  wed;^e  sliape.  Next  the  transverse 
process  of  the  atlas  is  identified  and  the  deep  cervical  fascia  divided.  This  wril  ex|)()se 
the  internal  ju<i;uhir,  which  should  be  separated  and  held  out  of  the  way.  There  will  now 
be  seen  the  spinal  accessory  nerve,  which  rmis  ol)li(|uely  downward  and  outward,  some- 
limes  in  front  of  and  sometimes  behind  the  juiijular  (Fill.  4(K^).  When  the  vein  is  held 
forward  and  the  fascia  well  retracted  both  the  hypo(>lossal  (Fij;.  404)  and  the  pneu- 
moi;aslric  nerves  are  seen,  with  the  internal  carotid  to  their  inner  sides.  The  former 
nuiv  be  identified   either  \)\  the   electric   current,  wliicli  will  cause  contractions  in  tlie 


Fk:.  403 


Fio.  404 


...d 


•  Exposure  required  for  anastomosis  of  facial  and 
spinal  accessory  nerves:  a,  facial  nerve;  fo,  sp.  acces.; 
r,  int.  jug.;  d,  digastric  muscle;  e,  atlas,  trans,  proc. 
(Marion.) 


Exposure  required  for  anastomosis  of  facial  and 
hypoglo.ssal  nerves:  «,  facial  nerve;  /),  sternomas- 
toitl;  c,  digastric;  d,  iiarotid;  e,  hypoglossal. 
(Marion.) 


muscles  supplied  by  it,  or  it  may  be  followed  down  to  where  it  turns  forward  around 
the  occipital  artery  and  gives  off  the  desceudeus  noni.  Here  it  should  be  sejjarated  until 
its  trunk  is  sufficiently  free,  so  that  the  facial  stump  can  be  inserted  into  it  without 
tension.  The  nerve  being  elevated  by  a  hook  a  slit  is  made  in  it,  about  f  inch  long. 
Into  this  the  wedge-shaped  end  of  the  facial  trunk  is  introduced,  and  held  there  by 
utilizing  the  sutures  which  have  already  been  pas.sed  through  its  sheath.  When  the  nerve 
is  thus  firmly  held  in  the  cleft,  with  its  end  turned  toward  the  direction  of  nerve  supply, 
a  little  eargile  membrane  may  be  wrapped  around  the  junction  and  the  wound  closed.^ 

Nerve  regeneration  has  been  known  to  follow  this  procedure  in  a  number  of  cases,  and 
it  has  given  encouraging  results.  Considerable  time,  however,  is  required,  and  the 
|)atients  should  be  warned  that  results  are  not  to  be  Cjuickly  expected. 

The  Spinal  Accessory  Nerve. — The  principal  reason  for  attack  upon  this 
nerve  is  sj)asm()<lic  torticollis,  or  wryneck.     It   is  exposed   through  an    incision   along 


Taylor  and  Clark,  New  York  Medical  Record.  February  27,  1904,  p.  321, 


618 


SPECIAL  OR  REGIONAL  SURGERY 


the  anterior  border  of  the  sternocleidomastoid  muscle,  extendino;  two  inches  downward 
from  the  ear.  The  nerve  is  found  a  little  above  the  level  of  the  hyoid  bone;  or,  again, 
it  may  be  found  by  an  incision  along  the  outer  border  of  the  muscle,  opposite  its  centre, 
just  above  which  it  will  be  detected  (Fig.  405). 

The  Deep  Posterior  Cervical  Plexus. — When  operation  upon  the  s])inal  accessory  ha.s 
failed  to  relieve  long-standing  and  serious  sjmsmodic  torticollis.  Keen  has  suggested 
to  divide  the  first,  second,  and  third  cervical  nerves.  The  o))eration  is  difficult  and  not 
always  successful ;  still  it  is  worth  trying.  A  transverse  incision  is  made  below  the  level 
of  the  lobe  of  the  ear,  the  trapezius  being  dividetl  and  dissected  up  until  the  great  occip- 
ital nerve  is  found.  It  is  followed  after  the  necessary  division  of  the  complexus  until 
its  origin  from  the  posterior  division  is  reached.  The  suboccipital  or  first  cervical 
nerve,  which  lies  in  the  triangle  close  to  the  occiput  that  is  formed  by  the  two  oblique 
muscles  and  the  posterior  rectus,  is  excised.  The  exterior  branch  of  the  posterior  division 
is  found  lower  down,  and  should  be  divided  close  to  the  bifurcation  of  the  main  nerve 
(Fig.  400). 

The  Cervical  Sympathetic. — The  cervical  sympathetic  is  a  most  complicated 
nerve  trunk,  furnishing  fibers  of  various  functions  to  the  skin,  and  to  the  deeper  parts 
fibers  which  are  vasomotor,  vaso-inhibitory,  pilomotor,  and  secretory  in  function.     It 


Fig.  405 


Fig.  406 


Exposure  of  the  spinal  accessory  nerve  alone: 
a,  digastric;  b,  jugular  veins;  c,  sternomastoid 
muscle;  rf,  spinal  accessory.     (Marion.) 


Incisions  through  which  the  various  nerves  in  the  neck 
may  be  sought:  o,  facial;  h,  facial  and  hypoglossal; 
c,  facial  and  sp.  acces.;  d,  spinal  accessory;  e,  cervical  plexus; 
/,  brachial  plexus.      (Marion.) 


supplies  the  various  glands,  the  upper  viscera,  the  heart  and  bloodvessels,  and  connects 
with  nerves  below,  which  supply  even  the  genital  organs  and  the  non-stri|)ed  muscles 
of  the  body.  The  upper  part  has  a  very  important  oculopupillary  function,  as  it  supplies 
the  dilator  pupilhie,  the  non-striped  part  of  the  elevator  of  the  upper  lid,  and  the  orbital 
muscle  of  Miiller,  i.  e.,  a  small  bundle  of  non-striped  muscle  which  lies  behind  the  globe 
and  projects  across  the  sphenomaxillary  fissure  at  the  back  of  the  orbit.  (By  contraction 
of  this  muscle  the  eye  may  be  pushed  forward.)  It  also  supplies  the  submaxillary  gland, 
the  cutaneous  bloodvessels,  and  the  sweat  glands  of  the  head  and  neck.  The  pupil 
dilating  fibers  arise  in  the  medulla,  run  backward  in  the  lateral  columns  of  the  cord  to 
the  ciliospinal  centre,  emerge  through  the  anterior  roots  of  the  first  and  second  dorsal  seg- 
ments, and  enter  the  inferior  cervical  ganglion,  thence  passing  upward  through  the  symjja- 
thetic  trunk  to  the  orbit.  Therefore  ocular  and  other  symptoms  are  j^roduced  not  only 
by  lesions  of  the  external  trunk,  but  also  by  lesions  within  the  cord  at  the  level  of  the 
upper  dorsal  segments.  These  nerves  may  be  injured  anywhere  in  the  neck,  or  com- 
pressed by  inflammatory  deposits  or  new-growths,  or  even  by  cicatricial  tissue  at  the 
apex  of  a  tuberculous  lung.  Many  cases  of  phthisis  show  inequality  of  the  pupils. 
One  nerve  may  be  injured  in  operations  on  the  neck,  the  result  being  slight  drooping 
of  the  lid  and  flushing  of  the  face,  as  well  as  excessive  perspiration  on  the  injured  side ; 


WOUNDS  OF  THE  NERVES 


619 


tlu-  c-onvspoiulin^  j)ii|)il  hciiifj;  sinullcr  tluui  (lie  other  hcciiusc  (jf  |)tiraly.si.s  of  the  dilators, 
but  contracting  to  lifjjlit,  as  the  third  cranial  nerve  wliich  supj)Hes  its  sphincter  is 
unaffected.  The  eye  will  then  sink  l)ack  somewhat,  owino;  to  jiaraiysis  of  Miiller's 
muscle,  and  thus  j)ermit  a  nearer  closure  of  the  lids.  Tliese  oculoi)Upillary  syni|)(oms 
are  path(><;;nomonic  of  jjaralysis  of  the  cervical  sympathetic.  Cocaine  will  not  dilate  a 
|)upil  whose  dilator  has  thus  been  paralyzed.  The  area  of  skin  suj)plied  with  sweat 
fibers  by  the  cervical  sympathetic  includes  the  corrcs|)on(lino;  side  of  the  head,  neck, 
shoulder,  and  u|)per  part  of  the  trunk  {Vh^.  407). 

When  the  cervical  sympathetic  is  unduly  stimulated  we  have  dilatation  of  the  pupil, 
exophthalmos,  widenini>;  of  the  palpebral  aperture,  delayed  descent  of  the  upper  li(l 
when  the  patient  looks  downward,  all  of  which  can  be  imitated  or  produced  by  dro])pin<); 
into  the  eye  a  solution  of  cocaine,  which  stimulates  the  nerve.^ 

The  surgical  symjKithetic  is  attacked  surgically  for  three  widely  variant  conditions: 
epilcpsii,  g/auronia,  and  r.roplit/ialmin  (joilrc — the  first,  because  of  its  vasomotor  control 
of  the  vascular  supply  of  the  brain;  the  second,  because  of  the  relation  of  the  nerve  to 
the  orbital  circulation  and  nutrition;  and  third,  because  of  its  relations  to  the  thyroid 
and  the  heart.  In  the  latter  case  it  is  especially  desirable  to  remove  the  lower  cervical 
ganglion  and  the  first  dorsal,  if  it  can  be  reached,  although  the  procedure  here  is  exceed- 
ingly difficult. 

The  tachycardia  of  Graves'  disease  is  due  apparently  to  irritation  of  the  accelerator 
nerves  of  the  heart,  which  come  from  the  sympathetic,  or  else  to  paralysis  of  the  regulator 
(pneumogastric)  supply.  The  former  spring  from  the  lower  part  of  the  cervical  cord 
and  the  upper  dorsal  segments,  and  pass  to  the  third  cervical  ganglia  and  to  the  first 
dorsal,  terminating  in  the  cardiac  plexus. 

The  operation  described  below  is  practically  that  advised  by  Jonnesco,  more  or  less 
modified  by  other  operators,  and  may  be  varied  to  some  extent  to  meet  the  exigencies  of 
particular  cases.  Thus  whether  it  shall  be  done 
through  one  or  two  incisions  will  depend  on  the 
will  of  the  operator.  It  is  made  about  as  fol- 
lows: A  long  incision  is  made  along  the  pos- 
terior border  of  the  sternomastoid.  The  latter 
may  be  either  retracted  forward  or  its  fibers 
separated,  in  order  that  the  fascia  on  its  inner 
side  may  be  reached  and  separated  from  the 
deeper  muscles.  This  fascia  should  be  divided 
as  high  as  the  base  of  the  skull.  The  upper 
ganglion  of  the  cervical  sympathetic  lies  on  the 
inner  side  of  the  anterior  tubercle  of  the  trans- 
verse process  of  the  second  and  third  vertebral 
processes,  resting  upon  the  muscles  covered  by 
this  fascia.  The  ganglion,  being  recognized  by 
its  shape,  and  the  sympathetic  trunk  being  thus 
identified,  the  nerve  should  be  divided  ami 
made  free,  as  high  as  possible  and  just  beneath 
the  base  of  the  skull.    (See  Fig.  408.) 

The  lower  end  is  to  be  exposed  by  continua- 
tion of  the  first  incision,  or  by  another  begin- 
ning 1  Cm.  above  the  clavicle  and  extending 
along  the  posterior  border  of  the  sternomastoid 
for  4  or  5  Cm.  The  platysma  should  be  entered  trunk.  (Stewart.^ 
and    the    tissues  separated    upward    until    the 

fingers  can  meet  in  a  channel  thus  made  by  connection  with  the  upper  incision.  The 
tissues  should  also  be  loosened  downward  until  a  point  has  been  reached  behind 
the  clavicle.  They  then  should  be  widely  retracted  and  the  inferior  thyroid  artery 
sought.  The  middle  cervical  ganglion  is  found  inside  of  its  curve.  Occasionally  this 
ganglion  is  replaced  by  a  plexus,  or  the  main  trunk  may  pass  behind  the  artery.  At 
this  level  it  is  to  be  seized  and  its  upper  divided  end  pulled  down  and  out  through  this 
opening.     The  nerve  trunk  should  then  be  followed  downward.     The  artery  should  be 


Fig.  407 


MON-STRIPED 
MUSCLE^ 


I^DORSAL  5 


"2"-°0OR5AL  5 


CIUO  SPINAL 
CENTRE 


DILATOR 

PUPILL/E 

MUELLERS  MUSCLE 

,NON-STRIPED) 

SWEAT  FIBRES 
\VA50  MOTOR  AND 
VASO  DILATOR  FIBRES 
MIDDLE 
GANGUON 


LOWER  GANGUON 


Diagram  to  illustrate  the  relations  of  the 
cervical  sympathetic  and  the  mechanism  of  the 
various   disturbances     following    lesions     of    its 


>  Stewart,  Some  Affections  of  the  Cervical  Sympathetic,  The  Practitioner,  February,  1905. 


G20 


SPECIAL  OR  REGIONAL  SURGERY 


Fig.  408 


freed  from  any  plexus  of  sympathetic  fibers  around  it,  all  of  which  should  be  destroyed, 
and  especially  those  fibers  which  constitute  the  middle  cardiac  nerve,  whicli  })ass  to  the 

inner  side.  The  main  trunk  is  to 
be  drawn  down  beneath  the  artery 
and  then  followed  downward  and 
outward  to  the  lower  ganglion, 
where  it  lies  behind  the  clavicle,  on 
the  neck  of  the  first  rib,  l>etween 
the  scalenus  anticus  and  the  longus 
colli.  The  ganglion  and  the  trunk 
should  be  separated  from  the  effer- 
ent and  afferent  branches  which 
connect  with  it,  as  well  as  from  the 
vertebral  artery;  being  thus  made 
free  it  is  again  drawn  outward. 
Here  one  should  divide  especially 
the  cardiac  l)ranches  which  form 
the  lower  cardiac  nerve,  as  well  as 
the  vertebral  branches  which  have 
so  much  to  do  with  controlling  the 
supply  through  the  verteljral  artery. 
The  o-Hiii'lion,  after  being  identi- 
fied,  should  be  finally  removed. 
The  nerve  should  be  traced  still 
farther  down  to  the  first  thoracic 
ganglion,  which  has  much  to  do  with 
supplying  the  heart,  and  this  also 
should  be  separated  and  destroyed 
(Fig.  400). 

It  is  rarely  necessary  to  provide 
for  drainage  after  the  operation, 
uidess  the  retraction  and  laceration 
of  tissues  have  been  very  great. 
iSIy  OAvn  preference  is  to  make  one 
long  incision  along  the  posterior 
border  of  the  sternomastoid,  by 
which  the  dissection  is  facilitated 
and  the  operation  made  less  com- 
plicated and  difficult.  When  done 
for  glaucoma  on  one  side  it  will  be 
sufficient  to  attack  one  nerve,  but 
when  for  epile]:)sy  or  for  exophthal- 
mic goitre  the  ojjeration  should  be 
bilateral.  When  for  epilepsy  or 
glaucoma  it  is  not  so  necessary  to 
remove  the  lower  cervical  ganglion ; 
this  is  indicated  rather  in  those 
cases  where  it  is  desirable  to  control 
the  accelerator  nerves  to  the  heart. 
The  operation  has  given  good  results  in  all  three  affections  named,  yet  it  is  one  of 
considerable  difficulty.  It  woidd  be  made  extremely  flifficult  by  the  presence  of  a  large 
goitre,  and  in  such  case  it  would  probably  be  better  to  extirpate  the  thyroid  rather 
than  to  attack  the  ner\'e.     (See  Glaucoma,  Epilepsy,  and  Exophthalmic  Goitre.) 


SjTiipathectomy.     Exposure  and  removal  of  middle  and 
upper  ganglia.     (Marion.) 

Fig.  409 


Sympathectomy . 


Seizure  and  removal  of  inferior  ganglion. 
(Marion.) 


CHAPTKK    XXXVI  I  I. 

THE  SPINK,  THE  SPINAE  COlil),  AM)  THE  J'KUII'IIEUAL  NERVES. 

SYRINGOMYELIA. 

TilK  term  si/ringovn/rUa  implies  irr('<;iilar  dilaliitioii  oi"  the  central  caiiiil  of  tlic  .spinal 
cord,  liavinfj;  a  coiiji;ciiital  ori<;in,  tcndinjf  to  relative  increase  later  in  life,  with  corre- 
spoiidinij  disturbance  of  function,  the  latter  includin^f  paresthesia',  loss  of  sensibility 
to  heat  and  cold,  more  or  less  motor  im|)airment  and  disturbances  of  nutrition,  more 
noticeable  in  the  rci^ion  of  the  joints  than  elsewhere,  the  latter  havin*^  been  already 
ct)nsi(l(>red  in  the  chaj)ter  on  the  -loints.  'i'he  dilatation  is  by  no  means  regular,  may 
occur  in  various  rejijious  of  the  cord,  and  attain  a  size  pennittino;  encroachment  uj)on, 
and  even  atroj)hy  of,  the  structures  of  the  cord  itself.  When  functional  disturbance, 
especially  j)aralytic,  has  become  very  pronounced  a  few  surgeons  have  ventured  to 
expose  the  cord  by  a  laminectomy,  and  endeavored  to  make  a  more  or  less  |)ermancnt 
openin<2;  with  (lrainafj;e  of  the  dural  cavity.  Thus  Keen  has  oj)erated  twice,  Abbe  once, 
and  Munro  three  times,  includin<«;  twice  on  the  same  ])atient.  Only  in  this  last  instance 
was  any  jxM-manent  relief  obtained,  and  this  was  at  the  expense  of  a  second  o])eration. 
It  is  doubtful  if  any  of  the  |)eculiar  joint  lesions  of  this  disease  will  be  in  any  way 
afiected  by  operation  for  this  purpose. 

TUMORS  OF  THE  SPINAL  CORD. 

Tumors  of  the  s])i!ial  cord  may  be  classified  as  follows  (Kranss): 

1.  Tumors  sjjriniiino;  ))rimarily  from  the  envelopes  of  the  cord:  (a)  Tumors  of  the 
vertebral  cohnnn,  and  {h)  tumors  of  the  meninges,  the  latter  including  those  arising 
from  the  external  surface  of  the  dura,  or  from  the  ])eriosteum  of  the  spinal  canal,  i.  e., 
extradural  tumors,  and  those  from  the  inner  surface  of  the  dura  and  the  other  membranes, 
that  is,  intradural  tumors. 

2.  Tumors  developing  in  the  cord  proper,  intramedullary.  These  are  generally 
gliomas  and  do  not  present  so  much  the  symptoms  of  cord  tmnors  as  of  syringomyelia. 

Vertebral  tumors  may  be  carcinoma  (secondary),  endoth(dioma,  sarcoma,  osteo- 
sarcoma, as  well  as  the  non-malignant  and  cartilaginous  or  osseous  tumors,  and  parasitic 
cysts,  /.  /■.,  echinococcns.     The  sarcomas  are  the  most  connnon  of  all. 

Sjrmptoms. — The  sym))toms  of  tumor  of  the  sj)inal  cord  depend  uj)on  the  part 
involved  and  differ  according  as  it  involves  the  cervical,  thoracic,  or  lumbar  portions  or 
the  Cauda  ecjuina.  They  are  to  be  classed  as  root  .syjuptoms-  and  cord  .'itpnptoins.  Root 
sipnptoms  include  pain,  paresthesia,  and  hyperesthesia.  The  pain  is  usually  ])ersistent, 
burning,  and  severe,  affecting  one  side  or  the  other,  if  the  tumor  be  laterally  placed,  or 
both  sides  if  central.  The  pain  follows  the  distribution  of  the  spinal  roots  rather  than 
the  course  of  the  intercostal  nerves,  /.  e.,  is  more  horizontal  and  less  oblique.  These  pains 
persist  and  have  the  characteristic  feature  of  not  presenting  painful  points  on  pressure, 
l^hev  are  commonly  referred  to  the  abdomen,  and  may  thus  give  rise  to  serious  mistakes 
in  diagnosis,  c.  (/.,  they  have  been  regarded  as  due  to  hejiatic  colic,  dry  pleuri.sy,  aj)pendi- 
citis,  etc.  Pain  may  assume  the  girdle  character,  which  is  usually  accentuated  by  move- 
ment, and  is  frecjuently  accompanied  by  herpes  zoster.  The  greater  the  involvement 
of  the  posterior  roots  the  more  painful  the  condition.  When  the  anterior  sensory  roots 
arc  involved  pain  may  be  wanting  and  the  disturbance  assume  a  type  of  paresthesia, 
with  final  anesthesia,  in  which  case  the  patient  would  at  first  complain  of  numbness 
and  prickling  sensations.  There  is  sometimes  noted  a  zone  of  hyper€'Sthesia  on  the 
•proximal  side  of  the  anesthetic  area,  or  this  zone,  if  not  hyperesthetic,  may  be  replaced 
by  a  condition  of  uncertaintv  of  sensation. 

( 021 ) 


622  SPECIAL  OR  REGIONAL  SURGERY 

The  cord  sijmptoms  arc  tlie  reliable  ones,  varying  according  to  the  segment  involved. 
The  portions  of  the  cord  where  lesions  can  be  best  localized  are,  for  instance,  the  third 
to  the  fifth  cervical,  including  the  origin  of  the  phrenic  nerve;  the  fifth  to  the  seventh 
cervical,  where  the  posterior  thoracic  nerve  comes  off;  the  seventh  to  the  eighth  cervical 
antl  first  thoracic  segments,  where  originate  the  dilator  nerves  of  the  pupil.  The  upper 
border  of  the  anesthetic  area  points  to  a  lesion  of  the  next  or  second  higher  spinal 
segment  than  the  level  really  represents.  The  lowest  level  of  the  lesion  corresponds  to 
the  highest  level  of  the  sensory  disturbance.  The  level  of  the  segment  area  of  the  skin 
of  the  back  does  not  correspond  to  the  level  of  the  spinal  segment  involved,  the  latter 
being  higher  up.  The  point  of  greatest  sensitiveness  over  the  spine  is  in  many  cases 
a  good  guide  to  the  segment  involved,  but  is  apj)licable  only  where  the  lesion  is 
posteriorly  placed.  The  absence  of  pain  or  tenderness  along  the  spine  means  little 
or  notliing,  but  their  presence  has  great  significance. 

Diagnosis. — The  diagnosis  of  a  cord  tumor  covers,  according  to  Krauss,  a  first 
or  subjective  period,  indicative  of  irritation  along  the  posterior  roots,  and  is  charac- 
terized by  pain  and  paresthesia.  This  is  followed  in  time  by  a  second  or  objective 
period  which  points  to  invasion  of  the  spinal  cord,  characterized  mainly  by  weakness 
and  later  by  paralysis,  with  disturbed  tendon  reflexes.  Diagnosis  early  is  extremely 
difficult,  for  pain  and  disturbances  of  sensation  are  produced  in  many  ways. 

Treatment.— The  treatment  of  spinal-cord  tumors  is  purely  surgical  and  should  be 
instituted  promptly  so  soon  as  diagnosis  has  been  made.  Only  in  tumors  of  syphilitic 
origin  will  internal  treatment  be  of  any  avail.  The  therapeutic  test  having  been  made, 
should  it  seem  wise,  and  proved  futile,  the  case  should  be  regarded  at  once  as  surgical. 
According  to  Krauss'  statistics  nearly  40  per  cent,  of  all  operated  cases  have  resulted 
in  recovery,  while  in  35  cases  of  sarcoma  8  have  resulted  in  recovery  and  G  in  improve- 
ment. This  is  really  a  more  gratifying  statement  than  can  be  made  with  regard  to 
brain  tumors,  and  should  be  regarded  as  lending  encouragement  to  surgical  pro- 
cedure. 

The  operative  details  will  be  discussed  later  in  this  chapter. 

THE  PERIPHERAL  NERVES. 

The  remarks  made  concerning  the  surgical  afTections  of  and  operations  upon  nerves 
contained  in  the  previous  chapter,  pertaining  to  the  cranial  nerves,  will  apply  equally 
well  to  the  peripheral  nervous  system. 

Constant  'pressure  as  well  as  contusions  of  nerves  will  cause  more  or  less  paralysis. 
The  surgeon  occasionally  sees  manifestations  of  this  kind  in  the  so-called  "crutch  par- 
alysis," due  to  pressure  upon  the  brachial  plexus  by  the  use  of  crutches,  and  in  another 
form  so  generally  associated  with  administration  of  an  anesthetic  as  to  be  called  "ether 
paralysis."  It  is  another  form  of  pressure  paralysis  due  to  indifference  in  letting  the 
arm,  for  instance,  hang  over  the  edge  of  an  operating  table  during  anesthesia  or  operation. 
It  does  not  call  for  operation  so  much  as  for  electricity,  massage,  and  similar  measures. 
Extreme  consequences  of  nerve  and  vessel  injury  are  portrayed  in  Fig.  410. 

Tumors  of  nerves  are  both  benign  and  malignant,  the  former  assuming  the  fibroma- 
tous  type  oftener  than  any  other,  and  frequently  involving  more  than  one  nerve  trunk, 
attaining  also  considerable  size  and  impairing  or  destroying  function  by  pressure.  In 
addition  to  the  true  fil)roma  of  nerve  sheaths  we  have  the  peculiar  type  of  fibromas  of 
nerve  stumps  seen  after  amputations,  and  the  multiple  neuromas,  again  largely  of  the 
fibromatous  type,  which  involve  many  and  in  rare  instances  nearly  all  the  peripheral 
nerves.  Cases  are  on  record  where  as  many  as  1600  small  and  large  tumors  have  been 
found,  strung  like  beads  upon  wires,  along  all  the  peripheral  nerves  throughout  the  body. 
Another  variety  of  fibromas  of  nerves  involves  those  of  the  skin  and  produces  small 
painful  subcutaneous  nodules,  although  these  may  attain  a  considerable  size.  Within 
the  past  few  years  there  has  been  a  much  better  familiarity  with  that  form  of  growth 
known  as  ple.viform  neuroma,  in  which  entire  nerve  trunks  are  involved,  so  that  they 
become  elongated,  thickened,  and  tortuous,  and  resemble  a  varicose  condition  of  the 
veins.  The  plexiform  nein-omas  are  found  in  any  part  of  the  body;  they  produce 
little  or  no  pain,  but  leatl  to  disturbances  of  function,  as  well  as  to  peculiar  irregular 
swellings  that  may  be  mistaken  for  lymphangioma,  and  which  are  often  accompanied 


77//-;  ]'Ki{n'iu:R.\L  nerves 


623 


by   piiiincntalidii   of  and   >i;n)\vtli   of  hair   upon   the  overlying  skin.     (See   chiipter  on 

TllIllOI'S.) 

For  the  various  purposes  ah-cady  uiciitioucd  (hilVniit  nerve  trunks  and  plexuses  are 
made  actcssihlc  lor  o|)eration  hy  the  i'ollowinif  methods: 

The  Brachial  Plexus. — The  brachial  plexus  is  reached  thr()U<i;h  an  ineisioni  similar 
to  that  for  liti;ation  of  the  subclavian  artery.  After  (jpeninif  the  dee|)  fascia  the  nerves 
are  sought  and  found  behind  the  subelavian  vein  and  lying  around  the  artery.  This 
plexus  is  stretehed  cs})eeially  for  the  relief  of  ehoreiform  spasm  or  ])ainful  nervous  affec- 
tions. The  various  nerves  of  the  upper  extremity,  after  leaving  the  brachial  plexus, 
are  made  accessible  to  operations  for  grafting  or  suture  as  below.     (See  Fig  4()().) 

The  Median  Nerve. — 'I'he  median  nerve  lies  in  front  of  the  brachial  artery  and  is 
exposed  llirongli  an  incision  as  if  the  artery  were  to  be  tied  in  its  course.  It  may  also 
be  found  on  tlie  inner  sitle  of  the  tendon  of  the  palmaris  longus,  where  it  lies  beneath 
the  i\vv\)  fascia. 

The  Ulnar  Nerve. — The  ulnar  nerve  is  reached  through  praetieally  the  same  incision 
as  till-  median,  when  it  is  sought  in  the  middle  of  the  arm,  but  is  farther  back.  It  lies 
near  the  surface,  just  behind  tlie  inner  condyle,  between  it  and  the  olecranon,  and  at  the 
wrist  it  is  on  the  radial  side  of  the  tendon  of  the  flexor  carpi  ulnaris. 

Fir.,  -no 


Gangrene  (mummification)  of  arm  resulting  from  injury  to  nerves  and  ves.sels.     (Preindlsberger.) 

The  Musculospiral  Nerve. — The  musculospiral  nerve  is  found  between  the  heads  of 
the  trice])s,  where  it  lies  in  the  groove  which  winds  obliquely  around  the  humerus. 

The  Radial  Nerve. — The  radial  nerve  lies  to  the  outer  side  of  the  radial  artery,  three 
inches  above  the  wrist.  Should  any  of  the  nerves  of  the  arm  or  forearm  have  been 
cut  by  an  accident  which  has  produced  an  incised  wound  they  should  be  sought  for 
in  the  wound  if  fresh,  and  in  the  neighborhood  of  the  scar  if  older,  and  should  be 
reunited  by  suture,  as  already  described. 

The  Great  Sciatic  Nerve. — In  the  lower  extremity  it  is  the  great  sciatic  ner\'e  which  is 
usually  made  the  subject  of  operation.  An  incision  midway  between  the  great  trochanter 
and  the  tuberosity  of  the  ischium,  by  which  the  lower  border  of  the  gluteus  muscle  is 
exposed,  will  enable  the  surgeon  to  identify  the  biceps,  to  divide  the  deep  fascia,  and 
find  the  sciatic  ner\'e  at  the  outer  border  of' the  muscle.  It  is  sought  for  the  purpose  of 
nerve  stretching,  and  it  may  be  pulled  completely  out  of  the  wound,  while  the  entire 
weight  of  the  limb  may  be  suspended  by  it. 

The  Tibial  Nerve.— The  tibial  nerve's  may  be  exposed  through  incisions  identical 
with  those  indicated  for  ligation  of  the  tibial  arteries. 

The  Anterior  Crural  Nerve. — The  anterior  crural  nerve  lies  in  Scarpa's  triangle,  near 
Poupart's  ligament,  on  the  outer  side  of  the  femoral  artery. 

Tetanus  should  be  treated  by  injecting  antitoxin  into  the  main  nerve  trunks,  as  well 


624  SPECIAL   ON   REGIOXAL  SURGERY 

as  into  the  spinal  canal.  The  individnal  nerve  trunks  of  the  hraeliial  plexus  may  be 
exposeil  in  the  upj)er  arm,  where  the  ])oint  of  the  hypo^lermie  syrintfe  needle  may  he 
inserted  into  their  sul)stanee.  The  same  exju'dient  may  be  employed  with  the  sciatic  or 
anterior  crural  trunks,  through  the  incisions  just  described.  The  same  measures  may 
be  used  in  cocainizing  the  nerve  trunks,  as  suggested  by  Crile  and  others,  and  described 
in  the  chapter  on  Alterations  of  Blood  Pressure  (p.  181). 

Abbe  has  suggested  to  treat  certain  eases  of  inveterate  neuralgia  of  the  ])eri])heral  nerves 
by  an  intraspinal  tlivision  of  the  posterior  nerve  roots. 

There  has  been  added  to  the  standard  operations  on  nerves  another  measure.  This 
consists  of  (/raffing  by  means  of  foreign  material;  using  a  section  of  nerve  trunk  removed 
freshly  from  some  animal,  or  inserting  catgut  loo])S  Ix^tween  nerve  ends  which  shall  serve 
as  trellises  upon  which  the  growing  nerve  tissue  may  arrange  itself.  Powers,  of  Denver, 
has,  for  instance,  reported  the  implantation  of  four  inches  of  the  great  sciatic  nerve 
of  a  dog  into  the  external  popliteal  of  a  man.  The  results  seemetl  to  be  good  so  far  as 
sensation  was  concerned,  but  negative  as  regards  motion.  Probably  no  method  of  nerve 
grafting  will  give  so  good  results  as  the  utilization  of  a  part  of  the  nerve  itself  to  be 
oi)eratetl  u])on,  by  ])artially  detafhing  and  turning  back  a  portion  of  its  central  end  and 
uniting  it  to  a  similar  flap  made  from  the  other  end.  Various  operators  have  made  use 
of  different  materials  for  the  purpose  of  forming  a  tube  around  the  nerve  ends,  and  thus 
excluding  other  tissues.  F'or  this  jnirpose  cargile  membrane  is  perhaps  as  serviceable 
as  any.     When  all  other  measiu'es  fail  the  method  by  long  catgut  sutures  may  be  adopted. 


DISLOCATION  OF  NERVES. 

A  few  of  the  nerve  trunks  may  be  displaced  by  injury  in  such  a  way  that  they  are  liable 
to  subset|uent  redislocation  The  condition  is  recognized  by  the  mobility  of  the  nerve 
trunk  under  the  skin,  l)v  peculiar  sensations  when  the  trunk  is  irritated,  and  often  by 
tingling  sensations  referred  to  its  distribution.  The  condition  is  most  common  in  con- 
nection with  the  ulnar  nerve,  just  behind  the  inner  condyle.  Should  nothing  else  give 
relief  the  trunk  shcndd  be  cut  down  upon  and  retained  in  place  by  suture  or  by  fixation 
of  other  structures  around  it. 


WOUNDS  OF  THE  SPINE  AND  CORD. 

Penetrating  Wounds. — Penetrating  wounds  of  the  spine  occur  both  in  military  and 
in  civil  practice.  Sometimes  the  vertebne  alone  are  injured;  occasionally  the  spinal  canal 
will  be  opened,  with  little  injury  to  the  bone,  only  the  cartilage  suifering.  All  such 
injuries  are  serious  in  ])roporti()n  as  the  cord  itself  may  be  injured.  Such  injuries  may 
be  direct  or  indirect.  Should  a  large  vessel  have  been  divided  the  cortl  may  sufi'er  from 
pressure  of  dot,  and  should  this  injury  occur  high  in  the  spine,  death  may  be  caused  by 
pressure.  The  severity  of  such  an  injury  is  generally  estimatetl  by  phenomena  pertaining 
to  the  nerve  supply  of  parts  below  the  wound.  Should  anything  indicate  partial  or  com- 
plete division  of  the  cord,  or  that  a  single  nerve  trunk  has  been  divided,  then  an  operation 
is  indicated  for  relief  of  symptoms,  and  for  nerve  or  cord  siiture  except  in  those  instances 
where  (lestructiou  seems  to  be  too  comj)lete  to  ^^■arrant  it. 

Gunshot  Injuries. — Gunshot  injuries  vary  from  small  punctures  and  penetrating 
wounds  to  extensive  laceration.  The  lower  the  injury  the  lower  the  mortality,  other 
things  Ijeing  eqiuil.  Such  injiny  to  the  cervical  region  generally  ])roves  (juickly  fatal.  The 
symptoms  here  are  not  essentially  different,  save  that  the  bullet  may  have  done  still 
more  harm  by  passing  beyond  the  cord,  and  that  to  the  signs  of  a  })enetrating  woimd 
may  be  added  those  of  a  traimiatic  hemothorax  or  some  other  serious  complication. 
It  is  necessary  to  distinguish  between  mere  stiffness  of  the  back  and  disinclination  to 
use  certain  groups  of  muscles  and  absolute  loss  of  motility.  The  former  may  indi- 
cate contusion  and  the  latter  severance  or  pressure.  After  some  ]ierforations  cere- 
bros])inal  fluid  will  escape.  In  one  instance  I  opened  a  sj^inal  canal  for  perforating 
gunshot  wound  with  complete  jmralysis,  and  found  not  only  that  the  l)ullet  had  divided 
the  cord  but  had  passed  through  the  vrtebra  into  the  lung  beyond.  A  very  curious 
phenomenon  presented  in  this  case  is  that  when  the  })assage  was  well  ojiened  air  passed 


PLATE  XLVI 


^l/i  c 


^th  C 


f>th  C 


7th  C 


StJi  C 


/St  D 


2d  D        mLVk\l 


Intraspinal  Hemorrhage,  mostly  Subdural,  v/ith  Minute  Subpial  Ecchymoses. 


,s77.v.i  nil- IDA.  si'ixA/.  .\f i:.\ I \< ;<)('/■: /J-:  (-,25 

backward  and  t'drward  lliniii«;li  llic  spinal  wonml,  llic  paticnl  llnis  partly  l)rcatliin<; 
tliroiijili  liis  l)ack. 

The  circct  ol'  pressure  from  hciiiorrlKujc  is  |)ra(ti(all\  (lie  same  w  licllu-i-  it  he  intradural 
or  extradural,  or  occurring-  within  tiic  structure  of  tlie  cord  itself.  The  presence  of 
hlood  in  the  .sj)iual  eaual  is  known  as  liriiiiilorrlKiclii.s-,  and  when  oceurriut;  witliin 
the  coi'd  itself  is  termed  licnutfonii/c/Ki.  'i'lie  typical  svinptonis  of  sensory  and  motor 
paralysis,  which  serious  pressure  upon  the  cord  always  pnxhices,  occur  when  produced 
by  mere  presence*  of  fluid  more  slowly  than  when  due  to  (he  introduction  of  ji  foreiirn 
body  or  to  eommimition  of  the  bone.  Diafjjnosis  is  (hen  nnich  facilitated  if  by  tiie 
personal  history  it  can  be  learned  (hat  there  was  an  iut(  rval  after  the  reception  of  the 
injury  and  before  the  occurrence  of  paralysis,  duriufj  which  (he  patient  had  reasonable 
use  of  the  i)arts  later  jjaralyzed.  This  interval  may  be  one  of  but  a  few  minutes'  dura- 
tion or  may  have  extended   over  several  hours. 

When,  on  the  other  hand,  such  an  interval  lastin<i;  .several  days  has  been  noted,  then 
the  intraspinal  lesion  nuist  be  either  one  of  acute  def:;eneration  or  of  suj)j)urativc  character. 
(See  Plate  XLVI.) 

The  (juestion  of  opcraiion  in  xpinal  Jirni(irrli(i(j(:s  will  fre(|uen(ly  be  raised,  and  is 
to  be  decided  in  ])art  by  the  intensity  of  the  sym])toms  and  in  part  by  the  character  of 
the  injury.  Incomplete  ])aralysis  would  indicate  a  lesser  degree  of  pressure  and  justify 
a  hoi)e  that  the  out])oure(l  blood  may  be  resorbed.  This  hope  may  be  further  enc(nir- 
aged  should  symjitoms  improve.  On  the  other  hand  symptoms  of  comjjlete  paralysis, 
indicating  serious  and  extensive  pressure  upon  the  cord,  would  justify  a  laminectomy, 
and  make  it  even  more  encouraging  than  though  it  were  done  for  a  crushing  injury. 
The  more  serious  cases,  then,  of  s{)inal  hemorrhage  would  seem  to  justify  exploration. 

Until  very  recently  it  has  been  held  that  a  comj)lete  cross-division  of  the  s])inal  cord 
must  necessarily  be  followed  by  a  hopeless  jniralytic  condition,  plus  the  changes  due  to 
ascending  degeneration  of  the  upjjer  segment.  The  results  of  laboratory  experiments 
have  made  this  quite  plain,  and  therefore  it  was  a  startling  innovation  in  surgery  when 
Harte  could  report  an  experience  contradicting  all  that  we  had  learned  to  believe  in  this 
regard.  In  spite,  then,  of  the  fact  that  experimental  suture  of  the  cord  after  its  division 
had  not  been  successful  in  animals  we  are  now  confronted  by  three  more  or  less  successful 
cases  reported  by  American  surgeons,  Estes,  Harte,  and  Fowler,  where  the  spinal  cord 
was  sutured  after  division,  with  at  least  partial  recovery  of  function.  In  Harte's  case 
the  operation  was  done  thrt>e  hours  after  injury;  in  Fowler's  case  ten  days  had  elapsed. 
Fowler  used  chromicized  catgut  sutures  in  the  cord  itself,  with  separate  sutures  of  the 
dura  with  the  same  material,  the  principle  here  being  the  same  as  in  nerve  suture,  and 
the  effort  being  to  do  as  little  harm  as  possible  with  the  needle  and  the  suture  material. 
After  a  simple  division  there  is  but  little  tension,  and  the  ends  of  the  cord  are  easily 
approximated. 

It  has  thus  been  pnjved  that  there  is  at  least  some  possibility  of  regeneration  of  the 
cord  after  such  destructive  lesions;  but  the  cases  which  permit  of  or  justify  this  measure 
will  be  rare,  although  it  is  gratifying  to  learn  that  there  has  been  so  much  encouragement 
afibrded  by  experiences  reported. 

THE  SPINAL  COLUMN. 

SPINA  BIFIDA;  SPINAL  MENINGOCELE. 

Spina  bifida  is  the  result  of  a  congenital  defect  in  the  construction  of  the  spine  with 
incomplete  closure  of  the  spinal  canal.  The  defect  lies  in  the  posterior  arches  of  the 
vcrtebrtfi;  the  bodies  are  rarely  involved.  For  this  reason  these  lesions  are  centrally 
placed,  i.  e.,  in  the  middle  line.  The  essential  feature  of  a  spina  bifida  is  protrusion 
of  the  spinal  membranes,  and  they  are,  to  all  intents  and  purposes,  spinal  meningoceles. 
These  tumors  sometimes  have  only  the  thinnest  of  skin  coverings;  at  other  times  they 
will  be  covered  by  considerable  masses  of  overlying  fat  or  fibrous  tissue. 

These  congenital  tumors  when  more  definitely  described  should  be  classified  as — 
1.  Meningocele,  where  there  is  simply  a  protrusion  (hernia)  of  the  dura,  which  may 
be  lined  with  some  branches  of  the  vertebral  nerves; 
40 


t)26 


SPECIAL  OR  REGIOXAL  SURGERY 


2.  Mcnnif/oiiii/rlorrlr,  wiiert'  .sonic  jMtrtioii  of  the  spiiiul  cord  projx  r  is  included  within 
the  sac ; 

3.  8i/ringmni/clocclc,wheT(;  the  central  canal  of  the  cord  is  dilated  into  a  cyst  of  some 
size,  over  which  the  structures  of  the  cord  proper  are  more  or  less  thinly  spread  out, 
the  whole  l)eintj  covered  with  the  spinal  dura. 

The  first  form  is  by  far  the  simjilest  and  most  amenable  to  treatment.  The  other 
forms  are  much  more  serious,  and  the  third  form  is  hopeless  so  far  as  operative  surgery 
is  concerned. 

The  greater  pro])ortion  of  these  cases  occur  in  the  luml)ar  region,  at  least  70  per  cent, 
being  met  with  in  the  lower  region  of  the  spine,  including  the  sacrum.  It  occurs  occa- 
sionally in  the  neck  and  in  the  mid-dorsal  region. 

Fig.  41 1  illustrates  the  general  appearance  of  such  a  tumor.  The  opening  of  communi- 
cation may  be  very  small  or  may  involve  the  arches  of  several  vertebrse.  So  with  the 
tumor  itself,  it  may  be  small  and  almost  imperceptible,  or  it  may  attain  almost  the 
size  of  a  child's  head.  The  overlying  skin  is  rarely  absent;  it  is  usually  covered  with  a 
growth  of  hair,  and  its  presence  in  the  region  of  the  spinous  processes,  coupled  with 
the  presence  of  any  perceptible  tumor,  should  cause  suspicions  of  the  so-called  spina 
bifida  orcuha. 

These  tumors  are  situated  in  the  middle  line  or  very  near  to  it,  and  are  compressible 
in  proportion  to  the  thinness  of  their  coverings.  When  small  they  can  be  collapsed  by 
pressure,  the  same  not  infrequently  causing  pressure  symptoms,  as  the  fluid  is  forced 

into  the  cranial  cavity,  such  as  cough- 
FiG.  411  {Y\g,    vomiting,    vertigo,   etc.      If   the 

fluid  can  be  easily  expressed  from 
the  sac  the  opening  may  be  regarded 
as  relatively  large.  If  pressure  makes 
no  alteration  in  the  size  of  the  growth 
the  case  should  then  be  regarded  as 
one  where  the  small  original  com- 
munication has  been  closed  by  natural 
processes.  Some  of  these  tumors  have 
more  or  less  of  a  pedicle  and  others  are 
broadly  sessile.  The  tendency  is  ever 
toward  increase  in  size,  being  rapid  or 
slow  according  to  the  thickness  of  the 
protecting  membranes  and  the  size  of 
the  opening.  While  spontaneous  oc- 
clusion may  occur  there  is  j)racticany 
no  spontaneous  repair  of  the  bony 
defect.  The  .mrgeon  should  beware  of 
a  tumor  of  eongenital  origin  situated 
in  or  near  the  middle  line,  anyichere 
from  the  root  of  the  nose,  over  the  head, 
and  down  to  the  tip  of  the  coccyx.  Such 
a  tumor  should  be  regarded  with  sus- 
picion until  shown  to  be  harmless. 
Many  cases  of  spina  bifida  are  ac- 
companied by  other  congenital  defects,  such  as  club-foot,  or  hydrocephalus.  Symp- 
toms may  or  may  not  be  present.  When  present  they  will'  be  of  the  paralytic 
type  and  affect  those  parts  of  the  body  below  the  level  of  the  growth.  They  are 
clue  to  the  involvement  of  the  cord  or  the  nerves.  The  ever-present  danger  in' such 
cases  is  of  rupture  with  escape  of  the  contents,  with  its  proportionate  reduction  of  intra- 
spinal pressure,  and  the  possibilities  of  infection,  with  rapid  death  from  meningitis. 
Inasmuch  as  some  of  these  cysts  have  such  thin  walls  that  transillumination  is  possible 
it  will  be  seen  how  great  may  be  this  danger. 

Treatment. — Treatment  should  be  made  to  meet  the  indications.  Only  in  cases 
which  are  deemed  inoperable  should  some  protection  be  relied  upon  and  worn.  This 
may  be  afforded  by  a  common  surgical  dressing  or  by  means  of  a  plaster-of-Paris  or 
waxed  gauze.  A  molded  shield  may  be  prepared  and  so  arranged  upon  a  band  or 
girdle  as  to  protect  the  cyst  from  external  harm.     Efforts  to  reduce  the  size  of  the  tumor 


Spina  bifida.      (Bradford.) 


CYSTS  .\.\J)   voce \  ill:. \L    Tl  MOUS 


027 


by  |)r(\s.siirc  arc  futile  and  use-less.  Tlic  skin  may  Ik-  proU-ctftl  by  njvcriii^  with 
colloditiii. 

The  radical  trvaiuinit  of  s])iiia  bifida  should  only  be  attempted  in  favcjrable  eases, 
but  in  such  instances  can  be  made  exeeedin<,dy  satisfactory  and  successful.  A  tumor 
with  a  small  j)edicie  may  be  treated  by  lij^ation,  the  skin  bein<;  divided  by  ellipticul 
incisions,  the  juhHcIc  proju-r  bein<f  surrounded  by  a  chromicized  or  silk  suture  and  the 
sac  then  excised.  When  the  ju-dicle  is  too  lar<^e  to  be  treated  in  this  way  and  yet  not 
very  lar<;e,  it  may  be  clo.sed  by  sutures  after  removal  of  the  sac,  and  drojjped  d(/wnward 
into  the  spiiud  openinij,  and  the  adjoininj^  ti.ssues  made  to  close  over  it  by  buried  and 
su])erficial  sutures.  It  is  the  lar<]jer  and  more  sessile  sacs  which  give  rise  to  the  greatest 
difHculti(\s.  The  attem})t  may  be^  made  to  excise  a  greater  portion  of  the  sac,  to  fold  in 
its  edges  and  to  ai)proximate  these  with  sutures  of  fine  chromic  catgut.  The  fold  thus 
formed  may  be  laid  downwanl  and  upon  the  spinal  groove,  the  aponeurotic  and  other 
firm  fibrous  tissues  in  the  neighborhood  being  loosened  sufficiently  so  that  they  may  be 
brought  together  by  buried  sutures,  and  the  balance  of  the  wound  closed.  I  have  a 
number  of  times  been  able  to  introduce  either  strips  of  metal  foil  or  thin  pieces  of  cellu- 
loid, or,  better  still,  ivory  trimmed  to  fit  the  bony  defect,  and  so  arranged  as  to  be  sprung 
into  grooves  made  on  either  side  of  the  osseous  canal.  If  ivory  be  used  for  this  j)ur- 
pose  the  thin  small  sheets  which  are  used  l)y  miniature  painters  should  be  [)rocured. 

Such  operations  should  be  made  at  the  earliest  practical  moment;  in  infants  espe- 
cially, but  probably  with  all  young  patients,  the  head  being  maintained  at  a  much  lower 
level  tliaii  the  sacrum  in  order  that  only  tlie  small(>st  (juantity  j)0.ssil)le  of  the  cerel)ros))inal 
fluid  may  escape.  I  have  also  used  a  small  amount  of  weak  cocaine  solution  after 
exposing  the  cord  in  the  s])iiial  canal,  in  order  that  reflex  impressions  may  be  avoided  so 
far  as  possible  and  shock  thus  prevented.  With  a  young  patient  the  amount  of  cocaine 
to  be  thus  used  should  not  exceed  more  than  2  or  3  Mg. 

Osteoplastic  methods  have  also  been  devised  for  the  purpose  and  may  be  practised 
in  cases  ])ermitting  them. 

INIany  of  the.se  cas(\s  do  not  come  to  operation  until  the  skin  is  excoriated  or  ulcerated. 
It  is  exceedingly  diffic-ult  vm(U-r  these  circumstances  to  make  an  aseptic  operation.  The 
subsequent  difficulties  of  maintaining  asepsis  should  also  be  foreseen,  especially  when 
lesions  are  located  low  in  the  spine  and  in  little  patients,  as  soiling  from  fliapers  and 
discharges  is  so  ea.sy.  After  such  operations  oiled  silk,  or  gutta-jx-rcha  tissue  should 
be  fastened  around  the  pelvis  by  rubber  cement,  in  such  a  way  as  to  make  a  water-tight 
covering  for  the  deep  surgical  dressings,  and  this  line  of  junction  should  be  scrutinized 
frequently.     These  operations  often  give  satisfactory  results. 


Fig.  412 


CYSTS  AND  COCCYGEAL  TUMORS. 

Many  congenital  tumors  are  met  with  alx)ut  the  region  of  the  sacrum  anrl  coccyx, 
some  of  which  have  the  essential  characteristics  of  meningocele,  while  others  are  rather 
of  the  dermoid  or  embryonal  variety  Tumors  of 
great  size  develop  from  the  region  of  the  coccyx, 
and  many  are  of  interest  to  the  pathologist. 

True  dermoids  often  begin  to  develop  within 
the  pelvis  and  then  escape  therefrom  in  this 
vicinity,  some  of  them  containing  soft  epithe- 
lial products,  others  being  dense  and  hard. 
(See  Figs.  72  and  7.3,  p.  206.) 

Every  tumor  of  this  general  character  and 
in  this  location  should  be  removed  as  early  as 
possible  unless  it  can  be  determined  that  it  is 
not  only  cystic  but  dangerously  large.  Of  even 
these,  however,  it  may  be  said  that  to  leave 
them  is  to  expose  the  patient  to  more  danger 
of  infection  than  is  incurred  during  a  legitimate 
surgical  operation.  There  should  be,  then, 
aboiit    such  a  case   serious    complications    and 

perplexities,  which  woidd  tend  to  make  a  com-  g^^^^j  ^^^^  showing  defect  in  sacrum, 

petent   surgeon   decline  to  operate   (Fig.   412).  (Warren  Museum.) 


628  SPECIAL  OR  REGIONAL  SURGERY 


SPRAIN  OF  THE  SPINAL  COLUMN. 

Concussion  of  the  Spine;  Railroad  Spine;  Litigation  Spine.— In  iSGfi  Erichsen 

published  a  series  of  lectures  (lealiii<2;  with  "Certain  obscure  injuries  of  the  nervous 
system  commonly  met  with  as  the  result  of  shock  received  in  collisions  on  railways." 
In  1875  he  expanded  these  lectures  into  his  celebrated  monograph  on  Concussion  of 
the  Spine,  a  work  which  served  first  to  arouse  the  greatest  interest  in  a  hitherto  neglected 
subject,  and  which  has  imfortunately  ser\'ed  in  later  years  as  a  basis  for  many  a  damage 
suit.  The  injuries  described  by  him  may  occur  as  the  result  of  railway  accidents,  hence 
the  name  often  applied  to  the  condition  which  they  cause — railway  spine.  Cynical 
observers  have  noted  the  frequency  with  w^hich  these  cases  appear  in  court  and  have 
stigmatized  the  condition  with  the  name  litigation  spine.  Erichsen's  original  work 
is  now  superseded  by  much  better  monographs,  although  his  clinical  descriptions  were 
full  and  complete.  Nevertheless  he  had  no  knowledge  of  minute  changes  in  the  nervous 
system  and  many  of  his  explanations  were  based  upon  theories  then  prevalent  but  now 
abandoned. 

These  injuries  involve  the  spine  as  a  whole,  and  the  spinal  column  is  so  firmly  held 
together  by  powerful  ligaments,  and  so  abundantly  protected  by  muscular  and  aponeu- 
rotic coverings,  that  its  contents  are  exempt  from  injuries  which  would  easily  involve 
those  of  more  exposed  joints.  An  injury  which  would  cause  serious  disintegration  wdthin 
the  spinal  cord  must  be  so  severe  as  to  inflict  other  and  well-marked  damage  upon  the 
surrounding  structures.  Consequently  a  large  part  of  the  injury  received  consists  in 
w'hat  may  well  be  called  strain  and  wrenching  of  all  of  these  component  structures. 
These  may  be  accompanied  by  minute  hemorrhages  into  the  cord,  with  or  without 
laceration,  while  exudates  may  result  therefrom  which  may  })ress  upon  the  spinal  nerve 
roots  or  cause  adhesions  within  or  without  their  sheaths,  all  of  which  may  lead  to  signs 
and  symptoms  which  may  persist  for  a  long  time.  But  the  theory  to  which  too  many 
have  held  in  time  past,  that  a  mere  concussion  of  these  parts,  without  other  injuries, 
can  be  followed  by  such  extensive  and  durable  lesions  is  not  tenable. 

Obviously  these  cases  are  of  a  character  frequently  to  appear  in  court.  Unfortunately 
the  signs  and  symptoms  are  so  vague,  so  variable,  and  the  latter  so  subjective  that  oppor- 
tunity is  afforded  for  deception,  opportunifij  of  which  both  dishonest  patients  and  dis- 
honest lawyers  too  frequently  avail  themselves;  this  to  an  extent  which  has  almost 
brought  the  condition  into  disrepute  among  the  better  class  of  practitioners  and  caused 
it  to  be  in  some  sense  neglected.  That  serious  lesions  do  follow  injuries  to  the  back  is 
undeniable ;  that  many  of  the  resulting  conditions  can  be  simulated  is  unfortunately  too 
true. 

Nervous  demoralization  and  more  or  less  chronic  invalidism  frequently  follow 
these  injuries,  producing  symptoms  which  are  mainly  functional  and  maybe  grouped 
among  the  traumatic  neuroses.  These  symptoms  are  mostly  ill-defined,  often  contra- 
dictory, and  accompanied  by  very  few  objective  features. 

If  malingering  can  be  excluded  the  best  way  to  regard  these  clinical  pictures  is  to 
consider  them  as  indicating  a  traumatic  neurosis — that  is,  a  nervous  disturbance,  with 
perversion  rather  than  abolition  of  function,  comparable  with  similar  conditions  from 
other  causes.  As  Angell  has  said,  its  symptomatology  is  largely  built  u]i  of  the  emotional 
featiu'es,  with  such  grotesque  nervous  disturbances  as  to  be  quite  inconsistent  with  any 
true  organic  malady.  In  the  latter  there  will  always  be  definite  indications  with  positive 
changes  and  normal  reactions,  while  each  segment  of  the  spinal  cord  will  have  its  oa\ti 
definite  features.  Quite  the  reverse  is  the  case  in  a  so-called  railway  spine,  where 
paralyses  are  incomplete,  where  loss  of  sensibility  fails  to  correspond  with  anatomical 
relations,  where  the  reflexes  are  contradictory  and  the  comjilaints  out  of  all  proportion 
to  the  injury  received.  Such  a  condition  is,  therefore,  a  psychosis  or  neiu'osis  rather  than 
a  somatic-  disease.  (Angell.)  As  a  mental  perversion  it  is  often  dependent  upon  the  domi- 
nating influence  of  an  imperative  conception,  which  may  or  may  not  have  an  honest 
basis.  Even  if  a  patient  be  not  tempted  to  malinger  or  simulate,  his  troubles  may  be 
exaggerated  by  expectant  attention,  which  of  itself  has  nothing  to  do  with  the  injury, 
but  rather  with  his  mental  attitude.  This  is  a  predominant  feature  of  those  cases  which 
go  to  trial,  and  while  it  may  persist  after  a  settlement  is  reached,  it  should  be  admitted 
that  the  morbid  condition  usuallv  subsides  when  litigation  is  terminated. 


FRACTURES  OF   Till'.   SPIXE  629 

Thesi'  iiiipcrativc  coiiccptioiis  arc  iiitciisilicd  hy  cinotioM,  I'car,  syiiipatliv,  or  anxk'tv. 
while  attfiitioii  hccoincs  luorc  and  more  .self-centred,  the  condition  finally  terminating 
in  a  more  or  less  self-indnced  hy|)n()tic  state — a  species  of  antosug^estion.  Similar 
cases  of  non-traumatic  orii^in  are  frcfjuently  observed,  which  are  then  called  neurasthenia 
or  hyst(>ria.  When  in  an  individual  already  neurasthenic  injury  occurs  it  almost 
invariably  produces  exaj^^crated  symptoms.  To  use  An<j;eirs  own  expression:  "Kail- 
way  spine  is  a  convenient  and  picturcs(|ue  teim  which  hypnotizes  juries,  even  as  shock 
has  hypnotized  j)atients.  It  is  dramatic,  hut  not  accurate,  "^riic  dama}fe  is  not  to  the 
.spine  nor  to  the  s|)iiial  cord,  hut  to  tiic  mind.  It  is  a  j)sychical  disorder,  not  a  physical 
one,  althouixh  it  has  a  j)hysical  expression  in  its  symptomatolofjy." 

Treatment. —Viewed  in  this  lit,flit  it  will  he  .seen  that  theVe  is  the  greatest  value 
attai  hing  to  physiological  rest,  beginning  immediately  after  the  injury  and  continuing 
until  the  subsidence  of  the  symptoms.  This  should  be  combined  with  measures  whicli 
improve  elimination  and  nutrition.  Confinement  to  bed  or  the  room  will  reduce  elimina- 
tion, which  should  never  be  allowed  to  decrea.se  in  any  way.  Bodily  and  mental  rest, 
combined  with  the  above  features,  followed  later  by  ma.ssage,  cold  spinal  douche,  elec- 
tricity (cither  for  its  actual  or  suggestive  value),  and  mental  encouragement,  constitute 
the  principal  methods  of  treatment.  A  case  of  this  kind  tinctured  by  a  hope  of  .secure- 
ment  of  ultimate  damages  will  be  not  only  resistant  but  difficult  of  successful  treatment. 


INJURIES  TO  THE  SPINE. 

The  principal  injuries  to  the  spine  proper  to  be  considered  here  consist  of: 

1.  Fractures; 

2.  Dislocations,  or  their  occurrence  together; 

3.  Injuries  to  the  cord  and  spinal  column; 

4.  Rupture  or  injury  of  the  muscles,  ligaments,  and  aponeuroses. 


FRACTURES  OF  THE  SPINE. 

The  spinal  column  is  so  strongly  put  together  and  its  bones  so  protected  that  fracture 
of  any  one  of  its  c()m])onent  j)arts  is  inconceivable  except  as  a  result  of  violence.  This 
may  occur  by  objects  falling  upon  it  or  by  the  body  falling  a  distance,  or  from  violent 
twisting  or  wrenching.  These  injuries  constitute  but  a  small  percentage — about  .3  per 
cent. — of  all  fractures.  They  occur  more  easily  and  commonly  in  the  upper  portion  than 
in  the  lower,  where  the  vertebrae  are  larger.  As  a  result  of  their  occupations  adult  males 
sufler  much  more  frequently  than  women  or  children. 

Diagnosis. — The  diagnosis  of  fracture  of  the  vertebral  column  is  rarely  difficult.  The 
disability  ])roduced  is  instantaneous  if  the  cord  itself  be  cornpre.s.sed.  If  the  cord  escape 
pressure  there  may  be  serious  symptoms,  but  without  paralysis.  The  most  serious 
feature,  then,  of  any  fracture  of  the  vertebme  is  the  amount  of  damage  done  to  the  cord 
proper.  The  so-called  gunshot  frac-tures  of  the  sphie  have  already  been  partially  treated 
of  above  and  in  the  chapter  on  Gunshot  Wounds.  They  constitute  a  somewhat  different 
class  of  lesions,  but  have,  in  common  with  those  above  alluded  to,  the  actual  fracturing  of 
the  bone  and  the  question  of  damage  to  the  cord.  In  most  respects  they  may  be  con- 
sidered with  the  non-penetrating  injuries.  Fractures  of  the  spine,  therefore,  may  be 
divided  into  (a)  fractures  with  injury  of  the  cord,  and  (h)  fractures  without  such  injury. 
In  many  cases  it  is  difficult  to  state  whether  the  cord  is  crushed  or  simply  more  or  less 
compressed  by  bone,  fluid,  or  exudate,  until  the  spinal  canal  has  been  opened  and 
explored. 

When  the  cord  is  totally  destroyed  there  will  be  total  loss  of  reflexes,  with  motor 
and  sensory  paralysis  complete.     (See  Fig.  413.) 

In  some  instances  there  is  visible  or  palpable  deform  I'ti/.  This  is  by  no  means  neces- 
sarily the  case.  It  is  more  likely  to  be  noted  in  the  upjier  portion  of  the  column,  where 
the  vertebral  spines  are  more  easily  palpated.  If  sufficient  time  haveelap.sed  there  will 
often  be  ec-chymosis.  The  principal  feature,  however,  of  spinal  fractures  is  the  'paralysu, 
which  results  in  most  instances  as  above.     Its  careful  study  is  requisite  both  for  minute 


630 


SPECIAL  OR  REOIOXAL  SURGERY 


Fig.  413 


diagnosis  and  localization  of  the  injury.  Para/ijsl.s,  ilini,  wlirfherof  motion  or  of  sentia- 
tion,  along  with  the  condition  of  the  reflexes,  (le.ser\es  careful  con.sideration  in  each 
instance.  It  is  of  the  greatest  importance,  because  by  it,  rather  than  by  other  causes, 
death  is  brought  about  in  the  majority  of  cases  which  outlive  the  first  twenty-four  hours 
after  injury.     Even  injury  low  dcnvn,  which  causes  paraplegia  with  loss  of  control  of 

the  bowels  and  bladder,  may  terminate 
^  "'  ^^^  fatally    in  time,  through    an    ascending 

infection  of  the  urinary  pa.ssages,  which 
may  finally  lead  to  pyelonephritis  and 
death.  This  has  often  occurred  as  the 
result  of  inattention  to  ])recautions  in 
the  use  of  the  catheter,  and  to  careless- 
ness on  the  part  of  the  patient.  Death, 
then,  may  be  caused  by  roundabout 
methods  of  infection  which  have  only 
accidental  connection  with  the  original 
injury.  Other  cases  die  of  septic  in- 
fection in  consequence  of  lack  of 
proper  attention  to  bed-.sores.  Again, 
with  cord  involvement  high  up  in  the 
d(jrsal  region  there  i.s  very  likely  to 
occur  a  rapid  ascending  degeneration, 
by  which,  one  after  another,  the  roots 
of  the  phrenic  nerves  are  involved  in 
their  order  from  below  upward,  until 
finally  the  patient  dies  of  asphyxia  from  paralysis  of  all  the 
respiratory  apparatus  (Fig.  414). 

.\si(le  from  such  evidences  as  actual  (li-.])laf  cinent  of  the  verte- 
bral spines  may  afford  the  localizing  diagnosis  is  made  mainly  by 
a  study  of  the  paralysis.  In  regard  to  this  paralysis  it  should  be 
remembered  how  it  is  produced  from  the  very  nature  of  the  injury 
itself.  That  occurring  within  from  a  few  minutes  to  a  few  hours 
after  tlie  injury  is  due  to  hemorrhage;  that  which  occurs  still 
in  jre  slowly  is  due  to  exudate  or  the  jjrcsence  of  pts;  while  a  late 
paralvsis  may  result  from  ]y)liomyelitis.  The  first  form  of  par- 
alvsis  may  be  produced  by  hemorrhage  either  within  the  central 
canal  (hematomyelia)  or  hemorrhage  within  the  membranes  or 
l\  structure  of  the  cord  itself  (hematorrhachis). 

''ir'  \  There   is   another  form  of  paralysis  due   to    embolism    wjiich, 

'"'B^-*-^  -  '-'Sijtf^       however,  has  but   little   to    do  with  the  ordinary  injuries.     The 
following  table,  inserted  bv  the  courtesy  of  Dr.  Dennis,  will  a.s.sist 
Fracture  of  body  of    j^^  loealizing  the  lesion  bv  a  study  of  these  paralyses  and  reflexes 

the   vertebra.      (Warren  .    '^ .   .     .  "  ''  i  •■ 

Museum.)  due  to  spinal  uijury: 


Crush  of  cord  and  its  mem- 
branes. Theresult  of  a  fracture 
of  the  spine.     (Erichsen.) 


Spimil 
Nerve. 


Paralyses  and  Reflexes  due  to  Spinal  Injury. 


Motor  Paralysis. 


Anesthesia. 


Reflexes. 


1.    Death  from  pressure  of 

odontoid. 
2-.3.     Death   from    paralysis 

of  diaphragm. 
4.    Deltoid  muscles  of  up-       Upper  .shoulder,  outer  arm. 

per  arm. 
.5.    Supinators  of  hand.  Outsideof  arm  and  forearm. 


Pupil 


Pupil,   scapular,   .supinator, 

triceps. 
Pupil,  scapular,  tricep.s,  post. 

wrist. 


0.     Biceps,  triceps,  exten--  Outer  half  of  hand, 
sors  of  wrist. 

7.  Pronators  of  wrist,  la-  Inner  side  of  arm  and  fore-  Pupil,  scapular,  po.st.  wri.st, 

ti.ssimus  dorsi.                       arm.  ant.  wrist,  palmar. 

8.  Flexors  of  wrist,  hand,  Inner  .side  of  hand.  Scapular,    post,  wri.st,  ant. 

musch  s.  wri-t,  palmar. 


DISLOCATIOS   OF    Tllh:   SPISE 


631 


Spiruil 

Nerrr. 


2-12. 


Motor  Paralysis. 

I'liuinl). 

Muscles    to    hack  and 
abilonieii. 


Anesthesia. 

riiiar  supply  to  hand. 

Skin  over  the  hack  and 
al)donien  in  areas  cor- 
responding to  dislrihu- 
tion  ol'  spinal  nerves. 


Psoas  and  sartorius.  Groin. 

(Quadriceps  extensor  Outside  of  tliigli. 

I'eiuoris. 

.\l)(luct()rs    and     iiwier  Front  and  in.'fide  of  thi^ii. 

rotators  of  thigh. 

.Adductors   of   thigh,  Inside    of  leg,   ankle,   and 

til)ialis  anticus.  foot. 

Outwaril    rotators     of  Back    of    thigh    and    leg; 

thigh,  flexors  of  knee  outsitle  of  foot. 

and  ankle. 


Reflexes. 

Scapular,  palmar. 
Epigastric,  4-7;  alidominal, 
7-11. 


Cremasteric. 

(Voinasteric,  patelhir. 

( 'rcniasteric. 

Cllutcal. 

Gluteal. 


_•  f  1-2.    Muscles  of  foot,  pero-  Out  .side  of  leg.  Plantar. 

S  J  nei. 

ri  1  3-5.     Perineal  inu.scle.s.  Perineum,    anus,    sacrum.         Ankle  clonus. 

^'  I  genitals. 

Injuries  low  in  the  liinihar  .segments  caii.se  incontinence  of  nrine  and  feces  hecanse  of 
the  location  of  the  centres  for  the  rectum  and  bladder  at  this  level.  Injuries  higher 
up  cause  retention  by  paralyzing  the  expulsive  muscles  of  the  abdomen.  The  refie.xes 
which  most  interest  the  surgeon  and  which  are  of  importance  to  him  in  diagnosticating 
the.se  and  other  traumatic  conditions  are  the  following,  with  their  method  of  detection 
(Bradford): 

Pupillary:  Dilatation  produced  by  jjinching  side  of  neck. 

Scapular:  Scratching  skin  over  scapula  causes  muscles  to  contract. 

Sujiinator:  Tapping  tendon  at  wrist  causes  flexion  of  arm. 

Triceps :  Tapping  tendon  at  elbow  causes  extension  of  arm. 

Posterior  wrist:  Tapjnng  tendons  causes  extension  of  hand. 

Anterior  wrist :  Tapping  tendons  causes  flexion  of  wrist. 

Palmar:  Scratching  palm  causes  flexion  of  fingers. 

Epigastric:  Stroking  mammee  causes  retraction  of  epigastrium. 

Abdominal:        Stroking  abdomen  causes  retraction. 

Cremasteric:      Stroking  inner  side  of  thigh  causes  retraction  of  scrotum. 

Patellar:  Striking  patellar  tendon  cau.ses  extension  of  leg. 

Gluteal:  Stroking  buttock  causes  dimpling  in  gluteal  'old. 

Plantar :  Stroking  sole  (4"  foot  causes  flexion  and  retraction  of  leg. 

Ankle  clonus:  Forcible  extension  causes  rhythmical  flexion. 
Much  will  depend  upon  the  minute  character  of  the  injury,  its  location,  and  the 
amount  of  displacement  of  fragments.  Fracture  of  a  spinous  process  causes  irregidarity 
of  the  tips  of  the  spines,  with  frequently  the  displacement  of  a  fragment  which  may 
be  moved  beneath  the  skin,  with  or  without  crepitus.  Fracture  of  one  or  both  laminae 
will  permit  mobility  of  the  spinous  process,  with  perhaps  displacement.  It  is  difficidt 
to  elicit  crepitus.  The  neural  arch  may  thus  be  broken  without  serious  involvement 
of  the  body  of  a  vertebra.  On  the  other  hand,  the  body  itself  may  be  fragmented,  com- 
pres.sed  out  of  shajDe,  or  so  loosened  as  to  permit  of  easy  displacement. 


DISLOCATION  OF  THE  SPINE. 

A  limited  proportion  of  serious  and  paralyzing  injuries  to  the  spine  consists  of  dis- 
location of  some  of  its  component  parts  without  fractures.  These  may  be  considered 
as  pure  types  of  dislocation,  but  they  constitute  less  than  one-fourth  of  such  cases.  In 
a  large  proportion  of  these  spinal  injuries  the  actual  lesion  consists  of  the  combination 
of  fracture  with  the  tlisplacement  which  it  permits.  Such  conditions  are  referred  to  as 
fracture  dislocaiions.  Unilateral  dislocation  in  the  cervical  region  produces  a  distortion 
of  the  neck  simidating  wryneck,  the  face  being  turned  to  the  opposite  side.  E.xcept  in 
very  fat  individuals  irregularity  will  be    perceived  in  the  line  of  the  cervical  spines. 


632 


SPECIAL  OR  REGIONAL  SURGERY 


When  high  up  dyspnea  is  a  constant  feature.  Traumatic  dislocations  are  sharply  dif- 
ferentiated, so  far  as  the  treatment  is  concerned,  from  those  of  slow  production  as  the 
result  (if  cervical  spondylitis.  In  the  acute  cases  tlie  muscles  are  spasmodically  con- 
tracted on  the  dislocated  side.  Irregularity  of  contour  may  be  detected  with  the  finger 
in  the  pharynx. 

Fig.  415 


Fracture  dislocation  with  great  displacement — patient  almost  completely  recovered.     (Buffalo  Museum.) 


In  the  lower  portions  of  the  spine,  which  are  both  larger  and  more  protracted,  are 
more  frequent  combinations  of  both  injuries  and  fewer  instances  of  the  single  type  of 
either.  Except  in  the  cervical  region  it  is  exceedingly  difficult  to  distinguish  between 
these  lesions,  for  the  question  of  operation  or  no  operation  is  decided  by  other  and  more 
conspicuous  features  (Figs.  410  and  417). 


Fig.  416 


Fig. 417 


Dislocation  between  the  fifth  and  sixth  cervical  vertebra?. 
(Erichsen.) 


Dislocation  of  the  spine  forward 
(Bryant.) 


Treatment. — The  injury  ha\nng  been  localized,  so  far  as  deformity  and  careful 
study  of  its  paralytic  features  will  permit,  the  questions  of  prognosis  and  treatment  be- 
come insistent.  In  the  pure  t^'])e  of  dislocation  tlic  ]irognosis  will  depend,  first,  upon 
whether  reduction  can  be  accomplished,  and,  secondly,  upon  the  amount  of  damage 
suffered  by  the  cord  previous  to  such  reduction.  Every  injury  of  the  cervical  spine  is 
of  most  serious  imjjort  because  of  the  possible  damage  to  the  phrenic  nerves.  Rapidly 
ascending  changes  may  terminate  life  in  two  or  three  days  even  thcnigh  reduction  be 


DfSf.OC AT/OX   OF    Till-:   SI'IXF 


633 


accomplished.  Tlic  injuries  to  liie  lower  pari  of  tiie  spinal  coiimiii  wliicli  ])ro<liiee  para- 
piet^ia  tlircatcii  life  iniK  li  less  direetly,  imt  too  t're(jueiitly  terminate  fatally  after  tlif 
lapse  of  weeks  or  luoiitlis,  as  the  result  of  infections  from  s|)rea(lin^  l)e(l-sores,(jr  infections 
throujjh  the  urinary  tract  jM-rniitted  l)y  the  constant  necessity  for  and  carelessness  in  the 
use  of  the  catheter.  The  pr<)<;nosis,  then,  in  almost  every  case  of  these  severe  spinal 
injuries  is  unfavorable,  at  least  if  it  he  let  alone  (Ki^.  41")). 

It  becomes,  then,  a  (piestion  of  what  can  he  done  to  im|)rove  the  local  conditions. 
Certain  eases  of  cervical  spinal  dislocation  have  heen  reduced  by  forcible  traction  upon 
the  head,  assisted  by  rotation  and  manipulation  with  the  hands  in  the  direction  indicated 
bv  tlu'  displacement  of  the  patient's  head,  as  well  as  by  such  indications  as  may  be 
secured  in  the  j)haryux.  A  considerable  dcfjjree  of  traction  may  be  necessary  in  this 
effort,  and  there  is  the  |)ossibility  not  only  of  failure  but  even  of  .serious  harm,  and 
perhajw  immediate  death,  since  a  fragment  loosened  may  be  made  to  produce  prom|)tly 
fatal  pressure  u]X)n  the  cord.  Such  a  measure,  then,  should  be  undertaken  with  the 
greatest  care,  and  not  without  a  comi)lete  understanding  with  those  interested  regarding 
its  dangers  (Fig.  41S). 

Fig.  418 


Method  of  reducing  dislocations  of  the  ceri'ical  vertebra;  by  manipulation.    (Lejars.) 


In  most  cases  it  is  impossible  from  the  exterior  to  estimate  either  the  damage  to  the 
cord  or  the  amount  of  fluid  outpour  until  the  spinal  canal  be  opened.  If  there  be  com- 
plete loss  of  reflexes,  with  absolute  insensibility  and  motor  paralysis,  then  complete 
transverse  destruction  of  the  cord  may  be  inferred.  In  these  instances  it  may  be  decided 
not  to  operate.  On  the  other  hand  it  may  be  felt  that  unless  the  damage  apj^ear  irre- 
mediable an  open  operation  for  inspection  and  relief  should  be  performed  at  the 
earliest  possible  moment,  since  pressure  on  the  cord  allowed  to  persist  even  for  a  few 
hours  causes  damage  for  which  there  is  no  compensation.  These  cases  may  then  be 
viewed  in  this  light— if  left  to  themselves  they  are  almost  hopeless.  It  therefore  is  a 
question  simply  of  what  can  be  accomplished  by  o])eration.  On  one  hand  the  j)atient's 
condition  may  be  materially  improved;  on  the  other  it  is  scarcely  possible  to  make  him 
worse.  The  dangers  of  such  operations  inhere  especially  in  the  anesthetic  and  in  the 
possible  introduction  of  se]xsis;  not  that  the  operation  itself  cannot  be  properly  conducted, 
\mt  that  it  is  often  difficult  to  keep  these  cases  free  from  contamination  during  the  sub- 
sequent course  of  events.  To  operate  through  bruised  or  infected  skin  would  prol)ably 
be  fatal.  These  operations,  then,  are  begun  as  explorations  intended  to  reveal  deep 
conditions.  When  one  has  freed  the  spinal  cord  from  j)ressure  and  has  removed  the 
products  of  hemorrhage  he  has  done  nearly  all  that  can  be  accomplished  in  such  a 
case. 


G34  SPECIAL  OR  REGIONAL  SURGERY 

Until  recently  it  has  been  supposed  that  comjilete  transverse  division  or  crushing  of  the 
cord  WPS  necessarily  hopeless  and  fatal.  As  jn-eviously  mentioned,  Estes,  Ilarte,  and 
Fowler  have  reported  instances  of  complete  division  of  the  cord,  with  subsequent  a})])roxi- 
mation  by  suture  and  with  at  least  partial  restoration  of  function,  that  have  lent  an 
element  of  hope  to  cases  previously  regarded  as  hoj)eless. 

For  my  own  part,  although  I  regard  these  cases  as  discouraging,  I  do  not  feel  like 
withholding  from  patients  the  only  possibility  of  improvement  which  can  be  offered 
them,  but  I  am  more  and  more  impressed  with  the  necessity  for  prompt  intervention 
if  this  benefit  is  to  be  obtained.  To  wait  a  few  days,  then,  until  it  has  been  made  (>vident 
that  nothing  can  be  done,  save  by  operation,  or  until  a  tardy  consent  is  obtained,  is  to 
rob  the  patient  of  the  hope  which  it  may  afford.  The  operative  treatment  should  be 
begun  immediately  after  the  diagnosis  is  made,  providing  that  this  be  ])romptly  done. 
Delay  is  more  than  inexpedient— it  is  absolutely  dangerous.  As  Burrell  has  jiointed 
out  it  is  scarcely  fair  to  decide  upon  a  course  of  treatment  from  a  study  of  statistics  alone, 
as  lesions  vary  within  widest  limits,  as  do  also  results  of  individual  operators.  Let 
each  case,  then,  be  decided  upon  its  merits,  but  let  whatever  is  done  be  done  promptly. 
If  there  be  excuse  for  delay  it  is  in  those  cases  where  paralysis  is  incomplete  and  where 
the  cord  apparently  has  not  been  seriously  compromised.  But  these  would  afford  the 
most  promising  results  after  o})eration. 

The  operations  itself  will  be  described  at  the  conclusion  of  this  section,  and  in  con- 
nection with  other  operations  practised  for  exposure  of  the  cord  when  involved  in  other 
lesions. 


HEMATORRHACHIS  AND  HEMATOMYELIA  (INTRASPINAL  HEMORRHAGES). 

These  occur,  as  do  hemorrhages  within  the  cranial  cavity,  with  or  without  serious 
other  lesions  of  the  investing  structures.  They  are  expressions,  of  course,  of  trans- 
mitted violence,  depending  so  far  as  known  essentially  upon  injury,  whether  the  hemor- 
rhage occurs  within  the  central  canal  of  the  cord,  within  its  structure,  or  within  the 
subdural  or  even  extradural  spaces.  Everywhere  within  these  regions  bloodvessels 
abound,  from  which  may  occur  sufficient  outpour  of  blood  to  make  pressure  upon  the 
cord  to  a  degree  producing  complete  paralysis.  The  duration  of  time  between  reception 
of  injury  and  the  occurrence  of  diagnostic  paralysis  will  l^e  to  some  degree  a  measure 
of  the  rapidity  of  such  outpour,  while  a  study  of  the  paralyses  themselves  will  permit  of 
localizing  the  injury.  The  syinptoms  consist  mainly  of  pain  in  the  spine  radiating  to 
some  distance,  often  referred  to  the  distribution  of  the  nerves  most  involved.  This 
pain  is  often  associated  with  muscular  spasm,  while  paralysis  may  be  a  very  early  or 
somewhat  tardy  symptom. 

Treatment. — Once  the  fact  of  pressure  upon  the  cord  is  established  these  cases 
come  under  ])ractically  the  same  rule  as  above.  While  there  is  a  possibility  that  a 
moderate  amount  of  bloody  outpour  might  be  absorbed  there  is  nearly  as  much  danger 
of  its  organization  and  of  permanent  involvement  of  the  cord.  In  fact  there  is  more 
reason  for  operating  in  cases  of  spinal  hemorrhage  than  in  cases  of  fracture,  since  it 
may  be  possible  to  thereby  accomplish  more. 

The  7ion-operative  treatment  of  p-actures  or  disloeations  consists  mainly  in  external 
support,  preferably  by  a  plaster-of-Paris  corset  projierly  applied,  and  by  maintaining 
elimination  and  nutrition,  while  affording  physiological  rest  for  a  sufficient  length  of 
time.  These  cases  will  need  massage  and  electricity,  ?".  e.,  stimulation  of  the  conijiro- 
mised  muscles,  and  extreme  care  should  be  give)!  to  the  prevention  of  bed-sores,  to  which 
they  are  peculiarly  liable.  Eiiery  precaution  shoidd  be  taken  also  against  any  possible 
retention  of  urine  or  feces.  The  incontinence  of  aji  overdistended  bladder  should  not  be 
mistaken  for  that  of  paralysis  of  its  sphincter  apparatus.  The  specimen  of  dislocation 
from  which  Fig.  415  was  taken  was  removed  from  a  patient  who  almost  completely 
recovered  from  the  effects  of  the  injury,  but  who  became  careless  about  the  condition 
of  his  bladder  and  who  suffered  an  ascending  urinarv  infection  that  terminated  his 
life. 

Of  these  cases  it  may  also  be  said,  then,  that  a  much  better  prosjiect  of  exact  diag- 
nosis and  atonement  for  harm  done  is  afforded  by  ex])loration,  since  as  between  com- 
pression of  the  cord  by  dot  or  by  bone  there  is  little  essential  difference. 


CONGENITAL  COCCYfUJAL   TU.}f(>h'S 


635 


The  suhjoiiicd   (able   inav    alVonl   assistance   in    I  lie  diagnosis  of   (he   injuries   above 
considered : 


Differential  Diagnosis  of  Diseases  and  Injuries  of  the  Spine  and  Spinal  Cord 

Fnictiirc.  Dislocdtl'iii.  Hci/ntldiiii/cliit.    Ilriiiiilnrrliiiclii 

Onset.  Tininediate.        Iiiiincdiatc.        Iiniiicdiatc.       I'rDgrcssive. 

Amsllicfiia.  Iniinediate.        Immediate         Immedialc.       Incomplete. 

l^iindi/sis.  Hemiplegia        Hemiplegia.       rara|)legia.       Hemiplegia  or 


(Is  of  liemiplegie  or  paraplegia.   In    partial 
typ(>    when    com-  di.slucation 

pre.ssion  i.s  unilat-  may    be 

eral,    paraplegic  absent, 

when  bilateral, 
and  local  when 
single  nerve  roots 
are  involved.) 

U.siially  pres 

ent. 
Rises  af  te  i 

second  or 

third  (lav. 


Dejorm  ity 
Temperature. 


Bowels  and  Bladder.  Paralvzed. 


paraplegia. 


.\riilr 
Polionnjellli.s. 
Slow.  ■ 
Absent. 
I'arajtlegia. 


Present. 

Absent. 

Absent. 

Absent. 

Same. 

Same. 

Same. 

Precedes    the 
paralysis  of 
degenera- 
tion. 

Paralysis 

Same. 

Affect  e( 

1  lale  it 

No  paralysis. 

usual. 

at  all. 

COCCYGEAL  OR  PILONIDAL  SINUS. 

In  the  neighborhood  of  the  coccyx,  usually  l)elow  its  tip,  between  it  and  the  anus, 
sometimes  above  the  tip,  a  small  dej)ression  or  sinus  mouth  is  occasionally  seen.  This 
is  usually  known  as  the  pilonidal  sinus.  It  is  the  persistent  remnant  of  the  original 
fetal  termination  of  the  spinal  canal.  It  varies  in  size  from  a  mere  dimple  to  a  cul-de- 
sac,  in  which  sebaceous  matter,  with  any  other  epithelial  products,  hair,  etc.,  as  well  as 
foreign  material  and  dirt  from  the  skin,  may  collect  and  excite  suj)])uration.  In  this  way 
an  abscess  of  considerable  size  may  form.  Sometimes  its  contents  will  be  found  to  be 
principally  hair;  hence  the  name  pilonidal.  Frequently  this  sinus  can  be  traced  down  to 
the  periosteum  and  into  the  remains  of  the  original  neurentcric  canal.  When  it  is 
distended  so  as  to  give  trouble  it  needs  only  to  be  freely  incised  and  thoroughly  cleaned. 


CONGENITAL  COCCYGEAL  TUMORS. 

In  the  region  of  the  coccyx  and  lower  part  of  the  sacrum  there  appear  tumors  of  con- 
genital origin  which  are  often  present  at  birth  or  may  not  develop  until  later.  These 
assume  various  sizes  and  aspects,  varying  from  mere  protuberances  to  large  pendu- 
lous tumors.  While  covered  with  integument  their  internal  structure  varies  within 
wide  limits,  and  they  are  usually  made  of  such  a  mixture  of  embryonal  elements  as  to 
entitle  them  to  be  considered  true  teratoma.  Even  organized  tissues  or  rudimentary 
organs  may  be  found  therein.  They  are  rare  and  constitute  ])ractically  surgical  curiosi- 
ties. Such  a  tumor,  if  troublesome,  calls  for  removal,  which  should  be  acconijtlished 
with  the  strictest  precautions,  as  the  spinal  canal  may  perhaps  be  opened  during  the 
procedure  and  most  inflammable  tissue  thus  exposed  to  infection  from  the  perineum. 

The  sacrum,  like  the  coccyx,  is  also  the  site  of  numerous  congenital  cysts  and  tumors 
which  may  appear  posteriorly  or  anteriorly.  Occasionally  they  form  within  the  bone 
itself.  Cysts  that  connect  with  the  spinal  canal  will  be  found  filled  with  cerebrospinal 
fluid,  and  some  of  them  are  essentially  spina  bifida  occulfa.  The  sacral  region  is  also  the 
site  of  predilection  for  those  teratomas  which  consist  in  whole  or  in  part  of  vestiges  of  an 
attached  fetus.  The  advisability  of  operation  must  be  determined  for  itself  in  each 
of  the.se  cases.     (See  Fig.  412,  p.  627.) 


636  SPECIAL  OR  REGIONAL  SURGERY 


COCCODYNIA;  COCCYGODYNIA. 

Under  this  name  are  included  severe  and  chronic  neuralgias  of  the  coccyoroal  rciricyi, 
including  its  joint,  which  occur  most  often  in  women,  and  usually  as  the  result  of  con- 
tusion or  direct  injury.  Occasionally  it  results  from  an  injury  inflicted  during  par- 
turition. It  gives  rise  to  a  degree  of  ])ain  and  tenderness  which  sometimes  is  almost 
disabling.  Because  of  the  insertion  of  the  levator  ani  into  the  ti])  of  the  coccyx  defeca- 
tion may  hectmie  distressing,  to  an  extent  which  leads  to  fecal  impaction  in  the  rectum 
from  postponement  of  evacuation  as  long  as  ])ossil)le.  The  sym|)toms  are  subjective, 
but  the  tenderness  is  frequently  exquisite. 

In  regard  to  treatmcmt  subcutaneous  division  of  the  tissues  around  the  bone  may 
afford  relief,  but  in  most  instances,  particularly  those  of  traumatic  origin,  an  excision  of 
the  coccyx  will  afford  the  only  cure.     (See  below.) 


OPERATIONS  ON  THE  SPINE. 

These  are  included  under  the  general  heading  laminectomy,  which  is  used  in  a  com- 
prehensive sense,  as  is  also  the  term  trephining. 

In  a  general  way  the  measure  is  about  as  follows :  Through  a  long  median  incision 
over  the  spines  of  the  region  where  the  lesion  is  localized  their  tips  are  exposed,  while 
the  muscle  groups  on  either  side  and  posterior  to  the  lamina^  are  separated  by  the 
knife  and  by  retractors.  Dense  fibrous  bands  may  be  nicked.  In  this  way  the  posterior 
aspect  of  the  neural  arches  is  exposed  to  the  desired  length.  The  exposed  spines  should 
be  removed  by  cutting  them  off  at  their  bases  with  bone  forceps,  although  they  may  be 
left  and  later  removed  with  the  posterior  bony  arches.  To  clear  them  away,  however, 
affords  a  better  view  of  the  field  of  operation.  The  ligamenta  subflava  are  then 
divided  transversely  at  their  upper  and  lower  margins,  after  which,  either  with  cutting 
forceps,  saw,  or  chisel,  the  laminsie  are  divided  on  either  side,  and  the  section  which  is 
loosened  pried  out  from  the  bed  in  which  it  rests.  More  or  less  fatty  tissue  will  be 
found  outside  of  the  dura  and  in  this  tissue  veins,  sometimes  of  considerable  size,  freely 
ramify.  These  may  be  seized  and  divided,  those  of  considerable  size  being  tied.  Great 
care  should  be  given  during  the  procedure  to  avoid  perforation  of  the  spinal  membranes 
by  the  points  of  the  instruments  used.  The  cutting  forceps  are  preferable  to  the  saw  or 
chisel,  except  for  work  in  the  lower  lumbar  region,  where  the  parts  are  stout  and  strong. 
Especially  in  case  of  fracture,  and  at  the  upper  end  of  the  spine  particularly,  care  should 
be  given,  with  the  force  used,  that  no  loose  fragment  be  so  handled  as  to  increase  the 
damage  already  done  to  the  cord. 

The  dura  being  thus  exposed  and  the  blood  cleared  away,  inspection  may  or  may 
not  reveal  the  nature  of  the  lesion.  A  probe,  gently  handled,  passed  upward  and 
downward  into  the  canal,  will  reveal  whether  the  cause  of  the  pressure  has  been  cleared 
away  or  not.  According  to  the  nature  of  the  lesion  it  can  then  be  decided  whether  to 
open  the  dura.  To  open  it  is  to  pave  the  way  for  fatal  infcc-tion,  unless  the  strictest 
aseptic  technique  has  prevailed.  On  the  other  hand,  to  leave  it  unopened  is  to  fail  to 
appreciate  the  actual  condition  of  the  cord  and  to  leave  an  important  matter  still  imdeter- 
mined.     The  dura  if  opened  should  be  closed  by  suture. 

Reference  has  already  been  made,  in  three  cases  now  on  record,  to  suture  of  the  cord 
as  a  whole.  Such  sutures  may  be  applied,  if  necessary,  in  a  manner  to  do  the  least 
possible  damage  to  the  structures  of  the  cord.  If  cerebrospinal  fluid  escape  too  freely 
the  patient  may  be  operated  in  a  position  with  the  head  lower  than  the  trunk,  avoiding 
leakage. 

Oatroplasfic  mrfhods  of  temporary  resection  of  the  posterior  arches  of  the  vertebrae 
have  been  devised  and  practised,  but  they  offer  no  particular  advantages,  and  are 
attended  by  disadvantages  which  have  caused  them  to  be  almost  abandoned,  save  in 
rare  instances  and  by  individuals  of  large  experience.     (See  Plate  XLVII.) 

In  regard  to  wiring  fragments  of  a  fracture  or  displaced  spine,  Hadra,  of  Texas,  was 
perhaps  the  first  to  carry  out  the  measure.  It  com  pries  simply  the  fixation  of  frag- 
ments by  wire  sutures  or  ligatures  which  bind  them  together  after  they  have  been  replaced 
through  a  more  or  less  open  wound,  such  as  is  included  in  the  term  laminectomy.     But 


PLATE  XLVII 


Osteoplastic  Resection  of  Posterior  Vertebral  Arches.      (Urban.) 


()i'i:i{.\ri()\s  o.v  Till-:  si'tsh:  (337 

rcsorl  to  wire  is  (o  Ik-  Icl'l  lo  tlic  jiidj^iiicnt  of  the  operator  and  the  needs  of  tlie  case. 
There  is  no  reason,  however,  why  it  may  not  he  used  here,  as  in  other  fractures  which 
arc  thus  made  compound,  if  there  wouhl  seem  to  l)e  prosj)ect  of  benefit  attaeliing  to  its 
use. 

Laiiiinrrtoui!/  is  |)ractised  also  in  I'otl'.s  dm'a.sr,  with  the  hope  of  relieving;  pressure  upon 
the  cord,  (hie  to  the  deformity  or  to  the  presence  of  tuluTculous  foci.  It  is  possil)le  that 
in  some  of  these  cases  an  incomj)lete  oj)cration  will  .serve  the  purpose.  Sufficient  should 
he  done,  however,  to  relieve  pressure  if  such  a  nicasure  he  indicated. 

When  laminectomy  is  |)ractiscd  for  the  pur])()sc  of  attackinjf  a  tumor  of  the  spiniil 
cord  the  exposure  of  the  cord  should  he  followed  hy  the  removal  of  the  tumor.  Some 
of  the.se  are  so  placed  as  to  make  the  procedure  simj)le,  while  at  other  times  it  will  be 
e.xceediniijly  difficult,  if  not  imj)racticable.  If  the  growth  has  so  extended  as  to  involve 
the  bones  themselves,  then  the  measure  will  be  futile  and  .should  be  abandoned;  but  an 
i.solated  tumor,  either  within  or  without  the  dural  sj)ace,  in  or  on  the  substance  of  the 
conl,  can  usually  be  removed  by  a  j)rocess  of  blmit  dissection.  Sometimes  the  small 
wounds  thus  made  will  ooze  considerably  and  hemorrhage  may  prove  troublesome; 
it  should  be  checked  before  the  j)arts  above  it  are  clo.sed.  Pressure  forceps  and 
ligatures  and  the  occasioiud  use  of  adrenalin  solution  will  afford  the  necessary  means 
for  combating  l)leeding. 

P\)r  nearly  all  of  these  operations  upon  the  spine  the  chisel  and  the  cutting  forc-eps  will 
suffice.  Some  operators,  however,  prefer  a  small  saw,  like  that  suggested  by  Doyen, 
which  has  a  guartl  that  can  be  so  set  as  to  determine  the  depth  to  which  the  instrument 
may  pass.  No  matter  what  instnmient  be  used,  great  care  should  be  taken  l(\st  it  pass 
through  and  beyond  the  bone  in  such  a  way  as  to  lacerate  the  dura  or  the  plexus  of  veins 
outside  of  it. 

The  sacrum  is  rarely  attacked  except  in  connection  with  some  of  those  tumors  already 
described. 

The  coccyx  is  easily  removed  through  a  median  incision,  the  parts  around  it  being 
entirely  separated  and  the  bone  thus  freed  removed  at  the  joint  with  stout  scissors  or 
cutting  forceps.  The  instruments  used  should  be  kept  in  contact  w'ith  the  bone  and  not 
allowed  to  injure  the  veins  between  it  and  the  rectum.  Such  a  Avound  should  not  be 
closed  completely,  as  a  cavity  always  remains,  which  it  is  better  to  pack  and  permit 
to  heal  by  granulation.     (See  Coccodynia.) 


CHAPTEK  XXXIX. 
THE  FACE  AND  EXTERIOR  OF  THE  NOSE  AND  MOUTH. 

Monsters  are  born  witli  almost  complete  absence  of  the  face,  which  is  called  apro- 
.sopia.  They  have  also  been  ol>scrve(l  with  clonJ)le  faces.  Again  a  condition  (jf  con- 
genital hyijcrtrophy  is  known  involving  one  or  both  sides.  On  the  other  hand  congenital 
atrophy  is  also  occasionally  noted,  affecting  one  or  both  sides.  The  former  is  likely  to  be 
of  syphilitic  origin  (hereditary),  in  which  case  it  will  be  accompanied  by  otlier  indica- 
tions such  as  corneal  opacity,  irregularity  of  teeth,  or  other  evidences  of  its  luetic  origin. 

Among  the  most  interesting  congenital  defects  are  those  connected  with  imperfectly 
closed  branchial  fistulas  and  the  various  outgrowths  therefrom.  These  may  lead  to 
fissures  extending  from  the  ear  to  the  mouth.  Fibrocartilaginous  growths  occur  along 
the  regions  of  the  original  branchial  clefts,  either  as  tags  of  skin  upon  the  face  or  so- 
called  supernumerary  auricles  or  auricular  apjjendages.  While  these  are  covered  with 
skin  they  usually  contain  a  cartilagintnis  nucleus.  They  are  most  common  in  front  of 
or  on  the  tragus.  They  may  be  single,  multiple,  or  symmetrical.  They  sometimes 
increase  in  size  and  at  others  remain  stationary. 

Fissures  are  seen  more  often  upon  the  central  portions  of  the  face,  especially  in  the 
nose  or  between  it  and  the  cheek.  About  the  root  of  the  nose  and  the  orbit  dermoids 
are  somewhat  common.  They  may  be  connected  with  fissures  or  fistulas,  and  extend 
u{)\vard  and  involve  the  dura. 

Absence  of  the  mouth  is  known  as  astomia,  and  of  the  lips  as  achcilia.  These  mal- 
fornuitions  are  exceedingly  rare.  Atresia,  or  narrowing  of  the  mouth,  is  more  common. 
While  the  lips  and  mouth  may  be  apparently  well  formed  there  may  be  imperfections. 
These  conditions  of  narrowing  call  for  division  on  each  side  and  union  of  skin  to  mucous 
membrane.  Fistulas  of  the  lip  are  extremely  rare,  but  are  found  occasionally,  especially 
opening  upon  the  lower  Up.  Branchial  fistulas  opening  upon  the  lips  have  also  been 
observed. 

A  condition  of  arrest  of  develoj)ment  of  one  or  both  jaws  leads  to  unnatural  smallness 
of  the  mouth  known  as  microstoma.  The  opposite  conditi(jn,  macrostoma,  is  jiroduced 
usually  l)y  fissure  of  the  cheek  on  one  or  both  sides,  extending  upward  and  backward 
from  the  labial  junction  and  due  to  incomplete  closure  of  a  branchial  cleft.  The  most 
common  congenital  defect  of  the  lij)  known  as  hare-lip  is  a  median  fissure  involving 
the  upper  lip.  This  occurs  in  all  degrees,  from  a  trifling  notch  at  the  vermilion  border 
to  a  hideous  defect,  in  which,  through  a  wide  cleft,  projects  a  relatively  overdeveloped 
intermaxillary  bone,  with  a  small  downward  projection  of  skin,  known  surgically  as 
the  philtrum.  This  defect  may  involve  much  more  than  the  lip  alone,  for  there  maybe 
failure  to  unite,  along  the  median  line  between  the  lip  and  the  uvula,  of  those  portions 
of  the  superior  maxillary  which  should  develop  symmetrically,  and  coalesce  as  they  are 
formed  from  the  rudimentary  maxillary  processes.  Any  portion,  then,  of  the  hard  or 
soft  tissues  may  show  failure  to  unite  in  the  middle  line. 

Hy]K'rtrophy  of  a  lip  is  known  as  macrocheilia.  It  is  not  imcommon  in  strumous 
subjects.     Another  form  is  known  as  mucous  ectropion.      (See  p.  37-3.) 

The  chin  may  be  malformed  in  the  direction  either  of  atrophy  or  the  reverse,  as  in  the 
so-called  double  chin.  A  deviation  forward,  known  as  galoche  chin,  is  also  recognized. 
A  peculiar  malformation,  consisting  of  the  implantation  of  a  supernumerary  inferior 
maxilla  by  its  own  symphysis  uy)on  that  of  the  subject,  is  known  as  hypognathy. 
Such  a  timior  will  occasionally  develop  to  considerable  size,  Avith  cystic  degeneration  or 
other  irregular  changes. 

Aside  from  the  common  forms  of  hare-lip  most  of  the  congenital  defects  that  occur 
about  the  face  are  to  be  explained  through  incomj)lete  closure  of  the  branchial  clefts 
( 638 ) 


A('(Jl  lh'/:J>   MM.I'oliMATKtSS  OF    Till':   FACK 


mo 


or  tlif  tlcvclopiiu'iit  (if  (UtiiiomI  (T.sI.s  and  ttiiiiors  lliiTcrnnii.  J)cviati()ii.s  rallicr  lliaii 
deft'ctij  appear  more  ct)min<)nly  about  tlie  riosi-  than  anywIuTi'  else.  Tliry  produce 
disfifjureuieuts  known  a.s  jni^-nose,  saddle-nose,  parrot-nose,  etc.  Aj,'ain,  douhlc  noses 
exist,  eacli  l)ein<j  more  or  less  well  formed.  In  sucli  a  case  the  sur^'eon  should  endeavor 
to  remove  a  part  t)l"  each  and  unite  the  remainint;  portions  in  one,  unless  one  of  them 
be  placed  away  from  the  middle  line,  in  which  case  it  nuiy  Ixi  extirpated. 

ACQUIRED  MALFORMATIONS  OF  THE  FACE. 

These  are  usiudly  tlic  result  either  of  mutilation  or  of  some  ulcerative  morbid  proi-ess. 
Injuries  of  the  face,  mdess  (-xtremely  carefully  and  promptly  attended  to,  are  connnoidv 
followed  by  sears,  which  may  cause  ^reat  disfifjuremcnt.  This  is  invariablv  true  <)f 
severe  burns,  which,  by  subsecjuent  contraction,  draw  features  badlv  out  of  shape,  and 
sometimes  close  the  mouth  or  j)ull  the  lower  jaw  down  uj)on  the  ne<k  and  the  chin  upon 
the  chest.  Serious  contused  W(nmds  are  frcfjuently  accomi)anie(l  bv  fracture  of  j)arts 
beneath,  and  shotdd  be  treated  as  a  compcnuid  fracture.  Considerable  portions  of  the 
facial  mask  are  sometimes  torn  away,  producing  hideous  appearances.  By  jjunctured 
wounds  the  maxillary  sinus,  orbit,  or  brain  cavity  may  be  perforated  and  foreign  bodies 
carried  in.  A  wound  may  be  so  placed  as  to  sever  Stenson's  duet.  All  of  these  injuries 
may  be  accompanied  l)y  serious  brain  disturbance,  as  the  result  of  the  contusi(jn.  Gun- 
shot wounds  will  ])resent  either  punctures  or  extensive  lacerations,  according  to  the 
proximity  and  the  weapon.  In  no  part  of  the  })ody  are  gun})owder  stains  more  observ- 
able or  more  deplored  than  ujkju  tlie  face.  In  order  to  {)revent  them  each  grain  of  powder 
must  be  picked  out  with  a  small  sj)ud  or  needle,  after  a  careful  scrubbing  of  the  face. 
Everv-  grain  of  gunpowder  allowed  to  remain  will  produce  a  minute  area  of  staining. 

Injuries  to  the  nose  may  require  plastic  reconstruction  or  the  formation  of  a  new 
nose  by  one  of  the  rhinoplastic  methods  later  described,  or  an  artificial  nose,  carried 
by  spectacles,  may  be  w^orn.  The  cartilages  of  the  nose  are  frequently  dislocated, 
thus  producing  deformity,  and  the  same  result  may  follow  fractures.  As  alreadv  indi- 
cated in  the  chapter  on  Fractures,  prompt  and  complete  replacement  with  support  are 
usually  sufficient  to  give  a  satisfactory  result. 

Deviations  of  the  nose,  and  especially  cosmetic  defects  which  result  from  injuries  or 
disea.se,  producing  the  so-called  saddle-nose,  when  not  extreme,  may  often  be  remedied 
by  the  injection  of  paraffin,  the  patient  being  either  under  cocaine  or  general  anesthesia. 

Burns,  injuries,  and  serious  ulcerations  about  the  cheeks  and  lips  produce  conspicuous 
disfigurement  (perhaps  none  more  so  than  a  serious  form  of  cancrum  oris)  with  a  con- 
siderable loss  of  substance.  In  this  way  may  be  produced  an  acquired  microstoma, 
or  adhesion  of  cheek  to  jaw,  which  is  known  as  syncheilia.  More  superficial  lesions 
may  produce  ectropion  or  eversion  of  the  lips,  or  acquired  macrostoma.  Cretins,  idiots, 
and  })atients  with  facial  paralysis  acquire  gradually  a  chronic  swelling  of  the  lower  lip 
with  drooling  of  saliva.  The  lip  may  enlarge  to  such  an  extent  as  to  ulcerate  as  the 
result  of  exposure.  Frostbite  also  produces  serious  deformity  by  ulceration  of  the 
skin.  ^Vhen  a  puncture  of  the  cheek  occurs  at  the  opening  of  Stenson's  duct,  i.  e., 
opposite  the  second  upper  molar  tooth,  there  may  occur  a  salivary  fistula.  In  a  recent 
clean  wound  the  duct  ends  may  be  stitched  together.  In  old  wounds  Souchon  recom- 
mends to  introduce  catgut  into  the  distal  end,  and  then  by  pressure  on  the  parotid 
to  discover  the  proximal  end  and  stitch  it  with  the  catgut  in  the  divided  portion ;  or  the 
wound  may  be  enlarged  and  the  proximal  end  turned  into  the  mouth  and  there  retained. 

Considerable  emphysema  may  follow  contusions  of  the  face,  especially  those  causing 
fracture  of  the  nose.  In  this  way  a  face  may  be  so  distended  as  to  produce  almost  a 
caricature  of  its  former  appearance;  this,  however,  will  subside  within  a  few  hours. 

Bv  virtue  of  its  extreme  vascularity  wounds  and  injuries  of  the  face  heal  with  a  sur- 
prising degree  of  prom[)titude  and  certainty.  This  affords  the  reason  for  the  satisfactory 
results  of  extensive  plastic  operations.  For  the  same  reason  secondary  hemorrhages 
mav  easilv  occur  and  aflditional  precautions  should  be  taken.  Exact  hemostasis,  before 
closure  of  wounds,  will  afford  protection  as  against  this  event.  Wound  edges  should 
be  neatly  trimmed  and  subcutaneous  sutures  may  often  be  used  to  advantage  to  minimize 


040  SPECIAL  OH  REGIONAL  SURGERY 

the  resulting  sears.  A  lesson  "how  not  to  do  it"  may  \)v  learned  from  the  t'aees  ui 
German  university  students  who  have  indulged  in  the  eommon  but  senseless  sport  of 
duelling,  and  who  are  said  to  rub  salt  and  alum  into  their  euts  in  order  to  make  the  sears 
as  eonspieuous  as  possible. 

NEUROSES  AND  CONSEQUENCES  OF  INJURIES  OF  NERVES  OF  THE  FACE. 

Anesthesia  of  parts  supplied  by  the  trifaeial  neeessarily  follows  divisitjii  of  its  various 
portions.  It  may  also  oeeur  as  the  result  of  a  deeji-seated  or  central  lesion.  In  course 
of  time  more  or  less  sensibility  will  return,  apparently  due  to  an  anastomotic  process. 
Facial  paralysis,  so-called  Bell's  palsy,  may  be  of  central  origin,  or  be  due  to  the  effects 
of  a  "cold"  following  exposure,  apparently  with  inflammation  of  and  an  exudate  around 
the  trunk  of  the  facial  nerve  as  it  passes  througii  its  bony  canal  hi  the  temporal  bone. 
It  is  also  the  result  of  a  division  of  the  nerve  trunk  either  outside  of  the  bone  or  in  the 
bony  canal,  where  it  is  occasionally  wounded  in  operations  upon  the  mastoid  or  in 
removal  of  the  parotid  for  malignant  tumor.  Facial  neuraUjia  is  an  aftection  of  one  or 
more  of  the  branches  of  the  fifth  nerve,  and,  when  assuming  a  spasmodic  and  inter- 
mittent type,  is  often  spoken  of  as  tic  douloureux.  Its  exciting  cause  may  be  a  carious 
tooth,  even  though  it  give  no  pain,  while  other  causes  are  lesions  in  the  neighborhood, 
such  as  callus,  foreign  bodies,  tumors,  bone  disease,  and  the  like.  Its  special  treatment 
has  already  been  indicated  in  the  chapter  dealing  with  the  Cranial  Nerves.  Many  of 
these  cases  of  neuralgia  gradually  diminish  the  patient's  strength. 


ULCERATIVE  AND   GANGRENOUS  LESIONS  OF  THE  FACE. 

The  serious  ulcerative  lesions  of  the  face  are  usually  due  to  tuberculosis,  syphilis, 
or  malignant  disease.  In  all  of  these  conditions  there  will  be  enlargement  of  the  neigh- 
boring lymphatics.  This  is  true  also  of  the  lesions  of  actinomycosis,  which  should  not 
be  forgotten  as  a  possil)le  cause.  The  free  border  of  the  lips  is  occasionally  ulcerated  in 
))aticnts  with  pulmonary  tuberculosis.  Otherwise  tuberculous  lesions  are  uncommon 
upcjii  the  lower  lip,  while  in  the  upper  lip  they  show  a  tendency  to  invade  and  spread. 
Syphilitic  ulcers  may  be  either  primary  chancres,  which  are  most  common  on  the  lower 
lip,  or  the  results  of  mucous  patches,  or  other  secondary  or  tertiary  lesions.  Of  the 
cancerous  ulcerations,  which  tend  always  to  break  down  and  spread,  without  any  tendency 
to  healing  in  the  centre,  epithelioma  is  the  most  common  form.  It  is  a  frequent  disease 
in  men,  occurring  much  oftener  on  the  lower  than  upon  the  upper  lip.  In  women  it  is 
exceedingly  rare  at  this  point.  The  difference  is  explained  by  the  liability  to  constant 
irritation  incurred  by  those  who  smoke  pipes  or  are  particularly  careless  about  their 
teeth.  Of  epithelioma  there  are,  as  is  well  known,  various  types,  including  the  so-called 
rodent  ulcer,  which,  however,  is  less  frequent  here.  The  location  of  the  lesion  subjects 
it  to  constant  irritation,  as  well  as  maceration  from  the  moisture  of  the  mouth.  Such 
a  growth  may  be  superficial  and  raw,  or  it  may  be  covered  by  scale  or  crust.  It  will 
nearly  always  have  an  indurated  and  raised  periphery.  A  papillary  form,  with  non- 
indurated  edges,  is  also  known,  as  well  as  a  diffuse  form,  Avhere  several  minute  lesions 
seem  to  coalesce,  with  elevation  of  the  central  portion.  "This  is  perhaps  the  most  malig- 
nant of  all,  as  it  has  no  well-defined  boundaries.  In  nearly  every  well-marked  case 
involvement  of  the  submaxillary  lymphatics  can  be  detected.  All  <A  these  cancers  of 
the  lip  and  face  should  be  removed,  with  ])lastic  re-arrangement  f)f  the  parts.  Growths 
of  this  kind  seen  early,  before  much  tissue  is  involved,  can  be  removed  with  permanent 
success.  Error  is  made  on  the  side  of  not  doing  suflficient  rather  than  doing  too  much. 
(See  Chapter  XXVI.) 

Cancrum  oris  has  already  been  described  in  the  chapter  on  Gangrene.  The  extensive 
destruction  which  it  may  cause  is  also  described  there.  The  condition,  when  seen  and 
recognized  early,  has  been  successfully  treated  by  local  applications  of  bromine  and 
the  actual  cautery.  It  is,  however,  a  destructive  and  unpromising  condition  with  which 
to  deal,  as  it  rarely  occurs  in  healthy  children,  but  usually  in  those  with  a  constitution 
already  vitiated  by  heredity  or  environment.     (See  p.  75.) 


TUMOh'S  OF   'J' HI-:  FAC'l'J 


041 


TUMORS    OF    THE    FACE. 

The  ])arts  (lc.scril)c<l  in  tliis  cliiiptcr  iiiiiy  \h-  the  site  of  almost  every  tumor  whidi  is 
met  with  in  any  otiier  |)art  of  tin-  l)o(ly;  in  addition  to  wliicli  there  are  two  wliieli  are 
l)eeuliar  to  the  nose  and  a<ljoinin<;;  tissues.  These  are  rhinopliijina  and  rliino.sckroma. 
They  have  both  been  described  briefly  in  the  ehapter  on  Tumors,  and  each  is  to  be 
(liti'enMitiated  from  the  otlier,  having?  a  very  (Hiferent  etiojofjy. 

RhiHoplii/iiKi  consists  of  vascular  enjfori^enient,  with  hy[)ertro))hy,  especially  of  the 
olandnlar  and  coiuiective-tissue  elements  of  the  skin,  which  bcjrins  about  the  ti|)  and 
the  ahe  of  the  nose,  and  |)roduces  disfijjnrini,'  deformity.  It  is,  hi>wever,  at  first,  (|uite 
imioeeut  in  its  character.  It  occurs  most  often  in  hard  drinkers,  and  is  to  be  re<,Mrded 
as  an  overgrowth,  coupled  with  a  laro;e  amount  of  secretion,  of  the  .sebaceous  (glands  of 
that  portion  of  the  skin.  This  .secretion  is  often  so  o;reat  as  to  escape  and  lead  to  the 
formation  of  scabs,  as  it  dries,  until  more  or  less  ulceration  takes  place.  The  nasal 
enlari^ement  is  rarely  symmetrical,  and  is  nearly  always  lobular,  so  that  the  overgrowth 
may  consist  of  a  series  of  nodules  whose  escai)ing  secretion  becomes  offensive.  The 
parts  are  often  discolored,  even  to  a  iniri)lisli  color,  in  con.sequcnce  of  venous  stasis. 
Frostbite  freciuently  predisposes  toward  it. 

Fig.  420 


Plexiform    angioma   of    face;    cirsoid    aneu 
rysm.     Not   benefited   by  ligation  of  e.icternal 
carotid.      (Lexer.) 


Illustrating  ravage.-^  of  rapidly  growing  vascular  sarcoma 
of  face,  involving  all  the  cranial  and  facial  cavities. 
(Lexer.) 


Treatment  in  incipient  cases  may  consist  of  a  sort  of  massage,  by  which  the  overloadctl 
glands  are  emptied.  In  more  serious  instances  the  diseased  tissue  should  be  extirpated, 
and  either  left  to  granulate  or  be  covered  by  a  plastic  operation. 

Rhinosckroma  is  a  serious  and  fatal  lesion,  consisting  of  a  parasitic  invasion  by  a 
peculiar  bacillus.  It  begins  as  a  painless  induration,  either  at  the  i^d^t^  of  the  nostril 
or  upon  the  upper  lip,  grows  slowly,  the  tissue  affected  becoming  firm  and  dense. 
The  growth  is  usually  lolnilated,  w'ith  fissures  or  excavations  between  the  lobules, 
which  may  crack  and  give  ri.se  to  a  yellowish  discharge  that  dries  into  crusts.  While 
the  aflfection  mav  begin  in  the  deeper  parts  of  the  nasopharynx  its  occurrence  there 
is  usually  the  result  of  extension  from  the  anterior  growth.  The  disease  may  occur 
either  in*  the  voung  or  in  the  adult.  A  case  illustrated  elsewhere  (see  p.  55),  for  which 
I  am  indebted  to  Dr.  (r.  W.  Wende,  proved  fatal  after  a  couple  of  years.  In  this  country 
it  is  rare,  but  occurs  frequentlv  in  some  portions  of  Russia. 

For  treatment  there  is  but  little  encouragement,  least  of  all  for  operative  intervention. 
Growths   nearlv  alwavs  recur  after  removal. 

In  the  cheek  cijsU  of  Sfcuson's  duct  and  dermoid  tumors  and  cysts  have  often  been 
observed  near  the  parotid  region.  The  so-called  "fatty  ball  of  Bichat"  is  occasionally 
41 


642 


SPECIAL  on  REGIONAL  SURGERY 


tlic  site  of  iiii  aiij:jionia,  which  may  press  ii[M)n  Strnson's  (hict  and  ho  af(<)iii|)airK'tl  hy 
calcuhis  in  the  parotid  ojhuid,  the  superficial  veins  heinfj  much  (Hhited.     (Souchon.) 

Fatty  tumors,  as  well  as  sarcoma  in  this  same  tissue,  are  prominent.  The  most  Ire- 
(juent  tumors  of  tiie  face  are  the  rpiffir/ioma.s  of  the  lip,  nearly  always  of  the  lower  lij), 
occurring  oftencr  in  men  than  in  women.  A  fi;rowth  of  this  character  at  this  site  is 
rei2;arde(l  as  an  exf)ression  of  the  result  of  irritation,  which  may  be  produced  by  a  carious 
tooth  or  by  constant  friction  of  a  pijX'-stem,  or  from  many  other  causes.  It  frequently 
develops  at  the  site  of  an  old  chronic  fissure.  These  growths  spread  from  small  begin- 
nings, and  if,  when  small,  they  were  extirj)ated  there  would  be  fewer  cases  of  cancer  of 
the  lip  spreading  to  and  involving  the  face  and  neck.  Every  ulcer  of  the  lip  whose  base 
becomes  indurated,  and  from  which  the  syphilitic  element  can  be  excluded,  should  be 
excised,  the  ensuing  defect  being  repaired  by  a  {)lastic  operation.      (See  above.) 


Fi(i.  421 


Fig.  422 


Fig.  423 


4^H-^ 


-V-^ 


\ 


Fi(i.  424 


Fig.  425 


Fig.  426 

l-l-i-i-/- 


Fig.  427 


Fig.  429 


\ 


■V 


Fig.  428 


Fig.  430 


Fig.  431 


I  I  ! 


Utilization  of  rectangular  flaps. 


OPERATIONS  UPON  THE  FACE  AS  A  WHOLE. 

The  tissues  composing  the  face  are  extremely  vascular,  hence  hemorrhage  is  profuse 
and  hemostasis  should  be  exact.  By  virtue  of  this  same  rich  blood  supply  the 
process  of  repair  is  prompt  and  satisfactory,  if  sources  of  infection  be  avoided.  Patients 
here,  more  than  anywhere  else,  desire  a  minimum  of  scar.  Incisions,  then,  should  be  so 
plannefl  as  to  jx-rmit  the  utilization  of  the  natural  folds  or  grooves  of  the  face.  They 
should  also  be  so  made  as  to  avoid  injury  to  main  trunks  of  vessels  and  nerves,  as  well  as 
to  Stenson's  duct.  Sharp  knives  and  the  least  possible  bruising  of  the  tissues  help  to  ensure 
the  desired  result.  When  possible  a  subcutaneous  suture  should  be  employed.  When 
this  is  not  sufficient  fine  needles  and   fine  suture  material  should  be  used.     A  reasonably 


(>i'i:h'.\ri().\s  rr<>.\  Tin-:  faci-:  as  a  wifoLh: 


()4:i 


short,  clciiM  womid  U|)()ii  tlir  face,  (  .s|)cii;ill,v  in  the  iicij,'lil)t>rlio(Ml  of  llw  moutli,  slioiild  l)c 
j)roti''(ti'<l  from  tin-  air  until  it  is  dry,  usiiiir  a  dustinj,' |)()\vd(r  and  then  covcrinj;  with 
coll()(hon.  In  oxtonsivr  oiH-rations  provisional  or  ixrniancnt  h^'ation  of  the  carotid  may 
Ix'  lu'crssarv;  usually  tlu*  rxtrrnal  l)raiuh  will  suflicf.  In  every. instance  jjlastic  re|)air 
should  he  made,  as  it  will  always  he  recjuired  after  the  excision  of  growths  involving 

tlu'  surface. 

Space  does  not  permit  of  detailed  or  specific  directions  for  all  possible  methods  of 
plastic  repair  of  facial  defects,  hut  Figs.  421  to  441  illustrate  the  principal  methods 
which  may  he  utilized  in  planning  and  sliding  flaps  which  shall  serve  this  jmrpose. 
These  mtiy  l)e  modified  or  combined  to  meet  special  indications. 


Fig.  432 


Fig.  433 


/  a  \ 


I'tg.  43- 


Fig.  436 


^  i  r 


Fio.  434 


y  \ 


t 


Fig.  437 


FiG.  438 


T^iG.  439 


Fig.  440 


Fig.  441 


Sliding  rectangular  flaps  into  desired  position. 

It  is  often  necessary  to  intermit  the  anesthetic  because  the  operator  must  displace  the 
mask  in  order  to  do  his  work.  Souchon  advises  an  apparatus  by  which  most  of  this 
delay  can  be  avoided.  By  means  of  a  rubber  bulb  a  current  of  air  is  passed  through  the 
bottle  containing  the  anesthetic  and  then  directed  through  a  tip  which  is  passed  down  in 
the  phar\Tix  through  a  nostril.  This  may  be  connected,  if  so  desired,  with  a  bag  of 
nitrous  oxide  gas,  which  is  illustrated  in  Fig.  442,  and  its  use  in  Fig.  443. 

Ligation  with  excision  of  a  section  of  the  external  carotid  has  been  suggested  by 
Dawbarn  as  a  means  of  cutting  off  the  blood  supply  in  cruses  of  inoperable  malignant 
tumors  of  the  fare,  thus  reducing  their  rate  of  growth.  In  tumors  of  the  jaw,  for  instance, 
he  would  also  tie  the  inferior  dental  arterv,  with  its  mylohyoid  branch,  just  before 
it  enters  the  inferior  dental  canal.     He  ad%dses,  also,  the  removal  of  one  inch  of  the 


644 


SPECIAL  OR  REGIOXAL  SURGERY 


inferior  dental  nerve,  thus  avoiding  pain  and  distress,  occluding  the  artery  on  the 
less  diseased  side  first,  waiting  for  two  or  three  weeks  before  attacking  the  more 
diseased  side,  for  should  there  be  noticeable  benefit  after  operation  on  tlic  more  affected 


Fig.  442 


Fio.  443 


Souchon's  intiii;ia.~ii 


iler. 


side  many  patients  would  be  unwilling  to  be  again  subjected  to  the  other  operation. 
Other  operations  include  those  made  upon  the  various  nerves  for  relief  of  neuralgia 
or  for  nerve  suture  of  divided  trunks.     These  have  been  described  in  a  prenous  chapter. 


OPERATIONS  ON  THE  NOSE. 


Fig.  444 


Plastic  operations  upon  the  nose  appear  to  have  been  practised  early  in  the  hi.-^tory  of 
surgery.  The  East  Indians  had  a  method  by  which  the  skin  of  the  forehead  was  made 
to  furnish  a  flap  from  which  a  new  nose  was  created.  This  was  known  as  the  Indian 
method.  It  has  been  somewhat  modified  of  late  years  by  raising  with  the  skin  flap  the 
periosteum,  or,  as  suggested  by  Konig,  the  outer  table  of  the  frontal  bone,  with  the  intent 

and  hope  that  something  resembling  the  nasal 
bone  might  be  secured.  The  so-called  Italian 
method  (named  the  Tagliacotian  operation,  after 
TagJiacozzi)  consists  in  utilizing  the  skin  of  the 
arm,  which  is  loosened  ac-cording  to  a  pattern 
preAiously  made,  leaving  it  connected  only  by  a 
))edicle  through  which  its  blood  supply  is  to  be 
afforded.  This  flap  is  usually  cut  out  and  per- 
fectly formed,  then  left  loose  upon  the  arm  for 
about  fifteen  days  until  its  viability  has  been 
thoroughly  jjroved  and  its  under  surface  is  gran- 
^  ^  ^^^^v^  tilating.     Th  n  the  edges  of  the  defect  in    the 

»^  'i^^^^^r  nose  are  pared,  as  well   ;.s  those  of  the  flap,  and 

the  arm  is  brought  into  such  position  as  to  allow 
fitting  the  latter  to  the  former,  where  it  is  held 
by  stitches.  The  arm  is  held  in  proper 
position  by  cushions  and  by  bandages  of  plaster 
of  Paris  until  imion  has  taken  place,  after  which 
the  pedicle  is  severed  and  the  arm  then  released. 

Lesser  deformities  of  the  nose  may  be  remedied 
or  repaired  in  various  ways.  Angular  deformi- 
ties may  be  excised,  while  a  sunken  bridge  may 
be  raised,  as  AVeir  has  suggested,  through  a 
bevelled  incision  at-  the  junction  of  the  nasal  and  maxillary  bones,  they  being  held 
in  place  by  a  transfixion  pin.  One  of  the  most  common  and  objectionable  de- 
formities is  the  so-called  saddle-nose,  which  may  be  treated  by  Weir's  method,  or  which 


■>addle-nose"  due  to  s>-philitic  destruction  of 
bone.      (.Lexer.) 


iiAiiK  jji'  AM)  ()i'i:h'ATi()\s  ri'ox  Tin:  ups 


045 


has  aflonlcd  satisfactorv  results  ai'fcr  (lie  injection  of  paraffin.  Hoc,  of  Roeliester,  New 
Yorl<,  lias  su<(ee(le(l  in  remedying'  many  of  the  more  trifling'  nasal  deformities  by 
operation  from  within  tiie  nose,  as,  for  instance,  in  case  of /^//^-//o.sr,  wliere  he  dissects 
from  within   superlluous   fat  and  connective  tissue  (Fig.  444). 


HARE-LIP  AND  OPERATIONS  UPON  THE  LIPS. 

Ilarr-lip,  or  ro/i)hi)iii(i  oj  tfic  ii/)j)rr  /ij>,  is  due  to  a  failure  in  coalescence  of  the  developing; 
maxillary  processes,  which  should  unite  early  in  fetal  life  to  form  the  lip,  alveolar 
process  and  roof  of  the  mouth.  This  failure  may  involve  hut  a  triflinjj  part  of  this  line 
of  normal  junction  or  may  he  complete.  Thus  anywhere  along  it  defects  mav  l)e  noted, 
such,  for  instance,  as  a  little  notch  in  the  lip,  a  small  o|)ening  in  the  hard  or  soft  palate, 


Fic.  44.T 


Fic.  447 


Incomplete  hare-lip. 

In;.  440 


Complete  fissure  in  double  hare-lip. 


Complete  bilateral  fissures  (coloboma)  of  face.  (Guersant.) 


or  a  bifid  uvula.  The  defect  in  the  lip  alone  is  known  as  hare-lip  because  of  its  normal 
occurrence  in  the  hare,  and  occurs  on  either  side  of  the  median  line,  absolute  median 
fissure  Ixnng  extremely  rare.  It  may  occur  alone  or  in  combination  with  deeper  fissures 
which  involve  the  gum  or  the  alveolar  process  alone  or  the  entire  palate.  In  extensive 
fissures  of  this  character  development  is  rarely  symmetrical,  and  one  side  is  usually 
not  developed  sufficiently  to  match  the  other.  This  makes  operative  treatment  the 
more  difficult.  The  more  complete  and  extensive  fissures  are  often  complicated  by 
excessive  development  of  the  intermaxillary  bone,  apparently  from  lack  of  pressure. 
This  permits  a  projection  of  the  septum,  and  especially  of  the  central  portion  of  the 
alveolar  process,  with  a  small  part  of  the  skin  and  c  )nnective  tissue,  wdiich  should  have 
been  blended  into  the  lip  proper.  It  represents  the  original  intermaxillary  bone  with  the 
portion  which  should  have  been  developed  downward  from  the  nasal  process  of  the  mid- 
frontal  region.  This  gives  a  snout-like  appearance  to  the  face,  and  nearly  always  neces- 
sitates doing  an  operation  for  closure  of  the  lip  in  two  sittings.  In  Figs.  445  and  446  will 
be  seen  wide  clefts  with  projecting  intermaxillaries,  while  Fig.  447  illustrates  a  much  more 
complete  coloboma  of  the  face,  with  complete  bilateral  fissures.  Figs.  448  and  449  show 
the  double  form  with  philtnim  or  snout.  Figs.  450  and  451  give  the  palatal  conditions 
of  irregularity  and  projection  of  the  intermaxillary  bone.     (See  Cleft  Palate.) 

All  forms  of  hare-liy)  call  for  operation  not  alone  for  cosmetic  purposes,  but  so   that 
patients  can  nurse,  drink,  eat,  and  talk  to  better  advantage.     Obviously  the  earlier 


646 


SPECIAL  OR  REGIOXAL  SURGERY 


such  operations  are  done,  other  things  being  equal,  the  better  the  results.  When  the 
cleft  does  not  include  the  deeper  tissues  it  may  be  closed  within  the  first  week  or  two  of 
infancy.  When  the  roof  of  the  mouth  is  involved  the  surgeon  is  peq^lexed  in  deciding 
which  is  the  better  of  two  courses — to  operate  or  to  wait.     Unquestionably  by  early 


Fig.  448 


Fig.  449 


Double  hare-lip  with  philtnun  or  snout. 


Complete  fissure,  with  labial  defect  and  projecting 
intermaxillary.     (Bnins.) 


closure  of  a  fissured  lip  a  gentle  but  constant  influence  is  maintained  to  press  the  di\-ided 
upper  edges  together,  or  at  least  to  influence  their  more  rapid  growth  toward  each  other. 
For  this  reason  it  would  be  desirable  to  op>erate  early.  On  the  other  hand  with  a  bad 
palatal  defect  it  is  a  difficult  thing  to  operate  until,  with  the  increasing  age  of  the  child, 
the  mouth  has  attained  a  size  which  will  permit  the  manipulations  required  for  the 


Fig.  450 


Fig.  451 


nitlStTating  the  osseous  (palatal)  defect  in  complete 
fissures.     (Bruns.) 


Projecting  intermaxillary  bone.      (Bruns.) 


purpose.     Nevertheless,  unless  there  be  some  sf>ecial  reason  for  delay  it  would  appear 
wise,  at  least  as  a  general  rule,  to  operate  early.     (See  Cleft  Palate.) 

The  underlying  principle  of  these  operations  is  easily  and  briefly  stated.     The  edges 
of  the  defect  should  be  freshened  and  brought  together  bv  sutures.     E.xtreme  care  should 


HARE  LIP  A\D  OPFRATIOXS   Cl'OX    TIN-:   L/PS 


047 


be  taken  that  ihe  vcriiiilion  honlcr  of  tlic  li|)  he  iiiaiiitaincd.  A  little  particle  nf  miieous 
menihrane  in  the  li|)  of  an  infant,  dislocated  to  a  level  hi<,dier  than  that  where  it  helonj^'s, 
will  apjM'ar  later  in  life  as  a  reddish  |)atch  upon  the  skin,  which  will  |)rove  (|uite  a 
disfifjurenient.      Sinijjle  fissurt^  of   the  lip  is  easily  managed  by  Ni'-laton's    procedure 


Fk;.  452 


B         B 
Malgaigne's  operation:  tlie  incision. 


Malgaigne's  operation:  the  sutures  in  position; 
the  lower  sutures  tied. 


(Figs.  452  to  457).     The  deeper  and  more  extensive  the  fissure  the  more  plastic  recon- 
struction is  required. 

Incision,  when  necessary,  may  be  extended  around  the  angle  of  the  nose  on  one  side 
or  both,  antl  the  lip  should  be  dissected  away  from  the  bone  sufficiently  to  make  it  movable. 


Fig.  454 


Fig.  455 


N^laton's  operation:  the  incision. 


Nelaton's  operation:  the  sutures. 


Operations  by  which  a  certain  dovetailing  of  the  little  flaps  is  performed  afford  more 
security  than  a  perfectly  straight  incision,  but  the  resulting  scar  is  rather  more  marked. 
The  more  perfectly  the  mucous  membrane  can  be  preserved  upon  the  under  side  of 
the  lip  the  better  will  be  the  result. 


Fig.  456 


Fig.  457 


The  operation  for  double  hare-lip. 


/  ,■*'"" 


Operation  for  double  hare-lip:  the  sutures  in  position. 


Hare-lip  pins  have  been  abandoned.  Sutures  only  are  used,  which  may  be  of  thread 
or  horse-hair,  catgut  absorbing  too  rapidly.  It  is  my  c-ustom  to  pass  a  retaining  suture 
of  stout  silk  through  the  cheek  on  either  side,  at  a  distance  of  one  inch  or  so  from  the 
wound  margin,  to  bring  this  forward  in  front  of  the  alveolar  process,  and,  by  using  a 
plate  and  shot  on  either  end,  to  prevent  tension  upon  the  line  of  junction.     This  is  very 


648 


SPECIAL  OR  RKdJONAL  SURGERY 


important,  for  children  will  fret  and  cry  in  a  manner  to  tear  out  many  a  stitch  not  thus 
fortified.  After  operation  youno;  children  should  he  snu<rly  enclosed  in  a  jirotective 
bandage  around  the  chest,  by  which  it  shall  be  made  impossible  for  them  to  <i;et  their 


Fig.  458 


Fig.  459 


Line  of  inci.sion,  according  to  Konig. 


hands  to  their  mouths.     It  is  vitally  necessary  to  maintain  absolute  rest  of  the  face  and 
j)rotection  from  any  possible  source  of  harm. 

Fissures  of  the  lower  lip  are  surgical  curiosities.     Should  one    be  met  it    may  be 
treated  on  the  same  general  princij^les. 


Fio.  4C0 


Cheiloplastic  operation  on  lower  lip.     (Tillmanns.) 


The  other  eheiloplastic  operaiions  upon  the  lips  are  those  made  necessary  by  excisions 
of  malignant  growths,  or  by  deforming  cicatrices  such  as  follow  burns,  syj)hilitic  lesion.s, 
and  the  like. 


Fig.  4G1 


Fig. 462 


E.stlan<ler's  cheiloplastic  oi)eratioii. 


Fig.  4G0  illu.strates  one  method  of  filling  a  defect  of  the  lower  lip,  while  Figs.  4G1  and 
462  indicate  a  method  of  bringing  down  a  flap  from  the  upper  lip  for  the  same  purpose. 


THE  SALIVARY  APPARATUS. 
FOREIGN  BODIES  IN  THE  SALIVARY  DUCTS. 

Foreign  bodies  occasionally  enter  the  salivary  ducts,  especially  Stenson's  and  Whar- 
ton's, where  they  may  set  up  an  inflammation  known  as  siaJoductilitis.  These  may 
consi.st  of  bristles,  fish-bones,  and  the  like.  Abscess,  in  con.sequence,  may  form  in  the 
gland  or  between  it  and  the  foreign  body.  Calculi  also  lodge  in  the  ducts,  where  they 
remain  as  foreign  Ijodies,  producing  .sometimes  a  disproportionate  amount  of  irritation. 


I.\FLAM}fATI(>X  OF  TIIK  SALIV MiY  (!l.A\'DS  G49 


FISTULAS  OF  THE  SALIVARY  DUCTS. 

Fistulas  oi"  till-  salivary  (iucts  involve  Stciison's  duct.  They  ()|)cn  on  tlu-  inside  of  the 
buccinator  muscle,  back  of  the  orifice  of  the  duct,  which  is  opposite  the  second  upper 
molar  tooth.  These  fistulas  of  the  parotid  fjland  may  he  recofjnized  by  the  pa.ssage  of  a 
probe  from  within  the  mouth.  When  they  o|)en  externally  they  result  nearly  always 
from  injury,  and  it  is  only  the  external  forms  which  are  troublesome.  One  may  resort 
to  the  mildest  measures  first,  and  cx])crimcnt  with  cauterization  of  the  orifice  or  com- 
pn'ssion  by  occlusion.  Thest'  measures  will  be  inellcctivc  if  there  be  no  opcnin<f  u|K)n 
the  inside  of  the  mouth,  in  which  case  one  must  be  made  by  rei'stablishin^  the  ori<fiiuil 
canal  or  formin<f  a  substitute.  For  this  j)urj)os(;  a  suture  may  be  pa.ssed  around  the 
duct,  back  of  the  fistula,  usin<]j  a  curved  needle,  and  makin<j  it  come  out  near  the 
point  of  entrance.  It  should  hold  the  duct  in  its  loo|).  This  suture  may  then  be  tight- 
ened and  the  distended  duct  punctured  on  the  inside  of  the  cheek.  When  once  the  flow 
of  saliva  is  diverted  to  the  mouth  the  edges  of  an  external  fistula  may  be  |)ared  and  clo.sed. 
In  obstinate  cases  which  have  resisted  all  other  metlujds  it  has  been  suggeste<l  to  remove 
or  destroy  the  gland  which  connects  with  the  duct  at  fault.  Even  this  is  not  an  ea.sy 
matter,  but  it  can  be  done  in  the  case  of  the  ])arotid  by  careful  dissection,  with  separation 
of  the  branches  of  the  facial  nerve  and  removal  of  the  greater  ])ortion  of  the  gland  itself. 

Congenital  anomalies  of  the  salivary  glands  are  rare  and  of  small  import.  Anyone  of 
them  may  be  disj)laced,  or  either  of  them  may  connect  with  an  accessory  gland  separated 
from  it  by  an  appreciable  interval.     Abnormal  duct  openings  have  also  been  noted. 


INFLAMMATION  OF  THE  SALIVARY  GLANDS. 

Inflammatory  affections  of  the  salivary  glands  give  rise  to  sialoadenitis.  Among 
these  by  all  means  the  most  common  is  parotiiis  (mumps),  which  often  occurs  in  epi- 
demic form.  It  is  an  infections  and  probably  contagious  disease,  usually  attacking  the 
young,  though  no  age  is  exempt.  The  period  of  incubation  is  about  fourteen  days. 
The  condition  begins  with  a  stomatitis  and  with  swelling  of  the  affected  jjarotid,  with 
edema  of  the  overlying  tissues.  It  is  accompanied  by  moderate  fever.  Swelling  may 
be  extensive  and  involve  the  entire  neck  region.  The  parotid  on  the  other  side  becomes 
affected  within  a  few^  days,  although  usually  not  to  a  similar  extent.  The  other  salivary 
glands  occasionally  participate.  The  febrile  stage  lasts  for  about  a  week,  after  which 
the  swelling  recedes  and  is  gone  within  from  two  to  four  weeks.  Occasionally  the 
affected  glands  suppurate,  in  which  case  the  condition  may  be  very  serious,  since  it  may 
simulate  Ludwig's  angina,  or  may  be  followed  by  sloughing  and  gangrene. 

Save  when  abscess  threatens  the  treatment  should  consist  of  warm  antise])tic  mouth- 
washes and  the  external  application  of  an  ichthyol-mercurial  ointment  or  of  Crede's 
silver  ointment.  W'hen  suppuration  threatens  early  incision  should  be  made  for  the 
relief  of  tension  and  prevention  of  destruction. 

A  frequent  and  important  complication  of  parotitis  is  orchitis,  or  swelling  of  the  testicle. 
This  is  an  unexplained  feature  of  these  cases,  and  occurs  mainly  in  sexually  mature  indi- 
viduals. It  is  the  testis  proper  which  suffers  and  not  the  epididymis.  Suppuration 
here  is  rare.  More  or  less  atrophy  is  a  remote  consequence  in  many  cases,  estimated 
at  about  one-third.  Wlien  both  testicles  are  affected  to  a  marked  degree  impotency  may 
follow.  Treatment  of  this  orchitis  consists  in  absolute  rest  in  bed,  with  elevation  of  the 
parts  affected,  often  with  the  application  of  an  ice-bag.  Painting  the  scrotal  skin  with 
guaiacol  in  small  amount  will  often  relieve  pain.  A  similar  complication  occurs  in  the 
female,  the  ovary  being  involved.  Aside  from  this,  other  complications  may  occur  in 
the  breast,  the  \'ulvovaginal  glands,  the  prostate,  the  heart,  the  eye,  and  the  ear. 

Apart  from  this  somewhat  specific  affection  the  parotid  and  the  other  salivary  glands 
may  become  involved  in  swelling  and  inflammation  on  account  of  surrounding  local 
infections,  or  the  presence  of  foreign  bodies,  stones  in  the  ducts,  etc.  ^Metastatic  ab- 
scesses, especially  in  the  parotid,  are  not  uncommon.  Considering  the  open  pathways 
offered  it  is  surprising  that  these  glands  are  not  oftener  involved  in  septic  conditions  of 
the  mouth. 


650 


SPECIAL  OR  REGIONAL  SURGERY 


MIKULICZ'S  DISEASE. 

Mukulicz  has  described  a  not  very  infrequent  simultaneous  affection  of  two  or  more 
of  the  sahvarv  glands,  occurring  in  middle  age,  characterized  hv  uniform  swelling  which 
may  involve  even  the  palatine,  labial,  and  buccal  glands.  It  is  spoken  of  in  German 
literature  as  Miku/irz'.t  diseasr.  The  swelling  j)rogresses  slowly,  so  that  the  glands 
reach  a  varving  size  in  the  course  of  years.  Thus  the  parotid  glands  may  attain  the 
size  of  the  fist,  and  other  glands  a  corresponding  increase.  Sometimes  the  adjoining 
lvmj)liatics  are  also  involved.  The  enlargements  are  not  tender,  but  may  interfere 
with  movements  of  the  tongue  and  jaw.  These  tumors  have  been  known  to  recede  after 
an  intercurrent  acute  disease.  Nothing  is  as  yet  known  of  the  cause  or  nature  of  the 
affection.  In  its  treatment  ai-senic  and  potassium  iodide  have  given  perhaps  the  most 
favorable  results. 

The  salivarv  glands,  especially  the  parotid,  are  as  likely  to  be  involved  in  the  manifes- 
tations of  tuberculosis,  actinomycosis,  and  syphilis  as  are  the  other  structures  of  the  body. 
Lesions  of  these  vari(jus  natures  will  be  appreciated  without  further  description. 


TUMORS  OF  THE  SALIVARY  GLANDS. 


Tumors  of  the  salivary  glands  are  not  uncommon.  The  parotid  is  more  frequently 
affected  than  either  of  the  others.  These  tumors  may  be  of  cystic  character,  either  large 
from  obstruction  of  the  excretory  duct,  or  small  and  numerous.  Almost  all  the  tumors 
described  in  Chapter  XXVI  may  be  found  in  this  region.    Simple  adenemias  are  common 


Fig.  463 


Fig.  464 


Mixed  tumor  of  the  paiutid. 


Hruns.) 


Mixed  tiiiaor  (jf  the  subma.xiUaiy  gland,    (v.  Bruns.^) 


and  the  parotid  especially  is  often  the  site  of  tumors  of  mixed  character,  in  which  the 
various  mesoblastic  elements  mingle  in  a  confusing  manner.  Cartilaginous  tumors 
here  are  frequent.  The  presence  of  cartilage  is  to  be  explained  on  Cohnheim's  hvpoth- 
esis.  Endothelioma,  sarcoma,  and  carcinoma  are  also  common,  especially  as  primary 
tumors  in  the  parotid.  Any  or  all  of  the  glands  may  also  suffer  by  extension  of  malignant 
disease  from  primary  foci  in  their  neighborhood  (Figs.  463  and  464). 

Cancer  of  the  parotid  is  especially  serious  and  discouraging,  because,  while  radical 
removal  is  necessary,  it  is  impossible  to  effect  this  without  destroying  the  facial  nerve 
and  producing  consequent  ])aralysis  of  the  face  on  that  side.  Such  an  operation  should 
not    be    made   without   explaining    to    the    patient    beforehand    its    inevitable    result. 


SALIVARY  CALCULI  CuA 

Only  when  seen  in  their  very  early  stages  can  these  tumors  he  so  efTeetually  removed 
a.s  to  not  leave  the  patient  liahle  to  secondary  or  metastatic  afl'cctions.  This  also  slujuld 
be  explained  to  them  in  order  that  the  surgeon  niay  protect  himself  from  blame. 

SALIVARY   CALCULI. 

Calculi  which  form  either  in  the  substance  of  the  glands,  or  much  more  commonly  in 
their  ducts,  by  precipitation  of  those  salts  held  in  solution  by  the  saliva,  are  of  the  same 
character  as  the  accumulations  of  the  so-called  tartar  upon  the  teeth.  They  are  met 
with  freciuently  in  Wharton's  duct  and  occur  more  often  in  men  than  in  women. 
They  may  vary  in  size  from  that  of  a  rice-grain  to  a  stone  more  than  one  inch  long. 
They  are  always  ovoid  in  shape  and  with  a  rough  exterior.  They  are  believed  to  grow 
much  as  do  gallstones,  as  the  result  of  some  previous  infection,  a  clump  of  bacteria  per- 
haps affording  the  nidus  on  which  calcareous  material  is  deposited.  The  affection  may 
be  spoken  of  as  .s'ialolithiasis. 

They  usually  give  rise  to  pain  and  swelling,  and  lead  occasionally  to  the  formation  of 
abscess  and  fistulous  oj)enings.  They  may  be  revealed  by  the  a^-rays,  or  the  operator 
may  search  for  them  as  for  stone  in  the  bladder,  with  a  small  probe  passed  through  the 
duct  opening.  The  discharge  of  mucopus  or  blood  into  the  mouth  would  suggest 
infection  of  this  kind.  They  may  also  be  recognized  by  thrusting  a  needle  through  the 
overlying  tissues  in  the  direction  of  the  swelling  which  they  produce.  Their  removal' 
through  the  smallest  incision  on  the  interior  of  the  mouth  which  will  suffice  for  the 
purpose  is  indicated.     No  attempt  need  be  made  to  close  the  opening. 

Operations  on  the  parotid  region  are  difficult  and  severe.  In  case  of  large  tumors 
the  external  carotid  and  the  common  carotid  may  be  ligated.  By  separating  the 
patient's  jaws  the  parotid  space  is  increased  and  deep  dissection  is  more  easily  made. 
Caution  should  be  taken  not  to  open  the  maxillary  joint.  Souchon  has  called  attention 
to  the  fact  that  the  safest  plan  is  to  proceed  so  long  as  the  surrounding  tissues  are  easily 
removed  en  masse,  and  to  stop  when  they  become  too  resistant  as  the  deep  surface  is 
approached.  Then  the  portion  of  the  tumor  which  has  been  cleared  should  be  cut  off. 
The  stump  thus  left  will,  in  growing  again,  become  more  superficial,  and  it  is  sometimes 
possible  to  effect  a  radical  removal  by  a  second  operation. 


CHAPTER    XL. 

THE  MOUTH,  THE  TONGUE,  THE  TEETH,  AND  THE  JAWS. 

CONGENITAL  DEFECTS. 

Aside  from  anomalies  due  to  incomplete  closure  or  erratic  development  from  the 
branchial  clefts,  the  principal  congenital  defects  of  the  regions  included  in  this  chapter 
are  as  follows:  The  mouth  is  essentially  a  coalescence  of  the  upper  end  of  the  foregut 
and  a  recess  known  as  the  stomotleum,  which  are  at  first  separated  by  membrane,  the 
latter  disappearing  early  in  fetal  life.  Some  remains  of  it,  however,  may  produce  a  nar- 
rowing of  the  oral  fissure  and  cause  one  form  of  micro.sioina.  Some  of  these  facial  defects 
are  due  to  formation  of  amniotic  bands  and  adhesions,  which  restrain  or  interfere  with 
the  normal  development  from  the  branchial  fissures.  ISIalformations  of  the  tongue 
may  accompany  other  anomalies.  A  median  cleft,  called  also  a  bifid  tongue,  and  de- 
fective develoj)ment  and  undue  adhesions  to  the  floor  of  the  mouth,  are  known,  whose 
most  trifling  expression  may  be  seen  in  the  so-called  to7igue-tie,  where  the  frenum  is 
too  short  and  needs  to  be  divided  in  order  to  release  the  tip  and  more  movable 
part  of  the  organ.  Adhesive  bands  may  also  attach  the  tongue  laterally  to  the 
cheek,  bands  between  the  cheek  and  the  gums  being  also  occasionally  seen.  An 
extreme  type  of  tongue-tie  is  known  as  anktjioglossum.  Abnormally  long  tongues  are 
also  met,  and  cause  an  actual  menace  from  danger  of  the  tip  Ijeing  swallowed,  as 
children  have  suffocatcfl  from  this  cause.  Congeiiital  macroglossia  has  been  described; 
it  is  usually  due  to  lymphangioma  of  the  tongue.  A  condition  known  as  lingua  plicata 
is  characterized  by  moderate  enlargement  of  a  number  of  either  longitudinal  or  transverse 
folds  or  rugse.  The  covering  mucosa,  however,  is  normal.  Complete  absence  of  the 
tongue  has  been  noted. 

Aside  from  malformation  of  the  upper  jaw,  cleft  palate,  there  are  arrest  of  development 
in  one  or  both  sides  of  either  jaw  and  a  failure  of  union  in  the  two  halves  of  the  lower 
jaw.  Anomalies  about  the  temporomaxillary  joint  interfere  with  its  fimction  and  may 
prevent  separation  of  the  jaws. 

Malformation  and  misplacement  of  the  teeth  are  extremely  common.  Thus  a  tooth 
may  develop  in  an  abnormal  position  by  displacement  of  its  body,  or  it  may  project  in  an 
abnormal  direction;  while  teeth  may  be  lacking  in  numljer  or  in  eruption,  so  that  a  given 
tooth,  usually  a  molar,  completely  fails  to  appear.  Absence  of  a  number  of  teeth  is 
more  rarely  notetl.  Numerous  cases  are  on  record  where  a  third  set  of  teeth  has  succeeded 
the  second  instead  of  the  latter  remaining  permanent.  Al)normalities  of  tooth  formation 
extending  to  the  dignity  of  tumors  of  the  dental  tissues  have  been  referred  to  in  the 
chapter  on  Tumors,  under  the  head  of  Odontomas.  Cysts  of  congenital  origin  not  infre- 
quently develop  around  imerupted  or  misplaced  teeth,  and  constitute  tumors  which  at 
at  birth  are  scarcely  noted  and  which  may  not  develop  until  later  in  life. 

Persistent  remains  of  the  thijroglossal  or  thi/rolingual  ducts  may  })e  seen  early  in  child- 
hood, or  not  until  late  in  life.  Their  consecjuence  is  occasionally  noted  in  the  existence 
f)f  fiMulas,  but  more  often  of  cgsts  or  dermoid  tumors,  which,  though  having  their  origin  in 
the  middle  line,  may  become  displaced  to  one  side,  and  when  seen  by  the  surgeon  have  a 
lateral  position. 

CLEFT  PALATE. 

Cleft  palate  is  a  congenital  defect  due  to  failure  of  coalescence  between  the  nasal  and 
maxillary  processes,  which,  ])roceeding  from  either  side,  should  meet  and  miite  in  the 
middle  line.  The  defect  may  be  so  slight  as  to  produce  only  a  small  notch  in  the  alveolar 
border,  or  a  small  opening  in  the  roof  of  the  mouth,  or  it  may  be  so  complete  as  tf)  consti- 
tute a  separation  with  the  formation  of  but  a  small  part  of  the  roof  of  the  mouth,  leaving 
(  6.52 ) 


Cl.hFT   I'ALATI-: 


()r)3 


lull  lidlc  tissue  scrvicc;il)lc  tor  any  possil)!*-  ojh  ralii)n.  Tlic  relation  hetween  the  |)ro(l- 
ucls  oi'  lateral  <,M-o\vtli  and  the  downwanl  |)r()jection  and  Torination  of  the  inlcriiKixillarij 
hour  \)\  the  niidl'rontal  and  nasofrontal  processes  is  too  e()ni|)le.\  to  i)e  deserihed  here  (Kig. 
4()5).  In  some  insttuu-cs  there  is  hut  little  evidence  of  the  formation  of  such  ii  hone,  while 
at  other  times  it  lias  not  only  hone  formation  hut  is  relatively  overdevelojM'd,  in  such  a 
way  as  to  make  the  lower  anterior  angle  of  the  septum  and  its  own  part  of  the  alveolar 


l'"i<!.  4()5 


Tic;.  400 


Double  cleft  palate. 


Left-sided  cleft  palate. 


Fit;.  467 


process  project  far  beyond  the  level  of  the  surrounding  tissues,  thus  producing  a  snout- 
like appearance,  which  not  only  makes  the  case  more  disfiguring,  hut  seriously  compli- 
cates o})erative  procedure.  Usuallv  the  lower  border  of  the  nasal  septum  will  be  found 
attached  to  one  side  of  the  cleft  (Fig.  466).  The  soft  palate  presents  the  same  fissure, 
anrl  the  uvula  is  often  neatly  separated  into  halves. 

The  coincidence  of  cleft   palate  with    hare-lip  has   been   described.     (See   p.  645.) 
While  they  often  are  combined,  either  may  occur  without  the  other  (Fig.  467). 

No  matter  how  incomplete  the  palatal  cleft  may  be  the  nose  and  the  mouth  are  con- 
verted into  a  common  cavity.  Suction,  as  from  the  breast,  is  impossible.  Infants  with 
this  defect  should  be  carefully  fed  by  hand;  as  they 
develop,  food  passes  readily  from  the  mouth  to  the 
nose,  while  there  is  corresponding  difficulty  in  swal- 
lowing. With  lapse  of  time  speech  becomes  defective 
or  almost  unintelligible.  There  is,  therefore,  every 
reason  for  any  possible  closure  of  such  defects.  Against 
the  mechanical  difficulties  on  one  side  should  be  weighed 
the  desirability  of  such  closure  on  the  other.  One  argu- 
ment advanced  in  favor  of  operation  on  hare-lip  is  that 
the  influence  of  the  pressure  thus  aflForded  will  tend  to 
hasten  the  natural  attempt  on  the  part  of  the  halves  of 
the  upper  jaw  to  grow  toward  each  other  instead  of  in 
the  opposite  direction.  On  the  other  hanfl,  by  closure 
of  the  lal)ial  defect,  the  space  within  is  materially  dimin- 
ished and  manipulation  made  more  difficult.  It  then 
becomes  a  serious  problem  when  to  operafr  upon  a 
given  case  of  cleft  palate.  The  operation  itself  is  usually 
one  of  no  small  mechanical  difficulty,  the  space  required 
for  manipulation  is  most  restricted,  the  procedure 
relatively  a  long  one  becau.se  of  the  anesthetic,  anfl 
necessity  for  its  frequent  suspension  in  order  that  the 
operator  may  proceed,  and,  because  of  these  difficulties 
and  delays,  the  attendant  shock  to  the  patient.  A  puny 
child,  unable    because  of  the  defect  to  take  sufficient 


Left-sided  hare-lip  and  cleft  palate. 
Marked  displacement  of  intermaxillary 
bone.     Boy,  aged  six  years.    (Bevan.) 


C54  SPECIAL  OR  REGIONAL  SURGERY 

nourishment,  is  then  in  far  from  a  favorable  condition  for  a  serious  operation. 
Without  a  general  anesthetic  no  child  will  endure  it,  while  local  anesthesia  in  the 
young  is  insufficient  on  account  of  their  timidity  and  involuntary  resistance.  When 
to  operate,  then,  should  depend  upon  the  condition  of  the  child,  the  dexterity  of  the 
operator,  and  the  width  of  the  cleft — that  is,  the  amount  of  work  to  be  done. 

Brophy,  of  Chicago,  has  taken  a  radical  and  advanced  position  in  this  matter,  and 
believes  that  these  operations  should  be  performed  in  early  infancy,  a  fact  which  liis  own 
large  experience  would  appear  to  demonstrate.  Yet  this  same  experience  has  developed 
in  him  a  facility  possessed  by  few,  and  that  which  such  an  operator  may  do  with  impunity 
can  be  duplicated  by  but  few.  He  finds,  however,  unansweral)le  argument  in  this: 
that  in  infancy  the  bones  of  the  jaws  are  scarcely  developed,  are  not  only  friable  but  very 
flexible  and  yielding;  that  even  in  the  very  young  the  tissues  unite  kindly,  and  that  very 
young  infants  seem  to  be  less  liable  to  extreme  shock  than  those  several  months  old; 
that  the  earlier  the  muscles  of  the  palate  are  brought  into  contact  and  action  the  better 
performed  are  the  functions  of  deglutition  and  of  speech,  and  that  if  they  are  not  used 
they  atrophy;  that  the  teeth  are  more  likely  to  erupt  normally,  and  that  the  extreme 
lial)ility  to  pharyngitis  produced  by  such  wide-open  fissure  is  obviated.  To  all  of  these 
statements  no  objection  can  be  raised,  and  the  only  arginnent  which  can  be  adduced 
against  Broj)hy's  position  is  the  actual  danger  of  the  operation. 

In  the  matter  of  time  it  may  be  said  that  in  extremely  competent  hands  operation  in 
infancy  is  the  ideal  method,  but  that  when  children  reach  the  age  of  two  or  three  years 
and  still  have  very  small  mouths,  not  much  is  lost  by  waiting  until  they  are  five  or  six  years 
of  age,  while  considerable  room  is  gained  for  ease  of  manipulation.  Much  depends 
also  on  the  temperament  and  obedience  of  the  child.  These  children,  like  most  of 
those  born  with  congenital  defects,  are  usually  pampered  and  spoiled  by  indulgent 
parents,  so  that  at  a  time  when  implicit  obedience  is  most  needed  it  seems  almost  im- 
possible to  do  anything  with  them.  In  dealing,  therefore,  with  such  a  child  one  should 
insist  upon  its  being  thoroughly  disciplined,  and,  at  the  same  time,  accustomed  to  manip- 
ulation within  the  mouth,  as  the  presence  of  a  finger,  tongue  depressor,  etc.,  so  that 
when  need  comes  for  their  use  the  child  shall  not  be  totally  unaccustomed  thereto. 
Every  case  should  also  be  })repared  so  far  as  possible  by  antiseptic  and  astringent  mouth- 
washes. A  nasopharyngeal  catarrh  which  shall  compel  such  a  patient  to  be  constantly 
swallowing  and  spitting  may  defeat  the  object  of  the  operation  itself. 

The  terms  usually  used  in  this  connection  are  uranoplasty,  which  means  closure  of 
the  hard  palate,  and  stanhi/lorrhaphy,  which  means  the  closure  of  the  soft  palate. 

Operations  for  Cleit  Palate. — The  responsibility  of  the  anesthetist  in  these  cases 
is  great.  Considering  that  he  has  to  work  through  the  same  cavity  as  the  surgeon  it  is 
sometimes  very  difficult  to  keep  the  child  in  a  consistent  state  of  narcosis.  The  inhaler 
devised  by  Dr.  Souchon  serves  an  admirable  purpose.  (See  p.  644.)  I  regard  chloroform 
as  the  safest  of  the  anesthetics,  as  it  is  less  irritating  and  provokes  less  flow  of  saliva. 
It  is  a  good  plan  to  cocainize  the  parts  previous  to  incision,  in  order  to  so  benumb  them 
as  to  make  reflex  impressions  less  pronounced. 

The  theory  of  these  operations,  like  that  for  hare-lip,  is  simple.  It  consists  in  fresh- 
ening the  edges  of  the  cleft,  bringing  them  together  and  holding  them  in  position ;  this 
requires  clean  work  and  a.  mouth  kept  clean — in  other  words,  it  calls  for  efficient  anti- 
sepsis, for  strict  asepsis  is  impossible.  All  carious  teeth  should  be  removed  or  put  in 
good  condition,  and  large  tonsils,  with  their  distended  crypts  and  reservoirs  of  decom- 
posing material,  and  all  adenoid  tissue  should  be  removed. 

Owen  has  shown  the  benefit  in  nursing  infants  of  using  an  old-fashioned  "slipper 
bottle,"  having  a  soft  giant  teat  with  a  hole  on  the  under  surface.  As  the  infant  sucks 
from  this  the  teat  fills  the  cleft,  and  as  the  child  compresses  it  in  sucking  the  milk  is 
directed  downward.  When  this  does  not  suffice  milk  may  be  given  in  a  warm  teaspoon, 
passed  far  back  over  the  tongue,  or  from  a  medicine  dropper. 

Owen  sustains  Brophy  in  the  contention  that  the  most  favorable  time  for  operating 
on  a  cleft  palate  is  between  the  age  of  two  weeks  and  three  months,  there  being  at  that 
time  less  shock,  and  the  bones  are  extremely  flexible.  Accepting  this  statement  as 
authoritative  the  operation  upon  young  infants  will  be  described. 

Previous  to  the  operation  a  warm,  nourishing,  and  stimulating  enema  should  be  given 
the  patient.  After  the  infant  is  anesthetized  the  tongue  is  drawn  forward  by  a  long 
suture  and  the  mouth  kept  open  by  a  mouth-gag.     The  edges  of  the  cleft  are  then 


cli:ft  I'M. ATI': 


655 


j);in(l  with  a  sharp  knife,  after  which  ctt'ort  should  he  made  to  |)re,s.s  the  ii|)|>er  niaxilhi' 
to^'etlier,  iti  order  to  t(  st  their  Hexihihty  and  the  i)o.s.sil)ihty  of  approximating  them  in 
this  manner.  This  will  rarely  l)e  suflieient,  however,  and  it  heeomes  neeessarv  to  raise 
the  cheek,  on  each  side,  toward  the  posterior  extremity  of  the  hard  |)alate  jtist  behind  the 
malar  process,  and  |)ass  a  knife  throujjh  the  outer  bony  surface,  makin<;  a  sulHcient 
tlivision  of  the  antral  wall  throuj^h  a  minimum  of  opening.  Rather  than  cut  too  much 
bone  at  first  the  knife  may  be  re-introduced.  The  actual  apj)roximation  of  the  maxilla? 
is  produced  by  silver-wire  sutures.  A  firm,  stout  needle  carrying  a  thick,  silk  pilot  suture 
is  passed  through  at  the  j)oint  above  mentioned  and  made  to  appear  in  the  fissure,  where 
tlie  loop  may  be  jnilled  down,  after  which  it  may  be  again  ])asse<l  through  the  other  side 
and  made  to  cmtTge  at  a  point  corresponding  to  that  at  which  it  entered.  'J'he  suture 
tints  j)assed  in  one  way  or  the  other  is  made  to  carry  a  strong  silver  wire  from  one  side 
aero.ss  to  the  other,  on  a  level  above  the  hard  palate,  emerging  on  each  side  within  the 
eheeks.  Another  wire  suture  is  similarly  jiassed  more  anteriorly.  Two  small  (jblong 
leaden  plates,  1.5  Cm.  in  length  and  35  or  40  Cm.  in  width,  drilled  with  two  holes,  are 
then  provided,  one  of  them  laid  along  the  outside  of  each  maxilla,  the  wire  sutures  passing 
through  the  lioles  which  they  contain.  On  one  side  the  ends  of  the  wire  are  then  twisted 
firmly  and  eut  short,  thus  forming  a  complete  grip  upon  the  j)late  on  its  side;  then  the 
jaws  are  pressed  finnly  together,  while  the  wire  sutures  on  the  other  side  are  similarly 
fastened  over  the  lead  jjlates  and  twisted  tightly  to  make  permanent  the  eflVct  produced 
by  pressure  with  the  fingers.  The.se  sutures  should  be  made  sufficiently  tight  to  permit 
of  a])i)roximation  of  the  borders  of  the  mucoperiosteal  surfaces,  already  freshened,  in  such 
a  way  that  they  may  l)e  held  together  with  fine  wire  or  horse-hair  sutures  and  without 
undue  tension. 

The  lead  plates  are  left  in.  situ  for  three  or  for  weeks.  If  necessary  the  wire  suture 
may  be  tightened  to  allow  for  relaxation  produced  by  pressure  effect.  Some  ulceration 
may  occur  beneath  the  plates,  but  this  heals  after  their  removal.  Theoretical  objection 
to  this  method  may  be  made  because  of  the  tendency  to  narrowing  of  the  upper  jaw. 
In  fact,  however,  it  is  only  restored  to  its  jiroper  dimensions,  as  that  part  of  the  face 
has  been  previously  widened  by  the  width  of  the  cleft.  Irregular  eruption  of  teeth  or 
irregularity  of  development  may  be  treated  by  a  dentist. 

When  the  vomer  affixed  to  the  intermaxillary  bone  projects  in  a  snout-like  manner 
it  is  necessary  to  remove  a  Y-shaped  section  from  it,  the  base  of  the  triangle  being  along 
the  margin  of  the  cleft,  in  order  that  the  projection  may  drop  backward  and  the  corre- 
sponding part  fall  into  line  with  the  rest  of  the  alveolar  process.  This  is  best  done  as  a 
preliminary  and  distinct  operation. 

Uranoplasty  in  older  patients  consists  essentially  of  forming  two  anteroposterior 
mucojjcriosteal  flaps,  from  the  hard  and  soft  palates,  on  either  side  of  the  cleft,  with 
their  inner  edges  neatly  pared,  which  should  be  separated  from  the  bony  roof  of  the 
mouth,  and  slid  toward  each  other  until  they  can  be  held  together  by  sutures.  These 
operations  are  best  performed  with  the  patient's  head  hanging  over  the  end  of  a  table, 
so  that  blood  may  not  find  its  way  into  the  trachea  or  stomach,  but  be  sponged  away. 
This  is  the  position  of  the  so-called  "down-hanging  head"  described  by  Rose.  In 
fat-necked  individuals  it  may  be  impracticable.  After  paring  the  borders  adjoining 
the  fissure  an  incision  is  made  just  within  the  alveolar  border,  close  up  to  the  teeth, 
parallel  to  the  former,  of  sufficient  length  to  permit  of  the  formation  of  the  flap  above 
mentioned ;  then  with  raspatories  or  elevators  it  is  detached  from  the  hard  palate.  In  a 
mouth  with  a  gothic  arch  or  roof  it  is  often  easier  to  form  these  flaps  and  to  bring  them 
together  than  in  others.  It  may  be  possible  in  such  cases  to  not  only  suture  the  edges, 
but  also  some  portion  of  their  raw  surfaces,  thus  ensuring  better  union.     (See  Fig.  468.) 

Branches  of  the  anterior  palatine  artery  will  bleed  freely  during  this  part  of  the  per- 
formance. Firm  pressure  and  the  use  locally  of  adrenalin  solution  will  usually  over- 
come this  difficulty.  As  the  incision  is  extended  backward  the  posterior  arteries  will 
cause  the  same  difficulty.  The  wider  the  defect  the  farther  backward  should  the  lateral 
incisions  be  extended.  Here  the  principal  obstacle  to  easy  approximation  of  edges  is 
the  activity  of  the  levator  and  tensor  palati  muscles.  Formerly  it  was  a  part  of  opera- 
tions to  divide  the  tendon  of  the  latter  as  it  passes  around  the  hamular  process.  It 
has  been  found,  however,  that  this  is  often  unnecessary.  A  tenotomy  of  this  tendon, 
however,  may  be  made  just  as  that  of  any  other  tendon  with  the  expectation  that  the 
gap  thus  made  will  be  filled  with  fibrous  tissue.     While,  on  one  hand,  it  is  of  great 


656 


SPECIAL  OR  REGIONAL  SURGERY 


advantcigo  to  spare  this  tendon,  on  tlic  otlicr  hand  its  nuiscl(>  may  Ix'  the  {)rinei|)al  faetor 
operating  to  i)ull  apart  those  surfaces  whieli  have  been  neatly  l)r()uji;iit  together. 

Fergusson  and  Langenbeck  have  not  liesitated  to  make  ostcuplu.stir  fiap,s  when  neees- 
sarv,  dividing  the  hard  palate  along  the  line  of  the  lateral  incisions  with  a  fine  chisel. 
This  is  not  often  recjuired,  and  complicates  the  case  to  an  undesirable  extent,  although 
it  may  be  necessary  in  wide  fissures  with  a  minimum  of  tissue  (Fig.  4G9). 

Sutures  are  best  maile  of  fine  silver  wire  or  of  black  silk,  as  the  ordinary  silk  is  usually 
too  absorbent,  and  {permits  infection  of  the  stitch  holes.  These  sutures  are  introduced 
with  any  one  of  a  variety  of  needles  devised  for  the  jjurpose.  A  complicated  neetlle  is 
not  necessary  for  this  purpose,  for  with  an  adequate  needle  holder  even  the  ordinary 
needles  can  be  used.  Silver  wire  may  be  fetl  directly  into  the  needle  or  through  a 
hollow  needle  devised  for  the  purpose,  or  sutures  of  silk  may  be  passed,  by  which  a  wire 
suture  is  pulled  after  them. 

Great  assistance  can  be  obtained  from  packing  strips  of  gauze  between  the  flaps  and 
the  bone  from  which  they  have  been  detached.  These  may  be  inserted  for  pressure 
effect  and  prevention  of  hemorrhage  during  the  operation,  and  later  may  l)e  substituted 
by  smaller  packing  of  antisejjtic  gauze  left  for  the  purpose  of  helping  to  minimize  tension, 
flaps  being  crowded  toward  each  other  by  their  use. 


Fig.  468 


Fig.  469 


Uranoplasty,  showing  incisions.      (Tiilmanns). 


Staphylorrliaphy,  sutures  placed.     (Konig.) 


The  parts  being  approximated  and  the  wound  suitably  tamponed  it  is  necessary  to 
keep  the  patient  as  (luiet  as  j«)ssible.  Young  infants  tend  to  keep  up  a  constant  sucking 
motion  with  the  tongue,  which  may  interfere  with  the  ciuietude  of  the  palate.  Small 
doses  of  bromide  or  chloral  may  be  administered  either  by  the  mouth  or  rectum,  for  every 
effort  at  crying,  coughing,  or  vomiting  tends  to  make  a  stress  upon  the  line  of  sutures. 
Vomiting  immediately  after  the  operation  is  not  necessarily  serious,  and  yet  should  be 
avoided.  Patients  sufficiently  old  to  talk  should  be  cautioned  not  to  converse.  Water 
is  better  for  the  patient  than  milk,  as  the  latter  does  not  allay  thirst  so  well  and  may  form 
curds.  Most  of  the  nourishment  for  the  next  few  days  should  be  administered  "bv  the 
rectum,  giving  only  water  through  the  mouth.  Children  should  be  watched  continuously 
lest  they  get  fingers  or  toys  into  their  mouths,  and  fretfulness  should  be  guarded  against. 
Thread  sutures  should  only  be  removed  with  scissors  and  force]«  after  the  expiration 
of  five  or  six  days.  A  useless  suture  is  a  foreign  body  which  does  more  harm  than  good. 
When  lead  plates  are  used  with  strong  wire  sutures  they  should  remain  from  two  to  four 
weeks.  In  young  or  undisciplined  children  it  may  be  necessary  to  give  an  anesthetic 
for  removal  of  the  sutures.  The  tampons  or  pledgets  of  gauze  should  be  removed  from 
day  to  day.     An  antiseptic  mouth-wash  or  spray  should  be  frequently  used. 

The  two  results  most  desired  are  prevention  of  passage  of  food  "from  the  mouth  to 
the  nose,  which  is  ahyays  commensurate  with  the  success  of  the  operation  itself,  and 
improvement  in  speech  and  voice.     The  earlier  the  closure  the  more  natural  the  voice. 


TIIF.   Morril  IS   (lEM'lRAL  657 

I*iiti('ii(.s  ill  adoIcscciK-c  or  adult  life  rarely  note  iiiticli  jjjaiii  in  this  respect,  while  those 
operated  in  early  childhood  may  learn  to  talk  almost  |)ert"eclly. 

There  are  cases,  espi-cially  those  which  have  <foiie  for  years  unattended,  wh(>re  the 
arch  of  the  mouth  is  of  such  j^othic  shape  and  the  defect  so  wide  that  disap|)ointinent 
is  sure  to  follow  in  at  least  one  of  the  above  res|)ects.  The  art  of  the  dentist  has  now 
reached  a  |)oint  where  plates  or  obturators  may  be  <'()nstructed  for  unsuitable  cases, 
which  will  i,nve  better  functional  and  vocal  results  than  any  which  the  surgeon  can  pro- 
duce. 

Another  form  of  palatal  defect  is  the  result  of  the  late  manifestations  of  .syphilif, 
and  small  and  large  j)crforations  may  occur,  usually  in  the  hard  rather  than  in  the  soft 
palate.  Thev  are  to  be  dealt  with  surgically,  but  not  until  after  the  patient  has  been 
subjectecl  to  a  course  of  antisyphilitic  treatment. 

THE  MOUTH   IN   GENERAL. 

The  mouth  more  than  any  other  part  of  the  body  is  the  hal)itatof  a  large  fauna  and 
flora  of  miiuite  organisms.  Over  one  hundred  different  kinds  of  bacteria  from  tliis 
region  have  been  identified  by  INIiller,  and  it  will  be  easily  seen  how  prone  fresh  wounds 
or  old  lesions  may  be  to  infection  from  these  sources.  Fortunately  but  few  of  these 
microorganisms  have  decided  pathogenic  propensities.  They  lurk  especially  in  two 
localities — the  crypts  of  the  tonsils  and  along  the  gingival  borders  and  alveolar  processes. 
Along  the  gingival  border  of  the  teeth  iariar  accumulates,  by  a  j)recipitation  of  mineral 
salts  from  the  saliva,  where  by  irritation,  cou})led  with  germ  activity,  the  gum  is  loosened 
from  the  teeth  beyond  the  level  of  the  enamel,  and  the  soc-kets  thus  exposed  to  various 
kinds  of  infection."  In  consequence  the  teeth  thus  undergo  cle^ital  caries,  become  loosened 
in  their  sockets,  while,  at  the  same  time,  infection  travels  along  lymph  paths  until  the 
germs  are  filtered  out  in  the  adjoining  cervical  lymjjh  nodes,  which  thus  suffer  enlarge- 
ment and  often  su[)[)urative  destruction.  An  intcr.siitial  gingivitis,  therefore,  is  always 
a  serious  menace  to  the  integrity  of  the  teeth.  This  will  furnish  another  argument 
for  a  semi-annual  inspection  of  the  mouth  by  a  competent  dentist,  that  he  may  clean 
away  all  tartar  accumulations  and  treat  the  gums  in  such  a  way  as  to  prevent  disinte- 
gration. In  elderly  people,  especially,  there  is  a  marked  tendency  toward  retrocession 
of  the  gums.  In  young  or  old,  when  this  condition  is  noted,  it  may  be  treated  by  appli- 
cations of  zinc  iodide,  either  of  the  dry,  minute  crystals  or  of  a  saturated  solution,  which 
may  be  used  daily  or  weekly.  By  such  precautions  the  teeth  may  be  preserved  to  old 
age,  the  importance  of  which  is  not  generally  appreciated,  since  the  teeth  are  necessary 
for  suitable  mastication  of  food  which  the  enfeebled  stomach  of  an  aged  person  can  more 
easily  digest. 

Infection  may  also  occur  during  the  period  of  eruption  of  teeth  in  young  people,  and 
serious  trouble  sometimes  accompanies  the  appearance  of  temporary  or  permanent  teeth. 
Gingivitis  of  toxic  origin  is  not  uncommon,  as  among  the  possible  effects  of  overdosage 
of  mercury  and  phosphorus. 

All  that  has  been  said  of  the  teeth  and  their  sockets  is  in  the  main  true  of  the  tonsils, 
which  afford  numerous  crypts  or  lacuna  in  which  germs  may  be  harbored  for  a  long 
time.  The  explanation  of  probably  75  per  cent,  of  enlarged  and  tuberculous  lymph 
nodes  is  afforded  by  infection  spreading  from  the  tonsils  and  teeth.  It  may  not  be 
tuberculous  at  first,  but  it  becomes  so  later. 

In  the  mouth  may  be  seen  expressions  of  actinomycosis,  tuberculosis,  and  especially 
of  syphilis,  among  the  more  chronic  lesions,  as  well  as  of  diphtheria,  erysipelas,  and 
the  result  of  the  oidium  albicans  of  thrush.  Tuberculosis  is  more  common  in  the  pharynx, 
while  the  syphilitic  infections  may  appear  anywhere  and  in  any  form,  as  chancre  on 
the  tonsil  or  the  lip,  nmcous  patches  of  the  tongue,  destructive  lesions  of  bone,  all  of 
the  earlier  and  most  of  the  later  expressions  of  the  disease  offering  serious  dangers  of 
contagion. 

Sto7natitis  is  a  term  generally  applied  to  the  lining  membrane  of  the  mouth  and  indi- 
cates little  regarding  its  nature  or  seriousness.  It  may  be  of  traumatic  origin,  as  when 
strong  caustics  have  Come  in  contact  with  the  mucosa.  Ulcerative  stomatitis  is  a  disease 
of  childhood,  due  to  the  activity  of  the  oidium  albicans  or  some  kindred  microorganism, 
it  being  usually  a  more  serious  expression  of  the  condition  known  as  "  thrush."  Washing 
42 


658 


SPECIAL  OR  REG W SAL  SURGERY 


the  mouth  frcfiucntlv  with  dihitt-  sohitions  of  hydrofjcii  peroxide  or  of  tinctun- ()f  iodine 
will  usually  be  all  tliat  is  necessary.  Resistant  ulcerations  may  l)e  treated  with  10  per 
cent,  solution  of  silver  nitrate.  Stoinafiti.s  (j(ni(jr(nto.'<a  is  another  name  for  tioma,  or 
catirrum  oris,  which  was  descril)ed  in  the  chai)ter  on  Gangrene.  In  these  cases  the 
surgeon  should  hasten  the  tedious  separation  of  sloughs  by  use  of  scissors,  curette,  or 
the  actual  cautery  (Fig.  471).  . 

Blastomijcetic  lesions  of  the  mouth,  and  especially  of  the  lips,  have  been  recognized. 
Bevan  has  reported  extirpation  of  granulomas  provoked  by  the  blastomycetes,  or  yeast 
fmigi,  wliich  are  known  to  produce  similar  effects  elsewhere  (Fig.  471). 


Fig.  470 


Fig.  471 


Misplaced  and  imprisoned  tooth.     (Forget.) 


Destruction  of  cheek  the  result  of  cancrum  oris. 
(Tiffany.) 


Severe  infections  of  the  mouth  may  also  involve  the  tongue  and  thus  produce  acute 
glossitis  or  mav  sj)read  to  the  connective  tissue,  or  the  submaxillary  region,  and  there 
produce  that  tvpe  of  phlegmon  called  Ludwigs  an r/iu a,  described  in  the  chaj)ter  on  the 
Neck.     The  source  of  infection  in  most  of  these  cases  is  a  tooth  or  tooth-socket. 

Injuries  and  ivounds  of  the  mouth  are  liable  to  septic  infection,  whether  they  occur 
from  mechanical,  chemical,  or  traumatic  causes.  Injuries  inflicted  by  the  mouth,  or 
rather  by  the  teeth,  upon  others  constitute  infected  wounds  of  a  serious  tyj)e.  Burns, 
scalds,  and  similar  lesions  inflicted  by  violent  caustics,  such  as  carboUc  or  nitric  acids, 
mav  be  followed  by  cicatricial  contraction  and  produce  serious  con,sequences.  So  far 
as  the  latter  can  be  foreseen  they  should  l)e  prevented,  while  for  their  more  extreme 
results  various  plastic  operations  may  be  performetl. 


THE  TONGUE. 

What  has  been  said  above  with  regard  to  the  possibility  of  infected  wounds  in  the 
mouth  applies  also  to  the  tongue  ami  other  parts.  It  is  often  lacerated  by  being  caught 
between  the  teeth  in  falls  and  blows  and  is  sometimes  bitten  by  epileptic  patients  during 
their  convulsions.  Free  hemorrhage  from  such  wounds  may  occur  and  may  require 
ligation  of  vessels  at  the  site  of  the  wound,  or  of  suture  of  tissues  rn  masse  with  catgut, 
or  ligation  of  the  lingual  artery  just  above  the  hyoid  bone.  Lacerated  wounds  should 
be  closed  with  sutures,  and  antise])tic  mouth-washes  should  l)e  frequently  used. 

Glossitis,  or  inflammation  of  the  structures  of  the  tongue,  may  appear  in  either  acute 
or  more  chronic  form.  To  some  extent  it  is  a  part  of  a  general  stomatitis,  but  no  matter 
in  what  form  occurring  it  is  an  expression  of  infection  from  a  source  easily  recognized, 
and  mav  be  limited  to  one  side  of  the  tongue.  Its  principal  features  are  swelling,  which 
mav  be  so  extensiAe  as  to  prevent  movement  of  the  tongue,  infiltration  of  the  floor  of 
the  mouth,  and  extension  of  a  phlegmonous  typ  down  the  structures  of  the  neck.     The 


Till'.  roxccE  fj59 

swclliiifx  may  also  involve  llic  cpifjloltis  and  larynx,  caiisinj;  cdcriia  and  even  snfVocalion 
unless  traclicoloiny  be  pcrrornird.  Tims  acute  j^lossilis  may  rre(|uenllv  lead  to  (il/.s-rr.s.s 
formation  either  in  the  fon<:;ue  or  the  a<ljoinin<^  tissues.  When  swellinjr  is  extreme  its 
formation  may  he  anliei|)ated,  and  free  incision  should  he  promptly  made  to  permit 
of  its  evacuation.  Naturally  the  re<,Mon  of  the  lari^e  vessels  should  he  avoided,  and, 
after  external  incision  the  focus  should  he  ri-ached  hy  hlunt  dissection.  Some  of  these 
cases  are  due  to  extension  of  an  erysipelatous  process  commencinfj;  externally.  Hven 
hrtnigln.ss'itis  may  he  accompanied  hy  serious  swellinj^  and  hi<;h  fever.  One  form  of 
this  affection  is  supposed  to  he  analof^ous  to  her|)es  zoster.  The  relation  of  [)hle<;monous 
fjlossitis  to  LudiCKjs  (UKjiiKt,  the  latter  heinir  descrihed  in  (Chapter  XI>I,  mav  he  readilv 
appreciated.  Sometimes  it  is  due  to  the  entrance  of  foreij^n  bodies,  as  fish-hones,  hone- 
splinters,  and  the  like. 

JMost  nrpMit  dan<rcr  is  that  of  as[thyxia  irom  pi'cssurc,  and  of  inspiration  pneumonia, 
for  the  infected  saliva  in  these  eases  will  trickle  down  within  the  larvnx  and  trachea. 
Even  (jangirne  of  tlir  foiKjur  has  been  oh.served  as  the  result  of  j)ressure,  while  the  teeth 
will  leave  their  impress  u])on  the  sides  of  a  swollen  tongue. 

The  more  chronic  iujrctioii.s-  of  the  foiu/iic  jire  si/pliili.s-,  tuberculosis,  and  actinomycosis. 
Syphilis  may  assume  a  primary  tyi)c  and  occasionally  typical  chancres  nuiy  he  .seen 
on  the  tonorue.  It  is  frecjuently  the  site  of  nnicous  patches  and  (jf  other  ulcerative 
lesions.  Tuberculous  ulcerations  of  the  tongue  assume  less  indurated  and  irregular 
borders,  and  nuiy  be  sus|)ected  in  connection  with  well-marked  tuberculous  lesions  of 
other  ])arts  of  the  res])iratory  tract,  being  jnirticularly  common  in  <'onsum|)tives.  These 
ulcers  yield  best  to  cauterization  and  antisej)tic  mouth-washes,  whereas  syphilitic  lesions 
rarely  (lisapj)ear  without  active  antispecific  medication.  Both  syphilis  and  tuberculosis 
produce  gummatous  tiunors,  the  former  more  frequently  than  the  latter.  The  former 
will  disappear  equally  readily  imder  suitable  treatment. 

Actinomyc-osis  of  the  tongue  is  rare  in  man.  It  constitutes  a  granuloma  which  may 
soften  and  present  a  ragged,  ulcerated  surface.     (See  Actinomycosis,  Chapter  VI 11.) 

Leukoplakia  im])lies  the  ap])earance  of  o{)a((ue,  white  patches  upon  the  mucous  sur- 
faces of  the  tongue  as  well  as  on  the  lining  membrane  of  the  mouth,  lij)s,  and  palate. 
They  are  far  more  fre(|uent,  however,  on  the  tongue  and  generally  appear  there  hrst. 
Here  they  appear  almost  as  if  tliin  scales  coukl  be  separated  from  the  surface  uj>on  which 
they  lie,  but  this  will  not  be  found  possible  w4ien  the  effort  is  made.  The  j^atches  are 
irregular,  but  sharply  outlined,  occasionally  confluent,  involving  the  entire  upper  lingmil 
surface;  while  the  plates  become  harder  and  more  roughened  as  they  grow  older,  and 
furroAvs,  subsequently  ulcerating,  may  appear  between  them.  The  afiection  is  chronic 
and  intractable.  It  occurs  cjften  in  the  mouths  of  smokers  during  middle  and  advanced 
life.     While  its  etiology  is  unknown  it  may  be  due  to  chronic  irritation. 

Between  leukoplakia  and  epithelioma  of  the  ])art  involved  there  seems  to  be  a  strong 
relation,  and  the  former  is  often  regarded  as  a  precancerous  stage  of  the  latter.  Epithe- 
lioma is  a  frequent  terminal  fcatvire  of  leukoj)lakia.  '^riiere  often  seems,  moreover, 
a  predisposition  to  it  in  syphilitic  individuals.  It  is  mainly  to  be  distinguished  from 
secondary  syphilitic  lesions,  which  may  be  done  by  recalling  its  chronicity  and  its 
obstinacy  to  the  treatment  which  would  disperse  the  latter. 

In  the  way  of  treatment  smoking  must  be  prohil)ited,  antiseptic  mouth-washes  often 
used,  with  cauterization  to  a  mild  degree.  These  methods,  however,  suffice  only  for  the 
milder  cases.  If  any  caustic  be  used  it  maybe  either  10  ))er  cent,  chromic  acid,  chemi- 
cally pure  lactic  acid,  or  nitric  acid,  caution  being  used  in  their  application.  The 
more  serious  forms  of  leukoj)lakia  will  usually  yiekl  to  k)cal  anesthesia,  folknved  by 
curetting  of  each  patch  until  the  raw  surface  beneath  is  exposed,  and  then  the  aj)j)li- 
cation  of  the  actual  cautery  Rigorous  treatment  is  necessary  w4ien  ulcerated  and  fissured 
patches  are  present. 

The  benign  tumors  of  the  tonqne  include  nevi,  often  in  connection  with  single  or  multij)le 
papilloma,  or  which  may  assume  the  type  of  multiple  paj)illomas,  each  of  which  is 
extremely  vascular.  Occasionally  the  tongue  will  be  seen  almost  covered  with  these 
small  growths.  This  condition  is  noted  usually  in  young  children,  and  is  j)ractically 
of  congenital  origin.  It  frequently  subsides  spontaneously,  but  may  require  the  actual 
cautery  or  something  ec|ually  radical.  The  other  benign  tumors  are  of  occasional  occur- 
rence, even  an  enchondroma  having  been  occasionally  seen.  Much  UKjre  common  are 
the  retention  cysts,  especially  that  particular  form  of  cyst  occurring  beneath  the  tongue 


(560  SPECIAL  OR  REGIONAL  SURGERY 

or  at  its  hnsv,  known  as  ranula.  This  term  is  vaguely  applied  to  cysts  produced 
by  obstruction  of  one  of  the  salivary  ducts  or  by  cysts  of  congenital  origin.  It  is 
caused  mainly  by  inc{)ni])lete  obliteration  of  the  thyroglossal  duct.  A  so-called  ranula 
may  contain  colorless  fluid,  more  or  less  thick,  and  mixed  with  epithelial  or  dermoid 
products. 

It  is  |)ossiblc  to  extirpate  nearly  all  of  these  growths  through  the  mouth,  with  aseptic 
precautions. 

Macrocjlossia  is  a  condition  of  congenital  enlargement  of  the  tongu(>,  due  mainly  to  a 
form  of  lymphangioma,  which  may  be  accompanied  by  vascular  papillomas  or  alteration 
of  the  mucous  covering.  Such  a  growth  will  produce  enlargement  of  the  tongue  to  an 
extent  that  does  not  permit  of  its  retention  within  the  mouth.  Excision  of  a  V-shaped 
portion  sufficiently  large  to  reduce  the  tongue  to  proper  dimensions  is  usually  requisite 
in  these  cases  (Fig.  472). 

Of  the  malif/nant  tumor,s-  of  the  tonque  epithelioma  is  by  far  the  most  common.  It  is 
rarely  seen  in  women,  and  not  often  i)efore  middle  life.  Here  more  than  in  almost  any 
other  [)art  of  the  body  the  possible  causative  factors  of  irritation  and  trauma  are  present, 

jagged  teeth    furnishing   the  usual    source    of   each. 
i''"=-  "^'^  It  is  known    also   to  be  a  frequent  sequel  of  leuko- 

plakia and  of  various  chronic  ulcerations  and  other 
lesions.  Other  benign  growths  occasionally  alter 
their  type  and  become  epitheliomatous.  It  occurs 
usually  on  the  exposed  surface,  and  tends  (|uickly 
to  an  ulceration  whose  border  is  indurated  and  often 
fissured.  It  is  ordinarily  distinctive  in  its  appear- 
ance, but  occasionally  needs  to  be  differentiated 
from  lesions  of  syphilis,  tuberculosis,  and  actinomy- 
cosis. Lymphatic  involvement  occurs  early  in  each 
of  these  conditions  and  may  be  confusing.  A  sus- 
picious ulcer  which  tends  constantly  to  deepen  and 
increase  in  dimensions,  accompanied  by  marked 
induration  and  lymphatic  involvement,  and  not 
Macrogiossia.    (Tiiimann.s.)  benefited   by  antisyphilitic  treatment,  will  generally 

prove  to  be  epitheliomatous.  As  the  lesion  extends 
there  is  involvement  of  all  the  sin-rounding  structures — the  floor  of  the  mouth  as  well  as 
the  jjharynx,  t\\v  salivary  glands,  and  even  the  lower  jaw  itself.  When  ])ain  is  felt  it  is 
usually  referred  to  the  region  of  the  ear.  There  will  be,  naturally,  interference  with 
all  the  functions  of  the  mouth,  as  well  as  with  speech,  while  starvation,  septic  infec- 
tion, and  hemorrhage  may  terminate  the  case. 

In  no  ])art  of  the  body  is  ])rognosis  more  imfavorable.  Recurrence,  even  after  early 
and  radical  operations,  is  usually  unavoidable,  and  it  is  doubtful  if  10  per  cent,  of  cases 
of  epithelioma  of  the  tongue  are  free  from  disease  at  the  expiration  t)f  three  years  after 
removal. 

Treatment  should  be  prompt  and  radical.  It  consists  of  extirpation ,  which  must  be 
extensive  to  be  ett'ectual.  A  small  cancerous  ulcer  on  one  side  of  the  tongue  may  justify 
removal  of  one-half  of  the  organ,  but,  imder  nearly  all  circimistances,  it  is  best  to  make 
a  complete  removal  of  the  tongue.  This  may  necessitate  a  formidable  operation,  and 
may  be  expected  to  materially  interfere  with  speech;  but  that  it  does  not  prevent  it  is 
shown  by  the  fact  that  in  medieval  days,  when  tearing  out  the  tongue  was  a  means  of 
j)UMishment  or  torture,  men  were  often  still  able  to  speak  intelligibly. 

Inoperable  cases  shoidd  be  made  comfortable  with  cleansing  mouth-washes  and 
applications  of  local  anesthetics,  coupled  with  such  anodynes  as  it  may  be  necessary  to 
administer.  Resection  of  the  lingual  nerve  will  sometimes  relieve  the  intense  pain,  while 
proximal  ligation  of  the  lingual  artery  may  arrest  rapidity  of  growth.  It  is  in  these 
inoperable  cases  that  Dawbarn's  suggestion  of  the  extirpation  of  the  external  carotid 
artery,  first  on  one  side  and  then  on  the  other,  may  be  put  into  practice,  the  intent  being 
to  so  completely  shut  off  circulation  as  to  check  growth.  In  some  forty  cases  or  more 
it  has  given  results  as  satisfactory  as  could  be  expected. 


UPKUATIOXS   VI'OS    Tilh:   TOSillJE 


GOl 


OPERATIONS  UPON  THE  TONGUE. 


Operations  ii|)()n  (he  toiijijiic  iiiclndr  jxiiiid/  c.vcl.sio/i  and  rom picic  extirpation,  |)crlia|).s 
with  nnich  of  (lie  adjoiniiifi;  tissues.  Ilt'i'c,  as  in  cvcrv  operation,  tlie  month  should  he 
thoroui^ddy  cleansed.  IJefore  extensive  operations  a  preHininary  Hf:;ation  of  the  liu<^ual 
artery  shouM  he  made  on  hoth  sides,  just  ahove  the  hyoid  hone.     (See  p.  .'^52.) 

A  small  lesion  at  the  tip  of  the  tonji;ue  may  be  exeised  hy  a  wide  V-shaj)ed  removal 
of  the  anterior  part  of  the  tongue,  under  cocaine  anesthesia,  the  edges  of  the  opening 
being  brought  tt)gether  with  sutures  of  silk  or  of  chromic  catgut,  for  ordinarv  catgut 
woiilil  be  too  quickly  macerated  when  thus  soaked  in  the  mouth.  The  lesion  may  be 
so  placed  as  to  not  j)(>rmit  of  this  V-slui|)ed  opening  being  .synunetrically  placed.  The 
same  rules,  however,  will  ap|)ly,  the  operation  being  |)erforme<l  with  a  sharp-bladed 
bistoury  or  with  shar|)  scissors,  bleeding  ves.sels  being  s<'ized  with  force|)s  as  they  are 
cut.  These  clean  removals  give  more  satisfactory  results  than  the  old  oj)erati<Mis  |)er- 
formed  with  tlu'  ecrasenr  or  cauttTy.  A  roviplrtr  cxcisicm  of  the  lateral  half  of  the  tongue 
is  etuiily  made  through  the  mouth,  the  organ  being  controlled  by  a  stout  suture  pa.s.sed 
through  the  other  portion.  'I'he  vessels  and  lymphatics  of  the  tongue  do  not  cro.ss  its 
septum,  and  all  the  hemorrhage  that  need  be  antici|)ated  will  come  from  the  side  attacked ; 
but  when  it  is  necessary  to  remove  an  entire  half  of  the  tongue  the  ca.se  has  usnallv 
progressed  to  such  an  extent  that  its  complete  removal  will  be  usually  indicated  and 
will  be  more  effectual. 

Of  the  various  complete  operations  upon  the  tf)ngue  but  three  will  be  described  here. 

Whitehead's  operation  com])ri.ses  an  almost  total  extir])ation  made  through  the  month, 
without  division  of  cheeks  or  lij)s.  The  patient  is  placed  in  a  semi-upright  or  upright  posi- 
tion. The  mouth  is  held  open  with  a  mouth-gag,  for  which  purpo.se  none  serves  better 
than  the  O'Dwyer  gag  used  for  intubation.  The  operation  is  begun  under  brief  but 
complete  anesthesia,  and  is  usually  com|)leted  before  the  patient  has  recovered  from  it. 

The  tongue  being  secured  with  a  stout  suture  pa.s.sed  through  it,  its  frenum  and  its 
attachment  to  the  fauces  are  divided,  along  with  all  other  reflections  of  the  mucosa. 
Ves.sels  which  spurt  should  be  caught  at  once.  CJeneral  oozing  may  be  disregarded. 
After  being  thus  freed  the  tongue  is  pulled  forward, 
a  strong  suture  j)assed  through  the  glosso-epiglottidean 
fold,  and  then  with  sharp,  slightly  curved  scissors  the 
entire  organ  is  cut  away  from  its  base,  the  lingual 
arteries  being  seized  the  instant  they  are  divided.  The 
operation  is  bloody  for  the  few  minutes  required  for  its 
performance,  but  is  quickly  done  and  with  a  minimum  of 
tlisfigurement.  By  the  last-mentioned  suture  the  stump 
can  be  pulled  forward,  should  the  epiglottis  tend  to 
drop  backward  and  'disturb  respiration,  or  should 
hemorrhage  require.  After  its  conclusion,  and  during 
the  after-treatment,  frequent  warm,  antiseptic  solu- 
tions should  be  used  for  washing  the  mouth,  and  it  is 
the  practice  of  some  to  paint  the  raw  surfaces  with  a 
styptic  varnish,  made  of  balsam  and  saturated  solution 
of  iodoform  in  ether.  In  order  to  avoid  the  passage 
of  saliva  downward  the  patient  is  encouraged  to  sit  up  and 
to  expectorate  freely  rather  than  swallow  infected  saliva. 

The  Regnoli-Billroth  operation  is  performed  by  turning  down  a  horseshoe-shaped  flap, 
its  convexity  being  taken  from  the  s}Tnphysis  of  the  jaw,  and  thus  opening  into  the  mouth 
from  below.  After  making  the  opening  sufficiently  wide,  the  tongue,  through  which 
a  traction  suture  has  been  passed,  is  pulled  through  the  submental  wound  and  its  ba.se 
divided  with  scissors.  Should  it  be  difficult  to  locate  bleeding  points  in  the  stump  a 
finger  may  be  hooked  in  the  pharynx  and  the  latter  pulled  forward.  The  submaxillary 
wound  is  then  closed  with  sutures,  with  one  drain. 

The  most  complete  of  these  operations  is  that  described  by  Kocher.  It  permits  of 
removal  of  the  tongue,  of  the  floor  of  the  mouth,  of  all  infecterl  lymphatics,  and  even 
of  a  portion  of  the  jaw  if  this  be  necessary.  A  line  A-B,  Fig.  473,  may  offer  sufficient 
exposure  by  incision,  but  the  line  C-D-E-F  will  permit  more  complete  attack.     Throuf'h 


Fig.  473 


Lines  of  incision  for  total  excision 
of  the  tongue.     (Chalot.) 


062  SPECIAL  OR  RKGIOSAL  SURGERY 

this  incision  a  flap  is  raised,  the  facial  vessels  heino;  ligated.  All  lymph  nodes  are  extir- 
pated, as  well  as  the  salivary  jrlands,  if  nec(\ssary.  After  se])aratin^  the  mylohyoid 
from  its  insertion  in  the  inferior  maxilla  the  month  is  opened  and  the  tonf^ne  drawn  ont 
thron<,di  the  incision,  where  it  may  then  he  ke])t  under  perfect  control.  It  will  facilitate 
matters  if  the  lini>;ual  arteries  he  secured  before  the  entire  ton<>;ue  is  cut  away.  In  some 
cases  a  ))r(>liminary  tracheotomy  is  considered  advisable,  lartrcly  because  the  perform- 
ance of  tlu'  o])eration  interferes  with  the  administration  of  the  anesthetic  in  the  ordinary 
way.  Should  it  be  done  the  pharynx  should  be  tamj)oned  until  the  conclusion  of  the 
operation.  The  trachea  tube  may  be  imme<liately  removed  or  left,  as  seems  advisable, 
while  the  patient  is  fed  for  several  days  with  a  stomach  tube. 

Operations  suoj<jjested  by  Sedillot  and  Lanffenbeck  include  division  of  the  lower  jaw 
in  such  a  way  that  by  separation  of  its  ])ortions  a  more  complete  exposure  of  the  floor 
of  the  mouth  is  afforded.  They  are  at  present  rarely  ado])ted,  uidess  extension  of  the 
disease  to  the  bone  should  necessitate  excision  of  some  portion  of  the  jaw  itself. 


THE  TONSILS. 

The  tonsils  are  the  most  conspicuous  portion  of  the  rino;  of  lym])hoid  tissue  which 
extends  completely  around  the  original  openino;  connecting  the  exterior  of  the  face  with 
the  u])per  end  of  the  neurenteric  canal.  This  tissue  is  ])articularly  inflammable,  and 
this  nniy  account  for  the  frequency  with  which  severe  infections  of  the  tonsils  occur, 
and  the  nii'.rked  toxemia  which  (omplicates  even  mild  degrees  of  the  same.  In  this 
lymphoid,  or,  as  it  is  usually  called,  "ar/r/zoi'V/,"  tissue,  crypts  and  follicles  abound,  and 
in  these  latter  all  sorts  of  infectious  materials  accumulate.  Thus  acute  infections,  as 
well  as  chronic  hypertrophies  due  to  pressure  and  irritation,  are  extremely  common. 

The  various  forms  of  ancjina,  i.  c,  sore  throat,  have  to  do  largely  with  exj)ressions  of 
these  infections  in  varying  degrees  of  severity.  The  adjoining  nuicosa  and  other  tissues 
frer|nently  ])artici])ate,  and  it  is  jjossible  to  produce  a  jiainful  degree  of  ch(>mosis  of  the 
membranes  involved  in  a  short  time.  Adjoining  lyin])h  involvement,  with  discomfort 
or  ev(>n  distress  in  the  region  of  the  throat,  and  sometimes  pronounced  general  malaise, 
are  extremely  common  accom])animents. 

The  "cynanche  tonsillaris"  of  the  older  writers  implied  an  acute  expression  of  this 
kind,  often  with  more  or  less  exudation,  which,  accumulating  upon  the  exposed  surfaces, 
|)i"oduces  there  a  membrane,  the  condition  being  most  noticeable  in  the  pronoimced  types 
of  diphtheria.  At  other  times  activity  is  manifested  rather  in  the  peritonsillar  structures, 
and  acute  and  su])])urative  types  of  cellulitis,  leading  either  to  abscess  in  the  tonsil  or 
dee])  in  the  neck,  are  the  result.  A  sur])rising  degree  of  toxemia  accompanies  these 
lesions  and  sometimes  severe  and  fatal  general  se])tic  infection,  perha])s  with  endocar- 
ditis. Ab.srrss  of  the  toii.nl  may  jiroduce  so  much  occlusion  of  th(>  pharynx  as  to  make 
breathing  difficult  and  even  almost  impossible,  perhaps  even  to  a  ])oint  requiring  trache- 
otomy. Tonsillar  abscesses  usually  evacuate  themselves  in  time;  if  they  are  opened  by 
the  surgeon  relief  comes  ])romptly,  with  evacuation  of  pus,  no  matter  how  brought 
about. 

Many  such  abscesses  could  be  easily  recognized  and  incised  were  it  not  for  the 
surrounding  inflammation,  which  j)revents  the  j)atient  from  opetiing  the  mouth  suffi- 
ciently wide  to  ex])ose  the  ];harynx.     Suffering  in  these  casc\s  is  acute. 

A  swollen  and  fluctuating  tonsil,  if  it  can  reached,  is  easily  perforated  by  a  sharp, 
straight  knife.  P^rasion  and  fatal  |)erforation  of  the  carotid  artery  has  been  known  to 
be  a  secjuel  of  such  a  case  unrelieved.  Again,  ])us  having  its  source  within  the  tonsil 
may  burrow  in  such  a  direction  as  to  jn-oduce  a  retropharyngeal  abscess. 

The  tonsil  is  rarely  the  site  of  primary  sijpJiiliiic  lesions,  more  often  of  the  secondary, 
and  occasionally  of  tuberculous  lesions. 

The  most  common  chronic  aftections  of  the  tonsils  result  from  failure  of  absorption 
of  inflammatory  products  after  acute  inflammations,  which  leaves  a  ])ermanent  enlarge- 
ment, and  which  is  constantly  irritated  and  provoked  into  further  growth  l)y  the  retained 
contents  of  the  tonsillar  cry])ts.  It  is  in  this  way  that  chronic  hi/pertrophi/,  or  the 
so-called  enlarged  tonsils,  residt.  These  conditions  are  especially  common  in  children, 
presenting  the  milder  forms  of  the  status  lym])hatic-us.  (See  Chapter  XIV.)  These 
enhirgements  are  seldom  seen  alone  in  the  tonsils.     Similar  involvement  of  the  lymphoid 


TUE   TOXSILS  003 

or  adciioitl  tissue  in  tlu- vault  of  tlic  pliarviix,  and  even  at  the  base  t)f  the  ton<^U(',  is  (|uit(' 
coiniiioii,  the  entire  orii^inal  lymphoid  riiii;  heinff  more  or  less  involved. 

'J'lie  eonse(|nenees  of  elirnnie  enlar<;ement  of  the  tonsils  have  nmeh  to  do  with  the 
siibsecjuent  welfare  of  j)atients.  Not  only  is  sju'ech  interfered  with  and  made  peculiarly 
"throaty,"  hut,  owin<r  to  encroachment  U|)on  the  natural  hrcathiiif;  space,  cliildnii 
sufl"erin<;  in  this  way  contract  a  hahit  of  carryin<i:  the  head  forward  and  sloo|)int,'  the 
shoulders,  in  order  therchy  to  increase  the  dimensions  of  the  naso|)harynx;  thus  they 
become  "month-breathers"  and  hard  of  hearin*;,  which  is  deleterious  to  their  intelli- 
gence as  well  as  to  tlu'ir  physical  well-beint,^.  Such  children,  in  time,  beconie  stujiid, 
unintellifient,  and  defective  in  many  ways.  There  is,  then,  every  reason  for  r(  movin<,' 
these  obstructions  to  res|)iration  and  for  doinj;  it  earlv. 

(^hildren  thus  sufVerin*]^  will  present  such  pccidiarity  of  voice  as  to  su<r<,'(  si  immediate 
examination  of  the  oro|)harynx,  while  the  ])osture  above  described  and  the  existence  of 
the  mouth-breathinir  habit  should  also  j)rompt  iiivcsti<:;ation.  An  instant  ins|)cction 
throuffh  the  widely  o])en  mouth  should  permit  the  detection  of  this  condition.  Should 
it  be  desired  to  estimate  it  more  thoroufjhly  it  may  be  done  with  the  fiufjcr,  althoutjh  it 
will  ))rov()ke  the  act  of  coughing  or  vomiting  ami  be  resisted  by  most  children.  Fre- 
quently the  enlargements  can  be  felt  from  the  outside.  There  is  but  one  suitable  treat- 
ment ff)r  such  a  case,  /.  r.,  tc)nsilloto7nij. 

Tonsillotomy  may  be  efl'ectcd  with  any  one  of  several  difi'erent  j)atterns  r)f  tonsillo- 
tomes  on  sale  in  the  instrument  stores,  most  of  which  are  neat  and  sj)eedy  in  their  work, 
but  the  surgeon  need  not  refrain  from  the  purpose-  of  removal  because  of  the  lack  of  such 
an  instrument,  as  it  may  be  easily  accom])lislied  without  one.  Young  and  timid  children 
are  probably  best  anesthetized,  although  if  one  can  establish  perfect  confidence  it  may 
be  possible  to  do  it  by  the  aid  of  local  anesthesia.  In  adults  the  latter  will  always  l)e 
sufficient. 

An  anesthetized  patient  should  be  placed  in  a  chair  or  semi-upright,  and  the  mouth 
widely  oj^ened.  The  circular  loop  of  the  instrument  should  be  fitted  over  the  tonsil, 
this,  if  necessary,  being  drawn  into  its  grasj)  by  a  small  hook  or  forceps,  after  which  by 
a  quick  motion  of  the  cutting  blade  the  |)rf)jecting  ma.ss  is  removed.  All  instruments 
are  made  to  be  used  with  either  hand  and  to  cut  on  either  side.  The  practised  of)erator 
will,  therefore,  use  his  left  hand  when  operating  on  the  right  tonsil  of  the  jjatient,  and 
vice  ver.m,  it  being  best  to  adopt  this  order,  for  should  he  be  a  little  clumsy  with  his 
left  hand  and  the  patient  be  thereby  .somewhat  disturbed,  the  right  hand  may  more 
dexterously  jierform  the  excision  on  the  otlier  side.  The  surgeon  should  be  thoroughly 
familiar  with  his  tonsillotome  before  using  it.  It  Ls  not,  however,  necessary  to  employ 
such  an  instrument,  and  it  will  often  be  more  satisfactory  to  grasp  the  projecting  tonsil 
in  the  bite  of  a  suitably  c(jnstructed  tenaculum  forceps,  or  even  hold  it  with  a  common 
tenaculum,  while  with  blunt  scissors,  long  handled  and  c  urvcd  uj)on  the  flat,  tiie  tonsil 
itself  is  cut  away. 

None  of  these  methods  gives  jiromise  of  complete  extirpation  of  the  tissue,  which  is 
often  chronically  diseased,  and  it  is  often  well,  therefore,  to  comjilete  the  extirpation 
with  the  sharp  sjioon  or  even  to  use  the  finger-nail  as  a  curette.  Hemorrhage  will  be 
active  for  a  few  moments,  but  is  nearly  always  controlled  with  either  iced  water  or  water 
as  hot  as  can  be  borne.  Only  rarely  does  it  give  rise  to  serious  trouble.  In  such  cases 
adrenalin  may  be  used.  Cases  are  on  record  where  it  has  been  necessary  even  to  tie 
the  carotid,  but  such  instances  are  mostly  bugbears  which  need  not  deter  one  of  good 
judgment  from  a  properly  devi.sed  o])eration.  Anti.se|)tic  gargles,  and  avoidance  of 
speech  and  swallowing  of  hard  food,  will  be  all  that  are  needed  in  the  after-management. 

The  young  and  the  timid  will  need  c(mi])lete  anesthesia,  which  should  be  ctmipletein 
order  to  abolish  reflexes,  and  cocaine  locally  to  en.^ure  this  condition.  J\Iany  of  these 
sul)jects  are,  however,  those  presenting  minor  degrees  of  the  status  li/iitphaticus,  to 
whom  anesthetics  shauld  be  administered  with  cavtion.  In  such  children  tonsillotomy 
should  be  combined  with  the  erasion  and  removal  of  other  involved  adenoid  tissue  in 
the  nasopharynx.  Inquiry  should  be  made  as  to  whether  the  patient  bleeds  unduly 
freely  after  minor  injuries.  In  a  bleeder  it  would  \)e  well  to  proceed  with  caution  or 
abstain  from  operating. 

Foreirjn  bodies  in  the  tonsil  are  as  often  fish-bones  as  any  kind;  they  all  give  ri.se  to 
serious  irritation.  True  calculous  formation  in  tlie  tonsil  is  known.  Every  foreign  body 
which  can  be  detec  ted  and  exposed  should  be  removed. 


664  SPECIAL  OR  REGIONAL  SURGERY 

Tumors  of  the  tonsil  are  usually  of  the  malignant  type,  either  epitheliomatous  or 
sarcomatous.  A  cancer  of  the  tonsil  should  be  recognized  as  such  very  early  if  ()])erative 
or  other  relief  is  to  be  effectually  attonled,  and  if  oj)eration  is  made  it  should  be  done 
more  thoroughly  than  can  be  done  through  the  mouth. 

External  pJiarijtigotomtj  is  the  measure  usually  re(iuired  for  this  purpose.  This  is 
usually  jx'rformed  by  making  a  long  incision  along  the  anterior  border  of  the  sternomastoid 
muscle,  and,  after  retracting  it,  making  careful  anil  blunt  dissection  down  in  the  direction 
of  the  tonsil,  sej)arating  tissues  which  are  evidently  not  involved,  but  excising  everything 
in  which  infiltration  can  be  recognized.  An  extensive  operation  of  this  kind  would 
justify  preliminary  or  provisional  ligation  of  the  common  or  at  least  the  external  carotid 
artery.  .  Care  should  be  taken  to  avoid  wounding  the  nerve  trunks,  especially  the  hypo- 
glossal, 

Subliijoid  pharyngotomy  is  performed  by  a  transverse  incision  just  below  the  hyoid 
bone,  with  division  of  the  platysma,  the  omohyoid,  the  sternohyoid,  and  the  thyrohyoid 
muscles,  leaving  enough  of  their  insertion  into  the  bone  to  permit  of  subscfjuent  reunion 
by  suture.  The  thyrohyoid  membrane  is  then  divided  in  such  a  way  as  to  also  permit 
of  its  reunion  by  sutures.  Then  the  mucous  membrane,  which  will  probably  now  pro- 
trude into  the  wound,  is  caught  and  divided,  retraction  sutures  being  inserted  in  the 
edges  of  the  wound.  The  epiglottis  may  be  retracted  or  a  suture  may  be  passed  through 
it,  to  be  used  as  a  retractor.  The  lower  portion  of  the  pharynx  is  now  exposed  and 
through  this  ojiening  the  tonsil  may  be  removed.  After  completion  of  the  deejjcr  work 
the  different  layers  of  the  tissues  are  reunited  with  chromic  gut  and  the  deep  wound  is 
drained. 

Transhyoul  pharyngotomy.  Vallas  has  suggested  a  central  method  of  approach  to 
the  pharynx  by  a  median  incision,  through  which  the  mylohyoid  muscles  are  separated, 
the  body  of  the  hyoid  exposed,  and  its  division  effected  with  stout  scissors  or  with  cutting 
forceps.  When  its  two  halves  are  retracted  a  space  over  an  inch  long  is  made,  through 
which  the  mucous  membrane  of  the  pharynx  may  be  opened,  this  being  done  by  making 
it  protrude  with  the  finger  passed  into  the  throat,  which  shall  thus  serve  as  a  guide.  In 
closing  the  wound  it  is  not  necessary  to  make  suture  of  the  hyoid  bone, 

THE  TEETH,  THE  ALVEOLAR  PROCESS,  AND  THE  GUMS. 

The  alveolar  process,  which  furnishes  the  actual  sockets  for  the  teeth,  and  which  carries 
that  peculiar  fibrous  texture  with  its  mucous  covering  known  as  the  gum,  is  a  frequent 
site  of  ulcerative  disease  and  fertile  source  of  infection.  While  the  toilet  of  the  mouth  is 
much  more  generally  attended  to  at  present  than  in  times  past,  the  majority  of  people 
are  extremely  inattentive  and  indifferent  to  the  condition  of  the  teeth  and  the  gingival 
borders.  As  elsewhere  stated  the  mouth  is  the  habitat  of  an  extensive  flora  and  fauna, 
and  deposits  of  tartar  along  the  gingival  border  afford  excellent  hot-beds  for  their  de- 
velopment and  growth.  This  accounts  for  the  marginal  idceration  of  the  gimi,  or  vleera- 
tive  gingivitis,  seen  in  so  many  mouths,  and  it  may  be  regarded  as  the  beginning  of  a 
disease  process,  pyorrhea  alveolari?  (Rigg's  disease),  that  will  eventually  cause  the  loss 
of  the  teeth  and  extensive  infection  of  the  lymphatics  in  the  neck.  In  almost  every 
mouth  where  such  accumulations  of  tartar  have  taken  place  the  expressions  of  local 
infection  may  be  traced  by  a  bluish  or  purplish  line  along  the  gingival  border,  with 
some  degree  of  sponginess  and  mild  ulceration. 

The  enamel  covering  the  teeth  is  extremely  resistant,  but  when  the  dentine  is  exposed 
below  the  enamel  line,  as  happens  in  such  instances  as  those  just  described,  bacteria 
may  easily  enter  the  dental  tubules,  and  dental  earies  or  alveolar  snppuration  is  the 
result.  In  order  to  prevent  such  disease  the  services  of  the  dentist  shoidd  be  secm-ed  at 
least  as  often  as  every  six  months,  in  orrler  that  all  tartar  may  be  removed  and  the  gums 
placed  in  a  healthy  and  resistant  condition. 

For  the  marginal  ulcerations  thus  j)roduced  there  is  no  better  treatment,  after  re- 
moving tartar,  than  the  local  application  of  zinc  iodide,  either  in  fine  crystalline  form 
or  in  saturated  solution.  It  is  not  so  much  the  \asible  surfaces  which  need  such  appli- 
cation as  does  the  gingival  tissue  in  concealed  locations  and  between  the  teeth.  Zinc 
iodide  is  not  only  an  excellent  antiseptic,  but  a  powerful  astringent,  and  meets  a  double 
indication.     It  may  be  applied  once  a  week  or  oftener. 


THE   ri:i:TU,    the   ALVEOI.AR   process,   AMj   the  (JCMS  Gf)') 

The  (U'lital  (Miauicl  is  the  protective  iiiediiiiii  wliicli,  \)v\u<r  once  injured,  exj)().ses  the 
dentine  beneath  to  tlie  possihihty  of  infection.  Snch  in jnries  are  nieclianical,  hiit  nsually 
niinnte.  'I'he  prac(ice  of  |)nttin<j;  ho)  food  into  (lie  niontii  and  inunecHately  followinjr 
it  witii  a  drink  of  iced  water  is  caicnhited  to  crack  the  enainei  on  a  tooth  as  it  would  on 
any  other  inatcM-ial.  Such  a  crack,  althouj^h  microscopic  in  (hineiisions,  |)erniits  tlie 
entrance  of  l)acteria  into  tlie  dentine,  in  wliose  tuhnles  they  nniltiply  an<l  |)ro(hice  ininule 
amounts  of  hictic  acid.  The  enamel  will  resist  this  acid  almost  indefinitely,  hut  the 
softer  dentine  is  dissolved  by  it,  and  in  this  way  cavities  are  formed  within  the  teeth,  and 
the  condition  known  as  denial  caru's  is  enfj;eudered.  While  it  recjuires  the  special  art 
and  trainlufjof  the  dentist  to  cope  with  such  conditions,  every  f^eneral  |)ractitioner  should 
be  familiar  with  the  circumstances  under  which  these  lesions  are  jjnwluci'd.  ('ouffcnital 
defects  of  the  emimel  alford  also  the  same  op|)orlunilics  for  infection. 

When  infection  has  extended  to  the  delicate  |)nl|)  cavity  and  when  one  of  the  terminal 
fibers  becomes  exposed  the  condition  is  accompanied  by  more  or  less  distress,  and  when 
the  alveolar  socket  becomes  involved  the  tooth  is  loosened,  either  temporarily  or  per- 
manently, accordinji;  as  tlu>  condition  is  treated.  Thus  a  small  alveolar  ah.see.s.s-,  icfcrred 
to  as  "gum-boil,"  may  result.  In  the  former  case  there  is  usually  a  small  simis  which 
leads  down  to  the  root  of  the  tooth,  either  through  the  spongy  bone  or  alongside  the  tooth 
itself. 

Plate  III  illustrates  the  conditions  in  teeth  midergoing  various  forms  of  caries, 
there  being  numerous  bact(>rial  forms  res|)onsil)le  for  different  tyj)es  of  the  disea.se. 

Treatment  here  does  not  differ  in  j)rinciple  from  that  for  treatment  of  caries  in  l)one. 
Its  e.s.sential  feature  is  actual  removal  of  all  infected  dental  tissue,  with  a  combination 
of  protection  against  further  infection,  and  that  substitution  for  lost  tissue  which  is 
effected  by  the  use  of  gold,  amalgam,  or  some  of  the  other  fillings  in  common  use  among 
dentists.  American  ingenuity  has  reached  its  acme  in  the  discovery  of  means  and 
methods  for  atonement  of  tissue  thus  lost  by  disease,  and  American  dentists  certainly 
lead  the  world  in  the  mechanics  of  their  art.  They  go  much  beyond  the  mere  filling  of 
diseased  teeth,  l)ut  have  devisetl  substitutes  for  teeth  actually  lost,  and  much  of  the  j)late 
work  of  the  past  is  now  substituted  by  what  is  known  as  erown  and  bridge  leork. 

Dentistry  as  a  part  of  oral  surgery  has  now  become  a  specialty  by  itself.  A  competent 
dentist,  therefore,  is  a  necessary  cooperator  in  the  treatment  of  all  diseases  of  the  teeth. 

It  is  mainly  when  disease  has  spread  from  the  teeth  to  the  surrounding  bone  and 
tissues  that  the  surgeon  as  such  intervenes.  Caries  and  neerosi.s-  of  a  small  or  large  part 
of  either  jaw  may  be  the  result  of  extension  of  disease  proc  esses  Having  their  beginnings 
as  above.  In  the  chapter  on  the  Neck,  when  dealing  with  the  subject  of  tuberculosis 
of  the  lymphatics,  it  is  stated  that  a  large  proportion  of  such  cases  due  to  the  propagation 
of  infection  from  the  oral  cavity  and  often  from  the  teeth. 

There  are  two  substances  used  in  medicine  and  in  the  arts  which  have  a  proclivity 
for  the  tissues  of  the  mouth  and  jaws  These  are  phosphorvs  and  vureiiry,  the  former 
usually  affecting  the  bone  and  the  latter  the  softer  tissues.  Before  legislation  had  been 
enacted  by  which  the  young  were  prevented  from  working  in  match  factories  jihosphorus 
necrosis  of  the  lower  jaw  was  not  uncommon.  Today  it  is  rarely  seen.  Again,  in  the  older 
days  when  mercury  was  given  in  large  amounts,  and  its  effects  were  not  as  well  guarded 
against  as  now,  mercurial  stomatitis  'proceeding  to  nlceration  and  even  loss  of  teeth  was 
not  an  uncommon  event.  Now  it  is  seen  only  in  those  who  have  an  idios}Tiicrasy  which 
makes  them  peculiarly  liable  to  its  effects.  The  mechanism  of  phosphorus  necrosis  is 
supposed  to  be  an  ossifying  periostitis,  with  formation  of  small  osteophytes  in  the  alveolar 
periosteum,  which  lower  tissue  resistance  and  permit  easier  invasion  of  bacteria  from  the 
mouth.      (See  p.  428.) 

The  extension  of  disease  from  the  teeth,  especially  of  the  upper  jaw,  upward  into  the 
antrum  of  Highmore,  with  its  consequent  infection,  is  elsewhere  discussed,  and  the  reader 
will  find  the  treatment  of  empyema  of  the  antrum  consiflered  in  Chapter  XXXVII. 

The  teeth  are  also  subjects  of  certain  tumor  formations  which  in  general  are  spoken 
of  as  odontomas,  and  have  been  mentioned  in  the  chapter  on  Tumors.     (See  p.  281.) 

Teeth,  moreover,  show  at  times  excessive  development  or  marked  displacement  or 
defects  of  development.  Thus  they  erupt  in  abnormal  positions,  or  fail  completelv  in 
eruption,  or  they  project  in  abnormal  directions  or  are  sometimes  amalgamated.  The 
art  and  science  of  the  dentist  permit  of  w^onderful  control  of  abnormal  development  of 
those  teeth  which  once  appear  upon  the  surface.     Children  whose  teeth  are  irregularly 


066  SPECIAL  OR  REGIOXAL  SURGERY 

placed,  or  which  arc  abnonnal  in  anv  n-.s])e(t,  should  l)c  jthurd  uiid(T  the  care  of  a 
competent  sjieciahst.  The  most  serious  tumors  of  the  teeth  are  those  connected  with 
cyst  formation,  which  may  assume  considerable  size.  A  dentigerous  cyst  is  proper 
material  for  the  surgeon  rather  than  for  the  dentist,  inasmuch  as  while  the  operation 
can  be  usually  done  through  the  mouth  it  may  require  external  incision  and  removal  of  a 
consideral)le  shell  of  bone,  j>erhaps  with  plastic  restoration  of  tissues. 


THE  EXTRACTION  OF  TEETH. 

The  general  practitioner  has  often  to  remove  diseased  teeth  as  well  as  the  surgeon. 
Tiie  theory  of  tooth  extraction  is  simj)le.  Its  performance,  especially  when  the  tooth  is 
diseased,  may  be  exceedingly  difficidt,  for  such  teeth  may  be  crumbled  in  consequence 
of  the  force  needed  for  their  removal. 

Forceps  of  different  shapes  are  required  for  the  various  teetli.  At  least  lialf  a  dozen 
different  patterns  are  requisite.  A  form  of  elevator  is  also  of  use  in  elevating  stumps 
which  may  lie  Ijcneath  the  alveolar  border. 

The  tooth  to  be  removed  should  be  seized  along  the  fang  and  beyond  the  crown. 
The  blades  of  the  forcejxs  should  be  pressed  firmly  down  and  along  the  tooth,  in  order  to 
separate  fniui  it  tin-  softer  tissues  of  ilic  i:uin  and  the  firmer  tissue  of  the  alveolar  socket. 
This  is  tliiiiiur  upon  its  outer  asjjcct  than  its  inner,  save  in  the  location  of  the  wisdom 
tooth,  and  it  is  the  outer  border  which  is  more  easily  broken  away  by  force  applied  toward 
the  cheek  rather  than  toward  the  interior  of  the  mouth.  Using  first  one  blade  of  the  for- 
ceps and  then  the  other  to  split  the  socket  and  separate  the  osteofibrous  tissues,  the  tooth 
being  then  firmly  grasped  between  them,  the  (jperator  makes  a  series  of  rocking  move- 
ments, by  which  it  is  itself  loosened  and  its  further  attachments  torn,  until  bv  a  lifting 
effort  it  can  be  extracted  from  the  socket.  In  this  minor  operation  the  head  must  be 
firmly  held  with  the  disengaged  hand,  or  better  between  the  forearm  and  the  operator's 
lindy.  whih'  with  that  hand  he  supp(jrts  and  nianiptdatu^  the  lower  jaw,  if  it  he  a  lower 
toi)th   whicli   is   to   be  removed. 

The  oix'ration  is  painful  for  the  moment.  ^Yith  timid  patients  local  anesthesia  may 
be  produced  with  cocaine  or  one  of  its  substitutes,  the  solutions  being  sterile,  and  either 
locally  applied  around  the  socket  or  injected  into  the  surrounding  tissues  with  the  ordinary 
hypodermic  syringe  needle.  Such  attempts  are  not  without  their  own  danger,  for  I 
have  seen  serious  infettion  follow  the  introduction  of  unsterile  solutions  by  dentists 
not  familiar  with  aseptic  technique.  Again,  nitrous  oxide  gas  may  be  administered,  it 
being  usually  necessary  to  employ  a  mouth-gag.  Recovery  from  anesthesia  is  prompt 
and  muscle  spasm  may  not  be  entirely  abolished;  therefore,  the  gag  should  be  inserted 
before  the  gas  is  administered.  It  luay  be  sufficient  for  the  purpose  to  employ  a  good- 
sizcfl  piece  of  cork,  to  which  a  cord  should  be  attached  in  order  that  it  may  not  disappear 
down  the  patient's  throat  during  a  violent  effort  at  inspiration.  The  horizontal  position 
is  the  safer  for  this  purjx)se. 

It  Ls  especially  the  removal  of  fangs  or  roots  which  gives  the  greatest  trouble  in  these 
cases.  For  this  purpose  special  forceps  are  devised,  but  for  their  use  i*  is  necessary  to 
clear  away  the  gimi  and  periosteum  and  to  cut  away  a  j>orti()n  of  the  alveolar  process. 
Such  broken  fragments  of  teeth  allowed  to  remain  give  rise  to  curious  reflexes,  such  as 
convulsions,  neuralgia,  etc.,  all  of  which  makes  it  apparent  tiiat  the  extraction  of  a 
tooth  being  imdertaken  it  should  be  thoroughly  performed.  After  its  removal  the 
jiatient  should  rinse  his  mouth  with  water  as  hot  as  can  be  borne,  to  check  hemorrhage. 
The  removal  of  the  tooth  liaAnng  left  an  open  pathway  for  infection,  antiseptic  mouth- 
washes should  be  frequently  used  and  the  socket  packed  with  antiseptic  gauze.  Except 
in  rare  instances  granulation  tissue  fills  the  caAity  and  the  process  of  repair  is  rapid. 

Among  the  accidents  which  may  follow  extraction  of  teeth  are  hemorrhage,  which  may 
be  checked  by  plugging  and  the  use  of  adrenalin.  Adjoining  teeth  are  occasionally 
injured  in  clumsy  efforts  at  extraction,  while  not  infreriuently  a  patient  who  has  not 
sufficiently  described  his  s\Tnptoms  has  indicated  to  the  dentist  the  wrong  tooth,  wliose 
consequent  extraction  has,  therefore,  not  relieved  him  of  his  difficulty.  Some  teeth 
have  such  spreading  roots  as  to  make  their  removal  extremely  difficult,  and  even  careful 
operators  have  occasionally  inflictetl  fractures,  especially  of  the  lower  jaw.  The  treat- 
ment of  such  an  accidental  fracture  will  not  be  different  from  that  of  fractures  otherwise 


THE  JAWS  667 

[jroduced.  Siuli  an  accidcMit  as  torciiiij  a  toolli  iipwani  into  llio  antrum  of  llij^liniore 
should  l)e  followed  by  its  removal,  oven  at  tlu'  cxikmisc  of  furtlicr  operation,  while  exces- 
sive tearini;  of  the  alveolar  border,  or  especially  of  the  \i\\n\,  may  he  treated  hy  suitable 
packinij  or  by  suturin<]j.  'I'he  accident  of  aspiration  into  the  larynx  of  j)art  or  all  of  a  tooth 
just  reniovi'd  has  been  known  to  be  followed  by  suffocation.  The  operator,  therefore, 
should  not  release  the  tooth  from  the  <i;rasp  of  the  forceps  until  the  latter  are  entirely 
out  of  the  mouth. 

15v  accident  or  from  inditl'erence  it  may  ha|)pcn  that  a  healthy  tooth  has  been  removed 
instead  of  one  diseased.  Should  this  lia|)peu  the  tooth  may  often  be  ir-inip/diitrd  after 
l)eiutf  cleansi'd,  and  will  usually  resunu'  its  |)revious  p(»siti(jn  and  function.  So  feasible 
is  such  re-im|)lantatiou  of  teeth  that  they  have  been  frecjuently  reniovecl  or  (rans|)laiit((l 
from  one  mouth  to  another,  for  a  compensation,  a  new  .socket  beinif  ma<lc  for  the 
reception  of  the  healthy  tooth  just  removed  from  the  mouth  of  the  individual  willing  to 
part   with  it. 

THE  JAWS. 

While  the  jaws  are  not  subject  to  affections  peculiar  to  these  parts,  there  may  be  seen 
in  them  peculiar  expressions  of  general  conditions,  made  so  by  virtue  of  enviromnent 
or  comi)lexity  of  tissues.  Most  of  the  acute  infections  of  the  jaw  bones  are  ])ropagated 
from  the  teeth  or  the  tooth  sockets.  There  may  be  jxTios-fifi.s-  and  o.sfronii/rlifi.s-,  and 
these  may  be  followed  by  a  sclerosing  process  or  acute  sup])uration.  The  jaws  are  j)rone 
to  be  thus  att'ected  in  consequence  of  the  acute  exanthems  and  the  infectious  fevers, 
while  the  effects  of  mercury  and  phosphorus  have  been  mentioned.  The  treatment  of 
the  inflammatory  affections  here  is  the  same  as  elsewhere,  i.  e.,  early  incision  and  com- 
plete evacuation  of  pus,  with  removal  of  necrotic  bone  or  other  tissue.  IVIany  sequestra 
may  be  removed  from  within  the  mouth  in  such  a  manner  as  to  avoid  disfiguring 
scars.  When  external  sinuses  complicate  the  case,  incisions  through  the  skin  should 
be  made.  These  may  l)e  so  planned  as  to  coincide  with  the  natural  wrinkles  or  folds  of 
the  face. 

The  tempornmaxiUary  joint  is  a  locality  of  considerable  interest.  Didocations  take 
place  here  in  consequence  of  blows  or  of  violent  muscular  effort,  and  are  easily  recognized 
because  of  the  fixation  and  displacement  which  they  produce.  Ordinarily  they  are 
easy  of  replacement.  These  luxations  may  be  unilateral  or  bilateral.  As  the  result  of 
violence  the  condyle  has  been  driven  upward  through  the  base  of  the  skull,  the  violence 
protlucing  such  injury  usually  being  fatal.  Aside  from  these  injuries  to  the  grosser 
structures  the  temporomaxillary  joint  is  not  infrequently  the  site  of  acuie  sijnovitis, 
or  more  extensive  inflammation,  usually  ])ropagated  from  surrounding  tissues,  but  some- 
times the  result  of  distant  infection.  In  phlegmons  of  this  region  the  structures  of  the 
joint  rarely  escape  a  sympathetic  participation,  while  parotid  abscess  and  similar  col- 
lections of  pus  may  penetrate  the  joint  and  destroy  it.  Again  it  is  occasionally  the  site 
of  a  postgonorrheal  arthritic,  or  it  may  suffer  as  do  other  joints  after  the  exanthems  and 
acute  fevers.  It  also  occasionally  becomes  involved  in  the  disturbances  accompanying 
irregular  eruption  of  the  last  molar,  i.  e.,  the  wisdom  tooth;  in  other  words,  it  may  suffer 
just  as  may  any  other  joint  in  the  body,  and  from  similar  causes. 

Ankijlosis  of  the  temporoma.villari/  joint  is  an  infrequent  result  of  its  involvement  in 
serious  disease,  or  may  result  from  lesions  of  the  adjoining  tissues,  as  from  the  cicatricial 
deformity  following  noma,  burns,  and  the  like.  Thus  we  may  have  either  a  true  or  a 
spurious  ankylosis  of  this  joint,  in  either  case  the  resulting  condition  being  intractable 
and  exceedingly  difficult  to  manage.  When  it  can  be  foreseen  as  a  consequence  of 
extrinsic  disease  it  may  be  prevented  by  the  insertion  of  a  mouth-gag,  and  more  or  less 
frefiuent  and  forcible  "stretching,  or  by  wearing  some  suitable  appanxtus  between  the 
teeth  which  shall  keep  the  jaws  apart,  and  wiiich  may  l)e  used  at  night.  A  pseudo- 
ankylosis  produced  by  cicatricial  bands,  and  long  neglected,  will  become  gentiine,  and 
require  as  radical  an  operation  as  though  it  had  been  interosseous  from  the  outset. 

For  the  relief  of  such  conditions  various  operations  have  been  devised,  in  each  of 
which  the  formation  of  a  false  joint  is  contemplated,  it  depending  upon  the  exigencies 
of  the  case  whether  this  shall  be  produced  by  the  division  of  the  horizontal  ramv.i  in 
front  of  tJie  masseter,  or  of  the  ascending  ramus  behind  the  mas.tetrr,  or  whether  there  shall 


668  SPECIAL  OR  REGIONAL  SURGERY 

be  actual  resection  of  the  temporomaxillari/  joint,  with  division  of  the  neck  and  removal 
of  the  condyle.  The  latter  procedure  is  the  more  ideal,  at  the  same  time  the  more 
difficult,  and  the  more  likely  to  permit  injury  to  the  branches  of  the  facial  nerve,  with 
consequent  paralysis  of  the  orbicularis  and  the  facial  muscles. 

I  have  elsewliere  described  a  peculiar  condition  of  relaxation  of  the  tempornmaxillary 
ligaments,  by  which  there  is  a  recurring  subluxation  of  the  joint,  noticed  most  often  during 
eating  and  accompanied  by  a  snapping  sound.  This  is  usually  unnoticed  by  the  patient, 
but  is  often  observed  by  others.  It  is  painless,  harmless,  and  not  ordinarily  amenable 
to  treatment.     (See  p.  528.) 

Tumors  of  the  jaws  proper  include  mainly  cysts,  which  are  often  comiected  with  odon- 
tomas, benign  tumors,  such  as  fibroma,  chondroma,  and  osteoma,  most  often  of  mixed 
type,  and  the  vialignant  tumors,  i.  e.,  sarcoma,  carcinoma,  and  endothelioma.  Malig- 
nant tumors  primary  to  the  bone  are  usually  of  sarcomatous  type,  though  these  may 
include  the  endotheliomas.  Carcinoma  and  epithelioma  do  not  originate  in  bone  texture, 
but  may  easily  spread  to  and  involve  it.  Thus  many  cases  of  advanced  ej)ithelioma  of 
the  lip  involve  the  bone  as  well  as  the  other  neighboring  tissues. 

Kpuli.s  is  a  somewhat  vague  term,  which  has  been  applied  to  tumors  which  spring 
from  and  mainly  involve  the  fibrous  texture  of  the  gum  and  the  periosteimi  covering  the 
alveolar  process.  The  term  itself  simply  implies  a  timior  upon  the  gum.  Microscopically 
these  tumors  are  usually  of  the  giant-cell  type  of  fibrosarcoma,  and  are  among  its  least 
malignant  varieties.  They  pursue  a  slow  course,  gradually  loosening  one  tooth  after 
another  as  they  invade  the  tooth  sockets,  show  very  little  tendency  to  spread  rapidly, 
and  are  usually  sharply  circumscribed  growths,  tending  to  ulceration.  They  seem  to 
be  products  of  irritation.  When  removed  they  rarely  recur.  The  surgeon  shoidd  excise 
involved  tissue  in  order  to  be  on  the  safe  side,  sacrificing  teeth,  gum,  and  alveolar 
process  as  widely  as  necessary  for  the  purpose.  Formerly  the  ejmlides  were  made  to 
include  different  expressions  of  fibroma  and  sarcoma  involving  the  gum,  but  the  name 
is  so  vague  that  it  would  be  better  to  speak  of  each  of  these  cases  as  its  histological 
characteristics  may  indicate. 

Benign  tumors  involving  the  entire  bone  may  necessitate  its  removal,  but  most  of  the 
dentigerous  bone  cysts  may  be  laid  open,  their  contents  evacuated,  their  size  reduced,  and 
the  remaining  cavity  allowed  to  fill  with  granulation  tissue;  while  malignant  tumors 
call  for  sacrifice  of  every  portion  of  tissue  involved,  often  including  the  skin,  and  in  the 
upjjer  jaw  much  of  the  complicated  structure  of  the  nasal  cavity,  or  in  the  lower  jaw 
the  loss  of  the  tongue  or  a  large  portion  of  the  floor  of  the  mouth.  A  cancer  of  the  lower 
jaw  may  be  removed,  with  permanent  good  result,  but  a  true  cancer  of  the  upper 
jaw  should  be  seen  early  and  mercilessly  extirpated  if  the  result  is  to  be  more  than 
temporary. 

OPERATIONS   UPON  THE  JAWS. 

Aside  from  those  already  mentioned  the  principal  operations  upon  the  jaws  consist 
of  partial  or  complete  excision. 

Removal  of  the  upper  jaw  is  a  rather  formidable  procedure,  frequently  made  so  by 
extent  of  the  disease  which  requires  its  performance.  The  presence  of  an  extensive 
and  ulcerating  tumor,  by  which  normal  anatomical  outlines  are  obliterated,  will  cause 
mechanical  difficulties  as  well  as  unusual  liability  to  hemorrhage.  During  some 
portion  of  its  performance  a  temporary  control  of  the  vessels  of  the  neck  may  be 
of  assistance.  This  can  be  usually  afforded  by  external  digital  pressure.  In  serious 
cases  a  ligation  of  the  external  or  the  common  carotid  may  be  of  assistance. 
If  soft,  vascular  tumors  protrude  into  the  nasopharynx  a  preliminary  tracheotomy 
should  be  performed,  tamponing  the  pharynx  in  order  to  prevent  escape  of  blood  down 
the  throat.  The  position  of  the  patient  with  the  down-hanging  head  may  be  also  of 
assistance  in  these  cases.  Of  the  various  incisions  employed  one  should  be  selected 
according  to  the  nature  of  the  case.  Most  of  the  operations  include  a  splitting  of  the 
upper  lip  near  the  middle,  with  continuation  of  the  incision  along  the  margin  of  the  nose, 
upward  toward  the  orbit  and  outward  along  the  orbital  border,  as  originally  suggested 
by  Fergusson.  This  permits  of  completely  raising  the  cheek  from  the  underlying  bone 
in  one  extensive  flap  and  turning  it  backward,  with  complete  exposure  of  the  anterior 
surface  of  the  superior  maxillary.     The  operator  next  proceeds  according  to  the  desired 


()i'i:u.\Ti<>\s  f'l'ox  Till':  jaws 


669 


Fig.  474 


exk-iit  ol"  iTiiioval.  li'  the  roof  of  the  iiioiitli  is  to  he  siurificed  the  f).steoperi().stcul  and 
soft  tissues  coniposiiif?  the  |)ahite  should  he  (hvided  as  far  from  the  uiiddle  line  as  may  he 
permitted,  then  reflected,  and  the  hone  (Hvided  with  chisel  or  with  cnltin^r  forceps.  It 
may  he  nece.s.sarv  to  remove  one  of  the  inci.sor  teeth  to  permit  the  insertion  of  the  chi.sel 
for  division  of  the  anterior  j)art  of  tlu-  jaw.  Bone  force[)s  or  a  chain  or  wire  saw  will 
.serve  for  division  of  the  zytjoma  and  the  external  or  lower  wall  of  the  orhit,  while  with 
chisel  or  forceps  the  nasomaxillary  rei^ion  is  divided.  The  loosened  hone  can  now  he 
seized  with  stronj,'  lion-jaw  forceps  and  wrenched  from  its  attachments,  which  may  then 
he  divided  with  .sci.s.sors  or  knife  as  they  are  encountered  (Fig.  474). 

Hemorrhage  will  he  profuse  at  this  juncture,  when  the  internal  maxillary  artery  i.s, 
with  many  of  its  l)ranehes,  thus  torn  across  or  severed.  The  surgeon  should  he  ready 
with  tamj)ons  and  forceps  to 
check  the  hieeding  and  secure 
the  vessels.  The  complete  Fer- 
gusson  oj)eration  includes  re- 
moval of  the  entire  upper  max- 
illa, hut  oftentimes  much  less 
than  this  will  suffice.  On  the 
other  hand  it  is  necessary  some- 
times to  go  still  farther  and  re- 
move more  hone  from  the  orhit  or 
the  nasal  cavity,  or  perhaj)s  to 
clean  out  the  orhit  entirely.  A 
case  which  necessitates  one  of 
the  more  formidahle  operations 
is  too  unpromising  to  make  it 
often  judicious  to  perform  it. 

When  the  tumor  involves  the 
overlying  skin  this  should  also  be 
sacrificed,  and  a  plastic  operation 
shovdd  he  made  to  cover  the  de- 
fect. The  skin  flaps  required  for 
this  purpose  may  he  taken  from 
the  tcm])le,the  forehead,  the  neck, 
or   adjoining   parts   of   the  face. 

Bardeniieuer  has  suggested  the  raising  of  osteoplastic  flaps  for  removal  of  tumors 
lying  within  the  jaw,  and  their  replacement  at  the  conclusion  of  the  operation.  He  lias 
also  devised  ingenious  methods  of  making  immediate  plastic  repair  which  are  worthy 
of  study,  hut  which  are  so  seldom  recjuired  as  to  not  justify  description  in  this  place. 

After  operation  the  hieeding  should  be  checked  by  torsion,  by  ligation,  by  sutures 
en  masse,  by  application  of  hot  water,  and  by  securely  tamponing  with  antiseptic  gauze,  by 
whose  pressure  oozing  is  checked  and  protection  from  infection  afforded.  The  patient 
is  allowed  to  sit  up  as  early  as  possible,  meanwhile  being  made  to  lie  upon  the  affected 
side  in  order  to  avoid  danger  of  aspiration  pneumonia,  and  using  an  antiseptic  mouth- 
wash with  relative  frequency. 

It  is  sometimes  possible  to  perfect  an  artificial  substitute  for  tissues  removed,  which  can 
be  inserted  after  the  operation.  The  loss  of  tissue  will  cause  more  or  less  disfigurement 
by  sinking  in  of  the  cheek  and  side  of  the  face.  After  the  parts  are  healed  an  apj)aratus 
made  of  gutta-percha  or  metal,  and  adapted  to  each  case,  by  which  most  of  the  lost 
symmetry  may  be  restored,  should  be  worn,  in  the  same  manner  as  an  artificial  denture. 
The  lower  jaw  seldom  requires  complete  removal.  It  is  rarely  necessary  to  go  so  high 
as  the  joint  or  the  coronoid  process,  although  occasionally  the  condyle  must  be  avulsed 
and  the  coronoid  either  cut  away  or  its  temporal  tendon  detached.  Most  of  the  exsec- 
tions  in  this  location  are  confined  to  some  portion  of  the  horizontal  ramus.  Except  in 
rare  instances  it  is  not  possible  to  make  a  complete  excision  of  the  lower  jaw  through  the 
mouth,  and  nearly  all  operations  are  practised  through  external  incision,  carried  along 
the  lower  l)order  for  a  sufficient  length,  and  extended  upward  along  the  posterior  border 
beyond  the  angle,  if  necessary.  In  most  instances  the  facial  vessels  are  directly  exposed 
and  should  be  secured  before  division.  Masseteric  attachments  are  separated  and  the 
instruments  are  kept  as  near  to  the  bone  as  the  circumstances  of  the  case  will  justify. 


Resection  of  superior  maxilla.      (I^arabeuf.) 


G70 


SPECIAL  OR  REGIOXAL  SURdERY 


Fig.  475 


III  well-nijirkcd  ulccratiiio;  cancer,  liowevcr,  tlie  .surtfcoii  should  (jo  nearly  an  inch  hevond 
its  ap])arent  border  and  remove  still  more  if  it  l)e  visible,  takinjj;  everything  which  seems 
involved.  Here  the  bone  is  usually  divided  with  a  chain  saw,  although  stout  cutting 
forceps  may  suffice.  It  may  be  necessary  to  remove  a  tooth  in  order  to  clear  a  |)iacc  for 
the  action  of  the  chain  saw.     Growths  involving  the  skin  necessitate  not  nierelv  linear 

incisions,  but  extensive  oval  excisions 
of  the  overlying  tissues.  All  the  in- 
volved structures  should  be  removed 
in  one  mass;  if  it  he  necessary  to  re- 
move the  floor  of  the  mouth  the 
divided  bone  section  is  seldom  cut 
away  until  it  can  be  removed  with  the 
rest  of  the  tumor.  The  healthv  mu- 
cous membrane  should  be  jireserved 
and  brought  together  with  catgut 
sutures  at  the  conclusion  of  the  opera- 
tion, as  the  more  carefidly  the  cavity 
of  the  mouth  can  be  shut  off  from 
the  balance  of  the  Avound  the  more 
])rompt  and  satisfactory  the  healing 
(Fig.  475). 

In  a  few  cases  it  may  be  possible  by 
the  use  of  stout  silver  wire,  or  some 
other  substitute,  inserted  between 
bone  ends  to  keep  them  apart  and 
thus  nearly  preserve  the  contour  of 
the  lower  |)art  of  the  face;  but  this 
can  be  ex|)ected  to  succeed  only  when 
the  cavity  of  the  mouth  can  be  com- 
pletely closed,  so  that  the  wire  or 
other  material  may  be  quickly  incor- 
porated in  granulation  tissue,  where 
it  is  ex])ected  to  remain. 

When  it  is  necessary  to  remove  the 
joint  end  of  the  bone  the  operator 
should  wj)rk  carefully  along  the  bone 
toward  the  joint  in  such  a  way  as  not 
to  injure  the  facial  nerve,  the  external  maxillary  artery,  or  Stenson's  duct.  With  a 
shar|)  se|)anitor  it  is  possible  to  thus  exjjose  the  joint,  and  after  opening  it  to  avulse 
the  articular  surface.  In  operating  for  necrosis  the  healthy  periosteum  should  be 
preserved,  while  in  the  removal  of  cancer  it  should  be  sacrificed  to  the  same  extent  as 
the  bone  itself. 

The  same  rules  apply  here  as  above  with  reference  to  the  closure  of  the  wound  and  the 
construction  of  Haps;  an  extensive  plastic  o])cration  being  sometimes  necessitated,  as 
when  a  large  portion  of  the  lower  lip,  the  chin  and  the  l)one  are  removed  for  extensive 
epithelioma.  Dead  spaces  should  l)e  avoided,  any  cavity  should  be  packed  sufficiently, 
opportunity  for  drainage  afforded,  and  the  mouth  cavity  closed.  Mouth-washes  should 
be  frequently  used. 

These  cases  should  be  prepared  for  operation  by  a  careful  cleansing  of  the  mouth  and 
the  local  use  of  antiseptics.  During  any  of  these  operations,  diseased  teeth  which  may 
recjuire  it  should  be  removed,  whether  they  occupy  the  site  of  the  operation  or  some  other 
portion  of  the  jaws.  The  cleaner  the  mouth  the  more  prompt  will  be  the  healing 
j)rocess. 


Resecticjii  of  inferior  maxilla.      (Faraljeuf.) 


CHAPTEK   XLI. 

TIIK  KKSIMKATORY  PASSACJKS  I'Kol'KK. 
MALFORMATIONS  OF  THE  RESPIRATORY  PASSAGES. 

TnK  cuiK/fiiitd/  iit(i//t>riii(ifi()n.s  of  till'  ii|)|)i'r  rc,s|)iiatt)rv  |);is.sa<ii'.s  |)crtaiii  niainlv  tf) 
the  nasal  septum  and  the  interior  ot"  tlie  coinplicated  nasal  cavities,  which  are  rarely 
syninietrieally  arraii<;;e(l,  and  which  often  dilfer  considerably.  The  iiwial  sephim  i.s 
frequently  deviated  or  \var])ed  to  one  side,  often  to  an  extent  niakin«]f  one  nostril  too  re- 
stricted for  easy  hreathinji;  |)ur|)()ses.  The  iio.strih  are  oeea.sionally  .seen  to  he  ahnonnally 
retracted.  Malformations  of  the  pliari/n.r  are  of  rare  occurrence.  The  mjt  palate 
is  occasionally  found  to  he  more  of  a  diaphrajfui  than  is  natural,  and  impfrjoiatifm  is 
sometimes  seen.  Pli(tripir/ral  fiMula.s-  have  been  mentioned  in  comiection  with  in<-oniplete 
closure  of  branchial  clefts.  They  occur  more  commonly  on  the  ri^lit  than  on  the  left 
side,  and  are  usually  incomj)lete.  A  fistula  ])laccd  in  the  middle  line  and  oj)enin<;  into 
the  larynx  or  trachea  is  also  occasionally  seen,  its  inner  ojjening  being  generally  found  on 
the  side  of  the  pharynx  and  just  below  the  tonsil.  This  is  not  neces.sarily  a  persistent 
remains  of  the  thyroglossal  duct,  but  may  have  a  different  origin.  Cy.stir  distentions 
not  infre(juently  occur  along  these  fistulous  tracts.  INIalformations  of  the  larynx  are 
rare  and  consist  maiidy  of  narrowings  or  stricture  formati(jns. 

Acqaiird  itial/oriitafion-s  of  the  respiratory  pa.ssages  are  common  and  are  the  result 
usually  of  previous  disease  or  injury.  They  may  a.ssimie  the  oh.sfrurtirc  tijpr,  as  when 
the  tonsils  or  the  other  adenoid  or  lymphoid  tissues  of  the  nasoj)harynx  become  hyper- 
trophied,  or  they  may  assume  the  constrictive  tjjpr,  as  Avhen  strictures  result  from  ukcra- 
tion,  produced  either  l)y  tlisease  or  by  caustics.  Such  diseases  as  diphtheria  cause  not 
only  paralyses,  through  the  nervous  system,  but  cicatricial  deformity  in  consequence  of 
ulceration.  The  latter  is  also  true  of  burns,  while  fractures  may  permanently  displace 
parts,  this  being  particularly  true  of  the  nose,  but  holding  good  also  for  the  hycMd,  and 
even  for  the  larynx,  Nearly  all  these  malformations  permit  of  more  or  less  surgical 
improvement  by  ojierations,  same  of  which  are  simple  and  easy  of  performance,  while 
some  will  need  the  highest  degree  of  trained  skill. 

Ozena. — Ozena  is  a  general  term  applied  to  ulcerative  lesions,  especially  involving 
the  Sehneiderian  membrane  in  the  nose,  and  causing  more  or  less  discharge  of  mucus, 
pus,  and  crusts,  nearly  always  offensive,  and  accompanied  by  evidences  of  deeper  idcera- 
tion,  involving  the  fragile  nasal  bones  or  the  nasal  septum,  and  constituting  expressions 
of  caries  or  necrosis  in  this  region.  Ozena  may  be  the  consequence  of  a  milder  catarrhal 
inflammation,  occurring  in  patients  of  vitiated  constitution  and  bad  habits  of  life,  with 
insufficient  attention  or  no  care  whatever.  Another  type  of  ozena  is  from  the  beginning 
of  syphilitic  origin,  and  it  is  especially  the  syphilitic  cases  which  present  the  most  offensive 
types  of  lesions,  yet  which  are  the  most  satisfact(iry  to  treat,  because  of  the  relative  cer- 
tainty with  which  they  yield  to  properly  directed  treatment.  Any  case  characterized  by 
profu.se  and  offensive  nasal  discharge,  in  which  by  suitable  illumination  and  examination 
ulcerations  can  be  detected,  should  be  considered  ozena. 

Treatment. — The  treatment  for  all  these  ca.ses  should  consist  of  local  cleanliness, 
alkaline  solutions  in  spray  or  by  irrigation  being  especially  indicated  because  of  tiieir 
cleansing  properties.  Warm  sterilized  salt  solution  may  also  be  used  for  the  same  pur- 
po.se.  All  visible  ulcerations  should  be  treated  by  local  applications  of  mild  silver  nitrate 
solutions,  or  some  other  combined  anti.septic  and  stimulant;  or  these  may  be  alternated 
w4th  local  applications  of  an  ointment  of  the  yellow  oxide  of  mercury  in  strength  of  0.5 
to  1  per  cent.  Local  treatment,  however,  is  but  a  ])art  of  that  which  should  be  instituted. 
In  every  case  where  the  syphilitic  element  can  be  recognized,  or  where  there  is  good 
reason  for  even  suspecting  it,  \igorous  antisyphilitic  treatment  should  be  begun  and 
prosecuted.     While  these  cases  nearly  always  need  one  of  the  iodides,  administered 

(671) 


672  SPECIAL  OR  REGIOXAL  SURGERY 

internally,  there  is  no  way  of  so  quickly  bringing  them  under  the  desired  influence  as  hy 
inunction  with  the  ordinary  mercurial  ointment.  Both  measures  should  he  carried 
along  simultaneously  until  the  combinati(Mi  proves  to  be  too  active,  when  the  inunction 
may  be  discontinued. 

In  addition  to  these  measures  such  cases  need  improvement  of  elimination  and  of 
nutrition,  and  the  best  restorative  tonics  may  be  combined  to  advantage  with  any  other 
special  medication  which  may  seem  to  be  indicated. 

FOREIGN  BODIES   IN  THE   RESPIRATORY  PASSAGES. 

Nowhere,  except  perhaps  in  the  ear,  are  foreign  bodies  more  likely  to  find  entrance, 
and  become  impacted,  than  in  the  resjiiratory  passages.  They  are^  introduced  cither 
through  the  nose  or  the  mouth.  They  consist  of  almost  all  imaginable  substances, 
introiluced  either  by  accident  or  design,  and  belonging  to  all  three  kingdoms — animal, 
vegetable,  and  mineral.  According  to  their  nature,  size,  and  lodging  place,  symptoms 
of  more  or  less  severity  will  ensue.  jSIigratory  bodies,  especially  small  insects  and 
j^arasites,  may  escape  from  the  nasal  cavity  into  one  of  the  accessory  sinuses,  where 
they  will  give  rise  to  great  irritation,  and  necessitate  perhaps  serious  measures  for  relief. 
The  presence  of  a  foreign  body  is  not  always  promptly  recognized.  In  some  instances 
it  is  discovered  only  by  accident,  as  when,  having  been  present  for  some  time,  it  has  pro- 
duced irritation,  with  or  without  ulceration  and  offensive  discharge.  Thus  a  shoe-button 
may  have  been  pushed  up  the  nose  of  a  little  child,  and  remain  there  undetected  for 
some  time,  ])erhaps  to  be  spontaneously  extruded  in  the  act  of  blowing  the  nose.  The 
])resence  of  a  foreign  body  in  the  nasal  passages,  then,  will  be  manifested  by  symptoms 
of  obstructed  nasal  respiration  and  by  other  evidences  of  local  irritation,'  with  pain, 
tenderness,  swelling,  and  discharge. 

An  object  easily  seen  is  ordinarily  easily  removed,  unless  it  has  some  peculiar  shape 
which  impedes  its  easy  withdrawal.  Local  cleanliness  is  the  first  prerequisite,  and  then 
in  most  instances  local  anesthesia,  which  may  be  produced  with  cocaine  or  one  of 
its  substitutes.  After  this  a  probe,  bent  into  tlie  shajie  of  a  blunt  hook,  or  forceps  of 
various  }«itterns  and  shapes  may  be  required,  and  will  usually  suffice  for  all  ordinary 
cases  which  can  be  detected  by  inspection  through  the  nostrils  or  with  the  rhinoscope. 
In  more  difficult  and  unusual  cases  the  fluoroscope  or  the  skiagram  may  be  made  to 
render  great  service.  Should  some  larger  object  be  found,  j)articularly  in  tlie  antrum, 
decjily  within  the  cranium,  then  a  more  formal  ojieration  will  be  demanded,  whose 
details  should  be  made  to  suit  the  needs  of  each  indi\adual  case.  When  a  mass  of 
inspissated  secretion  or  of  granulation  tissue  more  or  less  conceals  the  outline  of  the 
foreign  body,  everything  should  be  cleaned  away  with  irrigating  spray,  or  with  cotton 
wra])ped  around  a  probe  or  held  within  the  forceps. 

Calculi. — A  rare  condition  of  calculus  jormation  is  occasionally  met  with  in  the  nose, 
the  concretions  l)eing  formed  by  precipitation  of  the  mineral  elements  from  the  nasal 
mucus,  and  constituting  the  ordinary  rhinoUihs.  These  become,  in  effect,  foreign 
bodies,  and  are  to  be  recognized  and  treated  as  such.  After  syjihilitic  ulceration  portions 
of  bone  may  be  loosened  spontaneously,  and  dropped  into  locations  where  they  are  caught 
instead  of  being  spontaneously  expelled. 

It  is  known,  also,  that,  especially  in  tropical  climates,  there  are  several  species  of 
insects  which  enter  the  nostrils  and  there  deposit  their  effgs,  which  later  are  hatched  into 
the  resulting  larvcp,  the  latter  sometimes  being  expelled,  or  perhaps  developing  and 
burying  themselves  further  within  the  nasal  recesses.  Any  living  organism  nuiy  be  killed 
by  administratioti  of  chloroform  or  ether,  and  then  expelled  as  an  ordinary  foreign  body; 
or,  in  most  cases,  such  larva^  or  eggs  can  be  washed  away  with  an  irrigating  stream  to 
which  a  little  extract  of  tobacco  should  be  added.  Thus  maggots  have  been  found 
buried  within  the  nasal  mucosa,  and  requiring  extraction  by  means  of  forceps.  When 
larvre  have  invaded  the  sinuses  the  case  becomes  more  serious,  for  it  will  require 
free  exjiosure  l)y  perhaps  a  somewhat  formidable  operation  on  the  interior  of  the  sinus, 
which  should  then  be  carefully  cleansed  and  suitably  drained.  Living  organisms 
within  the  nasal  cavity  or  the  sinuses  will  cause  headache,  lacrvmation,  sneezing,  nasal 
discharge,  perhaps  with  epistaxis,  and  almost  everv  possible  expression  of  local  discom- 
fort. 


i<'<)h'i:i<; .\  ii()i)ii:s  i\  nil-:  ia:srii;.\Ti)in    i'assacf.s  073 

Foreign  Bodies  in  the  Phar3nix.     FonMjrn  hodics  in  \\\v  pliannx  arc  usually, 

when  stuall,  1<)(I<^((I  in  (lie  iici^lihorliond  of  (ho  loiisil,  or  caut^iit  in  the  lymphoid  tissue 
of  tho  tonsillar  rin>;-.  Acconhiif;  to  their  size  they  may  hccoine  impacted  at  almost  any 
point,  and  may  e\cn  cause  suH'ocatioii.  'I'hey  may  l)c  detected  sometimes  by  the 
fiutjer  alone,  or,  at  other  times,  only  with  (rood  illumination  and  local  anesthesia.  The 
irritation  which  tlu>y  j)ro(lucc  leads  to  l"rc(|uent  acts  ol"  swallowitiff,  the  latter  always 
exa^ijcratinji;  the  former.  Such  objects  as  small  fish-hones  and  the  like,  which  may 
cause  irritation,  may  easily  escape  or  defy  detection;  moreover,  such  objects  may  be 
niulti|)lc. 

For  the  sake  of  comfort  pellets  of  ice  may  be  fre(|uently  swallowed  and  cocaine  may  be 
used  locally.  Their  iwirwiion  should  be  promptly  practised.  In  rare  instances  emer- 
j^eney  may  call  for  prompt  tracheotomy,  but  this  is  rarely  the  case  unless  the  object 
be  impacted  below  the  cj)i<ijlottis.  Curious  instances  of  impaction  in  the  naso- 
pharynx, of  stran(i;c  foreign  bodies,  have  re(juired  the  administration  of  anesthetics  and 
even  serious  cutting  operations  for  their  removal,  by  cond)ined  manipulation  through 
the  nostril  and  the  oroj)liarynx.  Such  bodies,  however,  can  be  in  some  way  always 
removed. 

Li(]ui(ls  nuiy  be  aspirate<l  through  the  nose,  and  cause  strangling  attacks  of  coughing. 
They  are  then  more  easily  drawn  into  the  larynx  or  trachea,  where  they  will  cause  reflex 
piienomena  and  actual  obstruction,  according  to  their  nature.  Again  by  free  inhalation 
of  steam,  natural  or  superheated,  biu'iis  and  scalds  of  the  res})iratory  passages  may  be 
pro(kiced,  which  will  be  followed  by  edema  of  the  glottis  or  by  pneumonia.  The  inhala- 
tion of  extremely  strong  vapors,  like  that  of  ammonia,  may  cause  spasm  of  the  glottis. 
The  entrance  of  blood,  as  from  rupture  of  an  aneurysm,  or  of  pus,  as  from  a  liursting 
abscess,  or  the  escape  of  pus  from  one  side  of  the  chest  into  the  other  lung  by  way  of 
the  trachea,  may  cause  serious  symptoms  or  may  ])roduce  actual  suffocation.  In  opera- 
tions for  jnopneumothorax,  for  instance,  with  one  side  of  the  chest  well  filled  with  pus, 
one  should  be  careful  to  avoid  turning  the  j)atient  in  such  a  way  that  pus  may  run  over 
into  the  other  lung  and  thus  suffocate  him.  I  have  seen  death  occur  on  the  operating 
table  from  this  cause,  in  spite  of  every  precaution,  when  the  accident  itself  had  been 
anticipated. 

Solid  objects  may  be  of  all  shapes,  sizes,  and  materials ;  living  insects  are  occasionally 
aspirated  and  may  not  be  at  once  killed,  the  local  irritation  caused  by  their  presence 
producing  intense  spasm  of  the  glottis.  I  have  personally  known  of  two  cases  cjf  suffo- 
cation in  restaurants,  where  men  eating  hastily  died  as  the  result  of  imj)action  of  pieces 
of  meat  within  the  rima  glottidis.  Again,  bodies  may  pass  beyond  the  glottis  proper 
and  enter  the  trachea,  or  even  one  of  the  great  bronchi;  shoe-buttons,  for  instance; 
and  in  one  case  in  my  knowledge  a  small  hat-pin  passed  down  and  was  only  removed 
after  a  low^  tracheotomy  and  careful  search,  aided  by  a  skiagram.  Owing  to  the 
anatomical  arrangement  the  right  bronchus  is  more  frequently  entered  than  the  left. 
Immefliate  danger  of  suffocation,  of  obstruction,  or  spasm  having  passed,  there  is 
still  serious  menace  from  pneumonia,  with  or  without  abscess  or  gangrene  of  the  lung. 
Such  condition  occurring  in  a  young  child,  in  the  absence  of  the  history  of  passage  of 
a  foreign  body,  may  cause  some  difficulty  in  diagnosis.  The  greatest  help  would 
be  afforded  by  the  use  of  the  Rontgen  rays,  although  the  laryngoscope  alone  will 
sometimes  be  sufficient.  To  use  the  latter  to  advantage  it  will  probably  be  necessary 
to  allay  local  irritation  with  the  cocaine  spray.     (See  Figs.  476  and  477.) 

Treatment. — Treatment  should  be  operative,  although  in  some  cases  it  is  suffi- 
cient to  invert  the  patient  and  slap  him  on  the  back.  With  an  object  impacted  in  the 
glottis  relief  may  be  afforded  with  the  finger,  but  this  may  be  exceedingly  difficult, 
for  in  the  later  stages  of  suffocation  the  jaw  may  be  convulsively  shut  and  it  will 
be  almost  impossil)le  to  effect  entrance.  In  such  case  the  jaw  should  be  hastily  pried 
open  and  the  index  finger  carried  down  behind  the  base  of  the  tongue,  lifting  the 
epiglottis  and  dislodging  the  object.  If  this  fail  and  respiration  have  ceased,  attempt 
should  be  mafle  to  hastily  open  the  trachea,  even  with  the  blade  of  a  penknife,  and  to 
follow^  this  with  artificial  respiration.  Under  these  circumstances  the  vessels  of  the  neck 
will  be  engorged  with  venous  blood,  Avhich  will  escape  freely;  this  may,  however,  be  dis- 
regarded, the  primary  indication  being  to  get  into  the  trachea,  which  may  be  held  open 
by  turning  the  knife-blade  at  right  angles,  while  artificial  respiration  is  practised,  and 
until  a  couple  of  hair-pins,  for  instance,  can  be  secured,  bent  into  shape  of  blunt  hooks 
43 


674 


SPECIAL  OH  RFAIIOSAL  SURCEHY 


and  iiiadc  (o  act  a.s  tciiiponiry  rctnictor.s.     This  i.s  an  illustration  of  wliat  may  l)e  done 
in  tMncM'<i;encies. 

On  the  other  hand  these  operations  should,  when  possil)l(\  l)e  done  deliberately  and 
with  local  anesthesia.     Foreign  bodies  should  l)e  located  with  the  laryngoscope,  after 


Fig.  47G 


Toy-pin  (actual  size)  leuioved  by  external   pharyngotoniy  from  i)harynx  and  esophagus  ui  a  two-year-old  child- 
Recovery.     Skiagram  by  Dr.  Plummer.      (Buffalo  Clinic.) 

Fig.  477 


Skiagram  of  Fig.  476. 


which  they  may  be  removed  with  the  aid  of  the  illumination  thus  afforded,  or  by  mere 
sense  of  touch.'^  An  object  impacted  in  tJie  lari/n.v  proper  may  be  extracted  by  thijrotomij, 
whereas  when  it  has  passed  below  the  larynx  it  will  be  necessary  to  open  the  trachea, 
perhaps  even  low  down,  making  more  than  an  ordinary  opening  for  purposes  of  manipu- 
lation.   Numerous  forceps  have  been  devised  for  these  purposes.    Roaldes  reports  having 


i.wjcjiH-s  TO  Tiih:  ia:si>ii{.\T()ny  j'assages 


675 


removed  ;i  piece  of  iin |);i((ei|   iron  from   (he  hifureatioii  of  the  traelie;i,  \>v  means  of  a 
powerful  (/((iroiiKtfjnrl. 

In  the  eii.siiin<r  chapter  there  will  he  mentioned  a  method  of  exposing  hoth  tlic  trachea 
and  the  esophagus  by  posterior  incision  or  resection  of  the  tlioracic  walh 


I'll..  47S 


Tack  in  bronchus  of  yuung  child,  removed  after  a  low  traclieotomy.     Case  of  Dr.  Parnientcr's.     Skiagram  \>y 

Dr.  Plummer.      (Buffalo  Clinic.) 


INJURIES  TO  THE   RESPIRATORY  PASSAGES. 


Besides  those  inflicted  hy  foreign  bodies  injuries  may  he  produced  here  from  external 
conditions,  gun.sliot  woiind.s',  fractures,  and  a  variety  of  causes  which  need  not  he  specified. 
The  inhahition  or  the  entrance  of  violent  caustics,  cither  fluid  or  volatile,  may  produce 
edema  at  least,  or  actual  destruction  of  tissue.  The  glottis,  being  the  narrowest  portion 
of  tlie  respiratory  tract,  oflers  the  greatest  danger  under  concUtions  of  obstruction,  and 
fatal  dyspnea  may  ensue.  Thus,  for  instance,  burns  caused  by  inhaling  steam,  or  hot 
vapors  or  flame,  will  l)c  follow^ed  by  most  intense  reaction,  often  extending  beyond  the 
trachea  and  to  the  air  cells.  Edema  will  be  prompt,  while  pain,  shock,  dyspnea,  and 
loss  of  voice  will  be  instantly  produced.  If  the  patient  survive  the  early  complications 
he  may  succumb  to  ])neumonia  or  other  disastrous  sequels  in  the  lungs. 

Wounds  of  the  Larynx. — Wounds  are  nearly  always  complicated  by  other  injuries 
of  the  neck  or  face,  which  may  involve  vessel  or  nerve  trunks  of  primary  importance. 
Moreover,  such  woun<ls  arc  mostly  infected  and  lead  to  extension  of  phlegmonous 
involvement,  which  may  later  cause  mediastinal  or  deej)  cervical  abscesses,  and  all  sorts 
of  septic  and  pyemic  complications.  Even  when  recovery  ensues  cicatricial  contraction 
may  j^roduce  laryngeal  or  tracheal  stenosis,  with  defective  voice,  or  sometimes  fistulas, 
connecting  usually  with  the  trachea. 

Treatment. — In  the  treatment  of  such  wounds  provision  should  be  made  for  drainage, 
and  it  is  s(  Idom  advisal)le  to  make  too  accurate  a  closure  lest  its  very  intent  be  thereby 
defeated.  Unless  the  patient  be  suffocating  the  first  indication  is  to  check  hemorrhage, 
then  to  cleanse  the  wound,  and  later  to  make  such  approximation  of  its  surfaces  as  the 
case  may  permit.  Occasionally  in  order  to  obtain  a  good  result  in  the  upper  part  of  the 
respiratory  tract  it  would  be  good  [iractice  to  make  a  tracheotomy  below.  At  other  times 
an  O'Dwyer  tube  may  be  inserted. 

The  occurrence  of  edema  may  be  prevented,  or  at  least  its  severity  in  a  measure  con- 
trolled, by  the  use  of  adrenalin  solution,  1  to  10,(X)0,  while  the  local  use  of  mild  cocaine 


676  SPECIAL  OR  REGIONAL  SURGERY 

solutions  will  he  frequently  indicated,  in  order  to  check  irritahility  and  the  reflex  [)he- 
nomena  to  which  it  will  lead.  Local  symptoms  may  also  he  combated  hy  inhalation  of 
vapor,  with  soothing  solutions,  such  as  weak  preparations  of  cocaine  or  of  one  of  the 
opiates,  followed  by  mild  astringents  and  antiseptics— tincture  of  benzoin  or  oil  of  euca- 
lyptus, or  some  of  their  equivalents,  being  nel)ulized  and  used  in  a  spray.  Oj)iates  inter- 
nally should  be  prescribed;  while  with  delirious,  druid-ceu,  or  maniacal  patients  every 
effort  should  I)c  made  to  secure  ])hysiological  rest  and  to  subdue  restlessness  or  frenzy. 

Fracture  of  the  Larjrnx. — Fractui'e  of  the  larynx  is  a  somewhat  uncommon  acci- 
dent, due  to  direc-t  violence,  which  may  instantly  precipitate  symptoms  of  the  greatest 
severity.  It  may  be  simple  or  compound,  the  thyroid  Ixnng  obviously  most  often  involved 
and  the  cricoid  next.  These  injuries  will  occur  more  frequently  in  the  aged,  in  whom 
the  external  cartilages  of  the  larynx  are  prone  to  calcify  and  thus  become  more  brittle. 
A  fracture  of  the  larynx  precipitates  extreme  danger  of  suffocation,  either  from  dis- 
placement or  edema,  and  will  usually  require  a  prompt  tracheotomy,  which  may  be 
performed  with  a  penknife  in  the  absence  of  any  better  instrument.  It  may  be  indicated 
also  by  expectoration  of  bloody  mucus,  with  froth,  with  stridulous  respiration,  dyspnea, 
pain — which  is  increased  by  pressure  or  motion,  as  in  swallowing — and  the  local  indica- 
tions of  injury.  Thus  death  has  occurred  upon  the  field  during  a  game  of  baseliall, 
from  a  direct  blow  of  the  ball  upon  the  larynx,  no  one  who  knew  sufficient  to  perform 
it  reaching  the  patient  in  time  to  do  an  emergency  tracheotomy  as  above.  Edematous 
laryngitis,  which  is  not  sufficiently  serious  to  call  for  operation,  is  characterized  by 
dyspnea,  aphonia,  dysphagia,  cough,  laryngeal  irritability,  and  by  more  or  less  chemosis 
and  congestion  of  the  mucosa.  The  specialists  treat  certain  of  the  milder  forms  of  this 
condition  by  local  scarification  {i.  e.,  with  a  knife  made  for  the  purpose),  in  order  that 
by  considerable  local  hemorrhage  the  vascular  engorgement  may  be  relieved. 


NASAL   DEFORMITIES. 

These  consist  in  large  measure  of  deviations  of  the  nasal  septum,  with  or  without 
turbinate  hypertrophy,  due  to  previous  disease  of  the  Schneiderian  membrane, 
and  followed  by  thickening  and  structural  change.  Nasal  deviations  are  either 
of  congenital  or  acquired  origin.  An  absolutely  spiimetrically  arranged  and  di\ided 
nasal  cavity  is  a  rarity.  Thus,  though  one  side  is  rarely  a  replica  of  the  other, 
de\'iations  which  are  sufficiently  marked  to  cause  nasal  obstruction  are  commonly  the 
result  of  rapid  or  slow  disease.  They  will  be  seen  in  connection  with  other  body  deform- 
ities by  which  the  head  is  habitually  held  in  an  abnormal  position,  so  that  growth  in 
one  direction  is  thereby  favored.  Such  conditions  may  be  caused  either  by  irregularities 
of  vision,  by  enlarged  tonsils,  or  by  spinal  deformities. 

The  acquired  deviaiions  are  frequently  the  result  of  injuries,  not  necessarily  of  those 
sufficiently  severe  to  produce  fractures.  The  nasal  septum  proper  is  made  up  of  the 
cartilaginous  or  purely  nasal  portion,  the  vomer,  and  the  perpendicular  plate  of  the 
ethmoid,  any  one  of  which  may  be  separated  from  its  connections  or  warped  from  its 
perpendicular  plane.  Dislocation  of  the  cartilages  may  also  occur  in  the  young,  and, 
having  once  taken  place,  is  rarely  reduced  unless  treatment  has  been  both  prompt  and 
scientific. 

Angular  deviation  to  an  extent  which  often  produces  a  spur  is  not  necessarily  of  serious 
inconvenience  unless  it  protrude  sufficiently  from  its  proper  plane  to  come  in  contact 
with  one  of  the  turl)inates,  in  which  case  a  nearly  complete  obstruction  may  result,  with 
symptoms  of  constant  nasal  irritation.  Absolute  symmetry  being  rare,  and  mild  devia- 
tions being  very  common,  it  is  only  those  which  produce  either  visible  deformity  or  local 
irritation  which  require  surgical  treatment.  Obviously  after  injury  to  these  parts 
attention  should  be  given  to  overcome  present  and  prevent  further  dislocation.  This 
may  be  conveniently  done  by  the  introduction  of  small,  tubular,  nasal  splints,  of  celluloid 
or  caoutchouc,  made  for  the  purjx)se.  In  their  absence  short  pieces  of  a  stout,  silk 
catheter  may  be  used,  one  inserted  on  either  side  of  the  septum,  and  packed  aroimd 
with  a  light  tampon  of  antiseptic  gauze.  All  intranasal  splints,  no  matter  how  made, 
will  cause  considerable  local  irritation,  with  tendency  to  discharge,  and  will  need  to  be 
renewed  every  day  or  two. 

Deviation  having  resulted  in  permanent  deformity,  no  matter  how^  produced,  it  can 


NKOl'LASMS  OF   Till'.    S ASM.   CAVITIllS  077 

be  relieved  hy  operation.  Except  in  tlie  yoiiiif;  (his  may  l)e  performed  under  local 
coeaiiie  anesthesia,  'i'hese  measures  fall  under  (wo  heads — those  made  for  rnnoval  of 
'projections-,  or  sj)nrs,  and  (hose  (lircc(ed  (o  slniKjIititinKi  oj  nutrpi'il  or  (Icridtrd  xrplu, 
which  do  not  show  nuich  thickcninjjj. 

For  (he  treatment  of  |)rojec(ions  caustics  an<l  (he  actual  cautery  were  formerly  nnicli  in 
use.  They  have  been  now  almos(  abandoned  for  the  use  of  instruments,  such  as  a  strong; 
knife,  a  small  intranasal  saw,  or  cuttinjf  forcc|)s  of  various  |)a(terns,  adapted  for  use  within 
the  nose.  Onlythese  latter  means  will  be  mentioned  in  this  j)lacc.  ( "unin<;- instruments 
may  bt>  actuated  by  hand  or  by  electric  motors.  When  the  field  of  operation  is  small 
cocaine  anesthesia  is  nearly  always  sufficient.  E.xtensive  operation  inxolvinji;  both  misal 
cavities  may  often  be  better  ])erf()rmed  under  a  general  anesthetic.  The  nasal  cavity 
should  have  b(>en  pr(>viously  thoroughly  cleansed  by  the  aid  of  irrigation  with  alkaline 
solutions,  and  then  just  previous  to  oj)eration  with  hydrogen  peroxide.  Instruments 
should  be  absolutely  clean  and  sterile.  When  local  anesthesia  is  complete  it  is  suffi- 
cient to  seat  the  patient  with  the  head  supported,  opposite  to  the  o])erator,  to  illuminate 
the  nasal  cavity  with  the  head  mirror  or  some  substitute  therefor,  and  to  introduce  the 
knife,  saw,  or  f()rce|)s  in  such  a  way  that  the  removal  may  be  effected  with  one  move- 
ment, while  injury  to  surrounding  ti.ssues  is  avoided.  An  intranasal  saw  should  be  blunt- 
pointed,  and  should  never  l)e  pushed  so  as  to  touch  the  posterior  wall  of  the  pharynx. 
After  division  of  bone  the  final  detachment  of  the  mucosa  should  be  made  with  scissors 
or  knife.  Bleeding  after  these  o|)erations  is  rarely  severe,  although  free  at  first,  and 
may  be  controlled  by  a  tampon  made  of  a  narrow,  continuous  stri))  of  antiseptic  gauze, 
either  packing  it  into  the  nostril  and  occluding  it,  or  inserting  a  luisal  tube  and  ])acking 
snugly  around  it.  Only  in  rare  instances  is  it  necessary  to  tam])on  the  nose  from  the 
pharynx  by  the  use  of  the  Bellocq  cannula.     (See  below.) 

Warped  and  deviated  septa,  without  angular  projections,  may  be  sometimes  success- 
fully treated  by  dividing  the  septum,  either  with  knife  or  sci.ssors,  or  with  cutting  forceps 
whose  blades  make  a  stellate  incision,  l)y  which  the  curved  surface  is  so  much  weakened 
that  it  can  be  j^ressed  back  into  normal  shape,  where  it  is  retained  by  tampfniing  the  nostril 
on  the  affected  side.  The  pressure  required  for  this  purpose  is,  however,  sometimes 
irksome  or  even  intolerable.  A  method  of  using  a  long  pin,  like  a  small  hat-pin,  has  been 
suggested,  it  being  passed  through  one  nostril  into  and  out  of  and  again  into  the  septum, 
in  such  a  way  that  it  serves  as  a  splint,  to  keep  it  straight  for  a  sufficient  length  of  time. 
Later  this  ])in  may  l)e  removed  without  difficulty,  its  enlarged  head  lying  meantime 
concealed  within  one  of  the  nostrils. 


SUBMUCOUS  RESECTION  OF  THE  NASAL  SEPTUM. 

This  was  first  suggested  by  Killian  as  affording  a  method  not  subject  to  the  objections 
of  the  older  authorities.  It  may  be  performed  under  cocaine  anesthesia,  each  side  of 
the  septum  being  swabbed  with  a  20  per  cent,  cocaine  solution.  A  semilunar  incision 
made  through  the  mucous  membrane  and  perichondrium  on  one  side  is  the  more  con- 
venient. Through  this  opening  the  coverings  are  separated  from  cartilage  l)y  means  of 
a  sharp  and  a  plain  elevator.  Unless  the  perichondrium  be  itself  elevated  the  mucous 
meml^rane  will  be  torn  in  the  pressure  of  loosening.  The  cartilage  is  then  cut  through 
with  suitable  instruments  or  burred  away  with  a  dental  engine,  the  instrument  being 
guarded  by  a  finger  in  the  opposite  nostril,  which  acts  as  a  guide,  it  not  being  desirable 
that  the  membrane  on  that  side  shall  l)e  cut  through.  In  this  way  any  spurs  or  ridges 
may  be  removed  submucously  with  such  instrument  as  the  operator  may  .select.  The 
separated  membranes  then  fall  together  and  may  be  retained  by  light  gauze  packing 
without  any  suture. 

NEOPLASMS  OF  THE  NASAL  CAVITIES. 

Of  true  neoplasms  in  the  nose  the  most  common  are  those  myxomatous  or  fibromyxo- 
matous  develojomeuts  from  the  Schneiderian  membrane,  which  are  called  nnsal  polypi. 
Histologically  most  of  these  are  of  myxomatous  character.  Clinically,  however,  they 
seem  to  be  in  large  degree  products  of  inflammatory  and  irritative  conditions.  .\t 
all  events  they  constitute  sessile  and  later  pendulous  outgrowths,  occupyuig  diti'erent 


678  SPECIAL  OR  REGIONAL  SURGERY 

areas  or  occurring  in  clusters,  those  from  the  upper  part  of  the  nose  being  covered  with 
columnar  cells,  while  those  of  the  lower  pharynx  are  covered  with  fiat  epithelium.  They 
are  firm  or  soft,  according  to  the  amount  of  connective  stroma  which  they  contain. 
They  are  poorly  supplied  with  blood  and  their  contained  fluid  is  largely  com})osed  of 
mucin.  Wlien  involving  a  considerable  area  the  condition  is  referred  to  as  j)olyjjoid 
degpneraiion.  They  are  observed  at  all  ages  and  in  both  sexes.  Their  most  common 
seat  is  the  middle  turbinate,  toward  its  posterior  extremity,  and  they  also  hang  from 
the  septum,  but  may  be  found  in  any  part  of  the  nasal  cavity.  From  it  they  may  spread 
to  fill  the  adjoining  accessory  sinuses,  even  producing  al)sor))ti()n  of  their  bony  walls 
by  pressure.  They  also  produce  distortion  of  the  nose,  with  such  obstruction  as  to  pre- 
vent nasal  respiration.  They  may  involve  one  side  or  both,  and  may  hang  so  loosely 
attached  that  a  flapping,  valve-like  sound  is  heard  on  respiration. 

Symptoms. — They  produce  nasal  obstruction,  with  irritation;  more  or  less  dis- 
charge of  watery  or  acrid  mucus,  the  latter  sometimes  leading  to  excoriation;  while  by 
pressure  they  produce  headache,  es]:)ecially  when  located  high  in  the  nose,  or  deafness, 
as  when  they  j)ress  upon  the  Eustachian  outlets,  or  s\iiiptoms  of  sinusitis  according  as 
they  invatle  one  or  other  of  the  sinuses.  Other  reflex  symj)toms,  such  as  facial  neuralgia, 
reflex  cough,  lacrymation,  and  conjunctivitis,  frequently  accoin])any  them,  and  mouth 
breathing  and  snoring  are  almost  inevitable  consequences.  The  v(jice  becomes  impaired, 
as  does  occasionally  the  sense  of  taste. 

In  most  cases  they  are  easily  revealed  by  artificial  illumination  and  exposure  with 
the  nasal  speculum.  In  color  they  are  usually  pinkish,  and  may  be  seen  to  move 
with  the  res))iratorv  effort.  While  it  is  usually  easy  to  see  at  least  some  of  them,  when 
present,  it  is  difficult  to  detect  their  exact  point  of  origin.  With  the  rhinoscopic  mirror 
they  may  be  seen  projecting  into  the  nasopharynx.  Occasionally  one  will  be  detached 
by  violent  efl'ort  at  sneezing  or  blowing  the  nose. 

Fig.  479 


Jarvis  snare. 


Aside  from  the  danger  of  retained  secretion,  which  they  may  bring  about,  and  that 
attending  their  extension  into  adjoining  cavities,  there  is  in  elderly  people  at  least  an 
actual  jjossible  danger  of  their  undergoing  maUgnani  trau.s'fnrmation,  although  this  is 
not  common.  There  is,  however,  good  reason  for  their  removal,  anil  none  for  allowing 
them  to  remain,  for  they  are  always  .both  irritant  and  obstructive. 

Treatment. — Almost  every  other  method  of  treatment  has  yielded  to  that  of  re- 
moval by  the  Jarvis  snare,  or  its  ecjuivalent,  supplemented  by  the  occasional  use  of 
forceps.  In  order,  however,  to  exjiose  them  sufficiently  to  ])ermit  of  removal  it  is  often 
necessary  to  cut  away  a  portion  of  the  middle  turbinate.  In  extensive  polypoid  disease 
this  would  be  practically  always  required,  and  it  should  be  done  thoroughly,  for  nasal 
polypi  tend  usually  to  recur  unless  radically  attacked.  Local  anesthesia  is  suflicient 
for  the  majority  of  cases,  but  an  aggravated  instance  will  call  for  complete  anesthesia  and 
thorough  work,  esjiccially  if  the  accessory  sinuses  have  been  infected. 

The  snare  figured  in  Fig.  479  is  a  type  of  instrument  which  can  be  used  to  great 
advantage  in  dealing  with  these  cases.  When,  however,  it  c-annot  l)e  made  effective  by 
being  api)lie(l  around  the  actual  base  of  each  growth  its  use  should  be  supplemented 
by  that  of  the  curette.  No  actual  assurance  can  ever  be  given  that  there  will  be  no 
subsequent  (level()))ment  of  polypi.  Nevertheless  it  does  not  follow  that  new  j)()lypoid 
development  is  of  the  actual  nature  of  recurrence.  It  may  occur  independently  from 
the  same  causes  that  produced  its  first  appearance. 

It  should  hardly  be  necessary  to  insert  here  the  caution  that  no  operation  of  even  this 
degree  of  simi)licity  should  be  effected  without  careful  cleansing  of  the  nasal  cavity. 

Of  the  other  tumors  that  may  occur  within  the  nasal  cavities  none  can  be  said  to  fre- 
quently occur  here,  but  all  varieties  may  be  encountered.  Of  the  more  benign  tumors 
the  most  common  nre  the  vascular  growths  and  the  fil)romas,  or  mixed  form  of  fil)romas 
and  papillomas.     Epithelioma  and  sarcoma  occur  occasionally. 


ADEXOIDS  OF  Tlir.   P/tARy^JX  (jyj) 


FIBROMA  OF  THE  NASOPHARYNX. 

Fibroma  of  tlio  iiasoplian  ii\  is  imicli  more  common  lliaii  in  (In-  nasal  cavity  j)ropcr. 
Hero  it  assumes  its  usual  cliaractcrislics  as  a  more  or  less  lirni  and  dense  tumor,  ja^rowinji; 
slowly,  sometimes  from  a  large  base  and  af>ain  in  |)eduuculate(l  form.  A  form  occasionally 
met  with  sprini>;s  from  tlie  ])criosteum  of  the  base  of  the  skull  and  slowly  extends  into  the 
naso|)harvnx,  causing;  in  time  a  com])lclc  obstruction,  witli  disappearance  of  tlx'  snr- 
roundino-  structure  by  its  ])ressure  elVects.  Som(>  of  these  irrowths  are  of  a  considerable 
deo;re(>  of  vascularity.  WIumi  arisiiifj;  from  the  base  of  the  skull  they  become  almost 
ino|)eral>le  after  obtainin*;'  considerable  size.  I  have  seen  death  upon  the  operating 
table,  in  one  of  the  foreign  clinics,  from  uncontrollable  hemorrhage  occurring  during 
the  removal  of  one  of  these  growths.  A  growth  thus  situated  should  be  attacked  witli 
extreme  caution,  and  ])referal)ly  after  easier  access  has  been  made  to  it  by  division  of 
the  soft  j)alate,  and  removal  of  a  |)orti()n  of  the  hard,  or  j)erhaps  by  a  temporary  or  j)er- 
manent  resection  of  the  ujjper  jaw;  the  route  being  left  in  each  case  to  the  <|(>r-ision  of 
the  operator.      Provisional  ligation  of  the  carotids  may  be  also  made. 

The  same  is  true  of  the  other  tumors  of  the  nose  and  naso])harynx.  The  less  malignant 
they  are  the  more  they  justify  radical  attack.  By  the  time  a  sarcomaor  adcnocarcintjma 
of  dee])  origin  has  declared  itself  it  is  usually  too  late  to  justify  its  removal. 

ADENOIDS  OF  THE  PHARYNX. 

A  new-growth  of  different  form,  occurring  in  the  vault  or  around  the  outlines  of  the 
pharynx,  is  fretjuently  seen  in  the  shape  of  great  liypcrtrophij  or  ovrrrjrowth  of  the  /i/inph- 
oid  ti.s-.fuc,  already  and  elsewhere  alluded  to  as  composing  a  j)art  of  the  original  lymphoid 
ring  which  marks  the  site  of  the  embryonic  nasopharyngeal  canal.  This  lymphoid 
hyjjertrophy,  whose  commencing  expressions  are  seen  in  the  tonsil,  is  referred  to  as 
adenoid  grov)th.  Associated  with  it  occurs  more  or  less  hy])ertrophy  of  the  other  tissues, 
fibrous,  etc.,  according  to  whose  proportion  the  growths  will  be  soft  and  spongy  or  more 
dense  and  resistant.  The  so-called  adenoids'  occu])y  more  or  le.ss  of  the  naso])harynx 
proper,  reducing  its  dimensions,  encroaching  u))on  the  vault  of  the  pharynx,  materially 
reducing  the  breathing  space,  thus  leading  to  the  establishment  of  the  mouth-breathing 
habit,  as  well  as  to  alteration  of  voice  and  the  accompanying  disagreeable  features  of 
increased  secretion  of  the  parts.  It  leads  to  characteristic  appearances  which  may  be 
recognized  at  a  distance,  consisting  of  a  mouth  hal)itually  open,  with  more  or  less  j)ro- 
jecting  teeth,  pinched  nostrils,  (iothic  roof  of  month,  stooped  shoulders,  deformed  thorax, 
loss  of  hearing,  irritative  cough,  and  jiossibly  remote  reflex  effects,  such  as  laryngeal 
spasm,  general  neuroses,  chorea,  and  ei)ilepsy.  The  effect  of  these  changes  is  to  give 
not  merely  an  appearance  of  stupidity,  but  actually  to  interfere  with  mental  development. 
Save  in  exceptional  instances,  a  child  with  the  mouth-breathing  habit,  and  with  that 
peculiarity  of  voice  which  indicates  nasal  obstruction,  will  nearly  always  be  found  to  be 
defective  in  cerebral  activity,  if  not  actually  stupid.  The  longer  the  condition  is  allowed 
to  persist  the  greater  the  permanent  alterations  and  damage  permitted. 

Pronounced  degrees  of  the  condition  may  be  easily  recognized  by  the  habitually  open 
mouth  and  the  character  of  voice.  A  moment's  inspection  will  usually  reveal  the  char- 
acter and  the  degree  of  involvement.  When  adenoids  in  the  nasopharynx  attain  a  size 
sufficient  to*  produce  these  results  the  tonsils  are  also  usually  involved,  and  the  clinical 
picture  is  thereby  made  more  ])ronounced.  The  rhinoscopic  mirror,  if  it  can  be  used, 
will  give  a  picture  of  the  condition,  while  the  finger-tip  passed  upward  behind  the  soft 
palate  will  give  an  idea  as  to  the  extent  to  which  the  cavity  is  filled. 

By  virtue  of  the  interference  with  the  vital  function  of  respiration  thus  produced,  and 
because  of  the  retention  of  secretion  and  the  greater  exposure  to  irritation  through 
the  constantly  open  mouth,  individuals  with  this  condition  are  usually  anemic,  while 
many  of  them  give  evidence  of  the  .stafu-i  Ii/utpliafien.s-,  to  which  attention  has  been 
called  in  the  {^receding  jjages.  To  suck  an  extent  is  this  true  that  the  administration  of 
an  anesthetic  is  freqnentli/  attended  by  extra  danger,  and  the  operator  shonhl  (jive  the 
necessary  relief  on/y  after  careful  preparation.  This  should  consist  not  oidy  of  general 
measures,  by  which  the  condition  of  the  patient  may  be  improved,  but  by  local  cleansing 
of  parts;  and  finally,  as  a  preparation  for  the  anesthetic,  of  the  local  use  of  a  weak  cocaine 


680  SPECIAL  OR  REGIONAL  SURGERY 

solution,  by  which  reflex  excitability  may  be  controlled.  Just  before  administering  the 
anesthetic  in  these  cases  it  is  well  to  spray  into  the  nostrils  and  })liarynx  a  weak  cocaine 
solution,  after  which  the  anesthetic  may  be  administered.  In  most  instances  it  would 
be  better  to  use  ethyl  chloride  or  ether  than  chloroform,  not  because  the  latter  is  neces- 
sarily more  dangerous,  but  l)ecause  one  is  ])laced  less  upon  the  defensive  in  case  of 
accident,  owing  to  the  belief  that  it  is  not  so  safe  as  some  other  anesthetics.     (See  p.  164.) 

Operation. — Local  applications  being  of  small  avail  in  producing  either  condensation 
or  resorption,  the  treatment  of  this  condition  is  essentially  surgical.  With  children  an 
anesthetic  is  always  necessary.  With  adults  cocaine  may  be  sufficient.  The  best 
position  for  the  patient  is  that  with  the  down-hanging  head  (Rose's),  as  blood  is  not 
swallowed  nor  passed  into  the  lungs,  but  may  be  removed  as  fast  as  it  collects.  The 
hemorrhage  in  these  operations  is  generally  profuse  l)ut  of  short  duration. 

Adenoids  are  removed  either  with  a  .snare,  the  cureitr,  or  by  special  instruments  con- 
structed on  the  type  of  a  tonsillotome,  and  having  a  concealed  blade.  The  curette 
is  also  used  a^  forceps.  Two  or  three  curettes  and  forceps  are  sufficient  for  nearly 
all  purposes.  In  operating  the  instruments  are  guided  entirely  by  the  sense  of  touch 
and  the  operator's  knowlerlge  of  anatomy,  for  he  relies  upon  his  finger-tip  for  in- 
formation as  to  whether  the  tissue  has  been  completely  removed  or  needs  further  atten- 
tion. These  instruments  are  used  until  the  entire  vault  of  the  ])harynx  and  its  openings 
into  the  nasal  cavities  (ciioanfe)  are  freed  from  all  hy))ertro])hied  tissue  or  excrescence. 
The  posterior  wall  of  the  pharynx  should  be  scra])ed  until  it  is  smooth.  In  addition  the 
tonsils  should  be  removed  if  it  l)e  necessary,  while  the  lingual  tonsil  maybe  also  removed 
with  curette  or  forceps  if  it  be  involved.  For  a  few  moments  there  will  be  a  free  flow  of 
blood  through  both  nose  and  mouth.  In  some  instances  there  will  be  indications  for 
cutting  away  hypertrophied  turbinates  and  removing  nasal  polypi.  Hemorrhage,  at 
first  profuse,  quickly  subsides.  A  mixture  of  1  per  cent,  cocaine  solution  with  a  little 
adrenalin  is  the  best  hemostatic  for  local  use.  The  nostrils  may  be  packed  if  the  tur- 
binate has  been  cut  away,  or  the  entire  passage-way  may  be  left  open  for  the  purpose 
of  permitting  the  later  use  of  an  irrigating  stream,  l)y  which  blood  clot  may  be  washed 
away  and  antise})tics  a])plied.  While  using  and  relying  u})on  instruments  for  the  greater 
part  of  this  work  there  is  no  better  curette  for  concluding  the  work  than  the  finger-nail 
of  the  index  finger.  The  finger  being  introduced  recognizes  the  degree  of  relief  afforded, 
and  the  finger-nail  may  be  used  to  scrape  away  any  remaining  projecting  tissue. 

Various  operators  have  devised  formidable  operations,  varying  from  the  temporary 
resection  of  one  upper  jaw  to  Cheever's  ingenious  method  of  dividing  and  separating 
both  upper  jaws  in  one  piece  from  the  cranium,  and  thus  exposing  the  nasophar\iix 
from  in  front  and  above.     Such  operations  are  rarely  performed. 

Other  neoplasms  in  this  region  are  rysts  and  dermoids-  of  congenital  origin — those 
involving  the  original  craniopharyngeal  canal,  and  those  produced  from  pharyngeal 
diverticula.  These  produce  only  the  ordinary  manifestations  of  tumtjr  and  are  of 
pathological  rather  than  surgical  interest. 

EPISTAXIS  (NOSE-BLEED). 

The  escape  of  a  small  amount  of  blood  from  the  nose,  especially  in  childhood,  is  a 
common  occurrence,  and  may  occur  in  consequence  of  slight  traumatisms  or  even 
spontaneously.  The  so-called  nose-bleeding  of  children,  then,  is  scarcely  (jf  sufficient 
importance  to  justify  consideration  here,  nor  would  it  were  it  not  for  the  fact  that  it  may 
become  severe  and  even  dangerous.  Children  in  whom  it  frecjuently  recurs  will  lose 
sufficient  blood  to  become  anemic,  while  the  effect  of  its  frequent  occurrence  may  bespeak 
a  depraved  condition  of  the  blood  as  well  as  of  the  tissues  which  permit  of  its  escape. 
A  history  of  repeated  nose-bleed  should  prompt  an  investigation  into  the  general  condition 
of  the  patient  as  well  as  a  local  examination  of  the  nasal  passages,  where  some  explanation 
may  be  afforded.  For  instance,  a  polypus  may  be  foimd  whose  removal  will  then  be 
indicated,  or  an  exceedingly  spongy  and  vascular  area  may  be  revealed,  which  will  call 
for  a  touch  of  the  actual  cautery  or  the  use  of  the  curette. 

Besides  the  frequent  expressions  of  this  kind  in  chiklhood,  some  of  which  may  occur 
during  sleep,  there  are  other  forms  of  nasal  hemorrhage.  A  vicarious  menstruation  is 
known  to  assume  this  type,  individuals  thus  losing  blood  every  month.  This  is  a  rare 
but  well-known  phenomenon.     A  plethf)ric  individual  may  suffer  serious  epistaxis  at 


EPISTAXIS 


GSl 


;iny  time,  and  this  may  \>v  hciicdcial  unless  it  l)c  too  extensive.  Xasal  lieiiiorrliai:;es 
may  occur  with  certain  fevers.  huHvitlnals  with  a  hemorrha<j;ic  (Hathesis  are  jjecuharly 
liable  to  it,  and  it  is  seen  in  connection  with  jnirpura  ha'morrliafrica.  When  this  occurs 
in  the  dehilitated  or  di.ssipated  it  may  l)c  fatal.  Thus  epistuxis  may  terminate  fatally 
in  spite  of  all  that  can  he  done.  This  statement  recpiircs  sonu'  explanation.  "^I'lie  na.sal 
cavity  may  he  ti<fhtly  plu^'frcd,  hut  such  plu^<fiiiij;  cannot  he  made  pernument  i)ecause 
of  (lecom|)osition  of  ])roducts  tluis  retained  and  their  absorption,  with  consecpUMit  septic 
infection.  Xasal  tam|)ons  should  !>(>  removed  every  day  or  two,  for  the  purpose  of 
cleaidiness,  ahlioui:;h  their  removal  is  contra-indicated  when  the  necessity  for  phvsio- 
logical  rest  of  the  jjart  is  realized.  The  treatnu'ut,  then,  of  epistaxis  mav  i)e  trving, 
at  least,  and  in  rare  cases  will  jjrove  absolutely  disappointinii'  and  inclVci  tual.  1  iiave 
even  been  compelled  to  tie  the  couunon  carotid  to  save  life. 

Treatment.  —The  ordinary  nose-bleed  of  a  young  child  will  usually  subside  with 
the  application  of  cold  to  the  nose,  elevation  of  the  arms,  or  firm  pressure  upon  the 
upjHM-  lip  just  below  the  nasal  septum.  It  may  be  also  checked  by  an  irrii^ating  stream 
of"  cold  water,  or  by  a  spray  of  cocaine  or  weak  adrenalin  solution.  A  5  ])er  cent,  anti- 
pyrine  solution  also  makes  an  excellent  styptic  for  the  |)urpose.  Within  a  day  or  tw(j 
after  a  serious  hemorrhaije,  after  the  remainin<i;  clots  have  been  cleaiu'd  away,  a  thorough 
inspection  of  the  nasal  cavity  should  be  made  in  order  to  reveal  the  source  of  the  hemor- 
rhage and  jiermit  local  treatment. 

Nasal  hemorrhage  may  be  subdued  by  pluggiiu/  flic  anferior  )iarr.s  with  strips  of  gauze, 
or,  better  still,  after  the  introduction  of  a  tube  through  which  air  may  pa.ss  freely,  and 
around  which  packing  may  be  firmly  inserted.  The  ordinary  dry  styptics  should  not 
be  used,  for  they  may  produce  such  a  crusting  of  tampons  as  to  make  it  difficult  to 
remove  them.  ^lore  efficient  materials  can  be  used  in  solution.  No  tampon  should  be 
introduced  into  the  nostrils  which  is  not  tied  with  a  ligature  of  silk  in  such  a  way  that 
it  may  be  by  it  more  easily  withdrawn,  and,  at  the  same  time,  ])revented  from  going  too 
far.  If  the  source  of  the  bleeding  be  in  the  anterior  part  of  the  nasal  cavity  anterior 
packing  may  be  sufficient.  The  surgeon  should  not,  however,  be  deceived  by  the 
apparent  cessation  of  bleeding,  which  cannot  escape  through  the  nostrils  under  these 
circumstances,  but  may  continue  into  the  nasopharynx,  the  patient  swallowing  the  blood 
as  it  trickles  down.  Inspection  of  the  pharvnx  should  be  made  after  the  use  of  tampons. 
A  much  greater  degree  of  safety  is  afforded  by  posterior  iamponing  of  each  side  of  the 
nasal  cavity,  which  is  most  easily  effected  by  means  of  the  little  instrument  known  as 
BeUocqs  cannula,  whose  use  is  illustrated  in  Fig.  480. 

It  is,  however,  by  no  means  necessary  to  have  this  special  instrument  in  order  to 
accomplish  the  purpose.  A  soft  catheter  may  be  passed  backward  through  the  nostril 
until  its  end  appears  in  the  nasopharynx,  where  it  is  caught  with  forceps  and  drawn  into 
the  mouth.  Here,  by  means  of  a  needle  or  knot,  a  piece  of  silk  is  fastened  to  this  end. 
When  the  catheter  is  drawTi  out  from  the  nose  it  pulls  up  after  it  and  out  through  the 
nostril  this  bit  of  silk,  to   whose 

middle  is  tied  a  tampon,  made  of  Fic  480 

a  sufficient  amount  of  gauze  or 
similar  material,  folded  or  rolled 
into  the  desired  shape.  By  com- 
bined manipulation,  as  the  silk 
thread  is  drawn  upward  and 
outward  through  the  nostril,  it 
pulls  up  the  tampon  into  the 
nasophar\Tix,  w^here  it  should  be 
guided  into  its  place  by  the  tip"  of 
the  index  finger  of  the  disengaged 
hand.  If  necessary  this  procedure 
is  then  repeated  upon  the  other 
side,  and  thus  a  complete  double 
tamponing  can  be  effected.  If  the 
procedure  be  made  difficult  by  the 
extreme  sensitiveness  of  the  part 
this    can    be    overcome    by    local 

anesthesia.       The    tampon    maybe  Plugging  the  nares  with  Bellocq's  cannula.      (Fergusson.) 


682  SPECIAL  OR  REGIOXAL  SURGERY 

saturated  with  a  weak  adrenalin  solution  if  desired.  Ordinarily  such  a  tamjxin  ran  be 
easily  disencjacfed  and  removed  by  again  passing  the  finger  up  behind  the  soft  palate 
and  dislodging  and  withdrawing  it,  using  curved  forceps  for  the  pur}X)se  of  sec-uring 
it.  A  tampon  inserted  for  the  control  of  hemorrhage  should  be  left  iti  situ  for  at 
least  forty-eight  hours,  possibly  longer.  The  case  should  be  watched  for  a  while 
after  its  removal,  lest  it  might  require  re-introduction.  This  maneuver  is  made  easier 
by  fastening  the  tamjxjn  in  the  middle  of  a  long  piece  of  silk  as  described;  one  end 
being  l)rought  out  through  the  nostril  is  tied  to  the  other  portion,  which  is  allowed  to 
come  out  of  the  mouth.  The  latter  will  provoke  some  discomfort,  and  patients 
should  be  cautioned  not  to  disturb  it,  its  purpose  being  explained  to  them. 

Mulford,  of  Buffalo,  has  suggested  a  method  of  dealing  with  cases  of  epistaxis 
by  injecting  two  or  three  drops  of  reduced  adrenalin  solution  into  the  tissues  at  the  base 
of  the  u|)per  Hp,  in  close  proximity  to  the  course  of  the  arteries  which  pass  upward  on 
either  side  and  supply  the  septum.  The  injection  should  be  made  in  the  fold  of  the 
mucous  membrane  just  beneath  the  septum  of  the  nose. 


RETROPHARYNGEAL  ABSCESS. 

This  has  already  been  referred  to  as  the  product  of  tuberculous  disease  in  the  upper 
cenical  vertebne,  f)r  in  the  neighboring  l\-mph  nodes,  or  as  the  possible  sequel  of  more 
acute  infections  occurring  in  the  uj)])er  portions  of  the  neck,  proceeding  usually  from 
infected  tooth  sockets  or  other  lesions  within  the  nose  and  mouth.  Collections  of  pus 
in  this  location  may  be  circumscribed  or  may  be  extensive  and  rapidly  assume  serious 
phases.  A  chronic  abscess  is  essentially  a  tuberculous  expression.  Acute  abscesses, 
either  in  the  tissue  behind  the  phar\nix  or  to  either  side  of  it,  may  be  seen  in  cachectic 
children  and  assume  serious  phases. 

The  first  evidences  in  these  cases  are  those  of  ])liaryiigiti.>,  but  swelling  and  edema 
occur  rapidly,  septic  indications  become  unmistakable,  and,  finally,  almost  complete 
nasopharyngeal  obstnutiDu  may  occur.  The  discovery  by  the  palpating  finger  of  a 
fliK  tuaring  swelling  will  make  the  presence  of  pus  practically  positive.  If  the  operator 
Ijc  .^till  in  doubt  he  may  use  the  exploring  needle.  The  experienced  practitioner  will 
at  once  plunge  the  point  of  a  knife  into  such  a  swelling,  and,  at  the  same  time,  plan  his 
opening  in  such  a  way  as  to  aflford  the  l)est  possible  drainage.*  For  the  purpose  it  may 
be  necessary  to  have  the  patient  in  the  jxjsition  of  down-hanging  head,  or,  in  extreme 
cases,  the  patient  may  be  almost  inverted  in  order  that  pus  as  it  gushes  forth  may  escape 
through  the  mouth  rather  than  into  the  larynx  or  do"«ii  the  eso|>hagus.  The  operation 
should  be  df)ne  without  an  anesthetic.  The  mouth  may  he  ojiened  with  the  O'Dwyer 
mouth-gag,  or  it  may  be  forced  and  held  open  with  the  ordinary  tongue  depressor.  When 
pus  has  travelled  to  such  an  extent  as  to  give  the  case  the  importaiue  and  aspect  of  a 
deep  cer^^cal  phlegmon,  such  as  described  in  the  chapter  on  the  Xeck,  then  anesthesia 
is  necessary  in  order  that  by  external,  coinbincd  witli  internal,  incision,  escape  of  pus  and 
pro\-ision  for  drainage  may  be  permitted. 

Two  dangers  attend  inexcusable  delay  in  such  acute  cases — one  is  of  suffocation  from 
pressure  or  from  sudden  spontaneous  rupture  of  abscess;  the  other  is  of  invasion  of 
large  blood  trunks  in  the  \-icinity  and  |M)Ssibility  of  hemorrhage  after  erosion,  either  into 
the  abscess  cavitv  or  directlv  into  the  outer  world. 


THE  UVULA  .\XD  SOFT  PALATE. 

ELONGATION  OF  THE  UVULA. 

As  the  result  of  constant  irritation  by  coughing,  or  other  reflex  motions  of  the  phar^m- 
geal  muscles  produced  by  local  irritation,  the  uvula  frequently  becomes  elongated  to  a 
point  which  permits  it  to  rest  upon  the  base  of  the  tongue  and  there  to  produce  still  more 

'  Nevertheless  in  one  instance  an  eminent  American  practitioner  thus  hastily  incised  a  fluctuating  intra- 
pharyngeal  swelling  anrl  found,  to  his  dismay,  that  he  had  opened  a  carotid  aneurysm,  the  patient  dying  within 
five  minutes. 


THE  LARYXX 


()83 


irritation  and  rcflt-x  plK-iioiiifiia.  ratit-iits  siiiViTJiijr  in  this  way  will  he  noticed  to  make 
fre(jiient  attempts  at  swallowing  and  coughinij,  which  may  he  depressing,  and  may  lead 
to  disturheil  slee|)  and  even  an  asthmatic  form  of  hreathirig.  The  nvula  is  a  useless 
organ  when  it  has  attained  such  dimensions,  and  its  amputation,  or  at  least  its  shortening, 
are  indicated  in  all  such  cases  as  those  ahove  descrihed.  I^x-al  anesthesia  is  sufficient. 
Its  tip  is  caught  with  a  j)air  of  forceps  and  it  is  ciip|)cd  oti',  not  too  near  its  base,  hv  long- 
handled  and  sharp  scissors.  This  is  a  much  neater  and  more  ex|)cditioiis  method 
than  to  include  it  within  the  grasj)  of  a  wire  snare  and  somewhat  slowlv  crush  it  olf. 

Upon  the  uvuhi,  as  upon  the  soft  i)alat(\  pa|)ular  lesions  of  .v(/yj//?7/.s-  are  fre(|uently 
seen,  rarely  the  j)rimary  chancre,  hut  very  often  mucous  patches  or  the  deeper  ulcers, 
which  characterize  the  secondary  and  tertiary  lesions,  (lumma.s  also  may  form  within 
the  thickness  of  the  jialatal  tissues,  which  will  in  time  break  down  and  formVagged  ulcers, 
while  the  destruction  may  extend  to  the  bony  portions,  either  of  the  nose  or  ro(jf  of  the 
mouth,  and  then  necrosis  will  be  added  to  the  evidences  of  ordinarv  ulceration.  Tlie 
rapidity  with  which  these  sj)ecific  lesions  will  disapjjear  under  |)romj)t  and  vigorous 
constitutional  treatment,  along  with  that  local  cleanliness  which  should  include  removal 
of  necrotic  tissue,  is  surprising  and  gratifying. 

THE  EPIGLOTTIS. 

The  epiglottis  is  composed  of  yellow  elastic  cartilage  and  it  does  not  tend  to  calcifv 
during  the  later  years  of  life,  as  does  the  white  (jr  fibrocartilage  of  the  balance  of  the 
larynx.  Thus  its  elasticity  and  flexibility  are  fortunately  maintained  throughout  life. 
It  may  be  sometimes  injured  by  the  incised  wounds  elsewhere  described  un<ler  the  term 
"cut-throat,"  and  is  at  least  often  thus  exposed  when  not  actually  injurecl. 

The  epiglottis  seems  to  be  exempt  from  most  of  the  primary  diseases,  but  is  occasionally 
involved  in  lesions  of  surrounding  tissues,  in  which  it  may  then  participate.  Thus 
it  may  be  deformed  by  cicatricial  tissue  and  unduly  bound  down,  or  it  may  succumb 
to  advancing  ulceration  of  syphilis,  tuberculosis,  f)r  cancer.  Injuries  which  break  the 
lar}nigeal  box  rarely  affect  the  epiglottis  because  of  its  elasticity. 

While  an  extremely  useful  jiortion  of  the  body,  the  epiglottis  is  not  an  absolute  nece.ssity, 
for  even  after  its  removal  inflividuals  can  swallow,  although  the  act  requires  some  extra 
care.  Should  the  epiglottis  become  involved  in  cancerous  disease  it  should  be  removed 
with  the  rest  of  the  diseased  ti.ssue,  while  syphilitic  and  tuberculous  lesions  will  usually 
prove  amenable  to  a  combination  of  local  and  general  treatment.  Xew-growths  in  this 
region  are  extremely  uncommon,  but  will  prove  relatively  easy  of  removal  when  present. 

THE  LAR\T^. 

The  lar\Tigeal  cartilages,  save  the  epiglottis,  are  composed  of  white  fibrocartilage 
which  manifests  a  tendency  in  the  later  years  of  life  to  undergo  calcification.  This 
makes  the  organ  less  elastic,  changes  the  tonal  qualities  of  the  voice,  and  makes  it  more 
brittle  and  subject  to  possible  fracture  by  external  violence.  Fracinrcs  of  the  organ,  as 
of  the  adjoining  hyoid  hone,  have  been  elsewhere  discussed,  with  the  indications  which 
may  make  an  emergency  tracheotomy  necessary  because  of  hemorrhage  or  edema  of  the 
narrow  larnygeal  passage. 

Of  the  inflammatory  affections  of  the  cartilages  oJiondriiis  and  perichojuln'ti.s-  are  most 
common.  These  are  usually  seen  in  connecticju  with  other  expressions  of  tubercidous, 
syphilitic,  and  malignant  disease.  Nevertheless  they  are  known  to  occur  as  sequels  of 
the  exanthems  and  ordinarv  infectious  fevers.  They  may  be  followed  by  destructive 
ulceration,  which  will  lead  to  a  necrosis  of  the  cartilage  corresponding  do.sely  to  death 
of  bone  under  similar  circumstances.  In  due  time  there  may  form  a  cartilaginous 
.sequestrum,  and  this  will  require  removal  as  though  it  were  bone.  Dangers  attend  these 
lesions  in  two  peculiar  directions.  The  very  condition  which  produces  the  destructive 
inflammation  may  also  produce  either  hemorrhngr  or  ednna,  with  suffocation  which  can 
usuallv  be  prevented  by  an  emergency  tracheotomy.  On  the  other  hand,  when  repair 
follows  spontaneous  recovery  or  successful  treatment,  it  may  be  accompanied  by  such 
cicatricial  contraction  as  shall  materially  change  the  shape  and  impair  or  possibly 


684  SPECIAL  OR  REGIONAL  SURGERY 

destroy  the  function  of  the  hirynx  itself.  In  this  case  either  thyrotomy,  traclieotomy, 
or  laryngotomy  may  be  called  for,  the  opening  thus  made  being  expected  to  perma- 
nently remain. 

STRICTURES   OF  THE  LARYNX. 

Various  forms  of  siriciure  of  ihc  lanjn.x  may  be  similarly  j^roduced.  Such  strictures^ 
then,  are  due  to  previous  disease  or  to  injuries,  and  here  as  elsewhere  stricture  is  a 
consequence  rather  than  itself  a  disease.  It  occurs  in  consequence  of  syphilis  and  of 
the  tlestruction  following  lar^nigeal  diphtheria. 

What  is,  in  this  respect,  true  of  the  larMix  is  also  true,  though  less  often,  of  the  trachea, 
where  constrictions  may  occur  at  various  points,  with  reduction  of  caliber  or  such  distor- 
tion of  shape  as  to  produce  partial  or  even  finally  complete  obstruction.  The  peculiar 
scabbard-shape  which  the  trachea  may  be  made  to  assume  by  compression  between  the 
lobes  of  a  growing  goitre  has  l)een  elsewhere  described.  While  tlie  trachea  itself  is  in  this 
case  free  from  disease  the  obstruction  is  none  the  less  pronounced.  Similar  effects  are 
produced  by  pressure,  as  from  aneurysms  or  tumors,  even  at  a  distance.  Loss  of  voice, 
shown  to  be  due  to  paralysis  of  one  or  both  vocal  cords,  should  always  prompt  an 
examination  of  the  chest,  in  order  that  the  presence  of  an  aneurysm  or  other  tumor 
making  pressure  upon  the  recurrent  laryngeal  may  not  be  overlooked. 

Symptoms. — S}inptoms  of  lar}Tigeal  and  tracheal  stricture  comprise  (1)  those  of 
the  primary  and  active  disease  which  produces  them;  (2)  those  of  obstruction;  (3) 
those  of  suffocation  in  emergency  cases.  The  earlier  s\niptoms  are  those  of  increasing 
dyspnea,  which  may  vary  in  rapidity  and  extend  over  weeks  and  months,  or  which 
may  become  most  pronounced  within  a  few  hours.  There  is  also  a  change  in  the 
character  and  sometimes  complete  loss  of  voice,  hoarseness  of  the  speaking  voice 
changing  into  a  whisper.  The  condition  is  frequently  complicated  by  attacks  of  serious 
dyspnea,  often  at  night,  which  are  due  to  an  added  spasmodic  feature,  and  in  which 
death  may  suddenly  occur.  Usually,  however,  with  asphyxia  comes  muscular  relaxation, 
and  individuals  may  pass  through  a  large  number  of  these  attacks,  which  are  accom- 
panied with  extreme  mental  and  physical  suffering,  in  which  death  is  only  avoided  by 
final  relaxation.  Again  the  heart  may  suddenly  give  out,  and  then  the  case  becomes 
practically  hopeless.  In  recognition  of  causes  and  location  of  such  troubles  it  may 
be  held  that  when  hoarseness  precedes  dyspnea  the  lesion  is  in  the  larynx;  when  the 
reverse,  it  is  in  the  trachea.  Careful  auscultation  of  the  chest  and  thoroug-h  larvngo- 
scopic  examination  will  usually  enable  the  lesion  to  be  recognized.  The  lower  the  location 
of  the  stenosis  the  worse  the  prognosis,  because  of  its  inaccessibility.  So  long  as  the 
trachea  below  the  stricture  can  be  opened  life  may  be  prolonged  indefinitely;  but  when 
due  to  a  mediastinal  tumor  or  an  enlarged  tlnanus,  the  case  assumes  desperate  aspects 
and  may  bafHe  the  best-directed  efforts. 

Treatment. — Strictures  in  the  larynx  proper  may  be  treated  by  dilatation,  as  by  the 
introduction  of  intubation  tubes  of  increasing  size,  a  method  which  ordinarily  gives 
satisfactory  results.  Nevertheless  such  laryngeal  strictures  manifest  an  almost  ])ermanent 
tendency  to  recontract,  and  whatever  measures  are  addressed  to  them  have  to  be  frequently 
and  thoroughly  practised  and  over  a  long  period.  Fortunately,  however,  these  patients 
are  able  to  wear  an  O'Dwyer  tube  nearly  all  the  time.  When  these  internal  operative 
methods  fail  there  remains  only  an  external  opening,  which  may  be  made  through  the 
larynx  proper  (thyrotomy),  or  a  low  tracheotomy,  which  may  require  the  insertion  of 
short  or  long  tubes,  according  to  circumstances.  I^ong  trachea  tubes  are  made,  their 
lower  portion  being  composed  of  rings  fastened  together  in  such  a  way  as  to  cause  them 
to  be  called  lobster-tailed,  and  such  a  long  tube  may  be  passed  through  a  low  trache- 
otomy opening  and  made  to  extend  beyond  the  point  of  pressure  produced  by  an 
extrathoracic  or  an  intrathoracic  tumor.  By  the  use  of  such  an  expedient  life  may 
be  prolonged,  although  the  exciting  cause  may  prove  fatal. 

TUBERCULOSIS  OF  THE  LARYNX. 

Tuberculosis  of  the  larynx  may  appear  in  a  generally  disseminated  form,  involving 
nearly  all  the  structures,  or  in  circumscribed  localized  form,  as  a  tul)erculous  ulcer, 
which  may  produce  symptoms  depending  upon  its  exact  location.    Laryngeal  tubercu- 


Tl'liERCVLOSIS  OF   Tllh:  LAinXX  f,S5 

losis  iiiav,  moreover,  Ix-  Imt  ;i  local  expression  of  tlie  disease,  a|)|)areii(ly  pi'iiuarv,  or 
as  often  lia|)|)ens,  it  niay  he  an  aeeonipaninient  oi"  |»nlnionary  tnl)erenlosis,  the  laryni;eal 
troiihle  appearing  as  a  local  infection,  takin<f  place  hy  the  constant  passa^^e  over  the 
surface  of  tuberculous  sputum  which  the  patieut  is  ex|)ect()ratiufj;  at  frecjueiit  intervals. 
Thus,  eliuically,  we  may  have  a  miliary,  an  ulcerative,  or  a  gumuuitous  forui  of  the  disease. 

The  condition  is  freiiuently  referred  to  as  lartjnfjral  p/if/iisis;  and  is  mainly  to  he 
distiuguished  from  sy|)hilitic  laryn<ritis,  or  occasionally  from  eommcncinfi^  maliffnaut 
disease.  Local  .sijinpioni.s  include  those  of  chronic  laryngeal  catarrh,  with  hoarseness, 
iuipainnent  of  voice,  sensation  of  dryness  within  the  larynx,  and  fre(|uent  short,  hacking, 
unsatisfying  cough.  To  these  features  are  later  added  more  or  less  pain,  especially 
in  deglutition,  while  aphonia  will  finally  succeed  dysphonia.  When  the  e|)iglottis  and 
the  structures  near  it  are  involved  there  are  more  irritation  and  jjain.  Dyspnea  is  a 
measure  of  the  cneroaehment  upon  the  breathing  sj)aee  left  by  the  progress  of  the  dis- 
ease. Infiltration  of  all  the  i)arts  within  and  later  of  those  around  the  larynx  finally 
takes  place,  and  with  further  imj)licati()n  nervous  reflex  symj)toms  are  added  to  those; 
above  mentioned.  Cough  is  usually  a  distressing  feature;  the  S[)utuni  varies  in  amount ; 
saliva  is  increased  in  flow,  and  the  ex])ectoration  is  frecjuently  streaked  with  blood. 
In  advanced  disease  the  sufferings  of  the  patieut  become  excessive,  while  constitntionni 
symptoms  keep  ])ace  with  those  of  the  local  disease.  Thus  anemia,  emaciation,  del)ility, 
insomnia,  and  general  malaise  cause  the  patient  great  discomfort,  and,  coupled  with 
his  terminal  local  sym})toms,  make  death  an  absolute  relief. 

With  the  laryngoscope  varying  pictures  may  be  seen,  either  of  ulceration  or  of  general 
involvement  of  the  entire  interior  of  the  larynx,  which  will  be  tumefied,  irregularly 
swollen,  lUcerating  here  and  there,  while  the  vocal  bands  show  thickening  and  rough- 
enings  :!s  well  as  idcerations.  Gummatous  outgrowths  may  be  seen  at  almost  any  {)oint 
and  in  various  stages  of  ulceration.  A  more  distinctly  lujjoid  fonn  of  tuberculosis  is 
also  occasionally  seen  in  the  larynx,  w^here  it  assumes  more  of  the  nodular  aj)])earance 
characteristic  of  lujnis,  the  nodules  coalescing  or  disappearing  by  ulceration,  which  may 
leave  a  dense,  cicatricial  tissue  after  healing.     Primary  lupus  of  the  larynx  is  rare. 

Tuberculous  lesions  of  the  larynx  are  mainly  to  be  recogni/x'd  with  the  laryngoscope, 
but  they,  like  all  other  local  diseases  in  this  location,  produce  alteration  and  final  loss 
of  voice,  with  difficulty  of  breathing,  reflex  cough,  and  are  accompanied  by  general 
constitutional  symptoms,  according  as  the  disease  is  purely  local  or  an  expression  of  a 
general    affection. 

Treatment. — Treatment  should  be  both  local  and  general.  The  latter  may  be 
summarized  by  stating  that  all  measures,  including  proper  climatic  environment,  which 
are  found  to  be  of  advantage  in  ordinary  tul)ercid()us  disease,  will  prove  of  eqiuil  advan- 
tage here.  There  should  be  avoidance  of  exposure  to  all  irritation — coal  gas,  tobacco 
smoke,  vitiated  air,  etc. — while  absolute  rest  of  the  vocal  organs  should  be  prescribed 
and  all  attempts  at  singing  or  unnecessary  speaking  be  prohibited.  All  measures 
regarded  as  of  value  in  general  tuberculosis  will  find  an  equally  wide  field  for  their 
activities. 

Local  treatment  is  directed  toward  amelioration  of  discomfort  and  improvement  of 
local  lesions.  The  ff)rmer  may  be  afforded  by  steam  inhalations  with  some  soothing, 
volatile  antiseptic  added  to  the  spray,  such  as  methol,  oil  of  eucalyptus,  some  gentle 
opiate,  or  anything  that  may  give  local  anodyne  effect.  Cough  may  also  be  treated  by 
the  milder  anodynes,  of  which  cocaine  or  heroine  will  serve  for  most  instances.  Sleep 
is  to  be  secured  by  some  of  the  ordinary  hypnotics.  I^ocal  applications  may  be  made 
by  an  applicator  guided  by  the  laryngoscopic  mirror,  by  the  medical  attendant, 
or  through  watery  or  oleaginous  solutions  in  a  spray.  F'or  absolute  local  relief  a 
mild  cocaine  solution,  followed  by  the  use  of  a  very  weak  solution  of  silver  nitrate,  lactic 
acid  (C.  P.),  or  even  the  more  thorough  treatment  of  local  ulceration  by  means  of  the 
laryngeal  curette  or  touching  with  the  point  of  the  galvanocaustic  loop,  may  give  relief. 
The  treatment  of  laryngeal  tuberculosis  rarely  comes  within  the  domain  of  surgery 
proper,  imtil  the  disease  has  reached  a  degree  necessitating  some  radical  measure, 
such  as  thyrotomy,  with  crasion  of  the  affected  tissue,  or  possibly  a  laryngectomy,  with 
complete  removal  of  an  organ  which  is  too  thoroughly  diseased  to  warrant  hope  of 
repair. 


686 


SPECIAL  OR  REGIONAL  SURGERY 


SYPHILIS  OF  THE  LARYNX. 

Syphilis  of  the  hirviix  is  more  common  tluui  tiihcrculosis,  the  lesions  usually  belonging 
to  the  later  stages  of  tlu>  (hseases,  inchiding  especially  inucons  patches,  and  the  ulcerative 
expressions,  with  or  without  the  formation  of  small  gnnunatous  tumors.  The  loss  of 
voice  is  rarely  as  pronounced,  and  the  entire  course  of  the  disease  is  accomj)anied  l)y  less 
irritative  and  offensive  features  than  is  tuberculosis.  Diagnosis  will  l)e  materially  assisted 
l)y  the  discovery  of  suggestive  expressions  of  syphilis,  either  in  adjoining  or  distant  parts. 
Thus  if  mucous  patches  aj)j)ear  within  the  larynx  they  will  also  be  seen  within  the  mouth. 
Ulcers  which  are  produced  by  syphilis  have  well-(lefined  edges,  and  are  rarely  multiple; 
while  those  produced  by  tuberculosis  are  more  often  multi})le,  are  seated  upon  an  anemic 
base,  produce  more  distortion  of  laryngeal  structures,  and  more  residue  of  cicatricial 
tissue  at  points  where  healing  has  occurred. 

Treatment. — The  treatment  of  laryngeal  syphilis  is  essentially  constitutional,  for 
nearly  every  local  exjjression  will  clear  up  under  the  influence  of  properly  directed 
remedies.  However,  when  local  symptoms  are  imcomfortable  or  de[>ressing  they 
may  be  treated  as  are  those  of  tuberculosis,  by  soothing  sprays  and  the  local  application 
of  anesthetics,  astringents,  and  the  like. 


INTRALARYNGEAL  AND  INTRATRACHEAL  TUMORS. 

Within  the  larynx  tumors  may  occu|)y  the  space  beneath  the  glottis,  where  they  are 
referred  to  as  subglottic;  they  may  grow  from  the  structure  of  the  vocal  cords  and  l>ecome 
intraglottlc,  or  they  may  spring  from  above  the  glottis  and  from  the  aryteno-epiglottic 

fold.  Certain  forms  of  benign  tumor  are  rela- 
tively common  in  this  location,  while  others 
are  almost  imknown.  The  former  include  cysts, 
papillomas,  fibromas,  angiomas,  and  adenomas, 
as  well  as  the  ordinary  granidomas. 

A  nodular  lesion  seen  upon  tlie  vocal  cords, 
especially  in  singers,  which  is  hyperplastic  in 
character,  irritative  in  origin,  and  often  called 
"singer's  node,"  is  frequently  found  upon  the 
etlges  of  the  cords,  cither  as  a  single  or  l)ilateral 
lesion.  The  adjoining  structures  are  usually 
fjuite  vascular.  These  lesions  occur  in  those 
who  al)use  their  voices,  as,  for  instance,  in 
amateur  singers  and  newsboys.  The  nodules 
themselves  vary  in  size  from  that  of  a  pin's 
head  to  that  of  a  split  pea.  The  condition 
produces  hoarseness  and  impairment  of  the 
voice,  is  recognized  with  the  laryngoscope,  and 
is  amenable  to  treatment,  Avhich  should  consist 
in  absolute  rest  from  vocal  effort  and  gentle 
astringent  and  stimulating  a])plications.  If 
the  node  project  very  far  it  may  be  removed 
by  the  intralaryngeal  guillotine. 

Lari/ngcal  poh/pi  include  the  forms  of  benign 
tumor  above  mentioned,  most  of  which  assume 
in  time  a  polypoid  form,  and  cause  impair- 
ment of  function  according  to  their  location. 
Papilloma  is  by  all  means  the  most  com- 
mon of  these  growths,  and  may  present 
either  the  vascular  type,  bleeding  easily  and 
growing  rapidly,  or  the  firmer  and  denser  type  from  admixture  with  fibromatous 
tissue.  It  occurs  frequently  in  the  young,  and  may  even  be  present  in  the  newborn. 
Here  it  can  scarcely  be  detected  with  the  laryngoscope,  but  may  be  felt  with  the  finger. 
Cysts  take  their  origin  from  the  mucosa,  save  those  which,  possibly  of  embryonic 
character,  protrude  into  or  encroach  upon  the  larynx  from  without  (Fig.  481). 


Multiple  papilloma  of  larynx.      (Bergmann.) 


M.\ij(;.\A.\'r  TiMoh's  oi''  Till':  a.iat.v.v  .wd  ti{.\('Iii:.\  cs? 

Symptoms.  'I'hc  .syiii|)(()iii.s  of  I)(.'iii<i;ii  iiitralaryii^i-al  ^rrowtlis  arc  lar^^^cly  irrita- 
tive, iiKliidiiif^  couf^li,  witli  hoarseness  and  chaiifiie  of  voice,  and  <foin^  on  lo  |tro- 
dnction  of  dysj)nca  in  |)ro|)ortion  to  the  size  whicli  they  attain.  Later  complete 
aplionia,  with  spasm  of  the  fflottis,  may  be  the  result  of  their  presence,  while 
pedunculated  <rro\vtlis,  or  poly|)i  with  lon<,'  |)cdiclcs,  may  cause  afi;fi;ravated  symptoms 
by  circumstances  of  position,  the  patient  l)ein<^  nuicli  of  the  time  relatively  free.  Hoarse- 
ness, dvs|)nea,  and  cough,  without  other  evi<lences  of  iidlanuuation  or  epidemic 
disease,  should  always  lead  to  careful  inspection  with  the  laryn<!;oscope,  and. this  will 
reveal  the  size  and  situation  of  the  growtii.  'i'liese  examinations  can  be  made 
with  cocaine  and  <jive  satisfactory  iid'ormation.  Only  in  younjr  children  are  they 
dinicult,  or  sometimes  impossible.  Even  in  an  infant  with  a  hoarse  cry  and  spasmodic 
or  sutVocative  attac-ks  the  coiulition  may  be  suspected. 

Prognosis. — The  proijnosis  will  dej)en(i  uj)on  the  character  of  the  tumor  and  the  local 
conditions  /.  c,  size,  fixation,  location,  (>tc.  In  the  youn<;  it  is  serious  because  of 
the  dano;er  attendin<>;  its  removal.  Rational  adults  can  be  usually  jMit  in  excellent  condi- 
tion for  endolaryno;eal  o|)eration  by  the  aid  of  local  anesthesia,  and  expert  spe(  iaiists 
become  dexterous  in  their  inani[)uiation  of  the  specially  shaped  force|)s,  curettes,  and 
the  like  which  are  reijuired  for  removal  of  these  <rrowths.  As  elsewhere  a  truly  innocent 
tumor  in  this  location  does  not  recur  after  complete  extirpation. 

MALIGNANT  TUMORS  OF  THE  LARYNX  AND  TRACHEA. 

Of  these  tumors  the  most  common  is  cpithelicmia  iritliiii  the  larynx.  Sarcoma  occa- 
sionally ori<:;inates  from  the  vocal  bands,  true  or  false,  and  will  usually  form  a  nodular 
tumor,  of  ru<i;ose  surface,  until  it  begins  to  ulcerate.  Once  it  begins  to  break  down  it 
is  difficult  to  distinguish  from  the  other  varieties  without  the  aid  of  the  microscope;  but 
epithelioma  may  be  met  with  in  any  part  of  the  larynx,  generally  arising  from  the  ven- 
tricular bands.  Here,  as  ordinarily  upon  mucous  surfaces,  it  begins  as  a  small  nodule 
with  a  definite  zone  of  infiltratitju  about  it;  if  seen  early  it  may  be  mistaken  for  innocent 
papilloma.  As  infiltration  progresses  the  hoarseness  resulting  from  its  presence  will 
change  to  loss  of  voice,  !)ecause  of  the  fixation  of  the  tissues  whose  mobility  is  essential 
to  voice  production.  Pain  may  be  an  early  feature,  dei>ending  upon  ulceration  and 
exposure  (jf  sensory  nerve  endings.  Later  when  the  ulcerated  surface  has  become  deep, 
irregularly  covered  with  fetid  discharge,  and  more  or  less  concealed  by  edematous 
surroundings,  the  |)icture  is  more  complete  in  one  respect,  although  the  details  may  l)e 
obscure.  From  the  mucous  and  softer  tissues  the  disease  will  spread  and  invade  the 
cartilages  themselves,  as  well  as  the  tissues  outside,  and  so  with  the  progress  of  the 
cancer  the  entire  larynx  becomes  fixed  in  a  bed  of  infiltrated  tissue  extending  in  all  direc- 
tions, involving  the  "up])er  j)art  of  the  trachea,  the  ejiiglottis,  and  the  base  of  the  tongue. 
INIeantime  the  loss  of  voice,  the  distressing  cough,  and  the  other  evidences  of  local  inva- 
sion will  have  kept  pace  with  the  progress  of  the  disease,  and  dyspnea  \yill  come  on 
sooner  or  later  as  the  j)assage-way  becomes  blocked,  while  from  sudden,  violent  efiorts 
at  coughing  acute  attacks  of  edema,  which  may  result  fatally,  are  liable  to  occur.^ 

Tumors  of  the  trachea  pro|)er  are  far  less  common.  They  may  be  l)enign  or  malignant. 
Li  either  event  they  will  prove  to  be  of  about  the  same  type  as  those  already  discussed 
above  as  occurring  within  the  larynx.  They  cause  less  interference  with  speech,  l)ut 
as  much  or  even  more  difficulty  in  respiration. 

When  tracheotomy  was  a  frequent  resort  in  croup  and  diphtheria  a  peculiar  form  of 
new  formation  in  the  trachea  was  occasionally  encountered,  resulting  from  the  irritation 
of  the  trachea  tube,  whose  presence  sometimes  provokes  excessive  formation  of  granula- 
tion tissue,  whose  subse(iuent  contraction  brings  about  not  only  the  formation  of  a  dense 
granuloma,  but  cicatricial  contraction.  Hence  in  the  ohler  literature  references  to 
granulation  stenosis  were  common.  Now  that  intubation  has  almost  completely  replaced 
tracheotomy  for  these  purposes  the  latter  is  rarely  performed,  and  tubes  are  seldom  left 
more  than  a  day  or  two  in  situ,  so  that  this  kind  of  local  provocation,  with  its  conse- 
quences, is  rarely  encountered. 

It  mjiy  be  possible  by  expert  use  of  the  laryngoscope  to  see  a  tumor  located  within  the 
trachea.  If  the  patient  cannot  tolerate  its  use\he  parts  may  be  made  tolerant  by  the  use 
of  a  Aveak  cocaine  s{)ray.     Such  a  growth,  if  accessible  from  above,  may  be  removed 


688  SPECIAL  OR  REGIONAL  SURGERY 

through  the  glottis  by  forceps.  INIost  operators,  however,  |)refer  to  make  an  opening 
through  the  trachea  and  thus  profit  by  tlie  hirger  surgical  opportunities  thus  afforded. 
Such  an  operation  should  be  made  with  the  patient's  head  low  in  order  that  blood  may 
gravitate  to  the  pharynx  rather  than  to  the  lungs. 


OPERATIONS  UPON  THE  LARYNX. 

Cancer  of  the  larynx  was  regarded,  luitil  the  last  (juarter  of  the  previous  century,  as  an 
absolutely  hopeless  condition  for  which  nothing  could  be  done  until  it  became  necessary 
to  do  a  tracheotomy,  this  simply  affording  relief  from  some  of  the  distressing  features, 
but  aiding  nowise  to  check  the  })rogress  of  the  growth.  The  first  demonstration  of 
the  possibility  of  successful  removal  of  the  larynx  was  made  by  Czerny,  in  1870,  upon 
tlogs.  Watson,  of  Edinburgh,  had  removed  a  syphilitic  larynx  in  ioto  in  1866,  but  this 
summary  operation  only  became  known  to  the  world  thnnigh  a  publication  of  Foulis  in 
1881.  Meantime,  Czerny's  experiments  w^ere  so  successful  that  Billroth  was  induced  to 
attempt  the  removal  of  the  entire  larynx  in  a  case  of  cancer,  with  results  which  astonished 
the  profession  of  that  day.  Thus  introduced,  nevertheless,  the  mortality  rate  was  great, 
the  principal  cause  of  death  being  inspiration  pneumonia — that  is,  rapid  infection 
of  the  lung  through  the  widely  opened  trachea  and  the  entrance  of  saliva  and  fluids  from 
the  mouth.  Hahn,  of  Berlin,  undertook  the  improvement  of  the  technicjue  and  was 
able  to  reduce  the  mortality  from  this  cause.  INIeantime  another  radical  method — 
namely,  thyrotomy,  i.  e.,  opening  the  lar}Tigeal  box — had  not  fared  much  better  than  the 
measure  just  mentioned.  Thus  until  about  tw^enty-five  years  ago  the  radical  treatment 
of  laryngeal  cancer  stood  in  an  unpleasant  light,  partly  because  diagnostic  methods 
were  unsatisfactory  and  our  general  knowledge  of  the  disease  incomplete,  partly 
because  operation  was  always  delayed  until  late,  and  because  operative  measures  had 
yet  to  be  much  improved.  Tremendous  impetus  was  given  to  the  whole  subject  by 
the  celebrated  case  of  the  Emperor  Frederick,  and  the  acrimonious  criticisms  concerning 
its  conduct  were  not  without  benefit,  since  they  led  to  a  careful  re-study  of  the  whole 
situation,  with  its  numerous  subsidiary  questions,  among  which  was  the  possibility  of 
transformation  of  a  benign  into  a  malignant  tumor.  x\t  present,  largely  through  the 
labors  of  Hahn  and  Billroth,  in  Germany,  and  Semon,  in  London,  the  question  of 
operative  procedures  is  fairly  settled,  everyone  now  belie^^ng  that  the  disease  should 
be  radically  attacked  at  the  earliest  possible  moment,  opinions  differing  only  in  regard 
to  the  route  which  the  surgeon  should  adopt,  /.  e.,  whether  he  should  make  an  intralarvn- 
geal  operation,  as  is  now  favored  in  Germany;  a  th^Totomy,  as  preferred  in  Great  Britain, 
or  a  laryngectomy,  as  some  of  the  general  surgeons  in  all  parts  of  the  world  prefer. 

The  different  methods  of  attack  upon  the  larynx  for  cancer  may  then  be  summarized 
as  including  intralaryngeal  extirpation  through  the  natural  jiassages,  thyrotomy,  and 
partial  or  complete  laryngectomy. 

The  intralaryngeal  method,  seen  from  the  general  surgeon's  view-point,  can  only  be 
suitably  applied  to  a  limited  class  of  cases  which  are  recognized  early,  and  may  be 
best  performed  by  an  expert  laryngologist,  i.  e.,  one  accustomed  to  instrumentation 
within  the  pharynx  and  larynx.  It  includes  the  use  of  various  instruments  for  the  excision 
of  small  areas,  for  the  application  of  the  galvanocautery,  etc.  The  writer  agrees 
with  Semon  in  regarding  it  as  irreconcilable  with  the  principles  which  should  guide  us  in 
dealing  with  malignant  growths,  the  fundamental  one  being  the  removal  not  only  of 
the  growth  itself  but  of  an  area  of  surrounding  tissue.  This  intralaryngeal  method 
may  then  be  satisfactory  in  the  removal  of  benign  growths,  but  will  seldom  appeal  to 
the  operating  surgeon  when  he  deals  with  cancer.  Epithelioma  may  commence  at  the 
accessible  tip  of  the  epiglottis,  but  intrinsic  cancer  of  the  larynx  should  be  dealt  with  in  a 
more  radical  manner.  Thwotomy  is  the  operation  of  choice,  especially  among  the  British 
laryngologists.  It  seems  rational  to  believe  that  in  cases  where  diagnosis  is  made 
early  a  thyrotomy,  w  ith  removal  of  the  growth  and  a  wide  area  of  surrounding  tissue, 
including  portions  of  cartilage,  if  necessary,  may  prove  the  ideal  o])eration,  while  vocal 
results  are  lietter  than  after  extirpation.  It  is  necessary,  however,  that  diagnosis  should 
be  mafle  early  and  that  operation  be  made  thoroughly;  while  if,  after  opening  the  thyroid, 
it  should  appear  that  complete  extirpation  of  the  grow^th  is  otherwise  impossible,  then 
the  operator  should  make  a  complete  laryngectomy. 


OI'KUATIOSS   r/'O.V    Till-:   LAUYSX  {\^i) 

All  of  llicsc  ()|)('niti(>iis  arc  best  |)rc('('tlc(l  hy  use  (if  a  cocaiiit'  .s|)ray,  \\\  wliidi  cxtrciiic 
irrilal)ility  ol'  tjic  iiilffior  ol"  (lie  larviix  is  allaycti,  and  the  reflex  lowering  of  hlood 
l)re.s.sure  |)reveiite(l.      (Seep.  ITS.) 

T/iijrotoini/  i.s-  prrjormvd  (is  fo/loirs:  The  ])atieii(  is  |)referal)ly  in  tlie  position  with  dowii- 
hantjinj;  head.  An  incision  in  the  ine(liaii  line,  alxiut  three  inches  in  ienfjth,  is  made 
from  tile  np|)er  hortler  of  the  thyroid  cartilajfc  down  lo  a  |)oint  l)elo\v  the  cricoid.  With 
hut  slio;lit  sc|)arati()n  of  the  tissnes  it  is  made  to  t-xtend  directly  down  upon  the  al)ru[)t 
ridijc-like  anterior  horderof  the  thyroid  cartilaije,  lu'iow  which  will  he  exposed  the  crico- 
thyroid menihranc.  Into  this  tlie  knife  may  he  inserted  and  made,  with  cutting  ed^c 
U|),  to  split  the  halves  of  the  larynx  exactly  in  the  middle  line,  the  hiade  jjassint;  hetweeii 
the  vocal  cords,  unless  they  have  heen  nuich  distorted  hy  the  f^rowth.  In  that  case  the 
di.ssectioii  may  l)e  made  more  deliherately.  The  larynx  heinif  thus  split,  the  cricf)id 
should  he  divided,  after  which,  with  suilahlc  retractors,  the  interior  is  exposed  to  such 
an  ext(Mit  as  to  j)ermit  both  inspection  and  ])aipation.  Throui^h  the  openiufr  thus 
afforded  all  susj)icious  tissue  should  he  removed,  from  one  side  or  holli,  the  j)riinary 
(juestiou  I)ein<r  not  what  will  l)c  the  resultant  effect  upon  the  voice,  but  liow  hcst  to  com- 
pletely eradicate  the  cancerous  tissue.  With  the  j)atient's  head  hanging  downward 
there  is  less  likelihood  of  the  entrance  of  hlood  into  the  trachea.  Nevertheless  the 
tampon  raiinula  should  always  he  accessihle  so  that  it  may  he  inserted  should  it  he 
required.  The  tam])()n  cannula  is  a  trachea  tuhe  around  which  there  is  a  small  rul)her 
hag,  with  a  tuhe  (hrougli  which  it  may  he  inflatecl,  so  that  after  the  cannula  is  introduc-ed 
into  the  trachea  it  may  he  tamponed  hy  air  pressure  in  such  a  manner  as  to  permit  no 
passage  of  hlood. 

In  the  ahsence  of  one  of  these  specially  designed  tuhes  an  effective  substitute  may  he 
made  hy  the  ordinary  trachea  tuhe  wrapped  with  a  covering  of  antiseptic  gauze,  the  latter 
held  in  place  hy  a  few  turns  of  fine  silk  or  catgut. 

The  thyrohyoid  membrane  bears  the  superior  laryngeal  vessels  and  nerves,  and  it  should 
be  entered  through  the  middle  line  in  order  not  to  disturb  these.  Whatever  o])eration 
may  he  required  upon  the  tissues  within  the  laryngeal  box  may  he  conducted  with  knife, 
scissors,  curette,  and  the  fine  ])oint  of  the  actual  cautery.  The  interior  of  the  lar>7ix 
should  l)e  cleaned,  leaving  it  simply  as  a  part  of  the  respiratory  tuhe,  without  reference 
to  what  may  become  of  the  structures  within  it  devoted  to  voice  production.  The  car- 
tilaginous shell,  wdth  or  without  a  part  of  its  previous  contents,  having  heen  rid  of  the 
suspicious  tissue  within,  it  may  he  held  together  by  one  or  two  sutures  of  silver  wire 
or  hy  su])erficial  sutures  of  chromic  gut,  while  the  trachea  tuhe  which  may  have  heen  used 
may  he  left  for  a  day  or  two,  or  remov^edat  the  time.  Ordinarily  the  latter  course  will 
prove  the  better. 

Lari/n(/rrt(>mi/,  or  total  extirpation  of  the  larynx,  is  the  most  severe  procedure  of  all, 
hut  will  he  requisite  when  there  is  evidence  of  escape  of  malignant  growth  from  witliin 
the  true  confines  of  the  laryngeal  box.  Not  only  the  larynx  hut  more  or  less  of  the  sur- 
rounding tissue  may  be  removed,  with  infected  neighboring  lymphatics,  the  upper  portion 
of  the  trachea,  and  the  base  of  the  tongue. 

The  operation  may  he  preceded  hy  a  low^  tracheotomy  or  otherwise.  If  necessary  this 
should  he  done  several  days  in  advance,  in  order  that  the  patient  may  have  become 
tolerant  of  the  tube  and  of  the  new  method  of  breathing.  If  requisite  the  ordinary 
trachea  tube  may  be  substituted  for  the  tampon  tul)e  above  described,  in  which  case 
it  will  not  be  necessary  to  lower  the  patient's  head.  Otherwise  the  operation  is  perhaps 
best  performed  with  the  head  and  neck  in  the  Rose  position. 

The  incision  is  a  long  median  division  of  tissues  from  above  the  hyoid  to  an  inch  or 
more  below  the  cricoid  cartilage.  Through  it  the  anterior  border  of  the  thyroid  shoidd 
be  easily  exposed.  It  is  then  necessary  to  separate  on  either  side  the  sternohyoid  and 
sternothyroid  muscles,  the  lateral  mass  of  the  thyroid  body  being  drawn  to  either  side 
along  with  the  musculature,  the  isthmus  ha\ing  been  previously  doubly  ligated  and 
dividetl  for  this  ]nn-pose.  Now  as  rapidly  as  may  he  the  larynx  is  completely  isolated 
from  all  the  structures  around  it,  the  dissection  being  l)luntly  made.  After  freeing  it 
on  both  sides  it  is  drawn  forward,  first  to  one  side,  then  to  the  other,  so  that  on  either 
side  the  superior  laryngeal  artery  may  he  exposed  and  secured,  the  superior  laryngeal 
nerve  being  necessarily  diA-ided.  The  cricothyroid  branches  need  also  to  he  secured, 
as  well  as  any  other  vessels  which  may  spurt  hlood.  Circumferential  isolation  of  the 
larynx  is  now  completed  by  dividing  the  inferior  constrictor  of  the  pharynx  and  separat- 
44 


(590  SPECIAL  OR  REGIONAL  SURGERY 

ill"-  it  t'roiii  the  sitlc  of  tlu-  tliyroid,  kccpitiff  close  to  tlic  cMrtila^i'.  After  this  isolation  is 
oomplett'd  the  siiriiX'oii  has  the  choice  of  first  (lividint;  the  respiratory  tulx-  either  aliove 
or  below  the  larviix.  This  will  depend  lartjely  upon  his  own  choice,  hut  usually  the  j)r()- 
cedure  is  easier  when  the  first  division  is  made  either  through  the  cricothyroid  nienihrane 
or  between  the  cricoid  and  the  uj)])er  rinf>;  of  the  trachea  or  even  behnv  this  point,  if 
necessary.  With  a  low  division  first  the  })atient  will  immediately  begin  to  breathe  through 
the  o|)ening  thus  made  unless  a  previous  tracheotomy  has  been  done.  Ample  time  will 
be  afl'orded  for  the  introduction  of  a  trachea  tube  and  protection  around  it  to  j)revcnt 
entrance  of  l)lood,  when  the  larynx  may  be  lifted  and  se])arated  with  knife  or  scissors 
from  the  tissues  remaining  attached.  The  esophagus  begins  at  the  level  of  the  cricoid 
cartilage,  and  if  the  cricoid  is  to  be  removed  the  esoj)hagus  should  be  scjiarated  from  it; 
otherwise  it  is  not  disturbed.  Last  of  all,  in  this  order,  the  thyrohyoid  membrane 
will  require  division,  and  then  the  extirpation  is  completed. 

The  wound  is  large,  the  communication  with  the  oropharynx  is  unobstructed,  and  there 
will  be  constant  escape  into  the  newly  formed  cavity  of  secretions  from  the  nose  and 
mouth.  .Vt  first  the  patient  will  be  unable  to  swallow,  althotigh  there  may  be  constant 
desire  to  reflex  attempts  in  this  direction.  The  (juestions  to  be  decided  are  the  manage- 
ment of  the  wound  in  gross  and  the  suitable  treatment  of  the  ujiper  end  of  the  trachea, 
as  well  as  of  the  es()])hagus,  if  this  has  been  touched.  The  greatest  danger  is  that  of 
ins|)iratioii  j>neumoiiia.  Other  consideration  should  be  secondary  to  that  of  ])rcvention 
of  the  esca])e  of  fluids  down  the  trachea  and  the  consequent  ])roduction  of  pneumonia. 
General  experience  is  rather  to  the  efi'ect  that  the  best  results  are  obtained  with  a  mini- 
mum of  sutures,  the  large  ca\ity  being  lightly  packed  with  absorljent  material,  while  the 
upjjer  end  of  the  trachea  should  be  sewed  to  the  skin  as  high  as  possible  on  either  side, 
the  esophagus  being  allowed  to  take  care  of  itself.  The  patient  should  w^ear  a  trachea 
tube  for  several  days  after  the  operation.  Through  the  exposed  upjier  end  of  the  esopha- 
gus a  tube  may  be  i)assed  three  or  foiu"  times  a  day,  and  sufficient  nourishment  be  thus 
introduced  into  the  stomach.  The  jiatient  may  l)c  kcj)t  lying  upon  the  side  for  the 
greater  ])art  of  the  time,  so  that  saliva  may  escape  from  the  mouth. 

The  question  comes  up  later  as  to  what  substitute,  if  any,  may  be  afforded  for  the  lost 
larvnx.  ( lUsscnbauer  devised  an  improvement  on  what  was  called  the  "artificial  larynx," 
devised  origiiuilly  by  Foulis  and  then  modified  by  Hahn,  which  afforded  an  ingenious 
mechanical  substitute  for  the  larynx,  permitting  the  ])ro(luction  of  voice  by  vibration  of 
a  metallic  reed,  such  tone  as  it  produced  being,  like  that  produced  by  the  vocal  cords, 
modified  bv  the  vocal  organs  above  into  j^erfectly  intelligible  sjieech,  but  always  in  a 
monotone.  It  consisted  of  a  tracheal  tube  through  whose  external  o])ening  another  tube 
could  be  passed  uj)ward  to  a  point  where  it  lay  beneath  the  epiglottis,  if  this  were  left 
in  situ,  or  behind  the  base  of  the  tongue,  if  the  epiglottis  had  been  removed.  Tlirough 
this  the  ))aticnt  could  breathe  under  ordinary  circumstances.  By  a  little  ilcvice  at 
the  external  opening  the  touch  of  the  finger  upon  a  s])ring  would  throw  into  the  air 
current  a  thin,  metallic  reed,  by  whose  vibrations  tone  was  ])roduced,  to  be  modified  as 
mentioned  above.  This  was  the  principle  of  the  artificial  larynx  w^hich  w^as  worn  by 
many  patients  and  which  in  many  gave  good  results.  One  patient  of  my  own  wore 
one  for  seven  years,  although  he  discontinued  using  the  reed  because  the  peculiarity 
of  the  tone  attracted  more  attention  than  did  the  loud  "stage  whisper"  which  he  had 
cultivated.  Around  the  instrument  there  is  always  more  or  less  moisture  or  discharge, 
and  there  are  many  disagreeable  features  attending  its  use,  even  though  it  permit  the 
act  of  swallowing  without  any  difficulty. 

Solis  Cohen  introduced  a  method  of  treating  these  cases  by  fastening  the  trachea  to 
the  external  wound  and  ])ermitting  the  cavity  above  to  close  as  rajiidly  as  ])ossible.  In 
this  way  the  trachea  is  permanently  terminated  in  the  middle  of  the  neck  and  j)aticnts 
breathe  through  this  opening.  It  has  been  found  that  with  practice  they  can  retain 
sufficient  air  in  the  mouth  and  pharyngeal  cavity  to  permit  them  to  whisper  several 
words  at  a  time.  This  simplifies  the  procedure,  and  is  now  usually  adopted  after  extir- 
pation of  the  larynx. 

Partial  laripujrctomies  have  been  practised  through  external  openings,  one  lateral 
half  or  more  of  the  larynx  being  removed.  These  operations  have  been  few  in  number 
and  often  unsatisfactory.  They  should  be  reserved  for  cases  with  favoral^le  indications. 
When  recjuircd  they  are  performed  f)n  the  same  principles  as  those  already  outlined, 
only  the  extirpation  is  incomplete.     Certain  modifications  have  been  proposed  by  indi- 


()ri:i>ATi()\s  r/'o.v  vv//-;  ti{.\('iii:a 


cm 


viduals,  as,  lor  instance,  the  sii;;<,fcsti<)ii  made  l)y  (iliuk,  to  suture  the  operiinjr  in  tin- 
trachea  lo  a  huttoiihole  o|)eiiiii<r  made  in  the  overlying  skin,  by  whicli  iiicans  lie  thought 
to  prevent  inspiration  piicnnioiiia. 


OPERATIONS  UPON  THE  TRACHEA. 

Traclu'otoiny  is  the  general  (erni  ina<h'  to  coxcr  any  opening  into  the  lower  air 
passages  hetween  the  laiynx  proper  and  the  n|)per  end  oi'  the  sternum.  Laryn- 
gotomy,  crieotrai'heotomy,  tracheotomy,  etc.,  may  Ik;  descrihed  us  implying  l)y  these 
names  the  exact  location  ol'  the  ojjcning.  The  |)rinciple  is,  however,  the  same,  and  the 
details  of  the  operation  vary  hut  little. 

Tracheotomy  as  a  deliberate  oi)eration  is  dill'ercnt  from  tracheotomy  as  it  was  rormerly 
))ractised  for  diphtheria,  and  as  it  is  y(;t  done  in  emergencies,  some  cases  being  so  serious 
that  snil'ocation  will  occur  il'  the  opening  be  not  promptly  aH'orded.  In  the  former  case 
l)reparations  can  be  made;  in  the  latter,  operation  may  have  to  be  done  with  the  blade  of 
a  pcidvuife.  It  makes  considerable  dilVerence  also  whetlu>r  an  anesthetic  can  be  used. 
To  administer  chloroform  to  a  child  with  a  heart  already  weakened  l)y  the  toxins  of 
diphtheria  is  almost  to  invite  disaster,  and  yet  to  do  the  operation  without  an  anesthetic 
is  perhaj)s  impossible. 

The  middle  line  /.v  flie  line  of  snjelji  in  all  of  thes{>  operations.  The  danger  of  heart 
failure  from  the  anesthetic,  or  of  suffocation  from  tardiness  of  relief,  being  passed,  the 
other  principal    danger  is  that  of   hemorrhage.     The  isthmus  of  the  thyroid  may  be 

Fic.  482 


l'i)>itioii  III' patient  f(ir  tracheotomy.       (Wliarlun. ) 

divided,  but  always  with  preliminary  ligatures,  or  it  should  be  caught  between  the  blades 
of  pressure  forcej)s  on  either  side  before  dividing  it.  A  j)atient  with  a  short,  fat  neck, 
whose  cervical  veins  are  dilated  and  engorged  with  venous  blood  owing  to  partial 
asphyxia,  makes  a  difficult  and  undesiral)le  subject.  The  trachea  lies  nearer  the  surface 
at  its  laryngeal  end  than  in  its  lower  portion — i.  e.,  if  the  operation  be  low  in  the  neck 
deep  search  will  have  to  be  made  for  the  tube.  The  first  incision  should  be  made  suffi- 
ciently long,  never  less  than  two  inches,  and  should  be  so  planned  as  to  bring  the  operator 
down  upon  the  tracheal  rings.  By  this  time  sufficient  engorged  veins  may  have  been 
divided  to  cause  a  serious  oozing  of  dark,  venous  blood,  by  which  the  field  of  vision  is 
much  obscured.  r]xcei)t  in  emergencies  the  surgeon  may  wait  for  this  engorgement 
to  be  relieved.  The  trachea,  being  recognized  by  the  finger-tip,  is  seized  with  a 
tenaculum,  by  which  it  may  be  held  forward,  and  then  at  least  two  of  its  rings 
divided  with  the  knife-blade.  The  instant  the  opening  is  made,  if  the  patient  be  still 
breathing,  bloody  foam  and  frothy  blood  will  be  ejected,  and  for  a  moment  or  two 
the  bleeding  may  be  uncontrollable.  Under  these  circumstances  the  normal  blood  color 
soon  returns.  Artificial  respiration  should  be  practis(>d  at  the  same  time.  Supposing 
this  to  be  an  emergency  case,  with  little  or  almost  nothing  at  hand,  sutures  should  be 
passed  through  the  tracheal  oixMiing  and  through  the  skin  margin  on  either  side.  If  no 
other  retractor  be  at  hand  the  suture  materials  m:iy  be  left  long  and  tied  behind  the 
back  of  the  neck,  sufficient  tension  being  made  to  prevent  the  wound  edges  from  coming 
together.     Formerly  when  the  surgeon  was  called  to  do  this  operation  with  little  or  no 


692  SPECIAL  OR  REGIONAL  SURGERY 

help  the  writer  has  extemporized  a  couple  of  retractors  out  of  hair-pins,  bent  for  the  pur- 
pose, hooked  into  the  tracheal  wound,  then  tied  with  tapes,  which  were  luiitcd  behind 
the  neck,  while  the  wires  were  kept  from  l)eino;  j^ulled  out  of  place  by  a  skin  suture  on 
each  side.  There  is  now  less  occasion  for  these  crude  methods  since  the  introduction  of 
O'Dwyer's  intubation. 

With  trarheotomij  done  drliheraU'ly,  and  at  the  point  of  election,  usually  above  the 
thyroid  isthmus,  with  or  without  division  of  the  cricoid,  the  vessels  may  be  secured  as 
they  are  ex|)()sed  or  bleed,  and  the  trachea  should  not  be  opened  until  all  oozing  from  its 
exterior  has  been  checked.  For  this  purpose  the  patient  is  placed  upon  the  back,  the 
shoulders  raised,  the  head  thrown  backward,  and  the  neck  exposed,  a  pillow  being  placed 
beneath.  (See  Fig.  482.)  The  operation  may  be  done  under  cocaine  local  anesthesia 
or  with  a  general  anesthetic.  Incision  in  the  middle  line,  below  the  lower  border  of  the 
thyroid  cartilage,  is  made  two  inches  or  so  downward,  the  fascia  l)eneath  being  divided 
in  the  same  line  and  the  tissues  retracted  to  either  side  from  this  median  exposure.  Thus 
one  makes  access  to  the  cricothyroid  membrane,  the  cricoid,  the  upper  tracheal  rings,  and 
the  thyroidal  isthmus.  According  to  the  size  and  location  of  the  latter  (it  usually  lies 
in  front  of  the  second  tracheal  ring)  it  may  be  retracted  or  doubly  ligated  and  flivided  in 
the  middle.  The  difficidty  now  afforded  is  from  the  upward  and  downward  play  of  the 
larynx,  which  may  occur  during  forced  efforts  at  respiration.  To  steady  it  a  tenaculum 
should  be  introduced  just  above  the  cricoid,  a  little  to  one  side  of  the  middle  line,  firmly 
fastening  it.  With  this  held  in  the  left  hand,  thus  stead^ang  the  parts,  a  sharp-pointed 
knife  is  so  employed  as  to  divide  the  cricoid  and  one  or  two  U|)j)er  rings  of  the  trachea, 
being  cautious  not  to  wound  the  posterior  wall.  The  opening  thus  made  should  be  about 
one-half  inch  in  length.  Through  it  a  second  hook  is  now  passed  into  the  other  side  of 
the  cricoid  and  the  incision  held  open  by  their  agency  while  the  trachea  tube  is  introduced. 

This  procedure  may  be  modified  in  accordance  with  any  local  indications,  and  may  be 
made  according  to  the  needs  of  the  case.  When  the  opening  is  made  into  the  trachea 
below  the  isthmus  it  is  called  a  low  tracheotomy.  Here  the  anterior  part  of  the  trachea 
lies  free  from  the  skin,  but  may  be  covered  with  a  plexus  of  veins  connecting  with  the 
inferior  thyroid.  Farther  down  the  arteria  thyroidea  ima  may  be  encountered.  There 
is  always  reason  for  operating  as  high  as  the  case  will  permit.  The  trachea  may  itself 
be  displaced  by  the  growth  which  compresses  it  and  necessitates  the  operation.  Thus  it 
may  be  crowded  to  one  side,  other  anatomical  relations  being  disturbed,  or  it  may  be 
compressed  into  scal)bard  shape,  and  thus  be  difficult  to  find  or  to  open. 

The  moment  the  trachea  is  open  more  or  less  marked  expulsive  efforts  will  drive  blood 
and  foam  in  all  directions,  and  may  for  a  moment  obscure  the  field  of  vision.  Every 
precaution  should  be  taken  to  prevent  the  entrance  of  blood  into  the  trachea.  Pressure 
of  the  tracheal  walls  against  the  tube  to  be  inserted  may  check  hemorrhage  from  its 
margins.  The  operator  should  be  ready  to  suspend  all  other  procedures  and  make 
artificial  respiration,  and  he  should  also  be  prepared  to  open  the  trachea  suddenly, 
should  impending  suffocation  require  it. 

In  a  general  way,  then,  the  indiratintjs  for  tracheotomy  are  symptoms  of  rapidly  or 
slowly  threatening  obstruction  tf)  respiration  from  causes  either  within  the  larynx — e.  g., 
diphtheria,  foreign  bodies,  tumors,  and  the  like — or  causes  external  to  it,  such  as  tumors, 
phlegmons,  cicatrices,  etc.  Any  cause  which  interferes  with  the  free  play  of  air  through 
the  respiratory  tube,  which  can  be  either  relieved  or  atoned  for  by  the  operation,  will 
always  justify  it. 

Tracheotomy  tubes  are  mechanical  devices  for  not  only  keeping  the  tracheal  wound 
open  but  permitting  the  imobstructed  passage  of  air.  They  are  made  of  various  materials, 
of  which  silver  is  the  most  satisfactory,  as  ahmiinum  is  too  easily  acted  upon  by  the 
fluids  of  the  body,  and  rubber  occupies  too  much  space.  The  tracheotf)my  tube  is  a 
double  tube,  the  inner  one  slipping  easily  into  and  out  of  the  outer,  and  being  necessi- 
tated by  the  ease  and  abundance  with  which  secretions  may  collect  and  dry,  and  thus 
olistruct.  Were  it  necessary  to  remove  the  entire  tube  for  each  cleansing,  difficulty  might 
be  met  in  re-introducing  it,  whereas  the  iimer  tube  is  easily  removed,  (juickly  cleansed, 
and  restored  to  place  within  the  outer  without  disturbance  or  j)ain  to  the  patient. 

Aside  from  the  tracheal  tubes  ordinarily  used  there  are  others  made  excejitionally 
long,  and  with  flexible  lower  ends,  which  may  be  used  in  case  of  tumor  low  in  the  neck 
or  high  in  the  metliastinum — for  instance,  in  cases  of  enlarged  thymus,  where  it  is  neces- 
sary to  go  beyond  an  obstruction. 


ISTUliATIOM 


093 


In  tlu'  ajtrr-carr  of  tlu-se  casi-.s  it  siiould  he  rciiicnihcrcd  that  air  j)a.s.ses  direttly  into 
the  hnii;  without  heini);  warmed,  or  moistened,  l)y  passage  over  the  mucous  membrane 
of  the  upper  respiratory  tract.  The  j)atient,  tlierefore,  should  he  ke|)t  in  a  warm  njom, 
and  the  air  should  he  kept  moist  hy  the  use  of  a  croup  kettle  or  a  spray  machine.  The 
iniuM-  tui)e  should  he  kept  unobstructed,  the  length  of  time  durinj^  which  it  should  remain 
depcndini^  on  the  nature  of  the  case.  So  soon  as  its  usefulness  is  j)asscd  it  should  l)e 
removed.  A  tracheotomy  wound  kept  open  hut  for  a  day  or  two  will  (|ui(  klv  close, 
but  oni>  which  has  remained  oj)en  for  weeks  may  close  with  difHculty,  and  then  there 
may  be  trouble  from  jjranulation  stenosis  or  cicatricial  contraction.  (Sec  above  under 
Stricture.)  in  instances  where  a  j)ermanent  opcnin<r  is  to  be  nuiintained  it  is  desirable 
to  remove  the  tub(>  as  early  as  circumstances  may  j)cnnit. 


INTUBATION. 

The  j)erfection  by  Josepli  O'Dwyer  of  a  method,  at  which  others  had  worked,  of  sub- 
stitutinj;  intubation  of  the  larynx  for  the  old  tracheotomy,  not  only  shed  the  <rreatest 
luster  upon  his  own  name,  but  has  afforded  a  speedy  and  bloodless  method  of  accom- 
plishing much  more  than  had  been  previously  j)o.ssible  by  the  older  jjrocedure.  The 
method  comprises  the  emplacement  of  a  suitably  sized  and  shaped  tube  within  the 

Fig.  483 


O'Dwyer's  laryngeal  tube  and  introducer. 


Mouth-gag. 


Fig.  485 


iarm.x,  by  a  manipulation  guided  ^'^  '^^^ 

almost  entirely  by  the  sense  of 
touch,  for  the  relief  of  suffocative 
SMiiptoms  due  to  disease  at  this 
level,  and  leaving  the  tube  f»  sihi 
for  a  sufficient  time  to  permit  mor- 
bid activity  to  subside  and  justify 
its  removal. 

It  is  ad\'isable  to  have  a  half- 
dozen  tubes,  varying  in  size  from 
H  inches  to  2^  inches  in  length, 
and  of  corresponding  increase  in 
other  dimensions,  each  of  which 
affords  a  passage-way  for  respira- 
tory purposes,  and  is  also  provided 
at  its  upper  end  with  a  flange,  which 
shall  rest  upon  the  false  vocal 
cords  and  prevent  the  descent  of 
the  tube  into  the  trachea  l)elow. 
The  complete  set  of  instruments  as  now  furnished  by  all  the  manufacturers  pro\ndes 
an  assortment  of  these  tubes,  with  a  scale  indicating  which  one  to  use  upon  a  patient  of 
a  given  age,  and  includes  a  mouth-gag,  which  may  be  used  for  many  purposes,  and 
two  handled  instruments — one  intended  for  the  introduction,  the  other  for  the  extrac- 
tion of  the  metal  tubes. 


Extractor. 


694 


SPECIAL  OR  REGIONAL  SURGERY 


A  suitable  tul)e  having  been  selected,  a  strong  thread  is  passed  through  a  small  opening 
near  its  head,  thus  affording  means  for  withdrawing  it  should  there  be  need  before  it 
is  finally  left  in  its  resting  place.  The  particiilar  obturator  meant  for  the  tube  to 
be  used  is  then  firmly  fastened  upon  the  handle  and  over  it  the  tube  is  slipped.     The 


Fig.  480 


Intubation  of  the  larynx. 


instrument  should  then  be  tested  to  make  sure  that  disengagement  of  the  tube  will  easily 
take  place.  Everything  being  ready,  the  patient  is  then  held  in  the  arms  and  on  the  lap 
of  an  assistant,  in  the  position  indicated  in  Pig.  48G.  The  individual  holding  the 
patient  should  be  perfectly  reliable  in  the  matter  of  presence  of  mind  and  self-control, 
for  a  great  deal  depends  upon  having  a   child  firmly  and  properly  held    during  the 


Fig.  487 


The  tube  in  the  pharynx. 


moment  of  intubation.  The  arms  and  hands  of  the  patient  should  be  well  wrapped 
with  a  towel  and  firmly  held  by  the  side  of  the  chest,  for  the  temptation  is  inevitable 
to  put  the  hand  to  the  mouth  and  interfere  with  the  operator.  A  second  a.ssistant 
should  stand  above   and  behind,  holding  the  mouth- gag  in  po.sition,  as  represented, 


tNTUBATIGjsj 


G95 


and  steadvanci;  it  as  well  as  tlio  head.  It  is  necessary  that  the  mouth-fi;afi;  he  held 
firmly  in  place,  fur  if  it  shoidd  heconie  diseiiifajjjed  ihc  cliild  may  bite  the  ojjerator's 
finojer. 

StaiidiniT  in  front  of  tlie  patient  the  o|)('rator  identifies  the  tip  of  llie  e|)io;lottis  with 
the  forefiiii^er  of  (lie  left  hand  in  (he  pharynx,  this  fini^er  Ix'inir  used  at  the  same  time  to 
raise  and  fix  the  epij^iottis  and  also  to  serve  as  a  guide  to  the  tip  of  the  tube,  which  is 

Fi<i.  488 


The  tube  penetrates  the  larynx.     (Lejars.) 


passed  downward  alongside  it,  by  a  maneuver  similar  to  tliat  by  which  the  larvngoscopic 
mirror  is  used  in  the  pharynx  (Fig.  487).  When  the  tip  of  the  tid)e  reaches  the  location 
behind  the  epiglottis  the  finger  may  be  passed  a  little  farther  downward,  plugging  the 
entrance  to  the  esophagus,  while  at  the  same  time  the  handle  of  the  instrument  is  so 
manipulated  as  to  bring  the  tube  forward.     With  gentle  movement  in  the  right  direc- 


FiG.  489 


The  stem  is  withdrawn  while  the  finger  fixes  the  tube.     (Lejars.) 

tion  it  passes  into  the  larynx  (Fig.  488).  It  is  then  pressed  downward  until  the  flanged 
upper  end  has  passed  the  epiglottis,  after  which  the  tube  is  disengaged,  the  handle 
and  the  obturator  withdrawn,  and  the  u])per  end  of  the  tube  pressed  gently  into  place 
by  the  finger  which  still  rests  in  the  pharynx  (Figs.  48S,  489  and  400).  During  the 
manipulation  there  is  almost  complete  obstruction  of  the  glottis  for  two  or  three 
seconds.    The  eft'ort,  therefore,  should  be  to  shorten  the  procedure,  and  at  no  time  should 


696 


SPECIAL  OR  REGIONAL  SURGERY 


it  occ-upy  more  than  two  or  three  seconds.  If  the  huulniarks  arc  not  easily  reco<jnized, 
and  the  tube  is  not  placed  at  the  expiration  of  three  seconds,  the  operator  should  dis- 
continue for  a  few  more  seconds  in  order  that  a  few  inspirations  may  be  taken,  after 
which  he  should  try  again. 

Fig.  490 


The  finger  pushes  the  tube  into  place.      (Lejars.) 


When  the  tube  is  in  place  there  will  come  ease  of  respiration,  at  the  same  time  violent 
coughing  efforts,  because  of  the  irritation  thus  suddenly  produced.  So  soon  as  it  is 
apparent,  both  to  the  finger  in  the  pharynx  and  from  the  relief  of  obstructive  symp- 
toms, that  the  tube  is  in  its  proper  place,  the  finger  may  be  once  more  passed  into  the 
pharynx,  the  tube  pressed  down,  while  the  silk  thread  is  withdrawn,  since  it  is  not 


Fig.  491 


Withdrawal  of  the  thread.     (Lejars.) 


intended  to  leave  it  for  more  than  the  time  necessary  to  be  assured  that  the  tube  will 
not  have  at  once  to  come  out  again  (Fig  491).  Before  removing  the  thread  the  gag 
should  be  removed  for  a  few  moments,  so  that  the  effect  of  the  excitement  may  pass,  after 
which  it  may  be  re-introduced  for  the  purpose  of  withdrawing  the  thread. 


ISTUHATIOS  G97 

The  |)r()(('(lurr  is  by  no  ineaiis  a  .simple  nor  iirccssarily  easy  one,  and  it  should  hi'  prac- 
tised with  the  instrunu'nts  upon  tlie  cadaver  hetore  res<»rtin<j  to  it  on  the  Hvinji;  child. 

Tlic  tube  l)ein<j  phued  it  will  remain  to  l)e  decided  hy  the  suhseijuent  course  of  events 
how  Vn\\f  it  should  he  allowed  to  renuiin — in  some  <'ases  a  few  hours,  in  others  a  few  days. 
With  younj;  children  it  should  remain  for  at  least  a  week.  The  time  haviufj  arrived 
for  its  rciiiordl,  the  proce<lure  is  similar  to  that  re(juired  for  its  introduction.  The 
assistants  hold  the  child  in  the  same  |)ositi()n  as  before,  wliil(>  tiie  operator  substitutes 
the  extractor,  «,Miidin<,f  its  tip  a^'ain  by  the  sense  of  touch  alon<^  the  left  index  finjjer, 
which,  passed  down  into  the  pharynx,  is  made  to  discover  and  identify  the  u|)per  end  of 
the  metallic  tube.  So  soon  as  the  point  of  the  extractor  is  en<2;a<i;ed  within  the  tube  the 
blades  are  sej)arated  and  it  is  then  drawn  out,  while  the  finger  is  withdrawn  along  with 
it  in  order  to  nuike  its  removal  easier  and  to  prevent  its  loss  should  it  slij)  off  the  instru- 
ment. Unless  the  patient  struggles  violently  the  whole  procedure  should  be  conducted 
so  as  to  scarcelv  cause  the  slightest  staining  of  the  ex|)ectoration  with  l)lood. 

l^ariou.f  rait.^trs  may  rnjiiirr  abnijd  rniioval  of  flic  tube.  Thus  it  is  ]x)ssil)le  for  its 
caliber  to  be  become  occluded  with  tenacious  secretion.  This  may  produce  a  violent 
fit  of  coughing,  during  which  there  may  occur  spontaneous  exj)ulsion  of  the  tul)e.  At 
any  time,  when  it  is  seen  that  asphyxia  is  increasing,  or  when  violence  of  respiratory 
effort  would  indicate  obstruction  within  the  tube,  it  should  be  removed,  cleaned,  and 
re-introduced.  After  its  introduction  and  removal  the  operator  should  remain  within 
easy  reac-h  for  a  short  time,  to  be  sure  that  no  unpleasant  effects  result  and  that  no 
re-introduction  may  be  suddenly  required.  Should  obstructive  efforts  occur  the  child 
should  be  held  head  downward  and  be  slapped  vigorously  upon  the  chest.  This  may 
loosen  membrane  or  it  may  permit  dislodgement  of  the  tube  and  its  spontaneous  expul- 
sion.    The  latter  may  also  occur  during  the  act  of  vomiting. 

The  al)ove  description  is  meant  especially  to  apply  to  intubation  as  performed  upon 
young  children  for  the  relief  of  the  laryngeal  obstruction  consequent  upon  diphtheria. 
It  has  given  better  results  than  tracheotomy,  which  was  the  only  resort  previous  to 
O'Dwyer's  device.  It  is  usually  performed  easily,  and  is  devoid  of  the  horrors  frequently 
attendant  upon  an  emergency  tracheotomy.  But  intubation  is  not  necessarily  limited 
to  children  nor  to  cases  of  diphtheria.  The  emplacement  of  such  a  tube  may  be  called  for 
at  any  time  in  cases  of  threatening  or  actual  edema  of  flic  glotfis,  as,  for  instance,  from 
inhalation  of  steam  or  flame.  It  may  be  advisable  in  other  forms  of  intralaryngeal 
disease,  both  acute  and  chronic,  w^hile  individuals  suffering  from  laryngeal  stricture  or 
stenosis  find  that  they  can  wear  an  O'Dwyer  tube  almost  constantly,  not  only  with  relief, 
but  that  they  are  thereby  saved  from  the  more  serious  measure  of  opening  the  trachea 
or  removing  the  lar}Tix. 

Impending  suflFocation  having  been  relieved  by  intubation,  the  question  of  feeding 
arises.  The  principal  disatlvantage  attendant  upon  the  use  of  the  tube  is  partial  or 
complete  inability  to  swallow,  for  the  epiglottis  does  not  always  easily  close  over  the  tube 
and  prevent  entrance  of  fluid  into  the  larynx.  It  is  necessary  to  feed  patients,  especially 
the  young,  with  extreme  care.  For  this  purpose  there  is  no  food  better  than  ice-cream, 
while  little  children  should  be  placed  upon  their  backs,  with  the  head  lower  than  the 
body,  and  made  to  sw'allow^  in  this  position,  at  least  until  they  have  been  ac(-ustomed  to 
the  presence  of  the  tube  and  instinctively  learn  how  to  avoid  irritation  by  involuntary 
regulation  of  the  act  of  swallowang. 


CHAPTER    XLII. 

THE  NECK. 

CONGENITAL  ANOMALIES  OF  THE  NECK. 

These  consist  largely  of  defects  due  to  arrest  of  development  along  the  lines  of  the 
branchial  clefts.  Necessarily  of  embryonic  origin,  they  do  not  reveal  this  until  varying 
|)eriods  after  birth,  sf)metimes  n(jt  until  old  age.  They  consist  of  fistulas,  ojiening  either 
externally  or  internally,  or  more  commcmly  of  cystic  dilatations  of  the  interior  jX)rtions 
of  the  original  fissures.  External  openings  are  usually  seen  along  the  sternoma-stoid, 
either  in  front  or  back  of  it,  or  between  the  lar\Tix  and  the  cla\'icle.  Vestiges  are  also 
present  in  the  shape  of  little  tags  of  skin  containing  portions  of  cartilage  or  bone.  They 
frequently  occur  together,  the  tag  indicating  the  location  of  the  fistula,  whose  opening 
may  be  found  obstructed  with  crusts.  Internally  the  openings  are  usually  found  in  the 
phar^nix,  perhaps  in  the  larynx  or  trachea,  generally  near  the  tonsil  and  base  of  the  tongue. 
An  external  fistula  may  be  tested  for  its  completeness  by  injecting  a  colored  fluid  and 
inspecting  the  pharynx.  The  fistulous  ]»rtion  is  usually  markefl  by  a  cord-like  ma.ss 
which  extends  inward,  usually  toward  the  hyoid  bone.  Internal  blind  fistulas  may 
gradually  expand  and  constitute  one  variety  of  the  so-called  pulsion  diverticula  of  the 
pharynx  and  upper  esophagus,  their  dilatation  being  due  to  accumulation  of  food, 
and  gradual  stretching  in  this  way. 

All  of  these  embryonic  relics  are  of  interest  because  from  their  small  l)eginnings  large 
growths  may  take  place,  constituting  even  serious  surgical  problems.  These  growths 
may  present  in  almost  any  region  of  the  neck  and  frequently  extenfl  into  the  mouth, 
where  they  give  rise  to  certain  forms  of  raniila.  Almost  every  cystic  tumor  beneath  the 
tongue  or  jaw  is  open  to  the  suspicion  of  having  an  embryonic  origin.  ^lost  of  these 
vestiges  are  amenable  to  surgical  treatment  shr)uld  they  give  rise  to  discomfort  or 
tnjuble.  The  operations  required  are  sometimes  quite  extensive,  as  any  tumors  of 
branchiogenic  origin  are  especially  liable  to  adhesions  to  the  large  vessels ;  moreover, 
they  are  nearly  always  firm  and  the  dissection  thus  made  difficult.  A  dennoid  cyst  may 
be  evacuated  and  its  wall  or  sac  destroyed  or  dissected  out.  It  may  then  be  made  to 
heal  by  packing. 

Treatment. — In  the  treatment  of  fistulas  of  the  neck,  Konig  has  advised  that  a  curved 
pi-obe  be  passed  through  the  tract  to  a  point  close  to  the  tonsil,  at  which  point  on  the 
inside  of  the  mouth  or  pharynx  the  mucous  membrane  is  incised,  a  silk  thread  is  fastened 
to  the  end  of  the  probe,  pulled  out  with  it,  then  made  to  pass  to  the  external  enrl  of  the 
fistulous  tube,  which  is  then  invaginated  and  pulled  back  into  the  mouth,  where  it 
is  reduced  to  a  short  stump  which  is  fastened  to  the  margins  of  the  opening  of  the  mucous 
membrane.  The  external  wound  is  then  made  to  heal  as  usual.  This  treatment  suffices 
for  blind  internal  fistulas  of  the  cers'ical  region. 

It  is  a  matter  of  great  surgical  importance  and  interest  that  certain  branchiogenic 
remnants  persist  in  a  perfectly  harmless  manner  imtil  advanc-ed  life  is  reached,  after 
which  there  take  place  therein  cancerous  changes  which  convert  them  into  the  so-called 
ranrcrs  of  branchiorjenir  origin.  These  are  too  often  of  hojx'lcss  character  l)y  the  time 
they  are  seen  by  the  surgeon. 

( )ther  congenital  defects  consist  of  atrophies,  such,  for  instance,  atro))hy  of  the  sterno- 
mastoid  muscle,  or  of  certain  hypertrophies  which  may  be  unilateral  or  symmetrical. 

WOUNDS  AND  INJURIES  OF  THE  NECK. 

The  neck  is  ever^^vhere  expensed  to  incised  and  perforating  wounds,  partly  as  the  result 
of  pure  accident,  too  often  as  the  result  f)f  homicidal  efforts.     Tlie  most  exposed  parts 
are  supplied  with  veins  of  large  caliber  which  connect  directly  M'ith  the  heart,  and  what- 
(  098  ) 


WOUNDS   .l.V/>  IX./l'RIRS  OF   THE  MX'K  699 

ever  (l;iii<;'cr  tlicn>  may  Ix'  of  ciitrinicc  of  air  inin  l/ir  rciii.s,  imdcr  any  circiimstaiice.s,  is  in 
this  r('i;;i()ii  ciiliaiucd.  This  oiitraiicc  of  air  lias  hi'CMi  regarded  as  a  serious  and  often 
fatal  accident.  'I'hr  writi-r's  oxjK'ricncc  and  iTsearch  have  sliown  that  it  may  often  occur 
in  mild  dcffree  with  hut  little  temporary  disturbance.  Should  it  occur  the  fact  will  be 
indicated  by  a  sli<j;ht  j;iir<i;lin<jj  sound,  with  tunniltuous  action  of  the  heart,  dilatation  of 
the  pupils,  embarrassed  breathing,  and  every  indication  of  lowered  blood  pressure. 
Kvery  conjpelent  operator  will  secure  these  large  veins  before  dividing  them,  but  if  any- 
thing of  this  kind  should  be  noted  during  an  o|)eration,  |)ressure  or  |)lugging  of  the 
wound,  with  artificial  res|)iration,  |)erliaps  even  massage  of  the  heart,  and  traclieotomy 
if  necessary,  should  be  practised  until  the  j)atient  has  revived.  If  in  the  course  of  an 
exceedingly  deep  dissection  the  accident  can  hv  foreseen  it  nuiy  be  avoided  by  keej)ing 
the  wound  filled  with  warm  .sterilized  salt  solution.  This,  however,  will  seriously 
embarrass  the  ojierativc  work,  as  it  obscures  vision. 

The  lower  in  the  neck  a  serious  wound  be  received,  other  things  being  equal,  the 
more  dangerous  it  becomes.  Thus  j)enetrating  wounds  above  the  larynx  are  of  le.ss 
importance  than  those  below  it.  All  injuries  or  wounds  al)out  the  larynx  are  not  only 
likely  to  dislodge  its  interior  cartilages,  but  are  especially  likely  to  be  followed  by 
|)ressure  of  effused  blood,  or  the  consequences  of  a  ra])id  rdrnift  of  ihc  (jloffis,  which  nuiy 
l)rove  fatal  unless  the  trachea  be  oj)ened  below.  It  is  this  fact  which  makes  fracture 
of  the  larynx  so  dangerous  an  injury. 

A  wound  of  the  trachea  rarely  occurs  by  itself,  as  it  lies  deeply,  and  it  may  be 
especially  serious  if  vessels  in  this  neighborhood  have  been  so  injured  that  blood  may  be 
easily  poured  or  escape  into  the  lungs.  If  the  trachea  be  comj^letely  divided  its  ends 
will  be  separated  and  gap,  while  the  lower  end  will  be  draAvn  out  with  each  deep  inspira- 
tion. In  this  way  suffocation  may  quickly  occur.  In  all  such  cases  the  head  should  be 
placed  lower  than  the  body  (Rose's  position),  the  lungs  emptied  comj)letely,  the  wound 
enlarged,  and  the  tracheal  wound  be  sutured  or  else  a  tube  l)e  inserted.  The  treatment 
uuist  largely  depend  upon  the  number  of  hours  which  have  elapsed  since  its  infliction, 
and  the  condition  of  the  wound  itself.  In  these  cases  it  may  be  assumed  that  such 
a  wound  is  infected,  therefore  it  should  not  be  closed  without  provision  for  drainage. 

Any  injury  to  the  respiratory  tract  proper  will  be  indicated  by  the  character  of  the 
expectoration  and  the  sounds  heard  on  auscultation.  Such  injuries  are  likely  to  be 
complicated  In'  a  subsecjuent  bronchitis,  pneumonia,  deep  abscess,  or  various  other 
undesiral)le  sequences.  Under  the  suggestive  term  "Schluck-pneumonie"  the  Germans 
have  described  a  condition  which  we  describe  in  the  term  "inhalation  jHieumonia."  It 
implies  a  se]>tic  type  of  p/ueumonia  caused  by  the  ])assage  downward  of  foreign  material, 
including  septic  wound  secretions,  which,  not  being  expelled  promptly,  cause  a  tyj)e  of 
inflammation,  with  consolidation,  which  will  give  most  of  the  ordinary  physical  signs  of 
pneumonia. 

A  rather  distinct  type  of  incised  wound  is  that  included  in  the  term  "cui-thront.'' 
It  implies  a  homicidal,  usually  suicidal,  attempt  on  the  ])art  of  the  ignorant  to  sever 
the  large  vessels  in  the  neck.  This  is  but  rarely  accomplished,  the  injury  being  done 
to  the  larynx  and  the  trachea  and  the  tissues  anterior  to  the  vascular  trunks.  Usually 
inflicted  with  the  right  hand,  one  side  of  the  woinid  may  be  deeper  than  the  other. 
While  the  trachea  is  usually  cut  and  often  divided,  the  injury  may  be  to  the  lamix 
instead.  At  all  events,  a  w^de  gash  is  made  antl  there  is  considtM-able  hemorrhage,  the 
external  jugulars  being  nearly  ahvays  severed.  By  the  time  such  a  wound  is  seen  by 
the  surgeon  it  is  an  infected  wound  and  it  should  not  be  closed  too  tightly.  The  trachea 
may  be  sutured  by  itself,  but  it  will  be  best  to  place  therein  a  tracheal  tube.  Amjile 
provision  should  also  be  made  for  drainage.  In  some  instances  the  wound  may  be  left 
open,  at  least  for  a  few  days,  until  it  is  granulating,  and  then  be  closetl  l)y  deep  sutures. 
Care  should  always  be  given  to  those  of  desperate  suicidal  intent  and  to  the  maniacal, 
that  they  do  not  reopen  the  wound  in  continuation  of  their  previous  efforts.  This 
requires  careful  watching. 

Rupture  of  the  trachea,  either  due  to  A-iolent  coughing  or  straining  efforts  or  to  external 
violence,  is  known.  It  will  call  for  tracheotomy,  liecause  of  the  emphysema  which  will 
ensue.  Penetrating  w^ounds  of  the  large  arteries  and  veins  are  always  serious.  When  not 
extcTisive  they  may  be  followed  by  diffuse  or  circumscribed  hematoma  or  by  aneurysm. 
Nelaton  is  reported  to  have  stated  that  it  takes  four  minutes  for  a  man  to  bleed  to  death 
from  the  carotid  arterv,  and  that  two  minutes  should  suffice  for  its  ligation.     Any 


700  SPECIAL  OR  REGIOXAL  SURGERY 

iiijurv  to  the  vessels  shoiilil  \n-  followed  hv  their  exposure,  and  {Ji-ohahlv  hv  liifution  or 
suture,  in  order  to  prevent  tlie  eonditions  above  mentioned.  If  the  wound  he  low  in 
the  neek  it  would  he  [jroper  to  remove  the  upper  end  of  the  sternum  or  to  di\ide  the 
sternomastoid  suffieiently  to  expose  it. 

The  vertebral  artery  is  oecasionall y  injured,  mostly  in  the  osseous  canal  through  which 
it  passes.  At  the  base  of  the  neek  a  wound  at  or  near  its  origin  is  an  exceedingly  serious 
injury.     The  same  rules  apply  as  above. 

Wounds  of  the  /urge  reins  are  supposed  to  be  of  a  more  serious  nature  because  of  the 
possibility  of  inspiration  of  air,  /.  e.,  air  embolism.  These  vessels  are  occasionally  injured 
during  removal  of  deep-seated  and  adherent  tumors.  It  has  been  possible  in  some 
instances  to  make  a  lateral  snture  of  the  jufjular  vein  at  the  point  of  injury,  providing 
this  be  not  too  extensive.  Effort  at  reunion  of  thLs  kind  is  always  legitimate  if  the 
operator  feel  himself  equal  to  the  task.  The  jugular  vein  is  also  occasionally  exposed 
and  tied  low  down,  then  opened  above  the  ligature,  for  the  purpose  of  cleaning  out  its 
upper  portion  when  filled  with  infective  thrombi,  a  condition  occasionally  seen  with 
mastoid  abscess,  etc.  To  open  it  before  tying  would  be  a  surgical  mistake.  Bv  this 
process  it  is  practically  oljliterated  as  recovery  ensues. 

If  such  a  muscle  as  the  sternomastoid  be  partially  or  completely  divided  muscle  suture 
should  be  practised  and  the  head  and  neck  kept  at  rest  for  the  er.suing  few  da  vs. 

Injuries  to  the  eervieal  nerres  may  be  followed  by  ])eculiar  and  interesting  features. 
That  of  the  recurrent  laryngeal  will  cause  paralysis  of  the  lar^nigeal  muscles  on  one  side, 
with  consequent  difficulty  in  speech;  injury  to  the  cervical  s^-mpathetic  will  be  followed 
by  dilatation  of  the  pupils  and  protrusion  of  the  eyeballs  with  flushing;  of  the  spinal 
accessory,  by  mastoid  and  trapezius  paralysis;  of  the  phrenic,  by  paralysis  of  the  dia- 
phragm on  one  side;  and  of  the  pneumogastric,  by  embarrassment  of  respiration,  with 
j)iipillary  and  abdominal  s}^llptoIus,  which  are  variable.  Of  all  of  these  injuries  that 
to  the  phrenic  is  probably  the  most  serious.  Some  years  ago  I  tabulated  the  then 
recorded  cases  of  injury  to  the  pneumogastric  and  was  able  to  show  that  onlv  about 
50  per  cent,  of  such  cases  were  immediately  or  tardily  fatal.  The  phrenic  nerve  is 
then  the  only  one  within  the  neck  which  can  scarcely  be  spared.  Any  of  these  nerves 
when  di\-ided  should  be  reunited  by  sutures,  as  elsewhere  described. 

When  any  portion  of  the  bra/^hial  plexus  has  been  injured  a  corresponding  paralvsis 
of  the  ann  will  follow.  Wounds  of  these  nerves  should  be  sutured  at  once.  A  distinc- 
tion should  be  made  in  all  cases  between  hysterical  anesthesia,  malingering,  and  the 
actual  paralysis  of  injury.  Sometimes  the  amount  of  callus  thrown  out  after  a  fracture 
of  the  clavicle  will  include  a  nerve  of  sufficient  size  to  produce  a  neurosis,  usually  neu- 
ralgia, or  possibly  a  paralysis.  Excessive  callus,  or,  in  effect,  the  bony  tumor  which  is 
thus  produced,  may  be  removed  l)y  operation,  and  any  entangled  nerve  should  be 
hunted  out  and  liberated. 

Pressure  of  a  tumor  upon  a  nerve  will  cause  paralysis  corresponding  to  its  degree. 
When  this  comes  on  gradually,  even  though  it  ijivolve  the  phrenic  nerve,  the  conse- 
quences are  not  so  serious.  Repeated  irritation  or  pressure  may  cause  paralysis,  as  in 
the  cases  of  the  strap  of  letter-carriers  or  those  who  carry  burdens  slung  from  the  neck. 

Injuries  occur  to  the  cervical  muscles  during  parturition  and  a  hematoma  of  the  sterno- 
mastoid in  the  newborn  is  described.  The  muscle  is  contracted  and  the  head  bent 
over.  It  usually  disappears  by  resolution  within  a  short  time.  This  muscle  is  also 
ruptured  by  \iolencein  the  adult;  again,  heiuatoma  is  the  result,  with  at  least  temporary 
torticollis,  pain,  and  tenderness.  When  an  abrupt  di\-ision  can  be  recognized,  exposure 
of  the  ends  and  muscle  suture  would  be  indicated.  At  any  time,  in  the  presence  of  clot, 
it  would  be  proper  to  cut  down  and  turn  it  out. 

Syphilitic  myositis  is  often  seen  in  the  sternomastoid,  where  it  may  affect  the  entire 
muscle,  transforming  it  into  a  cord-like  mass,  or  where  it  may  occur  as  gummatous 
infiltration.  These  cases  occur  without  pain  and  without  known  cause  save  the  disease 
itself,  whose  possibility  should  be  established  by  the  history  of  the  case.  Again,  these 
muscles  are  sometimes  contracted  because  of  reflex  excitement  from  adjoining  inflam- 
matory foci.  Such  an  affection  subsides  shortly  after  due  attention  to  the  exciting  cause, 
unless  it  has  been  allowed  to  continue  too  long.  Inflammation,  even  of  the  destructive 
type,  may  be  propagated  to  the  muscles  by  continuity  from  a  neighboring  suppurating 
focus. 

Serious  phlegmons  of  the  neck  may  be  followed  by  jihlebitis  of  the  internal  jugular 


wocxns  AM)  is.n  Rii'.s  of  Tin-:  xeck 


701 


vein,  wliicli  iii;iy  he  n"C(>;x>>i^<'*'  '>v  fli<'  presence  of  a  palpahle  eonl-like  clot  witliiii  its 
lumen.  Sneli  a  (•((iidition  is  serious  heeause  of  tlie  ease  witli  wliicli  |)yeinia  may  ensue. 
It  would  1)1'  better  to  expose  tlie  vein,  to  tie  it  low  down,  to  freelv  excise  and  turn  out 
such  a  clot,  than  to  leave  it  to  create  serious  disturhance  a  little  later. 

( )f  the  po.s-trrior  portions  of  f/ir  neck  we  have  fewer  injuries,  and  these  less  serious, 
ex(i'ptin<:;  those  hy  which  the  vertebral  column  or  the  enclosed  sj)inal  cord  are  injured. 
These  injuries  have  been  referred  to  in  the  chapter  on  the  S|)ine.  A  hiirh  ])erforatin^ 
injury  of  the  cord,  especially  if  it  involve  the  medulla,  is  prom|)tly  fatal.  Infanticide 
has  be(>n  produced  by  a  long  needle  driven  between  the  (K'ei|)ut  and  the  vertelme,  corre- 
spondinjf  to  the  j)ithinfi^  of  small  animals  in  the  laboratory.  An  iujury  above  the  ori<,nn 
of  the  phrenic,  on  one  side,  is  not  necessarily  fatal.  Injuries  to  the  j)osterior  portion 
of  the  hiii;h  cervical  cord,  as  well  as  to  the  mend)ranes,  may  be  followed  by  more  or  less 
atrophy  of  the  <i;enital  or<i;ans,  with  corresponding!;  im|)otence,  Larrey  claiminf,'  that 
this  may  take  i)lace  even  when  the  cord  itself  is  not  affected. 

liiiptiiirs  of  nui.sclc.'i  and  .sr  pa  rations  from  their  insertions  or  oriffins  are  occasionally 
noted.  The  scaimhir  muscles  are  occasionally  torn  loose.  A  reflex  spasm  of  the  trape- 
zius which  follows  some  of  these  injuries  will  produce  a  jjosterior  form  of  acute  torticollis 
(wryneck)  described  in  the  chapter  on  ( )rth()])edics  (XXXIII).  The  resulting  deformity 
and  stiffening  might  be  confounded  with  arthritis  of  the  upper  vertebral  joints.  It  i.s 
to  be  overcome  by  traction  and  by  suitable  apj)aratus,  save  in  extreme  cases,  when 
division  or  excision  of  a  sufficient  portion  of  the  muscle  niay  be  ])ra(  tised. 

Of  great  interest  are  the  blood  vascular  tumors  of  the  neck,  both  those  of  sjjontaneous 
and  of  traumatic  origin.  Large  angiomas,  either  of  the  arterial  (cirsoid  aneurysm)  or 
of  the  mixed  or  venous  type,  are  seen  about  the  neck.  Here  more  than  anywhere  else 
are  found  peculiar  venous  dilatations,  especially  of  the  smaller  veins,  which  form  cavities 
in  a  tissue  that  becomes  thereby  almost  erectile.  Should  these  tumors  connect  with 
the  arteries  they  will  pulsate.  If  composed  of  larger  veins  they  will  prove  cjuite  com- 
pressible. These  tumors  should  be  extirpated,  care  being  taken  to  place  a  provisional 
or  permanent  ligature  upon  the  large  vessels  connecting  therewith  before  the  tumor 
itself  is  attacked.  Occasionally  the  ampullse  of  these  growths  become  sufficiently  large 
to  entitle  the  growths  to  be  considered  as  sanr/uinrous  ei/sts.  The  neck  is  also  frequently 
the  site  of  the  smaller  varieties  of  these  growths  which  constitute  the  ordinary  nevi. 
(See  chapter  on  Tumors.) 

Aneurysms  of  the  cervieal  vessels  are  more  frequently  of  spontaneous  than  traumatic 
origin.  They  may,  however,  result  from  contusions  or  penetrating  injuries.  While 
no  vessel  in  the  neck  always  escapes,  it  is  the  common  carotid  which  is  more  frequently 
affected  than  the  others.  The  general  subject  of  aneurysm  has  been  considered.  Care 
should  be  taken  not  to  confuse  the  vascular  and 
j)ulsating  goitres,  or  other  ])ulsating  cysts  of 
the  thyroid.  It  is  necessary  also  to  distinguish 
aneurysmal  pulsation  from  that  which  is  trans- 
mitted through  a  tumor  overlying  the  vessels  or 
whicli  may  be  seen  in  some  of  the  extensive 
malignant  tumors  of  the  neck.  When  the  diag- 
nosis of  aneurysm  is  made  the  surgeon  should 
decide  what  vessel  is  primarily  affected.  This, 
however,  is  not  always  possible,  as  an  aneurysm 
of  the  vertel)ral  artery  projecting  forward  is 
liable  to  be  mistaken  for  one  of  some  other 
trunk. 

Aneurysm  in  the  neck,  unless  very  deep,  and 
in  a  very  unfavoral)le  subject,  is  always  an  indi- 
cation for  operation.  W'hile  operation  neces- 
sarily includes  ligation,  either  on  the  proximal  or 
distal  side,  if  this  can  be  practised  the  sac 
itself  may  be  treated  just  as  though  it  were  a 
tiunor  of  any  other  character,  and  extirpated. 
I  have  myself   had    satisfactory   residts    by  the 

last-mentioned  procedure  (Fig." 492).     The  existence  of  laryngeal   paralysis,  especially 
unilateral,  which  is  not  easily  accounted  for   in  other  ways,  should  excite  a  suspicion 


Fig.  492 


Carotid  aneurysm  .successfully  treated  by  com- 
plete e-xtirpation.      (Autlior'.s  Clinic.) 


702 


SPECIAL  OR  REGIONAL  SURGERY 


of  anciiryMii,  with  consccjuont  ])rc.s,sure  upcjii  the  rcciiiTciit  hiryiigeal  nerve.  Its 
possibility  shoukl  he  excluded  as  ])art  of  the  diagnosis. 

Wouiuh  of  the  subclavian  vessels  give  rise  to  serious  hematomas  which  may  be  converted 
into  spurious  traumatic  aneurysms  of  arteriovenous  character.  When  such  a  tumor 
pulsates  it  is  j)robably  connected  with  the  subclavian  artery,  which  should  be  ligated. 
It  may  lie  possible  to  make  this  ligation  above  the  clavicle,  but  a  ])ortion  of  the  stcrniini 
should  be  removed  as  well  as  the  inner  end  of  the  claAacle  for  a  more  complete  cxposin-e. 
On  the  right  side  at  least  the  artery  can  only  be  reached  above  the  bone  after  dividing 
the  sc-alenus  anticus,  where  a  ])rovisi()nal  ligature  may  be  placed.  After  this  the  sac 
should  be  incised  and  the  vessel  ligated,  on  either  side  of  it,  so  that  the  ])ro visional  liga- 
ture may  be  removed.  On  the  left  side  it  is  safe  to  ligate  the  second  portion  of  the  artery 
at  once.  The  clavicle  should  be  divided  to  afford  better  exposure,  and  its  ends  reunited 
with  silver  wire  (Fig.  4i)3). 

Any  open  wound  of  the  subclavian  vein  is  a  serious  affair,  as  bleeding  will  be  profuse, 
and  there  is  also  danger  of  air  embolism.  Immediate  occlusion  with  an  antiseptic 
dressing  would  probably  afford  better  prospect  than  any  attempt  to  enlarge  the  wound 

Fig.  493 


Traumatic  anuuiy.-ni  of  axillary  artery. 

and  secure  the  divided  vessel.  If  the  vein  be  thus  attacked  its  proximal  j)ortion  should 
be  first  secured  in  order  to  avoid  the  entrance  of  air.  Meantime  much  of  the  hemor- 
rhage from  the  distal  end  may  be  prevented  if  j)ressure  be  made  in  the  axilla  upon  the 
axillary  vein.     If  the  vessel  be  secured  both  ends  should  be  tied. 

In  instances  of  accidental  injury,  or  that  included  in  the  removal  of  large  and  deep 
tumors,  the  thoracic  duct  on  the  left  side  and  the  lymphatic  duct  on  the  right  have  been 
injured  or  divided.  It  is  one  of  the  possible  dangers  in  performing  extensive  operations 
on  tlie  rf)ot  of  the  neck,  especially  on  the  left  side.  Its  occurrence  would  be  indicated 
by  oozing  of  the  milk-like  lymph.  The  accident  has  ncjt  been  frequently  rej)orted.  It 
would  render  closure  of  the  wound  without  drainage  impracticable,  but  it  has  been 
found  sufficient  to  place  a  deep  packing  and  to  rely  upon  the  natural  healing  process 
(granulation)  by  wdiich  such  a  Avound  would  be  gradually  closed. 

It  may  be  said  of  vascular  lesions  that  when  it  a])])ears  to  be  necessary  the  upper  part 
of  the  sternum  may  be  resected,  as  it  adds  little  to  the  danger  and  exposes  the  opera- 
tive field  in  a  more  desirable  way.  There  is  no  better  (jf)erative  method  for  ligation  of 
the  innominate  artery  than  that  which  includes  removal  of  the  upper  end  of  this  bone. 
Incidentally  it  may  be  added  that  this  is  also  justifiable  in  certain  penetrating  wounds  of 
the  trachea  and  in  attacking  retrosternal  goitres  or  lesions  of  the  thymus. 


PHLEGMONS  OF   THE  XECK  703 

PHLEGMONS  OF  THE  NECK. 

PhlcfimonoHs  afjrctious  in  tlic  icj^ion  of  tlie  neck  arc  serious  hccansf  of  tlu;  coniplica- 
tions  wliicli  may  ensue.  The  more  deeply  they  lie  the  j^reater  this  danger.  This  comes 
not  only  from  se|)tic  processes  which  may  follow  veins  and  lymphatics,  hut  from  l)urrow- 
in<2;  of  pus  aloui];  and  between  tlie  deeper  muscle  j)lanes,  which  may  carry  it  into  one  of 
llic  nicdiasliiial  spaces  or  within  the  thorax.  These  phlegmons  may  l)c  j)riuiarv,  or 
may  follow  infection  spreading  through  (he  open  cry|)ts  of  the  tonsils,  or  the  open  path- 
ways alforded  hy  diseased  teeth  and  hy  su|)crficial  ulcerations.  An  infection  of  a  tonsil 
may  cause  an  abscess  which  presents  beneath  the  jaw,  while  a  deep  axilhirv  abscess  may 
be  the  conscciuence  of  a  ])hlegnion  beginning  in  the  neck.  Not  infrc(iuently  they  come 
about  through  the  nu'chanism  of  infected  lymph  nodes,  which  may  sometimes  produce 
multiple  or  extensive  single  abscesses.  These  j)hlegmons  occasionally  follow  the 
exanthems,  es|)ecially  scarlatina,  and  the  variety  of  directions  in  which  infection  may 
spread  from  the  middle  ear  is  well  known,  since  it  may  cause  ])hleginon  in  the  neck  or 
cmi)ycnia  of  the  mastoid  antrun  and  even  fatal  disturbance  within  the  cniiiium.  When 
the  resulting  |)us  travels  downward  in  front  of  the  thyroid  and  sternum  it  will  appear 
U|)on  the  thoracic  wall;  when  behind  the  trachea  and  the  ocs()|)hagus,  or  altjug  the  large 
vcss(>ls  of  the  neck,  it  will  be  seen  either  within  the  thcjrax  or  at  the  root  of  the  neck, 
possibly  opening  into  the  esoj)hagus  or  spreading  to  the  axillary  space.  Rrtropliaryiujral 
abscesses  are  often  the  result  of  caries  of  the  vertebra^,  but  may  occur  in  consequence 
of  a  deej)  cellulitis  caused  by  extension  from  some  focus  within  the  luisopharyngeal 
cavity.  This  is  an  illustration  of  the  rule  that  pus  travels  in  the  direction  of  least 
resistance. 

Diagnosis. — The  diagnosis  of  pervical  phlegnums  is  usually  not  difficult,  especially 
when  they  are  superficial.  The  ever-present  indications  of  redness  and  edema  of  the 
surface,  pitting  U|)()n  j^ressure,  tender  swelling,  and  loss  of  function  of  the  surrounding 
parts,  often  with  fixation  through  muscle  spasm,  couj)led  with  the  general  systemic 
disturbance,  and,  in  desj)erate  cases,  the  indications  afiortled  by  the  blood  and  the  urine, 
will  enable  a  diagnosis  to  be  made,  usually  without  the  use  of  the  exploring  needle. 
This,  however,  may  be  employed  if  necessary.  The  same  is  true  in  lesser  degree  of  tuber- 
culous collections  of  pus  and  pyoid,  which  have  been  earlier  described  as  "cold  abscess." 
Only  in  the  beginning  of  its  course  can  any  doubt  arise  concerning  the  nature  of  a 
carbuucular  process. 

A  somewhat  typical  type  of  deep  phlegmon  is  often  referred  to  as  angina  and  Vincent's 
angina.  Semon  regards  these  manifestations  as  expressions  of  an  acute  septic  cellulitis 
which  has  been  described  as  abscess  of  the  larynx  and  as  erysipelas  of  the  larynx,  and 
which  other  writers  refer  to  as  cynanche  tonsillaris,  acute  peritonsillitis,  etc.  The 
disease  may  occur  in  healthy  individuals,  more  often  in  tlie  diabetic.  A.  violent  sore 
throat  is  followed  by  serious  dysphagia,  with  considerable  edema  of  the  phar^mx,  whose 
surface  is  of  a  dark-blue  color.  Patients  may  become  unable  to  swallow,  while  hoarse- 
ness with  aphonia  will  result  from  edema  of  the  glottis.  The  epiglottis  will  be  darkly 
discolored,  greatly  tumefied,  and  nearly  obscuring  the  entrance  to  the  larynx.  Dyspnea 
may  necessitate  tracheotomy.  A  light-colored  false  membrane  may  be  seen  in  the 
throat.  There  is  always  marked  lymphatic  involvement.  The  disease  may  be  more 
confined  in  some  cases  to  one  side.  Vincent  has  described  a  jvirticidar  s|)irillum  or 
bacillus  which  he  found  in  some  of  these  instances.  The  infection  here  doubtless  pro- 
ceeds from  the  mouth  or  the  tonsils,  its  activity  being  due  to  symbiosis  of  various  organ- 
isms. It  is  to  be  distinguished  from  Ludwig's  angina,  which  is  rather  a  submaxillary 
affection  than  a  retropharyngeal.     It  infrequently  leads  to  retropharyngeal  abscess. 

Ludwig's  angina,  also  callej:!  infectious  submaxiUarij  angina,  is  an  infectious  cellulitis 
of  the  mouth.  The  tongue  is  swollen  and  immovable;  the  mouth  more  or  less  fixed, 
with  difficulty  of  swallowing,  and  the  condition  is  one  of  extensive  infiltration,  with 
formation  of  ))us,  which  is  likely  to  burrow^  In  some  of  these  cases  the  iNIicrococcus 
tetragenus  is  the  organism  at  fault.  In  my  experience  when  present  it  leads  to  a  brawny 
infiltration  which  is  slow  to  subside  or  disappear. 

Treatment. — The  early  recognition  and  evacuation  of  pus  are  called  for  in  all  cervical 
))hlcgmons.  The  presence  of  pus  may  be  assumed  before  it  can  be  recognized  from 
external  evidence.     Therefore  when  swelling  begins  to  mask  anatomical  outlines,  or  to 


704  SPECIAL  OR  REGIONAL  SURGERY 

prodiK-e  difficulty  of  swallowing  or  breathing,  free  external  incision,  with  deep  dissection, 
will  prove  much  safer  than  to  leave  such  a  case  to  itself.  Retropharyngeal  abscesses, 
or  such  collections  as  may  be  recognized  in  the  tonsil  or  in  the  jjharynx,  may  be  opened 
from  within  the  mouth.  That  there  should  not  be  too  much  haste  in  this  direction 
however,  was  indicated  to  me  when  a  well-known  surgeon  plunged  a  bistoury  into  what 
he  supposed  to  be  an  abscess  of  the  tonsil  and  found  it  to  be  an  aneurysm,  the  patient 
dying  within  five  minutes  in  his  office. 

Early  and  free  incision  will  relieve  tension,  and  do  good  by  a  certain  amount  of  blood- 
letting, even  if  pus  is  not  reached,  while  an  easier  outlet  for  it  will  be  afforded  when  it 
does  form.  However,  the  surgeon  will  rarely  fail  to  find  it  if  he  goes  sufficiently  deep  or 
in  the  right  direction,  when  the  existing  symptoms  and  signs  are  of  serious  import. 

The  operator  should  incise  freely  in  the  beginning,  after  which  deep  dissection  is 
best  effected  with  some  blunt  instrument.  The  exploring  needle  may  afford  valuable 
information,  but  if  the  deep  tissues  be  edematous  we  may  feel  quite  sure  of  the  presence 
of  pus  in  the  neighborhood.  Souchon  has  described  a  method  of  guided  dilatation  which 
requires  a  series  of  dilating  instruments,  and  which  will  give  good  results.  Search  for  pus 
can  be  made  without  them  by  using  the  blade  of  a  disse(  ting  knife  or  hemostatic  forceps, 
or  the  blades  of  a  pair  of  scissors  to  stretch  a  small  opening.  The  less  tissues  are  cut  and 
the  more  they  are  thus  separated  the  better. 

Perilaryngeal  or  peritracheal  abscesses  are  likely  to  cause  dyspnea  and  show  a  tendency 
to  extend  downward  along  the  trachea  into  the  thorax.  In  these  locations  they  produce  a 
peculiar  diffuse  cellulitis,  which  was  described  by  Dupuytren.  Such  phlegmons  may 
extend  from  the  ear  to  the  clavicle  or  from  the  back  of  the  neck  to  the  larynx.  Pus 
will  collect  in  many  small  interspaces,  and  purulent  infiltration  will  affect  a^nv  of  the 
tissues,  and  may  prorluce  gangrene.  This  condition  has  also  been  des(^m^  by  Gray- 
Coley  and  by  Hannon.  The  surface  not  infrequently  seems  to  be  invol^Rrin  erysipelas. 
In  fact  it  is  doubtless  true  that  most  of  these  affections  are  of  the  streptococcus  type, 
where  it  is  impossible  to  distinguish  between  erysipelas  and  cellulitis.  Tracheotomy 
as  well  as  the  other  free  incisions  may  be  indicated.  An  early  tracheotomy  should  be 
made  whenever  suffocation  threatens  from  any  swelling  or  edema.  The  latter  occurs 
so  suddenly  that  a  tracheatomy  should  be  made  early  rather  than  wait  for  its  necessity, 
especially  when  patients  cannot  be  kept  under  constant  observation.  The  operation 
may  be  done  under  cocaine,  while  the  presence  of  the  tube  will  then  permit  the  adminis- 
tration of  one  of  the  ordinary  anesthetics  without  embarrassing  respiration. 

All  of  the  other  phlegmons,  no  matter  what  type  they  assume,  are  to  be  treated  on  the 
same  general  principles.  If  seen,  however,  before  incision  and  drainage  appear  these 
cases  may  be  treated  locally  with  the  compound  ich thy ol-mercu rial  ointment,  or  with 
Crede's  silver  ointment,  re-inforced  by  hot  external  applications ;  and  the  mouth  should 
be  frequently  rinsed  with  warm  antiseptic  solutions.  Any  lesion  within  the  mouth 
should  receive  its  own  proper  treatment. 

Carbuncles. — Carbuncles,  which  appear  perhaps  more  frequently  upon  the  back  of 
the  neck  than  elsewhere,  should  be  treated  by  the  radical  method,  i.  e.,  excision  of  all 
tissue  which  is  evidently  so  involved  that  it  will  subsequently  slough.  Even  an  extensive 
carbuncle  several  inches  in  diameter,  with  numerous  crater-like  openings,  and  presenting 
large  amounts  of  already  necrotic  tissue,  is  best  treated  in  this  same  way.  The  more 
quickly  the  tlead  and  dying  tissues  are  removed  the  better  for  the  patient.  Such  an 
operation  requires  an  anesthetic  and  the  free  use  of  scissors  and  a  sharp  spoon,  even  the 
scalpel.  After  being  freed  of  necrotic  tissue  the  exposed  surfaces  should  then  be  dressed 
with  brewers'  yeast.  In  general,  of  all  these  phlegmons,  it  may  be  said  that  nowhere 
does  the  general  rule  elsewhere  laid  down  in  this  work  better  apply,  i.  e.,  that  pus  left 
to  itself  will  always  do  more  harm  than  will  the  surgeon's  knife  if  judiciously  used. 

The  various  fixations  of  the  neck  by  muscle  spasm  or  muscle  infiltration  due  to  these 
phlegmons,  i.  e.,  the  temporary  forms  of  wryneck,  will  nearly  always  subside  as  infil- 
tration disappears.  Some  degree  of  permanent  contracture  may  follow  neglected  cases 
and  may  call  for  massage,  stretching,  and  the  use  of  a  suitable  brace. 


AFFECTIOSS  OF   TIIF  ('Fli\  ICAL   LYMI'll   SOhF.S 


705 


AFFECTIONS  OF  THE  CERVICAL  LYMPH  NODES. 


Fig.  494 


'I''Ii('  ccrvicjil  l\  lupliatics  art-  jil)Uii(liiii(  in  iiiiiiihrr,  as  llicy  iici'd  to  \)v  to  serve  their 
purpose,  considering  llie  variety  anti  extent  of  the  possihh-  sources  of  intection,  both 
i'roin  witiiin  and  withoul.  'I'hey  hei'onu'  enhir<i;e(l  even  in  a  Iri/hni:;  case  of  (onsilhtis, 
whiU"  in  uiorc>  serious  infections  they  partiei|)ate  witii  tlie  surroun(hn<f  tissues,  Ijut  soine- 
tiinos  suppurate  iiulependently  of  tlieui.  I'liey  are  involved  in  nearly  every  <ase  of  con- 
stitutional .s7//i/////.v,  ami  serve  as  an  index  of  the  saturation  of  the  system  with  the  specific 
poison.  'I'reatuient  for  the  same  should  never  he  discontinued  so  lonj;  as  tliey  are  f>er- 
ceptiMy  enlar;;t'(j.  They  participate,  then,  in  Ixjlh  the  hn-al  and  the  constilnliona! 
iid'ections. 

In  no  respect  is  (his  more  true  than  in  local  tuberculous  iidections,  or  in  others  which 
have  become  tuberculous  (hrouij;h  the  process  of  mixed  or  secondary  iid'ection. 

Tiihcrcii/osis  t)j  Ihr  rrrricdl  lifiit })linlir.s  is  then  one  of  tlu-  results  of  ])revious  mild  or 
severe  infections.  They  constitute  the  so-called  "scrofulous  glands"  or  svvellin<i;s  of 
writers  of  the  ])ast  <2;eueratiou.  There  may  be  seen  repeated  within  these  structures  tliose 
processes  which  in  the  hm<i;s  cause  at  one  point  softening];,  at  another  caseation,  and  at 
another  sclerosis.  An  acute  su])purative  process  may  also  be  going  on,  or  there  may  be 
found,  in  broken-down  cavities,  that  jnoid  material  which  is  often  seen  in  cold  abscesses, 
and  to  which  elsewhere  in  this  work  is  given  the  name  arche])yon,  indicating  that  it  was 
originally  of  a  truly  purulent  type,  which  it  has  lost  in  course  of  time. 

Tuberculosis  of  the  cervical  lymj)h  nodes  may  be  a  limited  and  almost  single  expression 
of  disease,  or  one  involving  both  sides  of  the  neck,  and  to  a  degree  that  may  {)roduce 
large  and  disfiguring  swellings.  It  is  nearly 
always  a  secondary  infection,  the  original 
lesion  being  found  upon  the  surface  of  the 
skin,  more  frequently  in  the  middle  ear,  the 
pharynx,  the  tonsils,  the  nose,  the  teeth,  or 
other  parts  within  the  mouth.  The  first 
measure  in  every  instance  should  be  to  trace 
this  source  of  the  infection,  since  to  leave 
it  uncared  for  is  to  invite  a  continuance  of 
the  disease.  The  course  of  events  often  is 
an  acute  exanthem,  a  chronic  tonsillitis,  a 
mildly  septic  involvement  of  the  lymph 
nodes,  followed  later  by  tuberculous  invasion 
through  a  port  of  entry  opened  by  the  pre- 
vious process  (Fig.  4!)4). 

Most  of  the  acute  septic  infections  of  these 
lymphatics  will  be  followed  by  local  abscess 
and  by  one  of  the  extensive  phlegmonous 
manifestations  described  above.  This  usually    ^ 

means     an     acute     abscess     formation,     which     Jtion,  and  showing  the  usual  and  various  cbangea. 

should  lead  to  early  incision  and   speedy  re-   (Lexer.) 

covery.      It    is   the   more   chronic   and   less 

suppurative  types  which  cause  serious  trouble.     They  occur  more  frequently  in  the 

young.     There  is    a  distinct    form,    however,  occurring    in    the   aged,   which  is  called 

lienile  tuhrrculosis.     Its  ])athology  nowise  difiers  from  that  of  the  type  occurring  in  the 

young,  although  it  has  a  ditiVrent  clinical  expression. 

When  the  lym])h  nodes  are  Init  recently  involved  they  are  simply  so  encapsulated  as 
to  be  cjusily  shelled  out  from  their  beds;  but  when  degenerating  and  slowly  suppurating 
they  become  so  firmly  embedded  in  the  surrounding  tissues  by  dense  infiltration  that 
their  extirpation  is  exceedingly  difficult.  This  condition  has  been  spoken  of  as  peri- 
adenitis, a  bad  term,  because  nowhere  in  this  work  are  l}Tnph  nodes  spoken  of  as  "glands." 
Not  infrequently  the  operator  will  find  large  masses  affixed  to  the  carotid  sheath,  or 
surrounding  the  vessel  and  nerve  trunks,  so  that  it  is  almost  impossible  to  separate  them. 
During  the  dissection  the  internal  jugular  may  be  torn,  or  one  of  its  branches  severed 
at  its  base,  while  an  important  nerve  trunk  may  be  so  lost  in  the  mass  that  it  is  almost 
impossible  to  distinguish  it,  and  it  may  not  escape  injury. 
45 


'Cluster  of  tuberculous  lymph  nodes  removed  by  dis- 


706  SPECIAL  OR  RhVIOXAL  SURGERY 

Treatment. — Searc-h  shoultl  \)c  first  made  fur  the  .source  of  the  infection,  since  to 
attack  the  consequences  of  the  disease  and  to  leave  the  cause  untouched  w<nild  be  a 
mistake.  If  it  be  a  chronic  nasopharyngeal  catarrh  it  will  require  considerable  local 
treatment.  If  an  enlarged  tonsil  this  should  be  removed.  If  due  to  dental  carie,s,  or 
ulceration  in  connection  with  faulty  dentition,  or  to  j)vorrhea  alveolaris,  the  patient  should 
be  sent  to  the  dentist;  if  the  trouble  be  in  the  middle  ear,  to  the  aurist;  if  the  infection 
come  from  tiie  skin,  as  in  various  ulcerating  skin  diseases,  again  appropriate  external 
measures  should  be  adopted.  When  the  patient  is  otherwise  in  good  condition  and  freed 
from  liability  of  furtlier  infection,  tiien  the  question  of  surgical  intervention  is  to  be  decided. 
Decision  will  rest  somewhat  upon  the  general  condition  of  the  patient  and  the  extent 
of  the  lesions.  A  consumptive  patient,  for  instance,  is  not  a  good  subject  for  surgery, 
and  it  may  be  held  that  the  lymphatics  will  be  benefited  by  such  change  of  climate  as 
is  indicated  for  his  tuberculous  lungs.  A  puny  or  anemic  subject  is  not  a  favorable 
one  for  an  extensive  surgical  operation,  such  as  the  removal  of  a  large  mass  of  those  nodes 
often  necessitates.  It  may  be  deemed  adN-isable  to  delay  while  the  patient  is  temporarily 
sent  to  the  mountains,  or  is  placed  upon  treatment,  including  arsenic  as  an  alterative, 
and  the  best  restorative  tonics.  Some  cases  not  favorable  for  operation  are  benefited  bv 
.r-ray  treatment.  This  should  be  judiciously  administered,  in  such  manner  as  not  to 
produce  a  dermatitis  nor  increase  the  infiltration  in  the  tissues  of  the  neck.  It  is  to  be 
advised  rather  in  cases  considered  inoperable  than  in  those  favorable  for  operation. 

Excision  is  the  measure  usually  resorted  to  because  of  the  promptness  of  its  effect, 
as  well  as  the  extent.  Excision,  however,  necessitates  an  exceedingly  careful  and  tedious 
dissection.  When  the  whole  side  of  the  neck  is  involved  I  would  a(h-ise  an  S-shaped 
incision,  by  which  a  double  flap,  with  much  better  exposure,  is  afforded.  There  may 
perhaps  be  found  two  quite  flifferent  sets  of  involved  nodes,  the  superficial  lying  rather 
to  the  outside  and  to  the  front  of  thesternomastoid,  which  will  be  adherent  to  the  carotid 
sheath,  and  a  deeper  set  l^ing  back  of  the  sternomastoid  whose  removal  will  usually 
take  one  down  to  the  transverse  processes  of  the  cervical  vertebne.  In  an  average  case 
there  may  be  found  all  possible  combinations  of  degeneration,  with  softening  and  cold 
abscess  on  one  hand,  and  caseation  and  calcification  on  the  other.  Proc-eeding  more 
deeply  masses  will  be  found  whose  existence  had  not  been  appreciated  from  the  surface. 
Nevertheless,  such  cases  usually  do  well  and  often  recover.  Thus  a  wound  extending 
from  the  mastoid  to  the  claA-icle  may  be  entirely  healed  within  a  week  if  the  wound  has 
not  been  infected  by  fresh  pus.  Such  extensive  wounds  should  be  treated  with  at  least 
one  drainage  provision,  a  drain  being  brought  out  through  the  wound  or  a  special  open- 
ing made  for  it,  at  a  point  where  the  resulting  cavity  vdW  empty  itself  with  the  patient 
Inng  upon  his  back  in  bed. 

For  all  these  operations  the  patient  should  be  prepared  in  the  best  possible  manner. 
It  \\ill  be  of  advantage  to  send  patients  to  the  woods,  while,  imder  any  circumstances, 
they  should  be  kept  under  those  surroundings  most  favorable  to  tuberculous  individuals, 
where  hypernutrition,  lively  elimination,  and  oxygen  fulfil  the  general  requirements.  They 
may  also  take  such  alteratives  as  arsenic,  and  such  drugs  as  creosote  or  its  derivatives, 
which  are  supposed  to  have  more  or  logs  specific  eflfect. 

A  distinct  type  of  involvement  of  the  cer\'ical  lymphatics  is  seen  in  connection  with 
the  spread  of  malignant  disease  from  adjoining  structures.  Nowhere  is  this  more  marked 
than  in  epithelioma  of  the  lip,  but  it  may  be  seen  in  cancer  spreading  upward  from 
below,  as  in  connection  \\\\\\  cancer  of  the  breast.  When  the  cervical  iMiiph  nodes 
are  involved  in  a  case  of  cancer  of  the  breast  a  hopeless  aspect  is  thereby  put  upon  it. 
Although  operation  may  be  justified  for  temporary  relief  it  should  be  so  understood. 


TUMORS  OF  THE  NECK. 

Aeroceles  of  the  neck  are  sacs  formed  by  air  distention  of  an  adventitious  pouch,  and 
constitute  a  species  of  local  emphysema,  due  to  weakening  and  yielding  of  some  portion 
of  the  respiratory  tract,  produced  by  such  strains  as  cough,  labor,  etc.  A  congenital 
dilatation  of  a  larMigeal  ventricle  may  produce  the  same  effect.  It  may  also  follow 
a  distinct  wound  of  the  trachea,  or  the  expansion  of  a  cavity  in  one  of  the  mucous  glands 
produced  by  its  ulceration  or  breaking  down.  They  may  also  residt  from  abscess  ca^■ities 
opening  into  the  respiratory  tract.     According  to  their  location  they  may  be  referred  to 


TCMojy's  OF  '/'III-:  .\i:<i< 


707 


as  laripKjocclts,  traclironlrs,  etc.  Tlic  tcnii  piuuinulocrlr  iiii|)lic.s  a  protrusion  ol'  (lie 
pleura  and  the  luu^  iiilo  llic  rcjifion  above  the  clavicle.  It  will  <jive  distinct  si<;ns  here 
on  percussion,  will  disappear  under  pressure,  and  ((uickly  recur  as  tlie  result  of  I'orced 


Jig.  496 


Congenital  multilocular  serous  cysts  (hydrocele)  of  neck. 
(Lannelongue.) 


Branchial  cyst.     (Case  of  Dr.  Parmenter.) 

e.xpiration,  coughino;,  etc.  It  may  even 
follow  the  respiratory  movements.  This 
latter  form  is  scarcely  amenable  to 
treatment  unless  tissues  can  be  brought 
together  over  it  and  the  opening  closed. 
The  other  aeroceles  are  more  or  less 
amenable,  according  to  their  location 
and  exciting  cause.  It  is  rare  that 
there  is  any  contra-indication  to  their 
exposure  and  extirpation. 

Of  the  many  true  cii-sts  of  the  neck  a 
large  proportion  are  due  to  incovipletc 
closure  of  some  'portion  of  one  or  more 
branchial  clefts.  These  have  already 
been  mentioned  in  the  chapter  on 
Tumors.  The  lesions  vary  from  trifling 
submaxillary  dermoid  tumors  to  exten- 
sive hydroceles  of  the  neck,  such  as  those  illustrated  in  Figs.  495  and  496.  Not  every 
congenital  tumor,  however,  is  of  branchial  origin.  There  is  a  possibility  of  the 
development  of  others  along  the  thyroglossal  duct,  along  the  great  vessels,  and  in  the 
neighl)orhood  of  the  pharynx  and  larynx.  Tnw  bursal  cysts,  as  well  as  true  athero- 
matous ciists,  also  develop  at  various  ages.  The  former  will  be  found  filled  with  scnnis 
fluid.  They  occur  on  the  anterolateral  aspect  of  the  neck  and  generally  on  the  left 
side.  Dermoid  ci/sts  also  abound  here.  They  have  an  ejiithelial  lining,  which  always 
indicates  their  congenital  origin.  They  frequently  do  not  develop  until  pul)erty.  They 
may  contain  various  epithelial  products,  which  may  escape  by  suppuration  or  perfora- 
tion. These  growths  sometimes  extend  into  the  mediastinum.  A  form  of  median 
thip-ohijoid  cLjst  of  this  character  often  grows  rapidly  after  confinement.  Such  a  cyst 
if  incompletely  treated  will  be  followed  by  ])ersistent  fistula.  All  of  these  growths  should 
be  thoroughly  extirpated  if  attacked  at  all,  or  widely  opened  and  packed,  and  then  made 
to  heal  by  granulation.  Fig.  497  illustrates  another  type  of  cvstic  growth  of  the  neck 
connecting  freely  with  the  lymph  spaces  and  vessels  and  regarded  as  a  congenital  l^Tuph- 
angioma. 

Still  another  type  of  cystic  growth  is  connected  with  the  anterior  jugular  vein.  It 
contains  sanguineous  fluid,  and  sometimes  true  venous  blood.  Connection  with  the 
vein  may  be  determined  by  making  pressure.  A  growth  easily  emptied  and  rapidly 
refilling  will  be  distinctive.  It  should  not  be  mistaken  for  an  aneurysm,  as  it  does  not 
pulsate.     It  is  known  as  a  sanguineous  cyst. 


70S 


SPECIAL  OR  REGIONAL  SURGERY 


The  tlidiciiltv  (if  (li.stiiiii;iiisliiii<:;  l)ct\vt'{'ii  (lennoid  cyst  and  (k'niioi*!  tuinor  lias  been 
im-iilioiied  in  Uie  cliapter  on  'I'uniors.     Tlie  distinction  is  one  (jf  small  importance,  for 

no  matter    what   its  character   such    a 
Fig.  497  growth  calls  for  extirpation.     A  similar 

dermoid  in  the  course  of  the  thyrolaryn- 
geal  duct  is  rej)resented  in  Fig.  498. 

In  the  neek,  mcjre  often  than  in  any 
other  part  of  the  Ixxly,  may  he  seen  well-i 
marked  cases  of  diffuse  lipoma.  These 
are  ])ainless  overgrowths  of  fatty  tissue,.' 
unencaj)sulated  and  consequently  liahle 
to  spread  to  an  unlimited  extent  (Fig. 
1!)'.)).  They  form  disfiguring  clinical 
l)ictures,  but  cause  no  unpleasant  symp- 
toms. They  are  scarcely  to  be  attacked 
surgically,  as  they  have  no  anatomical 
limit.  They  are  rarely  operated.  More 
circumscribed  growths  can  be  more  or 
less  easily  removed. 

Of  the  true  tumors  of  this  region 
little  need  be  said  here.  There  is  a 
form  of  fibrochondnjma,  springing 
from  a  branchial  cleft,  which  occupies 
the  external  orifice  of  a  congenital  fistula  a  little  above  the  clavicular  joint.  This 
makes  it  of  interest,  and,  at  the  same  time,  distinctive  in  character. 

Any  of  these  growths  may  give  rise  to  serious  pressure  symptoms  and  may  be  so  located 
as  to  make  tracheotomy  difficult.     They  often  extend  downward  liehind  the  sternum. 


I'laiichial  cyst  or  hydrocele  of  neck,      llaby  jix  weeks  old. 
(Case  of  Dr.  Parmenter.) 


Fig.  498 


Fig.  499 


Dermoid  (ad-hyoid)  cyst  at  base  of  tongue.     (Marchant.)         Diffuse  symmetrical  lipoma,  multiple.     (Lexer.) 

in  which  case  the  upper  part  of  that  bone  should  be  removed  in  order  that  they  may  be 
safely  followed.  Such  a  tumor,  if  it  so  extends  and  is  a  true  cyst,  should  be  treated  by 
free  incision  and  packing;  but  when  solid,  no  other  resource  than  extirpation  is  left. 


Tiir.  Tin  L'ojj)  A\h  Tin-  jwhwr/i)  ro/ds  700 

(  )ii  tlicir  posterior  aspct  t  tlic  <,Mra(t'.st  caiitioii  should  he  cxcrciscil,  and  it  iiiav  I)0  well  t<» 
leave  a  part  of  their  j)o.sterior  walls  to  avoid  the  daiif^er  of  injuritif:^  the  larji;e  veins. 

The  majority  of  tumors  that  j)reseiit  on  the  floor  of  the  month  which  are  not  of  nialij;- 
nant  ty|)e,  nor  adenomas  of  the  salivary  <,dands,  are  emhryonic  relics,  a  type  alluded  (o 
ahove.  A  small  vestige  of  this  kind  may  long  remain  d(uinant  and  then  suddeidv  assume 
a  raj)id  growth. 

Of  the  iitii/if/n(tnt  timinrs  there  are  many  e.\|)ressions  in  the  neck  of  endothelioma, 
of  sarcoma,  and  of  carcinoma,  the  latter  only  arising  from  epithelial  structures  like  those 
of  the  skin,  the  glands,  or  the  mucous  membrane.  They  may  extend  in  all  <lirections. 
Many  cancers  of  the  neck  are  metiustatic,  the  jjriimiry  growth  not  necessarily  being  in 
the  immediate  neighborhood.  A  distinct  form  of  cancerous  degeneration  of  embryonic 
vestiges  is  known  under  the  name  of  branchiognnc  rarrinoma.  It  is  .seen  usually  in 
elderly  jH'ople  and  along  the  line  of  the  branchial  clefts.  If  possil)le  it  constitutes  a 
more  hopeless  variety  than  otiiers,  because  of  its  origin  and  de[)th.  Certain  sarcf)mas  of 
the  neck  are  |)rone  to  assume  the  type  of  fungus  hematodes.  Any  tumor  of  this  character 
should  be  attacked  with  spoon  and  cautery,  for  the  vessels  which  bleed  so  (^asily  are  only 
those  of  the  growth  itself,  those  which  lead  up  to  it  and  around  its  margin  not  being 
enlarged. 

THE  CAROTID  BODY. 

The  carotid  body  seems  to  have  been  first  described  by  Haller,  in  1713,  although  his 
description  has  attracted  but  little  attention.  In  1833  Mayer  recognized  that,  aside  from 
the  well-known  cervical  ganglia,  there  was  met  at  the  bifurcation  of  the  common  carf)tid 
a  small,  so-called  glandular  structure,  about  the  size  of  a  grain  of  rice,  red,  firm,  and 
vascular,  much  resembling  the  superior  cervical  ganglion,  which  receives  sympathetic 
filaments  as  well  as  branches  from  the  vagus.  Luschka,  in  1862,  spoke  of  it  as  a  gland- 
like appendage  of  the  s^Tnpathetic  system  in  the  neck.  It  is  usually  wrapped  in  a  sheath 
from  the  adventitia  of  the  carotid  and  perhaps  by  more  or  less  fat,  the  former  having 
to  be  divided  before  the  gland  becomes  visilile.  It  seems  to  be  a  common  meeting-place 
for  fil)ers  from  the  superior  lar\Tigeal,  the  glo.ssopharvngeal,  the  s\Tnpathetic,  and  certain 
ganglion  nerve  fibers.  It  is  not  always  present  and  may  vary  in  ])osition,  lying  either 
below  the  flivision  of  the  artery  or  considerably  above  it  upon  the  external  carotid.  In 
any  case  it  is  enclosed  by  a  sort  of  capsule. 

Its  principal  surgical  interest  obtains  in  that  it  is  the  occasional  site  of  tumors,  which 
as  they  grow  will  have  intimate  and  perplexing  arrangements  t(j  the  surrounding  tissues, 
which  may  necessitate  most  painstaking  dissection,  or  may  call  for  sacrifice  of  the  large 
vessels.  In  one  case  reported  by  Scudder  the  tumor  became  larger  and  more  tender 
whenever  the  patient  caught  cold.  Such  a  tumor  will  not  of  itself  pulsate,  but  will  transmit 
pulsation  from  the  carotid  in  a  perplexing  manner.  They  move  sidewise,  but  not  ver- 
tically. When  vascular  they  may  (liminish  upon  pressure,  or  they  may  pass  in  between 
the  other  tissues  in  a  way  to  simulate  collapse  on  pressure.  They  lie  in  front  of  the 
sternomastoid,  above  the  level  of  the  thyroid  cartilage,  are  usually  of  slow  growth,  anrl 
are  sometimes  accompanied  by  such  vasomotor  disturbance  as  flushing  of  the  face  and 
irregularity  of  the  pupil.  They  are  likely  to  be  mistaken  for  tul)erculous  l^inph  nodes, 
or  for  common  tumors  of  the  neck.  While  Aiews  concerning  their  absolute  malignancy 
differ,  one  may  be  certain  that  at  least  they  rest  ujxjn  the  border  line,  and  should  in  all 
eases  be  removed.  Instances  are  reported,  however,  where  the  tumor  has  shown  an 
extremely  malignant  tendency. 

THE  THYROID  AND  THE  PARATH^OIDS. 

By  \nrtue  both  of  its  complex  functions  and  complicated  affections  the  thyroid  is  an 
object  of  surgical  interest.  Between  it  and  some  of  the  most  imix)rtant  body  changes 
there  is  intimate  relation,  and  its  effects  on  disposition,  mentality,  voice,  general  aj)pear- 
ance  anrl  behavior,  sexual  function  and  the  development  of  the  sexual  organs  are  matters 
of  common  knowledge.  The  latter  foitures  are  abundantly  illustrated  by  the  effect 
upon  these  parts  of  removal  of  the  thyroid.  Embrvrtlogically  it  flevelops  from  the 
floor  of  the  pharynx,  between  the  upper  branchial  arches.     Within  it  there  forms  a  duct. 


710  SPECIAL  OR  REGIONAL  SURGERY 

known  as  the  thi/roglo.'^snl  duct,  whose  crlossal  portion  ojwns  npon  the  l)ase  of  the  tongue, 
where  it  is  of  great  surgical  importance,  because  of  growtlis  of  embryonic  origin  occurring 
along  its  path,  and  because  downward  growth  of  cancer  of  the  posterior  portion  of  the 
tongue  usually  takes  the  same  course.  In  the  early  days  of  its  existence  it  contains  no 
iodine,  at  least  in  mankind,  this  lack  of  iodine  being  supplied  from  the  mother's  milk, 
the  babe  thus  receiving  from  its  mother  that  which  its  own  thyroid  at  first  fails  to  supply.* 

That  the  thyroid  normally  produces  substances  of  vital  import  in  the  human  economy  is 
shown  both  by  the  bad  efl'ects  of  their  overproduction,  as  in  tetany  and  certain  spasmodic 
affections,  with  final  clonic  rigitlity,  and  in  thyroidism  or  the  hyperthyroidism  of  (iraves' 
disease  or  exophthalmic  goitre,  with  its  tachycarilia,  mental  depression,  and  numerous 
other  sym])toms,  and  by  those  of  its  underactivity,  as  in  myxedema,  cretinism,  cachexia 
strumipriva,  and  certain  of  the  toxemic  neuroses. 

The  relations  between  the  thyroid  and  the  genital  organs,  especially  in  the  female, 
are  in  many  instances  pronounced.  Menstrual  suppression  and  pregnancy  are  often 
followed  by  thyroidal  enlargement,  and  nearly  every  W(jman  having  a  goitre  notes  its 
temporary  enlargement  with  each  menstriud  epoch,  and  its  ])ermanent  enlargement  with 
each  succeeding  pregnancy.  The  most  s])ccific  constituent  of  the  thyroglobulin,  which 
is  supposed  to  be  the  substance  formed  within  the  thyroid,  is  iodine,  which  is  present  in 
variable  amounts. 

In  general  it  may  be  said  of  the  thyroid:  (1)  That  it  secretes  some  material  requisite 
for  normal  nutrition;  (2)  that  it  has  much  to  do  with  the  assimilation  of  oxygen  by  the 
tissues  as  well  as  with  j^hosphorus  metabolism;  (3)  that  its  pecidiar  secretion  has  a 
marked  effect  in  lowering  blood  pressure  and  quickening  the  pulse,  in  the  former  respect 
being  the  direct  antagonist  of  adrenalin. 

The  parathi/roids  have  only  recently  assumed  importance  either  in  surgery  or  pathology. 
Their  existence  as  separate  structures  with  an  identity  of  their  own  was  first  demonstrated 
by  Sanstrom  in  18G0.  Up  to  his  time  they  had  been  assumed  to  be  small  accessory 
thyroids.  In  1884  they  were  described  l)y  Horsley.  Since  that  time  they  have  been 
an  object  of  the  greatest  interest  to  experimenters.  They  are  of  different  character  from 
the  thyroid  proper.  Nevertheless  the  two  are  not  absolutely  independent  of  each  other, 
for  removal  of  either  one  causes  changes  in  the  other;  the  symptoms  caused  by  removal 
of  the  parathyroids,  especially,  including  tremors  and  various  nervous  symptoms,  of 
which  tachycardia  and  sometimes  exophthalmos  are  the  most  prominent.  Experimental 
animals  Avill  usually  survive  removal  of  the  thyi'oid  alone,  but  to  take  away  all  four  of 
the  parathyroids  is  almost  invariably  fatal.  Anatomically  they  consist  of  two  pairs  of 
small  bodies,  with  an  average  diameter  of  ^V  inch,  having  color  and  texture  much  like 
the  thyroid  in  gross  appearance,  but  containing  epithelioid  cells,  lying  in  man  in  close 
relation  to  the  lateral  lobes  of  the  thyroid,  behind  them  and  to  their  inner  sides.  In 
minute  structure  they  resemble  that  of  the  pituitary  body.  Their  relatively  trifling 
size  and  deep  position  in  man  have  caused  them  to  be  neglected  in  pathology,  and  to  be 
seldom  recognized  during  operations  or  except  by  a  carefid  dissection  made  for  the 
purpose.  The  present  trend  of  opinion,  especially  among  the  experimenters,  ascribes 
to  them  an  important  role  in  the  production  of  exophthalmic  goitre,  it  being  made  to 
appear  that  by  some  neglect  of  duty  their  function  of  indirectly  regulating  the  heart  and 
controlling  the  sympathetic  system  is  not  properly  performed. 


CONGENITAL  AFFECTIONS  OF  THE  THYROID. 

Congenital  affections  of  the  thyroid  may  assume  the  type  either  of  defect  or  of  absence 
of  the  organ,  or  an  hypertrophy  which  may  involve  one  side  or  both.  Presumably  when 
the  thyroid  is  lacking  its  function  is  to  some  extent  assumed  by  the  thymus  and  perhaps 
by  other  portions  of  the  body. 

Anatomical  alterations  are  met  in  the  so-called  suprrmtmrrary  or  accessory  thyroids, 
which  may  be  due  to  separate  development  of  one  of  the  original  lobules,  or  they  may 
arise  independently.     These  vary  in  size,  location,  and  importance.     They  may  be  seen 

'  This  may  afford  an  explanation  of  the  unsatisfactory  character  of  artificial  foods,  as  well  as  of  cows'  milk, 
since,  unlike  the  babe,  the  calf  is  born  with  a  functionating  thyroid.  Cows'  milk  does  not  contain  in  this  resi)ect 
that  which  is  found  in  human  milk,  all  of  which  may  afford  a  reason  for  adding  minute  amounts  of  thyroid 
extract  for  a  short  time  to  artificial  foods  for  children. 


TCMORS  OF  Tin:   THY  noil)  711 

as  \n)!^\\  as  iIk*  liasc  of  the  toiii^iic  or  as  low  as  the  ii|)|)cr  end  ol"  tlic  stfriiiiiii  or  hcliiiid  it. 
Tissiir  of  this  kind  has  been  seen  in  the  body  of  tlir  hyoid  hone.  These  accessory 
masses  are  siil)ject  to  th(>  same  type  of  alfectioiis  as  tliose  which  involve  the  |)rincij)al 
thyroitl,  and  thns  tnniors  may  develo|)  in  tiic  anterior  region  of  the  neck,  wiiich  mav  cause 
some  perplexity. 

An  extraordinary  feature  of  thyroidal  ti.ssue  is  that  when  afi'eetcd  it  may  itifref|uentlv 
proiluce  mrtastd.sT.s,  even  to  distant  parts  of  the  body.  'I'hns  cases  are  on  record  oi 
beuiijn  jjoitre,  with  universal  metastases,  and,  on  the  other  hand,  of  numerous  metas- 
tases without  any  noticeable  thyroidal  enlar<i;ement.  They  occur  frequently  in  the 
o.sseous  .system,  and  in  the  lunj^s,  and  when  the  thyroid  is  the  site  of  a  colloid  ty|)e  of 
<;oitre.     The  same  is  e(|ually  true  of  the  malifjjnant  <;rowths  of  the  same  tissue. 

'i'iie  innnediate  results  of  a  total  removal  of  the  thyroid,  as  by  operation,  are  mij.xcdema, 
or  (•(irhr.ria  stniintj)nv(t,  conditions  which  re(|uire  a  few  weeks  for  develoj)ment  and  which 
may  be  |)receded  by  an  acute  mania.  These  conditions  are  indicated  by  anemia  with 
weakness,  defective  circulation,  swellin<ij  of  the  extremities,  usually  first  in  the  fingers, 
the  swelling  being  of  a  hard,  inelastic  type,  and  not  pitting  on  pressure,  aj)pearing 
later  in  the  face  so  that  the  features  become  altered.  Later  a])pear  al.so  muscular  tremors, 
with  tetanoid  convulsive  attacks.  These  results  of  thyroidectomy  may  be  combated 
by  feeding  thyroid  extract,  or  by  transplantation  of  thyroid  tissue  fn^ii  a  sheep  into  the 
ti.ssue  of  the  body  or  into  the  abdominal  cavity.  While  Horsley  and  others  have  been 
successful  with  the  surgical  j)r<)cedure,  it  is  usually  ncnv  sufficient  to  re.sort  to  continuous 
administration  of  thyroid  extract,  this  being  indicated  only  in  cases  where  thvToid 
activity  is  defective  and  being  contra-indicated  in  instances  of  overactivity,  such  as 
exo[)hthalmic  goitre. 

THYROIDITIS. 

Thyroiditis  as  a  more  or  less  acute  affection  is  occasionally  noted,  being  due  to  one 
of  the  infectious  fevers,  or  occasionally  following  dermatitis,  local  infections,  etc.  It 
may  assume  a  hemorrhagic  type  and  be  followed  l)y  |)roduction  of  hematoma.  It  may 
also  assume  a  su]){)urative  tyjje  and  lead  to  the  formation  of  abscess.  This,  if  impending, 
is  always  of  a  serious  nature,  as  it  is  sure  to  be  followed  by  local  cellulitis,  perhaps  with 
serious  j)ressure  symptoms,  and  escape  of  pus  along  the  deeper  fascial  planes  into 
the  thorax. 

A  n  acute  idlopath  ic  hijpertrophi/  in  children  has  been  noted  by  the  writer  in  one  instance, 
in  which  the  enlargement  was  rapid,  occupying  but  a  few  days,  and  had  already  caused 
such  compression  of  the  trachea  when  the  case  was  first  seen  that  even  a  tracheotomy 
])romptly  performed  did  not  serve  to  save  the  patient's  life. 

I )itra-u ferine  lii/pertrophij  of  the  thyroid  is  also  known.  There  are  at  least  fiv'e  cases 
on  record  of  this  condition  following  the  administration  of  potassium  chlorate  to  the 
mother  during  pregnancy.  In  one  case  reported  the  tumor  attained  a  size  sufficient  to 
constitute  a  serious  complication  in  delivery  of  the  child. 

Among  the  special  symptoms  produced  by  these  acute  affections  are:  difficulty  of 
swallowing,  which  may  lead  to  great  thirst ;  head  s^Tiiptoms  due  to  obstruction  to  the  return 
circulation,  with  congestion  of  the  face  and  epistaxis;  while  pressure  upon  the  pneumo- 
gastric  may  cause  nausea  or  vomiting.  The  treatment  of  such  a  case  when  seen  early 
should  consist  of  wet  anrl  ice-cold  applications  for  several  hours;  but  when  seen  later, 
especially  if  suppuration  be  already  threatening,  pus  formation  and  its  localization  may 
be  encouraged  by  hot  ap])lications,  followed  by  free  incision,  thus  relieving  tension  and 
evacuating  pus. 

Thyroiditis  occurring  in  goitrous  th\Toids  is  usually  referred  to  as  fifntmiiis,  as  the 
enlargement  itself  was  formerly  known  as  struma;  it  follows  the  exanthems  and  fevers, 
and  may  cause  sudden  and  distressing  complications. 


TUMORS  OF  THE  THYROID. 

Aside  from  those  thyroidal  enlargements  to  be  considered  under  the  heading  of  goitre 
may  be  met  tumors  of  congenital  origin,  especially  the  simple  or  complicated  cysts, 
which  may  grow  slowly  or  rapidly,  or  may  not  appear  at  all  until  puberty  or  adult  life. 


712  SPECIAL  OR  REGIONAL  SURGERY 

An  apparently  innocent  cyst  may  suddenly  increase  in  size  and  produce  serious  symp- 
toms, or  hemorrhage  may  occur  into  it,  or  it  may  rupture,  in  either  of  which  instances 
severe  pressure  symptoms  will  ensue.  All  cystic  tumors  of  the  thyroid  should  he  enucle- 
ated, an  operation  usually  easy  of  performance  unless  the  collection  he  multiloeular  and 
extensive.  If  an  entire  thyroidal  lohe  he  occupied  by  growths  of  this  character  it  may 
be  assumed  that  its  function  has  been  so  much  impaired  that  it  should  be  completely 
removed. 

The  thyroid  body  is  occasionally  the  site  of  teratomas,  i.  r.,  tmnors  containing  tissue 
of  each  blastodermic  layer.  No  two  such  tumors  are  alike.  They  may  assume  various 
sizes  and  shapes,  growing  in  various  directions,  and  will  hardly  define  themselves  until 
removal. 

The  benign  solid  tumors  consist  mainly  of  the  various  types  of  goitre. 

Of  the  malignant  tumors,  sarcoma  is  perhaps  the  most  frequent,  and  is  met  here  in 
all  its  varieties.  Endothelioma  occurs  here  also,  while  true  carcinoma  can  hardly  be 
primary  in  the  thyroidal  tissue,  but  may  frequently  extend  to  it  and  invade  it,  thus 
seriously  complicating  a  case  already  made  desperate  by  its  presence  in  the  neck.  Metas- 
tatic forms  of  true  cancer  may  alst)  occur  here  as  elsewhere.  For  a  growth  of  this  kind 
there  is  but  one  resort,  i.  e.,  extirpation,  but  this  will  be  difficult  and  usually  inexpedient. 

GOITRE;    STRUMA;   BRONCHOCELE. 

The  enlargement  or  hypertrophy  of  a  part  or  the  whole  of  the  thyroid,  now  known 
universally  as  goitre,  has  been  known  also  as  bronchocele  and  trachelocele.  The 
condition  is  one  of  imilateral  or  symmetrical  affection,  met  with  much  oftener  in 
women  than  in  men,  and  particularly  in  certain  regions.  It  is  most  prevalent  in  Switzer- 
land and  in  Upper  India.  It  is  occasionally  known  to  assmne  an  endemic  or  epidemic 
form,  the  affection  disappearing  from  the  region  of  the  country  concerned  after  a  period 
of  some  years.  Practically  nothing  is  known  of  its  cause.  Many  theories  have  been 
advanced,  that  which  finds  perhaps  widest  acceptance  referring  to  the  character  of 
the  water  supply. 

For  present  purposes  goitre  may  be  understood  to  include  the  following  forms: 
Simple  hyi^ertrophy,  the  so-called  parenchymatous  form; 
Thyroid  adenoma; 
Cystic  goitre; 
Exophthalmic  goitre  (Graves'  or  Basedow's  disease). 

The  'parenchymatous  form  consists  essentially  of  an  overgrowth  of  the  ordinary  thyroid 
tissue.  It  is  diffuse  and  unencapsulated,  all  the  thyroidal  tissues  j)artici]>ating  in  its 
structure.  Sometimes  whole  families  suffer  from  this  form  of  goitre,  and  f)ccasionally 
an  apparently  hereditary  influence  may  be  traced.  The  tumor  thus  ])ro(luced  may  attain 
great  size.  According  as  it  involves  one  side  or  both  will  it  l)e  symmetrical  or  otherwise. 
It  is  elastic,  smooth,  rounded,  sometimes  apparently  subdivided  by  furrows  which  mark 
the  original  lobar  arrangement.  It  displaces  the  structures  around  it,  and  may  attain 
a  large  size  without  producing  serious  pressure  effects.  When  these  occur  they  assiune 
the  type  of  dyspnea,  dysphagia,  and  laryngeal  paralysis.  The  growth  is  insidious,  usually 
increases  markedly  with  each  pregnancy,  and  may  spontaneously  recede.  Within  it 
changes  may  occur  which  lead  either  to  cystic  softening  and  formation  of  cysts,  or  fibrous 
trabeculje  may  appear  and  thus  make  it  more  firm  and  dense.  The  denser  the  growth 
the  earlier  the  pressure  symptoms  ap])car.  Occasionally  the  isthmus  alone  will  appear 
involved,  in  which  case  there  will  be  a  central  growth. 

The  so-called  thyroid  adenoma  (the  term  adenoma  being  used  on  the  supposition  that 
thyroidal  tissue  is  true  gland  tissue)  is  often  of  cystic  type.  It  consists  of  more  or  less 
isolated  tumors  of  general  thyroid  character,  but  circumscribed,  often  encapsulated, 
perhaps  undergoing  cystic  degeneration,  occurring  frequently  in  multi]ile  form,  and  pro- 
ducing cysts  of  all  sizes.  Such  a  growth  will  (lisplace  the  other  thyroidal  tissue  and 
may  give  a  decidedly  irregular  aspect  to  the  resulting  tumor.  The  cysts  often  c-ontain 
cholesterin.  In  recent  cases  the  capsule  is  thin;  in  old  tumors  it  may  be  calcified,  and 
so  may  be  the  tissue  within  the  cajxsule.  lliese  growths  are  seen  in  successive  gcMiera- 
tions  of  the  same  family.     They  have  their  l)eginnings  usually  in  the  earlier  years  of  life. 

Similar  growths  may  also  arise  from  the  outlying  portions  of  the  thyroid,  or  from  acces- 


Kxoi'nriiM.Mic  aoiTRE  713 

sorij  thijrDids,  so  that  llicy  may  he  t'oiiiid  hack  of  tlic  stcniiiin,  or  lyiii<^  deeply  in  the  neck 
or  near  the  base  of  the  toiij^ue.  If  near  the  surface  anti  cystic  they  tj;ive  a  sense  of 
fhictnation  which  the  harder  forms  do  not  afford. 

Endotracheal  Goitre. — A  recent  study  of  Eiulerlen  has  sliown  that  small,  goitrous 
•growths  make  their  appearance  within  the  trachea  more  eommonly  in  femaU's  than  in 
males,  and  in  patients  of  middle  afjje.  'VW  known  duration  of  (growth  has  varied  from 
a  few  weeks  to  fifteen  years.  lie  l)elieves  the  majority  of  the  eases  hej^in  to  t^row  at  the 
ajije  of  jiuherty.  Tliese  <rrowths  have  lu-en  found  on  the  posterior  wall  of  the  larynx 
or  in  tlu-  trachea  itself.  They  have  usually  rounde<l  hases  and  hroad  implantation,  with 
smooth  surface's,  covered  with  intact  mucosa.  In  most  instances  the  thyroid  itself  is 
also  enlar<;ed.  The  oidy  recorded  sym])tom  is  dyspnea,  j)roportionate  to  the  degree 
of  ohstruction.  They  are  probably  to  be  explained  by  the  inclusion  theory,  some 
thyroidal  rest  being  disintegrated  and  .so  entangled  as  to  grow  in  this  direction.  The 
only  satisfactory  treatment  is  ablation  of  the  tumor,  after  tracheotomy,  as  endolaryngea! 
operations  are  more  dangerous. 

These  constitute  the  ordinary  types  of  goitre.  Diagium.s  is  not  difficult,  as  the  result- 
ing tumors  are  more  or  less  j)rominent,  involve  the  region  of  the  thyroid,  and  rise  and 
fall  with  each  act  of  swallowing.  When  the  entire  organ  is  involved  the  tumor  may 
have  a  horseshoe  shape.  Large  veins  aj)pear  uj)on  the  surface,  while  j)ressure  symj)tonis 
will  correspond  with  its  size  and  location.  They  pursue  an  irregidarly  slow  course. 
Many  patients  attain  old  age  and  a  considerable  size  of  growth  without  such  discomfort 
as  to  require  operation.  Any  goitrous  enlargement  in  which  considerable  softening 
occurs,  with  formation  of  colloid  material,  is  entitled  to  the  term  in  frecjucnt  use,  ''col- 
loid goitre.^'  By  accident  of  location  any  growth  of  this  kind  behind  the  sternum  may 
cause  serious  pressure  effects  before  attaining  large  size.  In  symmetrical  enlargement 
of  both  lobes  the  trachea  may  be  so  compressed  as  to  be  narrowed  and  to  entitle  it  to  the 
term  .s-rdhhard  trachea. 

Iodine  has  been  used  externally  and  sometimes  with  benefit.  The  favored  method  in 
India  is  to  use  an  ointment  containing  one  grain  of  red  iodide  of  mercury  to  the  ounce. 
This  is  daily  rubbed  over  the  goitre  and  then  the  parts  exposed  to  the  bright  sunlight 
for  an  hour  or  more.  Iodine  has  also  been  used  by  parenchymatous  injection.  It  is 
mainly  used,  however,  by  those  who  ol>ject  to  operation  or  do  not  dare  perform  it.  The 
iodine  treatment,  whether  externally  or  internally  used,  is  usually  disaj)pointing.  So  also 
is  that  by  the  llontgen  rays,  and,  for  that  matter,  all  other  non-operative  measures. 
Operative  relief  alone  is  complete  and  final.     It  is  described  below. 


EXOPHTHALMIC  GOITRE. 

As  a  clinically  distinct  type  of  disease  this  was  first  described  by  Graves,  of  Dublin, 
in  1835,  and  five  years  later  by  Basedow,  of  Magdeburg;  hence  it  is  frequently  called 
l)y  their  names.  Although  the  thynnd  participates  in  the  clinical  picture  it  cannot  be 
stated  that  it  is  primarily  at  fault.  Three  marked  (objective  features  characterize 
pronounced  cases — thyroidal  enlargement,  more  or  less  pronounced  tachycardia,  and 
exophthalmos. 

So  far  as  known  there  is  an  essentially  toxemic  feature  behind  these  lesions,  which  is 
mysterious,  nor  is  the  nature  of  the  toxemia  certain.  No  constant  lesions  have  been 
found  in  the  nervous  system,  although  the  sympathetic  nerves  are  always  involved  when 
the  heart  and  the  eyes  are  affected.  The  three  cardinal  symptoms  or  signs  above  met^- 
tioned  are  nearly  always  a.ssociated;  but  with  pronounc-ed  rapidity  of  the  heart's  action 
there  may  be  but  little  involvement  of  the  thyroid  or  slight  protrusion  of  the  eyes.  What- 
ever the  original  toxemia,  or  its  source,  a  prominent  feature  of  the  condition  is  hyper- 
thyroidi-tm — i.  e.,  hypersecretion  of  the  substance  which  regulates  nutrition — whose 
overproduction  materially  disturbs  the  heart  and  vasomotor  nerves.  It  stands  in  strong 
contrast  to  myxedema  and  cachexia  struinijiriva,  which  are  cf)nsiflered  to  be  due  to 
hypothyroidism  or  diminished  secretion.  Consequently  it  is  not  to  be  treated  by  feeding 
thyroid  extract.  A  recent  view  which  has  much  to  suj)port  it  is  tliat  at  the  basis  of  this 
condition  the  parathyroids  are  so  concerned  that  any  o|)eration  which  includes  their 
extirpation  would  be  a  serious  menace.  At  present  it  may  be  held  that  the  parath\Toids 
are  intermediate  factors  between  the  primary  toxemia  and  the  hyperthyroidism. 


714  SPECIAL  OR  REGIONAL  SURGERY 

Aside  from  mere  thyroidtil  enlargement,  which  is  infinenced  by  pressure  and  shows 
an  increased  pidsation,  always  palpable,  sometimes  visible,  there  occur  increased  heart 
activity,  with  a  rapid  and  easily  influenced  pulse;  widening  of  the  palpebral  fissures, 
the  upper  lid  not  following  the  motions  of  the  globe,  with  defective  convergence;  rhythmic 
muscular  tremors;  increase  of  general  sensibility;  insomnia,  with  disturbed  sleep; 
])sychical  disturbance,  somethnes  amounting  to  melancholia  or  mania;  digestive 
disturbances,  including  diarrhea,  vomiting,  and  thirst;  cough,  with  frequent  and  shallow 
respiration;  loss  of  hair  and  nails;  sweating,  flushing  of  surface  and  sometimes  leuko- 
derma or  pigmentation  of  the  skin.  Terminal  symptoms  consist  of  all  those  mentioned 
above,  with  acute  mania,  high  temjicrature,  vomiting,  profuse  sweating,  dermatitis, 
jaundice,  and  final  convulsions  with  exhaustion,  all  these  resembling  those  of  death  in 
exjierimental  animals  after  the  removal  of  the  parathyroids. 

A  sign  recently  described  by  Teillas,  which  he  considers  pathognomonic,  consists  of 
deep-brown  jiigmentation  of  the  outer  surface  of  the  eyelids,  the  color  being  evenly 
diffused,  boimded  above  by  the  eyebrow,  below  by  the  margin  of  the  orbit,  the  conjunctiva 
being  not  affected.  Its  effect  is  to  apparently  increase  the  degree  of  ex()])lithalmos  and 
to  intensify  the  fixity  of  gaze  observed  in  these  subjects. 

Treatment. — This  is  not  the  i)lace  in  which  to  consider  in  detail  either  the  pathology 
or  the  drug  treatment  of  this  affection.  By  many  surgeons  it  is  regarded  as  a  surgical 
disease,  i.  e.,  one  to  be  treated  by  one  of  two  operative  methods,  either  thyroidectomy 
or  excision  of  the  cervical  sympathetic.  When  such  measures  as  electricity,  Riintgen 
rays,  and  hydrotherapeutic  treatment,  and  such  drugs  as  belladonna,  sodium  phosphate, 
arsenic,  iodine,  phosphoric  acid,  etc.,  have  failed,  and  when  the  antithyroidal  serums 
or  preparations,  such  as  thyroidectin  and  antithyroidin  have  proved  insufficient,  then 
surgery  remains  a  last  resort.  Unfortunately  this  is  too  long  delayed.  To  remove  the 
thyroid  so  soon  as  it  is  shown  to  be  producing  an  injurious  auKHUit  of  oversecretion  is 
neither  a  difficult  nor  a  dangerous  procedure,  but  to  wait  imtil  the  heart  beats  150  times 
a  minute  and  the  patient  is  nearly  maniacal  is  to  wait  until  he  is  almost  moribund  and 
until  it  is  too  late.  Nowhere  does  the  remark,  "The  resources  of  surgery  are  seldom 
succ-essful  when  practised  on  the  dying,"  apply  more  forcibly  than  to  such  cases  as  these. 

As  between  sympathectomy,  already  described,  and  thyroidectomy  (see  below)  it  may 
be  difficult  to  choose.  By  the  time  such  a  case  comes  to  operation  each  will  present  its 
distinct  difficulties.  The  question  is  mainly  one  of  choice.  A  large  tumor  will  obscure 
access  to  the  sympathetic  trunk  in  the  neck,  while,  on  the  other  hand,  the  neurectomy 
itself  is  probably  a  less  dangerous  procedure.  The  decision  should  be  l)ased  on  the  pre- 
dominance of  the  features  due  to  vasomotor  disturbances.  Thus  when  the  eyes  are 
prominent,  the  pupils  dilated,  the  palpel>ral  fissure  widely  open  and  difficult  of  closure, 
there  is  reason  for  attacking  the  middle  and  upper  cervical  ganglia,  which  are  not  so  diffi- 
cult of  access.  Again  when  the  heart  is  affected  there  would  be  a  special  indication  for 
extirpating  the  inferior  cervical  ganglion,  as  well  as  the  first  dorsal;  but  the  former  will 
always  be  difficult  in  the  presence  of  a  thyroidal  tumor,  and  the  latter  wellnigh  impossible. 
When,  however,  thyroidal  symptoms  are  pronounced,  witli  difficulty  in  respiration  or 
other  purely  pressure  effects,  thyroidectomy  is  indicated.  This  should  be  jx-rformed 
as  described  below.  An  effort  should  be  made  to  preserve  the  capsule,  at  least  on  the 
iimer  and  posterior  aspect  of  the  thyroid,  in  order  that  the  parathyroids  which  lie  in  close 
relation  to  it  may  not  be  disturbed.  Operations  upon  the  vessels  for  the  purpose  of 
controlling  the  circulation  are  rarely  practised,  and  the  question  in  these  cases  is  as 
between   partial  and   complete   extirpation. 

Curtis  has  recently  collected  from  the  statistics  of  two  German  and  two  American 
operators  136  cases  of  exophthalmic  goitre  treated  by  thyroidectomy,  with  17  deaths, 
chiefly  from  acute  thyroidism.  The  most  marked  improvement  realized  was  disappear- 
ance of  tremor,  nervousness,  and  insomnia,  and  of  a  feeling  of  anxiety,  so  common  to 
the  disease.  To  these  may  be  added  the  more  extensive  experiences  of  Charles  Mayo, 
which  present  extirpation  as  an  almost  ideal  method  of  treatment. 

As  remarked  above,  all  attempts  at  feeding  with  thyroid  extract  should  be  avoided, 
the  case  being  one  already  suffering  from  hyperthyroidism.  It  shoulfl  be  noted  that  in 
few  instances  the  thyroid  seems  to  suffer  from  its  own  overactivity,  and  passes  into  a 
stage  of  physiological  atrophy,  with  more  or  less  sul)sidence  in  volume.  In  such  a  case 
the  symptoms  of  Graves'  disease  would  gradually  change  into  those  of  myxedema. 

The  thyroid  itself  is  extremely  vascular  under  all  circumstances,  particularly  under 


TIIYIiOIDF.CTOMY  715 

these,  to  siicli  ail  extent  that  ])iil.sati()ii  Iiecoiiics  a  pnniiiiieiit  feature.  This,  liowevcr, 
should  not  he  luistakeii  hn"  that  h)nii  of  onhiiary  i^oitic  in  wliieli  the  vessels  tinderjfo 
increase  in  diiuensions  and  in  which  sonietiines  a  lond  hnat  may  he  heard. 

M(ili(/>i(i>if  (joitir  implies  a  ^generalized  involvement  of  the  thyroid  in  one  of  the  mali<j- 
nant  forms  of  neoplasm.  (See  helow.)  It  is  of  ra|)id  <;ro\\th,  with  more  or  less  infil- 
tration of  surroiindinti  tissues,  which  is  evidently  not  of  inflammatory  character  but 
more  distinctive. 

THYROIDECTOMY. 

This  may  he  j)artial  or  total.  It  is  imj)ortant  to  leave  a  portion  of  the  thyroid  in  order 
that  the  pati<'nt  may  not  suffer  from  the  eonse(|iu'nces  of  ntliijroitli.s-tii,  i.  c,  car/icxia 
stnnniprira.  It  is  fjeiu'rally  understood  tliat  if  one-sixth  or  one-seventh  of  the  total 
mass  can  he  left  in  .situ,  with  sufhcient  blood  suj)ply,  it  will  sufKee.  Thus  it  may  be  pos- 
sible to  leave  the  isthmus,  after  removing  both  lateral  lobes,  or  a  portion  least  affected 
of  one  of  the  latter  may  be  left  in  plac-e. 

The  character  of  the  incision  will  depend  on  the  size  and  position  of  the  enlargement. 
For  complete  thyroidectomy  a  horsesho{>-slia))ed  incision,  convexity  downwarrl,  should 
be  made,  extending  along  the  anterior  border  of  the  sternomastoids  and  then  acro.ss 
the  neck.  This  should  be  carried  through  tiie  platysma  and  su|KTfi<'ial  fascia>,  the 
anterior  jugular  veins  being  secured  when  cut.  The  fla])  thus  made  is  then  raised,  after 
which  a  large  part  of  the  subsecjuent  procedure  is  made  by  blunt  dissection,  and  separa- 
tion of  the  surrounding  muscles,  which  are  held  aside  with  retractors.  When  the  tumor  is 
so  shapetl  and  j)laeed  as  to  make  it  possible  it  is  well  to  approach  it  laterally  and  secure 
the  upper  and  lower  th}Toidal  vessels  on  one  side  or  both,  dividing  between  double  liga- 
tures. If  this  be  done  the  mass  can  be  drawn  forward  in  such  a  way  as  to  avoid  injury 
to  the  nerves  and  vessels,  the  operator  keeping  in  close  contact  with  the  capsule,  or,  for 
reasons  specified  above,  perhaps  dividing  and  shelling  out  the  mass  from  within  it. 
Although  the  tumor  may  be  occupied  by  large  vessels,  those  which  lead  up  to  it — i.  e., 
the  thyroids — are  rarely  much  enlarged.  Nevertheless  it  is  wise  to  secure  them  first. 
While  the  anterior  muscles  may,  in  many  instances,  be  separated  and  the  tumor  mass 
exposed  between  them,  there  are  cases  which  will  require  transverse  division  of  the 
sternohyoid  and  sternothyroid,  in  which  case  they  should  be  subsequently  sutured. 

One  of  the  complications  is  to  find  the  tumor  mass  extending  down  behind  the  sternum 
or  the  clavicle.  From  these  locations  it  should  be  separated  by  cautious  blunt  dissection, 
else  the  pleura  or  one  of  the  deep  veins  might  be  wounded.  The  former  accident  would 
be  instantly  denoted  by  the  passage  of  air  and  its  entrance  into  the  thorax,  the  latter  by 
severe  hemorrhage. 

In  exophthalmic  cases  it  may  be  held  to  be  especially  desirable  to  enucleate  the  thyroid 
from  within  its  capsule.  This  makes  the  performance  easier  in  some  respects  and 
more  difficult  in  others. 

Extreme  caution  should  be  taken  in  two  particular  respects:  First,  that  the  trachea 
be  not  compressed,  nor  its  caliber  interfered  with,  by  the  traction  efforts  used  in  ^emo^^ng 
the  mass.  The  second  caution  necessary  in  exophthalmic  cases  is  to  inahe  the  least  'possible 
amount  of  pressure  iipon  the  thyroid  during  the  operative  proeedure,  since,  as  mentioned 
above,  its  secretion  is  depressing  to  the  heart,  and  it  would  complicate  matters  to  force 
more  of  this  material  into  the  circulation  at  a  time  when  everything  conspires  to  reduce 
blood  pressure  and  the  reliability  of  the  heart's  action.  A  certain  amoimt  of  manipu- 
lation is  unavoidable,  but  this  should  be  made  as  gentle  and  as  slight  as  possible.  More- 
over, these  cases  arc  to  be  drained  to  permit  of  free  escape  of  thyroidal  secretion.  (IVIayo.) 

In  performing  thyroidectomy  for  Graves'  disease  advantage  should  be  taken  of  the 
pneumatic  suit  de\-ised  by  Crile,  and  the  patient  placed  in  the  semi-upright  position. 
These  are  advisable  precautions  to  take  in  every  such  operation.  The  position  allows 
more  natural  emptying  of  the  veins  at  the  base  of  the  neck  and  the  suit  permits  of  the 
blood  pressure  being  maintained  by  mechanical  means.  In  order  to  use  the  suit  to  best 
advantage  the  blood  pressure  should  be  noted  throughout  the  course  of  the  operation. 

The  enucleation  or  extirpation  concluded,  hemostasis  should  be  observed,  as  with 
returning  cardiac  vigor  secondary  hemorrhage  is  l^y  no  means  an  impossible  event. 
Everv  vessel  which  can  be  recognized  shoidd  l>e  carefully  tied,  and  tissues  which  ooze 
should  be  caught  up  with  suture  and  tied  en  masse.     All  the  deeper  portions  of  the  wound 


716 


SPECIAL  OR  REGIONAL  SURGERY 


should  1)0  brought  together  by  buried  sutures  in  such  ii  way  as  to  leave  no  dead  spaces. 
Cases  where  a  retrosternal  ])it  has  been  left,  by  removal  of  a  low-lying  growth,  should 
be  drained  to  avoid  the  accumulalion  of  blood/  Where  doubt  exists  as  to  security  from 
secondary  hemorrhage  it  is  the  writer's  custom  to  place  secondary  sutures,  and  to  j)ack 
the  cavity  with  gauze  dipj)ed  in  balsam  of  P(tu,  leaving  this  i)acking  in  place  for  two 
days,  then  removing  it  and  closing  the  wound  by  utilization  of  the  sutures. 

Shock  after  these  operations  may  be  extreme,  and  is  to  be  combated  by  transfusion  or 
infusion  of  salt  solution,  with  small  amounts  of  adrenalin. 

Should  the  surgeon  attack  a  so-called  malignant  goitre  he  must  be  prepared  to  meet 
with  greater  difficulties  and  perhaps  to  abandon  the  operation  before  its  comi)letion. 
Death  on  the  table  is  not  unusual  in  such  cases.  ' 

Operation  under  cocaine  local  anesthesia  is  often  most  advantageous,  and  is  the  rule 
in  such  clinics  as  that  of  Kocher,  in  Berne.  The  patient  shoud  be  well  narcotized  with 
morphine,  after  which  a  weak  cocaine  solution  is  injected  along  the  projjoscMl  line  of 
incision.  The  pain  produced  by  the  balance  of  the  work  is  not  beyond  endurance,  while 
the  dangers  are  certainly  minimized,  especially  in  cases  where  there  is  compression  of 
the  trachea  or  excessive  heart  action,  the  latter  being  particularly  true  in  Graves'  disease. 

Fig.  500 


Patient  placed  in  semivertical  position,  and  enclosed  in  Crile's   pneumatic  suit,  as  recommended   for  many  cases 
of  goitre,  brain  tumor,  or  other  serious  operations  about  the  head  and  neck.      (Crile.) 

There  is  less  fulness  of  veins,  and  there  is  neither  coughing  nor  vomiting.  The  operative 
features  are  the  same  as  those  described.  As  the  anterior  thyroid  artery  is  apjjroached 
all  possibility  of  including  the  recurrent  laryngeal  nerve  in  "the  ligature  is  avoided  by 
having  the  patient  talk,  injury  to  the  nerve  producing  instant  hoarseness.  If  the  growth 
extend  low  and  into  a  pit  behind  the  sternum  it  may  be  ]x)ssible  to  extir])ate  it  from  abt)ve 
(lownward,  and  finally  to  lift  it  from  its  bed,  securing  its  base  or  pedicle  with  an  elastic- 
ligature. 

A  danger  common  to  all  thyroidectomies  is  that  of  injury  to  the  trachea.  This  is 
avoided  when  there  are  no  abnormal  adhesions,  but  when  the  growth  surrounds  the 
trachea,  or  is  firmly  fastened  to  it,  such  an  accident  may  ha]>pen  in  spite  of  the  greatest 
care.  According  to  its  size  and  location  the  surgeon  may  entleavor  to  close  the  opening 
with  sutures,  or  he  may  insert  a  tracheotomy  tube  or  leave  the  wound  o])en  sufficiently 
to  pack  it  snugly,  preventing  entrance  of  fluid  itito  the  trachea,  at  the  same  time  expecting 
the  wound  to  be  subsequently  closed  by  granulation  tissue. 

Sympathectomy  as  a  measure  directed  toward  the  treatment  of  exo])hthalmic  goitre, 
as  well  as  of  glaucoma  and  certain  forms  of  epilepsy,  has  been  decribed  in  Cliapter 
XXXVII. 


Till-:  TIDMUS  717 


STRUMITIS. 


Strumitis  is  a  term  a|)|)li('(l  to  actual  iiillaiuuialion  of  an  already  ^nitrous  tliyroid. 
It  may  Htllow  sucli  iulVctious  disrascs  as  ty|)li()id,  or  it  may  l»c  au  a|)|)ar(Mitly  spontaneous 
inl't'ction  witliout  known  ciiuse.  It  may  run  an  acute  course,  tendin<f  rapidly  to  suppu- 
ration, in  whicli  case  there  will  he  not  only  pain  and  tenderness  in  the  thyroid  itseli',  hut 
all  the  local  e\idenees  of  pyofj;enic  infection,  with  infillration  and  ru])i<l  formation  of  i)»is, 
perliai)s  with  wides|)rea(l  phlejjjmon  of  the  neck.  Thi.s  is  a  serious  condition  and  may 
call  for  larly  and  free  incision  of  the  infected  urea.  A  hemorrhagic  form  of  strumitis 
is  also  known.  The  thyroid  may  also  he  the  site  of  metastatic  ahscesses  in  cases  of 
pyemia,  in  whicli  case  there  will  he  hut  few  local  indications. 


TUK  THYMUS. 

The  tliynms  li<:;ures  hut  rarely  in  surfi|;ical  interest,  hut  when  seriously  affected  it  causes 
most  pronounced  symptoms.  Its  princi|)al  activity  is  shown  previous  to  hirth  and  during 
the  earliest  months  of  infancy,  and  it  should  have  disajipeared  hy  the  age  of  puherty. 
Instead  of  atrophying,  as  it  shoidd,  it  may  undergo  lnjjjcriropln/,  hy  which,  on  account 
of  its  location,  serious  pressure  is  made  upon  the  trachea  and  the  hase  of  the  neck.  I'his 
may  occur  suddenly,  so  that  a  tumor  in  its  loeation  rajiidly  (leveloj)s  and  will  prove 
fatal  unless  surgical  relief  he  afforded.  This  constitutes  an  aeute  hypertrophy  of  the 
thynuis,  which  is  more  than  a  mere  surgical  curiosity.  In  one  ease  seen  hy  me  a  lf)ng 
trachea  tuhe  was  with  difficulty  inserted  just  in  time  to  prevent  death  hy  asphyxiation. 
In  ease  of  such  tumor  the  upper  end  of  the  sternum  should  he  removed  and  the  tumor 
enucleated,  or  the  thymus  should  he  sewed  up  to  the  sternum  and  the  tumor  thus  raised 
out  of  its  hed. 

The  thynuis  is  of  special  interest  in  connection  with  the  status  lymphaticus,  which 
has  heeii  referred  to  in  a  previous  chapter.  Its  connection  in  such  cases  with  hyper- 
trophied  hin])lioid  elements  all  over  the  hody,  and  especially  of  the  adenoid  tissues 
of  the  nasopharynx,  was  therein  descrihed,  and  the  seriousness  of  the  condition,  with 
the  menace  which  it  offers  to  anesthesia,  as  well  as  the  extreme  cautions  to  he  ohserved, 
were  fully  rehearsed.  The  significance  of  laryngismus  stridulus  and  its  relations  thereto 
were  also  mentioned.  x\ll  this  is  of  extreme  importance  to  the  surgeon,  as  every  child 
with  so-called  thymic  asthma,  and  with  symptoms  of  lymphatism,  should  be  watched 
carefully  and  anesthetized  cautiously.     (See  Chapter  XIV.) 

Acute  inflaiiimalion  of  the  thijmvs  as  well  as  hemorrhages  within  it  have  heen  ohserved. 
It  may  also  he  the  site  of  cystic  tumors,  perhaps  of  hemorrhagic  origin.  Suj)puration 
in  these  cases  is  possible.  In  brief,  the  thymus,  when  acutely  inflamed  and  sujjpurating, 
may  he  excised,  when  the  tumor  may  be  removed;  but  when  simply  somewhat  involved, 
as  in  the  status  lymphaticus,  it  is  best  let  alone,  except  in  the  presence  of  urgent  indica- 
tions to  the  contrary. 


CHAPTER    XLIII. 
THE  THORAX  AND  ITS  CONTENTS. 


MALFORMATIONS  OF  THE  THORAX. 

Congenital  malformations  of  the  thorax  are  not  uncommon,  yet  but  few  of  them 
permit  of  surgical  remedy.  One  or  more  of  the  ribs  may  be  absent  or  defective  in  forma- 
tion and  produce  lateral  distortion  of  the  spine.  The  clavicle  also  may  be  defective 
on  one  or  both  sides,  or  absent.  This  is  a  defect  which  causes  but  little  inconvenience, 
in  spite  of  its  prominence.     The  chest  as  a  whole  may  develop  defectively  or  irregularly, 

some  of  these  conditions  being  expressions  of  intra- 
uterine rickets  and  others  being  due  to  unknown  or 
uncertain  causes.  Thus  we  have  the  absolutely  flat 
chest  seen  most  often  in  connection  with  an  unduly 
rounded  back,  the  flattening  appearing  rather  in 
front,  while  perhaps  the  anteroposterior  diameter  is 
actually  increased.  As  Hutchinson  has  shown,  this 
may  be  a  persistence  of  the  fetal  type  of  chest. 
Pigeon-chest  or  keel-shaped  chest  may  be  regarded  as 
a  reversion  to  a  more  primitive  type,  the  anteroposte- 
rior diameter  being  increased  at  the  expense  of  the 
lateral.  The  reverse  of  this  deformity  is  the  so-called 
funnel-shaped  chest,  where  the  sternum  is  depressed 
and  the  lateral  dimensions  increased.  In  addition 
to  the  defects  thus  noted  in  the  ribs  and  sternum, 
absence  of  a  vertebra  has  been  known,  the  condition 
not  producing  deformity,  but  rather  an  appreciable 
shortness  of  the  spine.  Malformations  are  seen  fre- 
quently in  the  sternum,  which  may  be  fissured  in 
either  direction,  or  may  present  perforations.  With 
these  similar  defects  of  the  ribs  may  also  be  seen, 
even  to  a  degree  permitting  congenital  hernia  of 
the  thoracic  contents. 

Supernumerarij  developments  find  their  expression 
usually  in  an  added  rib,  either  in  the  cenncal  or  in 
the  lumbar  regions.  This  condition  is  practically 
never  noted  at  birth  and  may  pass  unnoticed.  Never- 
theless a  cervical  rib  may,  in  adult  life,  produce  dis- 
comfort or  actual  interference  with  function,  partly  by  pressure  upon  the  subclavian 
artery  or  the  brachial  plexus.  When  found  it  is  in  relation  with  the  seventh  cer\'ical 
vertebra,  and  the  space  between  it  and  the  first  dorsal  rib  is  occupied  by  muscle  developed 
for  the  purpose.  The  scalenus  anticus  may  be  inserted  into  its  anterior  edge.  When 
sufficiently  prominent  to  produce  troublesome  symptoms  it  may  be  recognized  by 
palpation,  and  cases  of  doubt  may  be  made  clear  by  a  radiograph.  Shoidd  it  prove 
troublesome  it  may  be  removed,  an  operation  requiring  considerable  caution,  because 
of  its  close  relation  to  the  pleura,  which  might  easily  be  opened.  It  may  be  exposed 
by  such  an  incision  as  would  be  used  for  ligation  of  the  subclavian  artery. 

The  thoracic  muscles  occasionally  show  anomalies,  either  in  arrangement  or  by  their 
absence,  the  pectoralis  major  being  occasionally  wanting  in  whole  or  in  part,  and 
furnishing  the  most  frequent  illustration  of  these  defects,  which  are  usually  unilateral. 
(See  Fig.  502.) 

Congenital  luxations  of  either  extremity  of  the  clavicle  are  also  occasionally  seen, 
particularly  of   the  inner  end.     A  peculiar  displacement  and  relaxation  are  thereby 
permitted,  with  some  degree  of  functional  loss. 
(718) 


Congenital  malformation  of  chest. 

(Sayre.) 


MALFOim .\ri()\   OF   Till-:   THOhWX 


719 


Tlif  acfjiilrcd  tiuiIjoniKiliDiis  of  tlic  chest  may  l)c  |)ni(liicc(l  rroiii  a  variety  (•!"  causes. 
Tliiis  in  coiiiiectioii  with  iioii-closiire  of  llie  loraiiieii  ovale  and  (lie  coiisecjiieiit  (listiirhaiico 
ol"  heart  action,  with  its  ovenievelopiiieiit  of  the  rij^ht  auricle,  the  left  side  of  the  cliest 
nijiy  l)e  pushed  forward  and  the  apex  heat  found  far  helow  its  normal  position.  Asym- 
metry in  the  younjij  may  also  he  produced  by  several  dilfercnt  intrathoracic  conditions, 
the  most  eommon  heinfi;  pleurisy  and  empyema,  with  their  consecjucnt  distention  of  the 
pleural  cavity,  and  later  a  tendency  to  cicatricial  contraction.  In  this  way  marked  forms 
of  lateral  curvatun*  are  produced.  In  a  j)revious  chapter  it  was  stated  that  overffrowth 
of  lymphoid  tissue  in  (he  nasopharynx,  ordinarily  .s|)oken  of  as  a<lenoids,  with  eonse(|uent 
einharrassment  of  respira(ion,  leads  in  lime  to  stoo|)  shouKlers  and  poor  development 
of  (he  (horax.  Deformity  may  also  he  produced  by  sueh  defective  vision  as  shall  compel 
a  [)eeuliar  or  abnormal  posi(ion  of  the  head. 

Via.  502 


ConKenifal  absence  of  the  pectoralis  major  inuscl 


If.      (Richardson.; 


In  chronic  rmphyseina  there  is  noted  a  peculiar  harrcl-.shapc  of  the  chest,  which  is 
also  to  1)6  regarded  as  an  acquired  deformity.  Paralyses  of  the  internal  thoracic  muscles 
will  also  permit  of  asyinmetrical  growth,  and  projection  of  the  lower  angle  of  the  scapula, 
giving  it  a  wang-like  aspect. 

The  most  common  cause  of  thoracic  asymmetry  or  deformity  is  rickets,  which  may  be 
an  early  or  a  late  manifestation.  By  the  ordinary  changes  permitted  in  the  epiphyses 
and  along  the  costochondral  junctions  is  produced  the  peculiar  apjiearance  known  as 
"rickety  rosary."  In  these  cases  the  effect  of  the  weight  of  the  upper  part  of  the  body 
upon  the  soft  and  changeable  structures  of  the  osseous  and  cartilaginous  ril)s,  as  well  as 
the  vertebrfe  and  the  sternum,  are  to  be  noted.  Pronounced  types  of  deformity  result 
from  such  changes,  producing,  extreme  cases  of  pigeon-breast,  or  of  hollowing  in  front 
known  as  birds'  nest  deformity,  while  alterations  occur  in  the  vertebrae,  producing  various 
expressions  of  kyphosis  and  scoliosis.      (See  Fig.  504.) 


720 


SPECIAL  OR  REGIOXAL  SURGERY 


These  deformities  of  tlie  hac-k  thus  profhiccd  rf(|uire  to  he  differentiated  from  those 
prochiced  hv  Pott's  disease,  the  former  heiiifj  unaccompanied  by  s\7nptoms  and  occurrincr 
slowly,  while  the  latter  are  usually  accompanied  hy  pain  and  are  pro«rressive  in  character] 
as  well  as  more  or  less  disahlinrj.  With  a  softened  skeleton  in  a  rapidly  rrrowintr  child' 
such  triflinf;  influences  as  the  position  assumed  in  the  nurse's  or  mother's^ arm,  or  that 
habitually  taken  in  sleej),  may  affect  and  modify  snnmetrical  f;rowth.  Rickety 'deform- 
ities of  the  spine  and  thorax,  if  not  too  far  advanced,  permit  of  heint;  checked  and  much 


Vj'..  501 


Deformity  of  the  tborax,  the  result  of  rickets. 
(Gibney.) 


Malformation  of  chest  following  empyema. 
(Say  re.) 

imi^roved  by  braces,  alon^  with  the  measures 
indicated  in  rachitis.  Without  the  latter,  how- 
ever, the  former  would  be  almost  ineffectual. 

Malformations  may  also  he  produced  hy  in- 
juries or  certain  orcwpations  Extensive  burns 
may  cause  cicatricial  contraction;  contusions 
may  produce  paralyses,  and  more  serious  lace- 
rations may  leave  extensive  scars,  which  will 
gradually  warp  the  chest  out  of  shape.  Burns, 
for  instance,  which  may  involve  the  axilla  and 
the  upper  arm,  may  be  followed  by  such 
dense  scars  as  to  limit  the  motion  of  the  arm. 
Skin  grafting  should  be  resorted  to  early  in  the  treatment  of  lesions  thus  produced. 

Tight  lacing  is  the  source  of  a  mild  form  of  thoracic  deformity,  by  which  the  chest 
capacity  is  reduced,  the  respirations  made  peculiar  in  character,  the  liver  displaced  down- 
ward, and  the  general  welfare  of  the  indi\idual  materially  affected.  Influence  of  the 
right-hand  habit  is  frecjuently  quite  apparent  in  that  the  right  side  of  the  chest  becomes 
overdeveloped  as  compared  with  the  left.  This  may  be  seen  in  a  large  number  of  work- 
men who  use  heavy  tools  especially  with  the  right  hand.  Certain  occupations,  as  well 
as  sports,  lead  to  constant  assumption  of  the  stooping  position,  with  the  inevitable  round 
shoulders  and  drooping  head  so  apparent  in  bicycle  riders. 

Tattooing. — As  a  local  expression  of  a  bad  habit,  or  in  some  instances  almost  of  a 
criminal  instinct,  tattooing  may  be  mentioned.  This  is  seen  usually  upon  the  chest  and 
arms.  It  is  a  prevalent  custom  among  sailors,  and  is  regarded  by  alienists  and  anthro- 
pologists as  a  habit  indulged  in  by  criminals  and  the  insane.  La  Cassagne  has  spoken 
of  tattooing  as  "an  uninterrupted  and  successive  transformation  of  an  in.stinct."     Among 


i.\./r/i'i/:s  TO  Till-:  riiou.w  .wn  its  <(>\ texts  72 1 

tilt'  iiilialiitaiits  of  tin-  l':ii  ilic  l>laii(l>  it  is  aliiiust  a  mutual  itraclicc,  aud  aiuou^Mlicui  the 
tattoo  marks  arc  often  t'oiind  n|)oii  tlie  i)a(k  and  upon  the  sexual  or<^ans.  TIh- materials 
usually  em|)loyed  are  lamp-hlack,  iiidi<,'o,  and  India  ink  for  the  hiaek  or  hlue  tints,  and 
eiinud)ar  or  carmine  for  the  red.  Practisccl  as  it  is  hy  the  imsclioolcd  and  the  i{;nr>rant 
it  may  he  followed  hy  all  forms  of  local  infecti(jn,  while  syphilis  has  heen  thus 
transmitted. 

For  the  rrmnval  of  iattoo  iiinrlcs  many  methods  have  heen  sujj^ested,  hut  few  have  l)een 
found  satisfactory.  The  minute  |)articles  of  pifj;ment  have  hecome  .so  deeply  lod<;ed  that, 
like  |K)wdcr  marks,  it  re(|uires  iidinite  ))atienee  in  their  detection  with  the  lens  and  indi- 
vidual removal,  or  those  |)ortioiis  of  the  skin  must  he  destroyed  which  contain  them. 
Mei'hanical  methods  should  he  limited  to  localized  stains,  unless  a  plastic  operation  is 
preferred,  and,  after  removal  of  the  affected  area,  healthy  skin  may  he  transplante<l  hy 
one  of  the  j)lastic  meth  )ds  or  we  may  resort  to  skin  grafting.  Actual  cauterization  with 
strong  caustics  or  with  the  actual  cautery  will  l)e  followed  hy  suj)erfieial  sloughing, 
which  may  remove  the  disfigurement.  It  is  questionable,  however,  if  the  resulting  scar 
will  l>e  considered  much  of  an  imj)rovement  upon  the  ])revi()us  condition. 

INJURIES  TO  THE  THORAX  AND  ITS  CONTENTS;  CONCUSSION  OF  THE  CHEST. 

As  a  result  of  a  severe  blow  made  hy  a  blunt  object  there  may  re.sult  a  form  of  ron- 
nission  or  commotion,  similar  in  its  results  to  the  conditions  which  were  formerly 
described  in  the  cranial  cavity  as  concussion  of  the  brain,  but  which  are  now  known  to  be 
due  to  refle.x  vasomotor  disturbances,  by  which  blood  pressure  is  seriously  affected  and 
extreme  degrees,  perhaps  fatal,  of  shock  or  collapse  produced.  It  is  possible  for  fatal 
injuries  thus  produced  to  leave  little  or  no  evidence  that  may  be  discovered  at  the  autopsy. 
Hence  the  term  concussion  of  tlie  chest  may  be  retained  as  descriptive  of  what  has  taken 
place,  and  implying  serif)us  symptoms  j^roduced  through  the  agency  of  the  nervous 
.system,  especially  through  its  s}inpathetic  plexus.  In  such  instances  the  heart  is  seriously 
affected  and  may  continue  to  beat  feebly  for  some  time,  as  in  shock  from  other  injuries. 

Severe  blows  upon  the  chest  also  disturb  the  function  of  respiration,  and  it  is  possible 
that  asphyxia,  even  to  a  fatal  degree,  may  result  from  a  momentary  paralysis  of  the  entire 
respiratory  apparatus  thus  produced.  In  such  cases  artificial  respiration  will  be  required 
In  many  instances  patients  will  complain  of  not  merely  distress,  but  severe  pain,  which 
may  require  local  anodyne  measures  as  well  as  the  administration  of  an  opiate. 

Contusion  of  the  chest  leaves  more  visible  and  lasting  effects  uj)on  the  tissues  of  the 
chest  wall.  Thus  extensive  hemorrhages  may  residt  and  hematomas  form,  or  ribs 
may  be  broken,  with  or  without  injury  to  the  pleura,  or  internal  hemorrhages  may  occur, 
as  from  a  ruptured  intercostal  or  internal  mammary  artery,  the  consequences  of  such 
injuries  not  necessarily  appearing  at  the  time,  but  developing  later.  Alfjng  with  these 
injuries  to  the  chest  there  may  occur  other  injuries  to  the  abdominal  viscera  or  to  other 
portions  of  the  body.  Something  will  depend  u|xm  the  distention  or  relative  emptiness 
of  the  lungs  at  the  time  of  injury,  and  whether  there  may  have  been  at  the  same  time  a 
sudden  closure  of  the  glottis,  in  which  case,  by  an  external  blow,  something  resembling 
an  explosive  effect  may  be  produced  within  the  air  passages.  The  degree  of  stomach 
distention  may  also  have  its  own  effect.  Laceration  of  lung  tissue  will  usually  be  shown 
by  appearance  of  bloody  froth  at  the  mouth,  as  well  as  by  more  or  less  dyspnea.  Rapidly 
developing  symptoms  of  pressure  upon  the  lung  would  indicate  the  accumulation  of  blood 
within  one  pleural  ca\-ity  and  cause  the  ordinary  physical  CA-idences  of  the  presence  of 
fluid.  The  diaphragm  nuiij  he  ruptured,  and  the  proper  viscera  of  one  cavity  be  displaced 
into  the  other.  When  emphysema  of  the  tissues  of  the  chest  occurs  it  is  usually  safe  to 
assume  that  a  rib  has  been  fractured,  even  though  the  injury  cannot  be  located  or  even 
otherwise  recognized. 

A  series  of  later  lesions  may  result  from  such  contusions,  which  may  be  of  serious 
character.  Thus  there  has  been  described  a  so-called  contusion  pneumonia,  whose 
symptoms  are  similar  to  but  milder  than  those  of  the  genuine  disease.  It  is  a  residt 
of  inflammatory  and  hemorrhagic  infiltration.  It  may  lead  to  a  pleuropneumonia, 
with  subsequent  hydrothorax  or  pyothorax,  or  these  may  take  place  more  directly  and 
without  its  occurrence.  The  products  of  this  disease  afford  foci  in  which,  later,  tubercu- 
lous expressions  are  commonly  met.  It  has  been  shown  experimentally  that  the  blood 
46 


722  SPECIAL  OR  RKGIOXAL  SURGERY 

serum  of  animals  subjected  to  severe  injuries  of  the  chest  and  alxlomen  has  well-marked 
toxic  properties.  Thus  the  appearance  of  sugar  or  alhuinin  in  the  urine  or  of  other 
toxemic  infhcations  may  be  perhaps  explained. 

Treatment. — The  ireatment  of  the.s-e  injuries  should  include  the  relief  of  pain;  the 
performance  of  artificial  respiration,  along  with  the  inhalation  of  oxygen;  the  customary 
treatment  for  shock,  with  the  use  of  adrenalin,  when  needed,  for  raising  blood  pressure; 
absolute  rest,  and  especially  the  enforcement  of  local  physiological  rest  by  bandaging 
or  the  apjilication  of  broad  strips  of  adhesive  plaster  about  the  thorax.  In  addition  to 
these  general  measures  special  indications  should  be  met  when  they  arise.  The  occui-- 
rence  of  phenomena  indicating  the  development  of  pneumonia  or  collection  of  fluid  should 
be  noted,  as  the  latter  may  call  for  removal,  with  perhaps  ligation  of  a  vessel,  if  it  be 
bloody,  or  later  evacuation,  should  it  be  serum  or  pus.  External  extravasation  will 
usually  disappear  under  soothing,  warm,  and  moist  applications.  No  hesitation  need 
be  felt  in  opening  a  hematoma  which  does  not  show  a  disposition  to  prompt  resolution. 
Other  non-perforating  injuries  include,  for  example,  severe  burns  or  scalds,  which  mav 
need  the  same  treatment  as  when  occurring  in  other  parts  of  the  body.  Fluid  may 
accumulate  within  the  chest  when  there  has  been  any  such  serious  external  disturbance. 


PENETRATING   WOUNDS  OF  THE  CHEST. 

Penetrating  wounds  of  the  chest  are  generally  inflicted  by  stab  or  gunshot  injury. 
Two  serious  elements  of  danger  accompany  these  injuries:  the  first  immediate,  that 
of  hemorrhage  from  division  of  some  yessel  of  importance  concealed  from  sight ;  the  other 
that  of  injeciion,  for  either  by  the  penetrating  object  itself  or  by  air  or  clothing  which  may 
follow  it,  infection  may  ensue,  which  may  result  in  septic  pneumonia,  pyothorax,  or 
some  deep  phlegmonous  process,  with  always  dangerous  and  sometimes  fatal  results. 
Gunshot  wounds  vary,  and  according  to  the  character  of  the  missiles  and  the  weapons 
from  which  they  are  dischargerl.  Those  occurring  during  warfare  and  made  by  bullets 
of  the  Krag  or  Mauser  t}^De  are  usually  driven  with  such  velocity  that  they  produce 
a  minimum  of  laceration,  eyen  though  they  pass  through  the  chest.  Such  injuries 
have  in  the  late  wars  in  different  parts  of  the  world  been  frequently  observed,  and  have 
shown  a  surprisingly  low  mortality  rate,  proA^iding  only  that  the  heart  itself,  the  peri- 
cardium, the  large  vessels,  and  the  spine  be  not  injured.  Stories  of  the  battle-field  afford 
abundant  illustration  of  men  shot  through  the  chest  being  scarcely  affected  by  the 
injury,  but  continuing  in  action,  at  least  for  some  time,  and  finally  recovering.  On  the 
other  hand,  the  ordinary  revolver  or  pistol,  with  which  most  affrays  in  civil  life  are 
terminated,  does  not  drive  its  bullet  with  nearly  the  same  velocity,  and  is  more  likely 
to  inflict  a  serious  or  even  fatal  wound.      (See  Plate  XLMII.) 

A  bullet  or  a  stab  wound  almost  invariably  so  opens  the  thorax  as  to  permit  the  immedi- 
ate entrance  of  air.  In  theory  this  should  be  followed  by  prompt  collapse  of  the  lung; 
in  fact,  however,  this  is  only  partial,  and  often  surprisingly  so.  If  such  a  bullet  wound 
be  occluded  the  air  thus  admitted  is  more  or  less  absorbed,  disappearing  into  the  blood- 
vessels, and  the  lung  once  more  expands  to  its  natural  dimensions.  jMuch  will  depend, 
therefore,  on  the  size  and  character  of  the  wound  as  to  whether  occlusion  may  occur 
spontaneously,  or  may  be  practised  through  the  first-aid  dressing  or  its  equivalent. 

The  entrance  of  air  may  be  recognized  by  a  certain  degree  of  embarrassment  of 
respiration,  by  alteration  in  the  percussion  note,  and  often  by  its  passage  to  and  fro 
through  the  opening. 

The  principal  indications  of  possible  injuries,  in  addition  to  those  just  noted,  will  be 
the  occurrence  of  paroxysmal  coughing,  with  inspiration  of  blood,  and  the  added  physical 
signs  of  the  presence  of  blood  in  the  pleural  ca\-ity.  Thus  dulness  on  percussion,  with 
the  line  of  dulness  altering  with  position,  will  indicate  the  presence  of  fluid,  and  should 
this  occur  soon  after  the  injury  it  can  only  be  regarded  as  an  e\'idence  of  hemorrhage 
into  the  pleural  cavity.  A  combination  of  abnormal  tympanitic  condition,  as  above, 
with  the  physical  signs  of  fluid  beneath,  will  indicate  a  condition  of  pneumohemothorax. 
These  signs  will  change  from  hour  to  hour  or  from  day  to  day  in  accordance  with  altering 
internal  conditions.  If  they  become  rapidly  more  pronounced  they  indicate  a  condition 
which  "^ill  probably  call  at  least  for  free  incision,  evacuation  of  blood,  and  very  likely 
determination  of  the  source  of  its  escape  and  proper  attention  thereto. 


PLATE  XLVIII 


Radiograph  of  Chest,  showing  Mauser  Bullet. 

(From  Plate  X,   "  Use  of  Rontgen  Ray  by  the  Medical  Department  of  U.  S.  Army  in 
the  War  with  Spain,  1898.") 


i'i:M:ru.\Ti\<;  wocsds  of  tiii-:  chi:st  72;i 

All  iii((M'co.sl;il  arlcrv  is  of  itself  ;i  siiuill  xcssci,  l)iit  when  cut  across  l)\-  the  cdjfc  of  a 
knife  or  torn  In-  (Ik-  passaj^'c  of  a  hiillct  it  may  pour  siidiciciit  blood  into  a  pleural  cavity 
to  cause  serious  (lys|)iiea  and  |)erlia|)s  fatal  result.  To  discover  at  the  coroner's  inquest 
(hat  a  |)a(ieiit  has  been  allowed  to  die  because  no  one  had  the  judgment  to  enlarge  the 
wound  and  assure  himself  whether  such  a  hemorrhage  was  not  occurring  is  not  at  all 
creditable  to  those  in  charge  of  the  ease.  The  combined  dangers  of  infection  and  of 
colhijjse  of  the  lung  are  not  so  great  as  those  of  |)ossibly  fatal  hemorrhage,  or  intrinsic 
disaster  through  septic  infection  from  neglect  of  this  kind. 

.\si(le  from  the  injuries  thus  produced  to  the  respiratory  apparatus  there  are  t.hose 
especially  involving  tlir  heart.  It  has  been  su|)|),»sed  that  gunshot  wound  of  the  heart 
was  necessarily  fatal.  Inhere  is  now  reason  to  ihitd-c  that  this  is  not  invariably  true, 
even  in  individuals  not  promptly  oj)erated  upon,  while  the  resources  of  modern  surgery 
have  enabled  the  surgeon  to  save  a  number  of  cases  of  absolute  gunshot  injury  to  the 
pericardial  sac  and  even  to  the  heart  itself.  (This  subject  has  alreatiy  been  considered 
in  the  chapter  on  Surgery  of  the  Heart  and  (ireat  Vessels.)  Every  case  which  is  not 
jiromjitly  fatal  is  worth  attempting  to  save,  if  suitable  hclj)  be  at  hand,  by  a  resection  of 
the  chest  wall,  e.\|)osure  of  the  jiericardium,  and  of  the  heart  itself,  with  the  introduction 
of  sutures  or  the  use  of  the  ligature  wherever  these  may  a])])ear  to  be  necfled. 

The  occurrence  of  more  special  forms  of  traumatic  lesion  may  be  indicated  by  ])articular 
features,  '^rims  if  the  rsophafjus  has  been  wounded  the  patient  may  expectorate  or 
vomit  blood,  whose  presence  in  the  stomach  could  not  be  explained  by  other  features  of 
the  case.  On  the  other  hand  blood  whicii  comes  into  the  mouth  fnjm  the  lungs  may  be 
swallowed  and  its  appearance  in  the  ejected  materials  thus  accounted  for.  A  violent 
disturbance  of  cardiac  regularity  or  evident  paralysis  of  the  diaphragm  may  be  accounted 
for  by  injury  to  the  pnnimogaHtrlc  or  -phrenic  nerves. 

Treatment. — In  regard  to  the  general  treatment  of  these  injuries  the  use  of  the  probe 
should  not  be  encouraged,  at  least  in  the  way  in  which  it  was  formerly  used.  It  is  a 
serious  matter  to  stir  up  clot  or  to  open  up  a  wound  with  a  probe,  thus  inviting  free 
entrance  of  air.  Nearly  all  the  information  desired  may  be  more  accurately  ol)tained 
by  careful  physical  examination  and  study  of  symptoms.  It  should  never  be  used 
except  Avith  aseptic  precautions.  It  affords  little  information  as  to  the  course,  and 
practically  none  as  to  the  location  of  a  bullet  which  has  penetrated  the  chest  wall.  It 
may  possibly  be  of  service  in  searching  for  a  bullet  in  the  muscles  of  the  back,  but 
the  only  information  it  is  capable  of  furnishing  is  afforded  by  a  skiagram.  Miscella- 
neous i)robing  should  be  condemned,  and  in  these  injuries  is  rarely  justifiable. 

The  first  measure  to  adopt  in  cases  of  gunshot  wound  of  the  chest  is  io  determine  that 
the  heart  has  not  been  disturbed;  the  next  to  estimate  what  injury  may  have  occurred  to 
large  vessels,  then  a  general  determination  of  the  other  surgical  features  of  the  case. 
The  patient  who  shows  no  dej)ressing  sjmjjtoms  nor  develops  them  during  the  ensuing 
few  hours  may  be  left  with  only  a  temporary  occlusive  dressing  placed  over  the  wound; 
but  increasing  embarrassment  of  respiration,  or  weakening  and  increasing  rapidity  of 
pulse,  should  be  carefully  watched  to  guard  against  internal  hemorrhage.  If  it  be  learned 
that  there  is  such  internal  bleeding  prompt  action  should  be  taken  for  its  control. 
This  means  anesthesia  and  perhaps  thoracotomy,  with  resection  of  one  or  two  ribs,  in 
order  to  afford  s]:)ace  through  which  to  practise  deep  suture  or  ligation.  So  long  as 
one  side  of  the  chest  alone  is  involved — i.  e.,  one  lung  thus  exposed — the  surgeon  may 
widely  open  the  chest  and  meet  every  surgical  indication  without  the  necessity  for 
artificial  respiration  or  the  use  of  the  Fell  apparatus.  It  is,  however,  advisable  to  have 
this  at  hand  for  such  work,  while  cases  demanding  such  extreme  measures  can  scarcely 
be  made  worse  by  the  performance  of  a  tracheotomy  and  resort  to  some  means  for 
forced  and  artificial  respiration. 

To  simply  enlarge  a  small  bullet  opening  or  punctured  wound,  in  order  to  be  sure 
that  an  intercostal  artery  has  not  been  injured  adds  but  little  to  the  danger  and  much 
to  the  security  of  such  a  case.  In  case  of  doubt  give  the  patient  tlie  benefit  of  that  donbt 
and  operate  to  any  necessary  extent.  When  hemorrhage  is  slight  and  not  alarming  it 
may  be  sufficient  to  make  the  occlusive  dressing  include  a  tamponing  of  the  opening 
between  the  ribs,  gauze  being  packed  in  the  opening  in  such  a  way  as  to  prevent 
hemorrhage. 

A  study  of  the  escaping  blood  will  permit  of  differentiation  between  arterial  and  venous 
hemorrhage,  that  which  escapes  from  the  lung  being  ordinarily  of  the  latter  type.     Richter 


724  SPECIAL  OR  REdlOSAL  SURGERY 


has  .sutrgcstc'd  an  iiio;ciii()U,s  inctliocl  of  deciding;  wlictlicr  liciii()rrlia<fc  coincs  from  an  inter- 
costal artery  or  lung  tissue,  hy  introducinjr  a  sterilized  ])iccc  of  pasteboard,  similar  to  a 
visiting  card,  rolled  up  in  the  form  of  a  circular  tube  and  flattened  with  a  crease;  should 
blood  flow  out  along  the  groove  it  shows  that  it  is  an  intercostal  artery  W'hic  h  is  bleeding; 
but  if  it  flows  out  of  the  wound  through  the  tul)e  the  source  of  the  bleeding  is  the  pul- 
monary tissue  itself.      (Dennis.) 

The  question  of  the  presence  of  a  jorehpi  bodi/,  bullet  or  otherwise,  is  im])ortant.  This 
is  less  so  when  it  is  a  c[uestion  of  the  bullet  itself  than  of  driving  in  some  fragment  of  rib 
or  of  foreign  body  introduced  from  without.  A  bullet,  a  broken  knife-blade,  or  anything 
of  such  charact(>r  will  be  revealed  by  an  .r-ray  j)ictiire.  The  prol)e  will  rarely  give  this 
infonnation.  (Nothing,  (objects  carried  in  the  pocket,  or  various  other  foreign  material 
may  escape  detection. 

The  first  measure  of  importance  is  the  determination  of  the  occurrence  of  serious 
internal  hemorrhage,  the  second  is  the  emergency  treatment  of  the  injury  itself,  which 
should  include  primary  aseptic  occlusion,  to  be  followed  later  by  other  measures.  A 
witlulrawal  of  fluid  is  also  indicated.  Escaped  blood  may  be  contaminated  and  jiroduce 
later  a  ])yothorax.  As  the  result  of  a  traumatic  ])leurisy  serum  may  collect  within  the 
ensuing  few  days,  and  it  too  should  be  removed.  It  should  be  first  found  with  the 
exploring  needle.  If  seen  to  be  free  from  pus  it  may  be  withdrawn  l:)y  the  aspirator; 
but  if  it  be  destined  to  become  pus,  then  the  sooner  it  is  evacuated  by  incision  the  better. 

Increasing  embarrassment  of  the  heart's  action,  which  is  not  caused  by  the  collection 
of  blood,  may  be  due  to  pi/opericardium.  So  soon  as  the  j)hysical  signs  indicate  gradual 
enlargement  of  the  cardiac  area  the  exploring  needle  should  be  used.  A  traumatic 
pericarditis  may  simply  require  aspiration  of  the  pericardium,  whereas  the  presence 
of  pus  in  the  pericardial  cavity  will  not  only  necessitate  aspiration,  but  occasionally 
open  incision,  with  or  without  drainage.  The  appropriate  manner  of  affecting  these 
procedures  will  be  found  more  fully  discussed  in  the  section  on  the  Heart. 


INJURIES    TO   THE    THORACIC    VISCERA. 

In  general,  and  without  regard  to  the  nature  of  the  accident,  ifi juries  to  the  thoracic 
viscera  include  wounds  of  the  pleura,  the  lung,  the  diaphragm,  the  various  large  and 
small  vessels,  the  pericardium,  the  heart,  the  thoracic  duct,  and  the  nerves. 

Wounds  of  the  Pleura. — Injuries  to  the  pleura,  including  rupture,  are  produced  by 
severe  blows  which  do  not  inflict  fractures,  although  these  are  rare  in  the  absence  of  such 
injuries.  They  are  usually  not  accompanied  by  external  markings,  but  are  indicated 
rather  by  dyspnea  and  cough,  with  involuntary  limitation  of  resj^iratory  motions  and  by 
the  physical  signs  of  escape  of  blood  (hemothorax)  or  air  (])neumothorax),  or  l)y  some 
crepitati(jn  at  the  site  of  fracture,  which  may  be  recognized  with  the  stethoscope.  In 
many  instances  lacerations  of  the  ])leura  are  accompanied  by  more  or  less  injury  to  the 
lung,  perhaps  with  perforation  of  air  cells  or  small  bronchi  and  the  inevitable  pneumo- 
hemothorax.  With  a  w^ound  situated  near  the  twelfth  rib  the  lung,  which  extends  nor- 
mally only  to  the  tenth,  may  escape  injury.  A  small  wound  of  the  pleura  is  of  little 
consequence.  By  itself  it  is  of  serious  import  only  as  it  is  accompanied  by  more  serious 
disturbances  of  the  lung  which  it  envelops,  or  the  heart  w^hich  it  contains. 

When  air  passes  freely  to  and  fro  through  the  opening  in  the  chest  wall,  without  expec- 
toration of  froth  or  bloody  mucus,  it  may  be  assumed  that  the  lung  itself  has  not  been 
injured.     To  this  condition  the  name  traumapnea  has  been  given. 

Uncomplicated  cases  of  pneumothorax  usually  take  care  of  themselves,  the  air  being 
gradually  absorbed  by  the  bloodvessels.  In  certain  cases  this  air  niay  be  Avithdrawn 
by  the  aspirator.  A  small  amoimt  of  blood  within  the  pleural  cavity  is  usually  absorbed. 
An  amount  sufficient  to  embarrass  respiration  should  be  withdrawn  either  with  the 
aspirator  or  by  incision.  For  the  latter  purpose  the  wound  may  be  utilized  when  properly 
situated. 

Wounds  of  the  Lung. — Wounds  of  the  lung  are  made  immediately  dangerous 
by  injury  to  its  bloodvessels  or  are  given  a  serious  aspect  by  the  possibilities  of  various 
forms  of  infection,  including  septic  pneumonia.  In  serious  cases  this  may  jiroceed  to 
abscess  formation  or  gangrene.  Should  either  of  these  be  sufficiently  localized  no  surgical 
procedure  directed  to  evacuation  or  to  excision  or  removal  of  the  gangrenous  tissue  can 


L\.l(  h'lh'S   TO   THK   TiroUACIC    \lS(:KJiA  725 

hr  inoiv  (la!i<2;('n)ii,s  tliiin   tlic  coiKlition   left  lo  itself.     The  surj^coii  inav,  tlicrd'orc,  he 
iin|H-lU'(l  t(i  iK-rlonii  a  |)ii('imi()t()niy  or  a   piiciiiiicclimiv . 

\Vlu'ii  tlic  luiiff  tends  to  protrude  or  prolapse  tliroiii^li  an  external  iiijiirv  tiie  condition 
is  referred  to  as  pni'iniiocclc,  or  sometimes  as  lirnila  or  prohijisc  oj  l/ic  liint/.  Tliis  is 
rare,  and  occurs  usually  in  connection  with  ])unctures  orstal)  wounds  placed  anteriorly 
jind  i;'enerally  low.  'i'lie  lun<f  may  he  entantfled,  after  liaxinif  heen  forced  out  hv  violent 
cou^'hin«j;,  and  the  external  portion  has  l)een  known  to  he  stranifulated  in  such  a  way 
as  to  slough  otV.  Should  this  occur  liie  mass  may  he  jx-rmitted  to  slou<,di,  or  it  may  he 
removed  hy  cautery  or  hy  li<j;ature,  the  wound  heiu<>:  left  to  heal  by  granulation.  In  rare 
instances  the  pueumocele  has  been  covered  by  the  parietal  pleura,  as  is  abdominal 
hernia  by  jwrietal  peritoneum. 

Another  form  of  ])ueumoceIe  is  the  later  conse(|uence  of  injury,  the  soft,  crackling, 
or  crepitating  tuuior  presenting  beneath  the  skin  and  returning  the  usual  breathing  sounds 
when  auscultat(>d.  It  may  increase  and  diminish  in  size  with  the  respiratory  movement. 
Such  ji  hernia  uiay  occur  beneath  a  scar  or  through  ruptured  intercostal  musc-les.  It 
is  of  suiall  surgical  conse(|ueuce,  and,  if  troublesome,  may  be  retjdned  by  a  suitable 
l)ad. 

The  lung  is  occasionally  rnpturrd  l)y  a  violent  concussion  of  the  chest,  as  is  also  the 
heart.  Its  consequences  will  be  emphysema,  pneumohemothorax,  with  vomiting  of 
blood,  and  later  infection. 

The  later  consequences  of  hemothorax,  simple  or  uncomplicated,  may  be  trouble- 
some pleuritic  adhesions,  by  which  freedom  of  respiration  is  im])aired,  and,  it  uuiy  l)e, 
chest  motions  interfered  with  and  chest  develojnneut  limited.  The  pleural  surfaces  are 
usually  gradually  drawMi  toward  each  other  by  the  development  of  granulation  tissue 
and  its  sul)se{(uent  contraction  and  condensation. 

Wounds  of  the  Diaphragm.— The  diaphragm  may  also  be  lacerated  by  the  com- 
pressing effects  of  violent  blows,  either  upon  the  chest  or  abdomen.  In  consequence 
there  may  be  passage  of  viscera  (hernia)  from  either  cavity  into  the  other.  Accurate 
recognition  of  these  cases  will  scarcely  be  possible,  but  the  development  of  distinct 
abdominal  symptoms  or  noticeable  displacement  of  the  heart  or  of  the  abdominal 
viscera  may  lead  to  exploratory  section,  w^hich  shall  reveal  the  location  of  the  rent 
and  ])ossibly  ])ermit  of  appropriate  re])air  or  suture. 

Injuries  to  the  Thoracic  Duct. — The  thoracic  duct  is  occasionally  injured  by 
penetrating  wounds,  while,  at  the  base  of  the  neck,  it  has  l)een  known  to  be  divided  in 
the  course  of  the  removal  of  deep  and  adherent  timiors.  In  the  latter  case  the  escape 
for  a  short  time  of  the  milk-like  chyle,  which  it  carries,  will  give  evidence  of  the  injury. 
Several  cases  on  record  show  the  comparatively  innocent  nature  of  the  injury  and  its 
tendency  toAvard  spontaneous  recovery  without  the  necessity  for  further  intervention. 
The  very  low  pressure  of  the  fluid  in  the  duct  is  a  contributing  cause  to  this  exemption 
from  serious  harm.  Should  the  duct  become  obliterated  near  its  upper  end  (loul)tless 
collateral  circulation  will  enable  the  right  and  smaller  duct  to  take  up  its  work  and 
continue  it. 

Injuries  to  the  Upper  Nerve  Trunks. — In  regard  to  injuries  of  the  upper  nerve 
trunks  in  the  chest  it  is  necessary  to  add  but  little  to  statements  made  regarding  injuries 
to  the  same  nerves  in  the  neck.  The  writer  has  collected  over  fifty  cases  of  destructive 
injury  to  the  pneumogastric,  in  over  one-half  of  Avhich  recovery  followed.  It  has  been 
showTi  that  unilateral  resection  of  the  vagus  is  almost  devoid  of  danger,  though  when  it 
is  required  the  nerve  is  rarely  in  a  normal  condition.  Unless  the  nerve  be  attacked  or 
involved  below  the  branch  which  forms  the  recurrent  laryngeal,  laryngeal  sym])toms 
may  be  certainly  expected.  Irritation  to  the  cervical  sympathetic  is  usually  followed 
by  dilatation  of  the  pupil,  widening  of  the  palj^ebral  fissure,  some  degree  of  jjrotrusion 
of  the  bulb,  and  ])aresis  of  that  side  of  the  face,  while  absolute  sympathetic  i)aralysis, 
such  as  follows  division,  will  produce  dilatation  of  the  pupil,  ptosis,  and  increased 
flushing  of  that  sifle  of  the  face.  The  syinpathetic  nerve  may  have  to  be  extirpated  in 
certain  cases  of  excision  of  malignant  tumors.  Again,  it  has  been  deliberately  resected,  as 
recommended  by  Jonnesco  and  others,  for  the  cure  of  epilespsy,  of  exophthalmic  goitre, 
and  of  glaucoma.  This  will  demonstrate  the  fact  that  injury  to  it  is  not  necessarily  of 
itself  a  severe  accident. 

In  certain  injuries  to  the  chest  branches  of  the  hracJiial  plexiif!  will  be  divided  or  com- 
promised, or  displaced  by  fragments  of  bone  or  otherwise.     When  nerve  pressure  can 


726  SPECIAL  OR  RKGIOXAL  SURGERY 

be  recognized  the  compressing  cause  should  he  removed.     If  a  nerve  he  divided  every 
attempt  should  he  made  to  suture  it. 

Partial  or  comj)lete  division  of  the  large  vascular  friink.s-  is  usually  too  promptly  fatal 
to  justify  much  consideration  here.  On  the  other  hand,  injuries  to  the  intrrro.sfal  and 
internal  mamviarii  vessels  are  not  uncommon  and  should  not  he  fatal  if  only  they  can 
be  jjroperly  recognized  and  treated.  It  is  stated  that  even  an  intercostal  artery  may 
pour  four  pounds  of  blood  into  the  ])leural  cavity  in  case  of  gunshot  or  stab  wound. 
The  presumi)ti()n  would  be  that  one  of  these  vessels,  if  injured,  is  wounded  at  the  site 
of  the  evident  puncture.  While  this  is  usually  true  it  is  possible  that  a  bullet  penetrating 
may  have  divided  an  intercostal  on  the  opposite  side.  If  a  ligature  is  to  be  applied  it 
should  be  done  on  each  side  of  the  wound,  whereas  a  tampon  used  to  check  hemorrhage 
may  be  packed  in  such  a  direction  as  to  comj)letely  meet  the  indication.  While  many 
methods  have  been  suggested  for  arresting  l)leeding,  the  surgeon  will  enlarge  the  puncture, 
seek  out  the  source  of  the  hemorrhage,  and  then  resort  to  ligature  or  to  t;nnponing,  as 
the  case  may  indicate.  When  the  tamjjon  is  used  it  is  well  to  push  ahead  of  it  a  j)iece  of 
gauze  like  a  glove  finger  and  fill  this  with  the  tampon,  in  order  to  ensure  complete  removal 
of  the  whole  mass  at  the  proper  time. 

This  is  true  also  of  injuries  to  the  internal  mammary.  Dennis  mentions  five  eases, 
quoted  to  him  by  Langenbeck,  of  perforation  of  the  chest  with  a  sword-blade,  as  the  result 
of  duels  among  university  students  of  Gottingen,  of  which  number  two  died.  The  latter 
also  stated  that  up  to  1876  there  never  had  been  a  successful  ligation  of  this  artery. 
The  vessel,  leaving  the  subclavian  between  the  two  heads  of  the  sternomastoid  muscle, 
lies  in  its  course  just  to  the  inner  side  of  the  sternum,  with  the  vein  on  its  inner  asj)ect. 
Near  the  clavicle  it  lies  on  the  pleural  sac,  where  if  injured  the  pleu.ra  will  not  escape. 
Lower  down  the  pleura  is  not  necessarily  opened,  although  it  rarely  escapes.  As  Dennis 
shows,  the  inference  from  this  is  that  tamponing  the  wound  in  the  two  upper  intercostal 
spaces  is  impracticable,  while  below  these  it  might  succeed,  as  the  triangularis  sterni 
lies  between  the  pleura  and  the  artery.  The  mortality  of  the  injury  has  been  stated 
to  have  been  nearly  70  per  cent.  Diagnosis  is  not  difficult  so  long  as  the  blood  escapes 
externally.  With  a  wound  properly  situated  and  rapid  accumulation  of  blood  within 
the  chest,  and  increasing  collapse,  assumption  of  the  injury  or  provisional  diagnosis  will 
scarcely  prove  fallacious. 

The  internal  mammanj  when  injured  shoukl  be  secured.  The  o|)erator  need  never 
hesitate  to  resect  a  portion  of  the  sternum,  or  the  rib  ends  or  cartilage,  in  order  to  expose 
it,  since  no  danger  can  be  so  great  as  that  of  nc^t  finding  it.  Incision  may  be  matle 
along  or  between  the  ribs,  parallel  to  them,  or  over  the  known  course  of  the  artery. 
After  retracting  the  tissues  down  to  the  bone  a  sufficient  amount  of  the  bone  should 
be  removed  to  afford  space  for  the  examination.  The  pleura  shoidd  be  first  separated, 
care  being  taken  not  to  inflict  upon  it  more  than  a  minimum  of  injury.  A  T-shaped 
incision  will  afford  more  room  when  the  case  is  complicated.  The  ends  of  the  vessel 
having  been  found  and  secured,  it  becomes  then  a  cjuestion  of  em])tying  the  chest  of 
the  blood  already  accumulated.  This  is  ])referably  done  by  incision  placed  laterally 
and  sufficiently  low,  with  the  introduction  of  a  drainage  tube.  Should  the  blood  be 
already  coagulated  the  incision  should  be  made  sufficiently  wide  to  permit  of  breaking 
up  the  clot  and  comj)letely  removing  it. 

Treatment. — In  general,  witli  regard  to  the  treatment  of  all  these  injuries,  it  should 
be  said  that,  in  addition  to  whatever  local  measures  may  be  indicated,  general  rest  of 
the  parts  should  be  secured  by  as  coni])lete  immobilization  of  one  or  both  sides  as  can 
be  effected.  This  should  be  made  a  part  of  the  treatment  of  all  fractures,  simple  or  com- 
pound, as  well  as  of  all  perforating  injuries.  Anodynes,  hypnotics,  and  the  like  need 
to  be  used  both  to  restrain  uiotion  and  to  allay  cough,  either  of  direct  or  reflex  origin, 
by  which  harm  is  always  done. 


THE  THORACIC  WALLS. 

The  complex  structure  of  the  thoracic  walls  is  not  exempt  from  the  infections  and 
other  diseases  which  may  involve  skin,  muscle,  cartilage,  and  bone.  Thus  upon  its 
surface  all  sorts  of  phlegmonous  lesions  may  occur,  assuming  carbimcular  or  localized 
type,  or  occasionally  ending  in  widespread  gangrene,  usually  of  that  particular  tj'pe 


Tllh:   r IK) RACK'    WALLS 


727 


which  is  (hie  (o  the  Tii()rl)i(l  activity  of  the  ^'as-roniiiii^r  |,;,(illi,  whose  first  expression  is  a 
(jniKliruou.^niiphiisnmi.  These  infections  occur- not  only  in  eoiiseciueiici' of  some  external 
irritation,  hut  are  seen  after  the  infectious  fevers,  as  well  as  in  connection  with  syphilis, 
tuberculosis,  scurvy,  aetinoinycosis,  and  other  forms  of  infection.  Tuhereulous  disease 
befrinnui^r  ,,„  the  exterior  of  the  chest  wall  may  spread  to  the  interior  and  even  deeper, 
and,  ncc  versa,  tuberculous  lesions  begimiinjr  within  the  chest  si)read  to  the  adjoiniiifj 
bone,  producing  caries,  and  then  to  the  exterior  surface,  the  resultiufr  simises  beinjr 
irreo;ular  and  sometimes  opening  at  a  point  at  considerable  distance  from  the  origin 
of  the  trouble. 

All  the  infectious  processes,  whether  slow  or  rajud,  nee<l  radical  attack,  including 
free  incision,  curetting,  removal  of  diseased  bone,  cauterization  of  the  afi'ected  area,  and 
suitable  dressing  and  ])ackiiig.  Carious  rihs  or  portions  oj  flir  strnniiii  may  be  removed 
withont  fear,  it  being  necessary  in  certain  atlvanced  cases  to  remf)ve  nearly  the  entire 
sternum.  Any  concealed  focus  of  disease  is- sure  to  spread  and  do  more  harm  than  will 
a  well-directed  attempt  to  eradicate  it.  Infection  originating  within  the  bone  may 
spread  in  either  direction,  and  may  give  rise  to  pleurisy,  with  adhesions,  and  possibly 


I'lo.  505 


Fig.  50(J 


M. 


^ 


Jilrosion  of  sternum,  the  result  of  pressure  of  an  aneurysm. 
Wood  Museum.     (Dennis.) 


Erosion  of  vertebra;,  the  result  of  pressure  of  an 
aneurysm.     Wood  Museum.     (Dennis.) 


even  subsequent  abscess  of  the  lung.  The  same  is  true  of  the  diaphragm,  while  products 
of  infection  travelling  in  the  proper  direction  may  cause  the  beginning  of  an  extensive 
subphrenic  or  hepatic  abscess. 

The  pressure  of  atlvancing  tumors  will  sometimes  cause  surprising  changes,  not  so 
much  the  result  of  ulceration  as  of  mere  absorption  in  the  path  of  the  advancing  mass. 
Thus  ancurijsms  will  gradually  erode  the  sternum  or  the  ribs,  and  in  time  form  bulging 
projections  from  within  the  chest,  which  may  ultimately  rupture  and  thus  terminate 
the  case.  Even  upon  the  vertebral  column  the  effects  of  such  pressure  are  pronoimced. 
Figs.  505  and  506  illustrate  what  may  happen  under  circumstances  just  detailed. 

Remarkable  expressions  of  subcutaneous  emphysema  may  be  seen  in  certain  cases  of 
fracture  of  ribs,  with  perforation  of  the  lung,  air  escaping  into  the  tissues  and  puffing 
up  the  whole  uj)per  part  of  the  body  and  neck,  giving  it  an  appearance  and  shape  very 
different  from  the  original.  For  this  condition  there  is  no  particular  treatment,  save 
immobilization,  by  whicii  respiratory  efforts  shall  l)e  limited.  Ordinarily  the  tissue 
distention  quickly  subsides.  Should,  however,  putrefactive  organisms  enter  with  the 
air  there  mav  arise  emphysema,  terminating  in  gangrene,  with  fatal  se])ticemia. 

Painful  affections  of  the  thoracic  walls  are  associatcfl  with  lesions,  either  of  the  inter- 
costal nerves  or  the  ganglia  or  s])ecial  nerves  with  which  they  are  connected,  which  pro- 


728  SPECIAL  OR  REGIONAL  SURGERY 

duce  intprcnsfohirvralgiao\  various  t_v|)('.s,  includin^f  that  witli  its  peculiar  cniptioii  known 
as  herpe.t  zoster,  or  as  the  hiity  call  it,  "shingles"  (heiiif,'  a  corruption  of  the  Latin  ciiKju- 
lum,  meaning  a  girdle).  Neuralgia  may  also  he  caused  by  inclusion  of  nerve  branches  in 
callus  which  is  formed  around  a  badly  united  fracture  of  the  ribs.  The  diseases  of  the 
vertebne  which  lead  to  softening  and  changes  of  shape  will  also  permit  of  pressure 
upon  nerve  centres  and  trunks,  which  cause  more  or  less  pain,  referred  more  often 
to  the  distribution  of  the  nerves  involved  than  to  their  origin.  Thus  the  referred  pains 
of  spondylitis  (Pott's  disease)  are  to  be  thus  explained  and  are  sometimes  very  pro- 
nounced. We  give  the  term  "neuralgia"  to  those  ])ainful  affections  for  which  there 
is  no  satisfactory  explanation,  and  tlnis  we  are  told  that  in  intercostal  neuralgia 
there  are  three  points  of  tenderness,  known  as  those  of  Valleix,  whose  determination 
confirms  the  diagnosis — the  first  being  at  the  point  of  exit  of  the  sj)inal  nerve  from  the 
vertebral  canal,  the  second  in  the  axillary  line,  and  the  third  close  to  the  costosternal 
articulation.  Abrams  has  shown  that  if  a  freezing  spray  be  applied  over  the  first  spot 
the  neuralgia  will  at  once  subside  if  it  be  of  peripheral,  but  not  if  of  central  origin. 
Again,  if  one  pole  of  the  galvanic  current  be  placed  on  the  affected  side  and  the  other  u|)on 
any  one  of  the  above  spots  the  ])ain,  if  neuralgic,  will  disaj)])ear.  If  the  current  employed 
be  the  Faradic,  and  the  ])ain  subside,  its  cause  is  located  in  the  muscles,  as  the  induced 
current  does  not  influence  the  pain  of  a  genuine  neuralgia.  (Dennis.)  So  far  as  the 
treatment  of  these  painful  affections  is  concerned  it  is  rarely  surgical;  although  it  was  the 
relief  afforded  by  the  accidental  stretching  of  an  intercostal  nerve  which  first  suggested 
to  Nussbaum  the  utility  of  nerve  stretching  as  a  more  general  procedure,  and  it  was  thus 
introduced  to  the  profession.  The  treatment  of  herpes,  i.  e.,  of  that  form  of  neuralgic 
aft'ection  which  is  characterized  bythe  appearance  of  papules  which  soon  become  vesicu- 
lar, which  collect  in  clusters  and  appear  along  the  course  of  certain  intercostal  nerves, 
is  rarely  surgical.  It  is  not  difficult  to  distinguish  this  from  ordinary  eczema,  which  does 
not  follow  the  nerve  distribution  and  is  not  accompanied  by  the  severe  pain  of  herpes. 


THE  MEDIASTINUM. 


MEDIASTINITIS. 

The  principal  interest  attaching  to  diseases  in  either  mediastinum  pertains  to  the 
conseqiu'uces  of  spreading  infection,  which  will  be  practically  always  of  the  ])hlegmonous 
type,  and  which  will  produce  clinical  exjiressions  varying  much  with  its  location  and 
the  direction  of  its  course.  These  are  inchuled  under  the  general  head  of  acute  or  chronic 
medlastinitis,  which  might  be  the  result  of  an  extension  from  above,  as  from  cervical 
abscesses,  spondylitis  of  the  cervical  vertebra,  deep  cervical  phlegmons,  and  the 
like;  or  the  result  of  perforation,  or  of  foreign  bodies  impacted  in  the  esophagus  or 
elsewhere;  or  may  again  come  from  the  osseous  structures  of  the  chest  proper,  spine, 
ribs,  and  sternum.  Doubtless  certain  cases  of  subphrenic  abscess  are  the  result  of  sup- 
puration begun  in  the  mediastinum.  Instances  are  also  occasionally  seen  after  typhoid 
and  the  other  infectious  and  contagious  fevers. 

The  indicaiions  of  mediastuiifis  consist  of  intrathoracic  soreness  and  j)ain,  increased 
upon  coughing  and  deep  inspiration,  difficulty  of  deglutition,  disturl)ances  of  respiration 
and  of  heart  action.  Any  irregularity  of  the  pupils  is  evidence  of  irritation  along  the 
sympathetic  nerves.  Displacement  of  the  heart  means  accumulation  in  its  neighborhood 
and  pressure  disturbance.  The  lesion  which  will  produce  this  will  probably  give  dulness 
on  percussion,  and  alterations  of  the  ordinary  chest  sounds.  With  trouble  high  in  the 
thorax  the  recurrent  laryngeal  may  be  involved,  Avith  the  inevitable  change  in  the  voice. 
If  the  pneumogastric  be  compressed  there  will  be  rapid  and  irregular  heart  action.  If 
the  esophagus  thus  suft'er  dysphagia  will  result.  vShould  the  presence  of  pus  be  suspected 
a  differential  blood  count  may  do  much  to  clear  up  the  diagnosis.  Should  pus  come 
near  the  surface  it  will  probably  give  the  ordinary  surface  indications  whch  one  should 
be  cjuick  to  appreciate  and  to  relieve.  Collections  of  pus  within  the  chest  tend  always 
to  migrate  and  pus  may  burrow  to  a  considerable  distance. 

Treatment. — The  treatment  of  phlegmonous  medlastinitis  mainly  depends  upon 
recognition  of  the  lesion  and  its  degree  of  accessibility.     Certain  deep  forms  are  hope- 


PLATE  XLIX 


Neurofibroma  of  Skin. 


riMoiiS  OF    Till-:    Tlloh'.W 


729 


less,  since  flicy  tend  to  kill  Iicl'drc  even  |)ii.s  caii  Ix-  locati-d  and  cvafiiatcil.  So  soon  as 
tlxMV  1)0  t'oiiiul  any  surt'aci'  iiidicalioii  siirtfical  attention  should  he  |)roni|)tly  (;ivcii. 
Any  ot"  tlu'se  cases  may  l)e  coni|)iicate(|  hy  se|)tic  conditions  williin  the  lun<;  or  acciiinu- 
lations  within  the  |)leurai  cavity.  The  latter  at  least  may  he  reco<fni/,ed  and  relieved. 
The  proper  use  ol"  the  ex|)l()rin<i;  needle  may  alVord  much  inlormation,  and,  in  the  presence 
of  suitable  indications,  the  sternum  should  he  trephine<l  and  exploration  made  heliind 
it.  The  main  tliinij;  iti  Jill  these  cases  is  to  distin^nish  hetween  pressure  effects  j)rodueed 
by  plilegmon  and  those  due  to  aneurysm  or  tumor.  Only  rarely,  and  then  only  by 
surfjeons  of  wide  ex|)erionce,  should  radical  measures  he  attemptetl  for  the  latter. 
Chronic  processes,  of  tid)erculous  character  and  leadinir  to  lormation  of  cold  abscesses, 
will  usually  produce  sym|)toms  much  less  urgent,  while  the  nature  of  the  relief  to  be 
alforded  will  scarcely  be  left  in  doubt. 


TUMORS   OF   THE   THORAX. 

I'riiiiari/  lumurs  of  lite  chest  wall  constitute  less  than  1   per  cent,  of  those  occurring 
in  general  practice;  this,  of  course,  not  having  reference  to  secondary  developments 

Fig    507 


'"IMk 


Circumscribed  lipoma  of  back.    (Dennis.) 


Congenital  diffuse  lipoma  of  back.     (Mixter.) 


from  cancer  in  the  breast,  which  are  somewhat  frequent.  Of  the  benign  tumors  those 
which  most  frequently  appear  upon  the  surface  are  the  lipomas,  which  are  seen  either 
in  circumscribed  or  diffuse  form,  as  illustrated  in  Figs.  507  and  508. 

They  are  sometimes  multiple  and  perfectly  innocent,  save  as  they  may  attain  large 
size  or  ulcerate  fnmi  surface  irritation.  The  granulomas,  especially  those  of  syphilis 
and  tuberculosis,  are  common,  appearing  either  as  superficial  tumors  which  idcerate, 
or  as  deeper  ones  which  may  break  down  in  the  course  of  months  or  years,  after  perhaps 
involving  the  ribs  or  a  considerable  portion  of  the  chest  wall.  Actinomycosis  is  |)erhaps 
as  often  seen  in  this  region  of  the  body  as  anywhere. 

The  fibromas  are  seen  more  commonly  in  the  axilla  and  beneath  the  thoracic  muscu- 
lature. The  chest  is  a  frequent  site  for  those  pedunculated  fibromas  which  have  been 
described  under  the  term  keloid.  A  most  striking  case  of  neurofibroma  of  the  skin  is 
portrayed  in  Plate  XLIX. 


730 


SPECIAL  OR  REGIONAL  SURGERY 


Chondromas  of  the  chest  are  slow-growing,  usually  |)aii)less,  may  involve  a  considerable 
area,  both  of  bone  and  cartilage,  are  not  infrequently  the  seat  of  cystic  changes,  and 
often  undergo  a  final  sarcomatous  degeneration.  All  this  is  true  in  lesser  degree  of  the 
osteomas,  which  are  of  the  cancellous  type. 

The  malignant  tumors  of  the  thorax  proper  are  mostly  sarcomas  which  assume  various 
types,  according  to  their  cellular  characters,  the  round-cell  sarcomas  growing  rapidly, 
becoming  extremely  hemorrhagic  and  fungous,  and  tending  to  kill  early,  while  the  larger 
and  more  spindle-cell  and  the  giant-cell  forms  grow  relatively  more  slowly,  and  may  even 
be  successfully  removed  (Figs.  509  and  510.) 


Fii;.  r,()9 


Sarcoma  of  rib  and  pleura,  result  of  injury  by  a  base-ball.      (Dennis.) 


Carcinoma  of  the  chest  wall  is  generally  the  result  of  extension  from  cancer  of  the 
breast  or  of  some  other  epithelial  structure.  Advancing  carcinoma  spares  nothing, 
and  may  not  only  perforate  the  chest  but  involve  the  lung  beneath,  with  or  without 
later  ulceration,  and  the  occurrence  of  pnemnothorax. 

While  these  are  the  more  common  forms  of  tumor  of  this  region  there  are  no  known 
growths  w^iich  may  not  occasionally  be  met  here. 

Treatment. — The  treatment  for  all  these  tumors  is  extirpation.  With  benign 
growths  outside  of  the  ribs  proper  this  is  usually  a  simple  matter.     When  the  whole 


TIMOHS  OF    rilh:    TllOh'.W 


731 


Fio.  510 


or  nearly  tlic  whole  (liickiicss  of  llic  clicsl  wall  is  invoKcd  il  Ix'coiiics  (lien  a  serious 
problem  how  tar  to  proceed  in  the  elVorl  to  extirpate.  This  is  Irue  alike  whether  stennnn 
or  rihs  are  involved.  The  entire  slerninn  may  l)e  separated  from  its  snrronndin^s  and 
lifted  out  of  place,  and  this  would  he  justifiahle  wiien  dealini^  with  an  os.seons  or 
cartilaj;inous  o;r()Wth.  If,  however,  it  were  distinctly  sureomatous  it  would  he  hardly 
worth  while.  If  in  sncli  an  operation  the  pleura 
be  spared  and  air  not  admitted  to  the  ])leural 
cavity  almost  anything  is  allowable.  If,  how- 
ever, it  appear  that  it  will  be  necessary  to  <)|)en 
the  j)leural  cavity  caution  should  be  observed.  Of 
late  vears,  howt'ver,  less  h(>sitation  has  been  felt 
in  this  reijard,  and  Tarham  and  others,  includiufj; 
myself,  have  shown  that  extensive  j)ortion.s  of  the 
thoracic  wall  may  be  resected  without  the  neces- 
sity for  em|)loyment  of  the  elaborate  operative 
methods  suggested  by  some  recent  experimenters. 
For  instance,  Sauerbruch  has  devised  a  "{)neu- 
matie  cabinet,"  the  ))atient's  head  resting  outside 
when  the  anesthetizer  administers  the  anesthetic. 
The  balance  of  the  body  rests  within  the  cabinet, 
which  is  sufiiciently  large  to  accommodate  the 
operator  and  two  or  three  assistants,  and  which, 
being  closed,  is  subjected  to  a  lowering  of  atmos- 
pheric pressure  equivalent  to  10  Mm.  of  mercurial 
column,  or  to  a  difference  in  atmospheric  level  of 
1000  to  1200  feet.  The  patient  breathing  air  at 
external  pressure  does  not  suffer  the  collapse  of  the 
lung,  thus  exposed,  which  would  otherwise  take 
place.  The  operation  being  comj)leted  within 
the  cabinet,  the  dressings  are  applied  and  her- 
metically sealed,  and  the  door  then  opened  and 
pressure  equalized.  Subsequent  dressings  can  be 
made  in  the  same  way.  Thus  has  been  afforded 
a  scientific  method  of  doing  that  which  the  ex- 
perience of  many  American  surgeons  has  shown 
to  be  only  theoretically  indicated.  Sauerbruch's 
device  is  ingenious  in  theory  and  complicated  in 
operation. 

A  simpler  method  is  to  apply  theFell-O'Dwyer 
apparatus  over   the   face  and  thus  kee])  up  arti- 
ficial respiration.     It  is  not,  in  theory,  so  ideal  as  to  open  the  trachea  and  practise  this 
procedure  as  is  done  in  the  experimental  laboratory,  but  is  much  simpler  and  will 
usually  suffice,  should  anything  of  the  kind  be  required. 

A  malignant  tumor  of  the  chest  wall  whose  overlying  skin  is  seriously  involved,  and 
whose  removal  would  leave  a  defect  which  it  would  not  be  possible  to  cover  with 
integument,  shoukl  not  be  disturbed.  It  might  be  possible  in  certain  cases  to  partially 
transj)lant  the  breast  in  such  h  manner  as  to  permit  closure  of  a  defect  thus  made. 
Nevertheless  it  is  questionable  if  any  cancer  advanced  to  the  extent  of  requiring  this 
procedure  is  to  be  considered  operable. 

Nor  should  any  malignant  tumor  of  the  chest  wall  be  operated  if,  in  addition  to  its 
own  presence,  there  be  indication  of  the  involvement  of  the  lymphatics  or  other  structures 
within  the  chest,  such  indications  including,  for  instance,  cough,  loss  of  voice,  dyspnea, 
dysphagia,  disturbance  of  pneumogastric  control  of  the  heart,  displacement  of  the  latter, 
or  great  accumulation  of  fluid  in  any  of  the  chest  cavities.  The  only  exception  to  this 
statement  is  ])ossibly  when  the  lung  has  attached  itself  to  its  interior  surfac-e,  but  yet 
not  so  extensively  but  that  removal  of  a  small  amount  of  lung  tissue  will  not  interfere 
with  extirpation  of  the  growth.  Cases  of  recurring  carcinoma  wliere  the  chest  wall  is 
completely  involved  rarely  justify  operation. 


Skiagram  of  a  large  sarcoma  of  the  thorax 
and  humerus,  whose  bhiodvessels  were  in- 
jected previous  to  taking  thea-ray  picture. 
(Lexer.) 


732  SPECIAL  OR  REGIONAL  SURGERY 


TUMORS  OF  THE  LUNG. 


Tumors  of  the  lung  proper  might  be  made  amenable  to  surgery,  in  certain  instances, 
if  an  exact  diagnosis  could  be  made.  Occasionally  this  is  possible,  though  but  very 
rarely.  Particles  of  lung  tumor  have  been  expectorated  and  their  minute  character 
recognized,  so  that  actual  diagnosis  has  been  made.  As  in  the  alxlomcn,  cancer  of  the 
thoracic-  viscera  will  usually  lead  to  an  accumulation  of  serous  Huid,  and,  in  both  instances, 
thus  obscure  rather  than  simplify  reccjgnition.  Quincke  has  shown  that  the  j)rcscnce  in 
such  pleuritic  effusions  of  fat  cells  (hydrops  adiposus)  is  significant,  since  they  rarely  if 
ever  occur  in  any  other  exudates. 

Primary  tumors  of  the  lung  are  usually  sarcomas  or  endotheliomas.  Carcinoma 
is  exceedingly  rare,  save  as  secondary  to  cancer  in  the  breast.  Even  sarcoma  is  itself 
usually  secondary  to  disease  in  some  other  part  of  the  body,  metastasis  having  occurred 
through  the  blood  channels,  instead  of  through  the  lymjjhatics,  as  is  the  case  with  car- 
cinoma. Tumors  arising  in  the  pleura  may  be  of  endotheliomatous  tyjie  and  are  usually 
acc-ompanied  by  the  presence  of  bloody  serum.  Extremely  rare  tumors  within  the  chest 
are  those  of  dermoid  origin,  connected  more  often  with  the  jjleura  than  with  the  lung 
proper.  These  may  suppurate  and  communicate  either  externally  or  internally.  One 
known  case  mentioned  by  Dennis  was  that  in  which  such  a  tumor  communicated  with 
a  bronchus,  so  that  the  patient  coughed  up  hair.  Si/philitic  gummas  are  also  found  in 
the  lung,  either  in  multiple  small  form  or  in  masses  oif  considerable  size.  They  are  slow 
in  development  and  may  give  rise  to  no  special  disturbance.  Dennis  has  described 
instances  in  which  these  growths  have  become  encapsulated. 

Two  other  forms  of  tmuor  are  not  very  rare  in  this  situation :  one  is  that  produced  by 
aciinomijcosis;  the  other  occurs  in  echinococeus  disease  and  in  the  formation  of  hydatid 
cysts.  The  former,  developing  within  the  lung  projjer,  tends  to  migrate  toward  its  sur- 
face, to  include  the  pleura,  and  finally  to  invade  the  chest  wall.  vSuch  a  tumor  when 
exposed  in  either  location  can  scarcely  be  differentiated  from  a  breaking-down  sarcoma, 
except  by  the  recognition  in  it  of  the  small,  calcareous  particles  which  are  so  pathogno- 
monic of  this  disease.  (See  Actinomycosis.)  In  the  living  patient  the  sputum  will 
frequently  contain  these  particles,  while  under  the  microscope  the  peculiar  club-end, 
thread-like  fungus  formation  may  be  recognized.  The  disease  is  usally  of  slow  develoj)- 
ment,  but  occasionally,  especially  when  mixed  with  a  secondary  infection,  may  be  rapid. 
Significant  tumors  may  also  occur  in  other  parts  of  the  body.  Actinomycotic  tumors 
upon  the  surface  may  be  attacked  with  curette  and  cautery."  Injectionsof  iodine  are 
also  of  value.  For  actinomycosis  of  the  lung  proper  potassium  iodide  and  Lugol's 
solution  are  indicated  as  well  as  copper  sulphate. 

Hydatid  cysts  occur  within  the  lungs  in  about  10  per  cent,  of  cases  of  echinococeus 
disease.  Their  contained  fluid  is  alkaline,  of  low  specific  gravity,  colorless,  and  contains 
the  characteristic  booklets  which  are  pathognomonic  of  this  disease.  A  circumscribed 
collection  of  fluid  within  the  chest,  shown  to  be  due  to  this  condition,  may  be  tapped 
or  inc  ised  and  drained.  When  occurring  in  the  lung  it  not  infrequently  leads  to  secondary 
pyothorax,  while  operation  for  the  latter  may  reveal  the  existence  of  the  former.  Any 
hydatid  cyst  of  the  lung  which  can  be  recognized,  or  be  made  accessible,  may  be  treated 
by  incision  and  drainage,  the  lung,  if  not  already  adherent,  being  first  fastened  to  the 
chest.  Inasmuch  as  the  condition  develops  in  the  lower  lobe  and  on  the  right  side  this 
is  occasionally  a  practicable  procedure.  As  the  diagnosis  is  usually  made  only  after 
the  primary  cyst  has  ruptured  and  small  cysts  are  cast  off,  produc-ing  more  or  less  pleuritic 
effusion,  the  attempt  may  still  be  made  "to  do  this  by  a  free  incision  of  the  chest  wall, 
perfecting  the  diagnosis  and  completing  the  procedure  at  this  time. 

THE  HEART. 

There  is  but  little  to  be  said  about  the  heart  in  addition  to  that  elsewhere  stated,  where 
such  injuries  as  gunshot  wounds,  stab  wounds,  etc.,  are  considered.  Rupture  of  the 
heart  without  external  injury  is  possible  under  conditions  of  fatty  degeneration  or  soft- 
ening produced  in  consequence  of  embolus  or  thrombus.  Aneurysms  of  the  heart 
are  also  known  by  which  it  is  weakened  and  permitted  later  to  give  way.     The  final 


THE  lAMIS  733 

riiptiiiT  is  iisiiallv  tlic  ((iMscciiifiicc  ni  smiic  ciiiDiion  or  cxfrii  cxcrtiDii,  altlioii^li  it  may 
occur  willi  injury  to  sonic  oilier  |)art  of  tiic  body,  as  after  a  Mow  upon  tlie  alxlonicn. 
Death  may  hi-  instantaneous,  or  occur  more  slowly  as  the  result  of  (illin<;  of  the  peri- 
canlial  sac  and  rapidly  increasin<;  emharrassment  of  heart  action. 

)l  uuiuis  (ij  tlif  heart  j)roduce  synco|)e  ant!  shock,  restlessness,  extreme  anxietv,  with 
<lysi)nea  an(l  such  disturbance  of  heart  activity  as  to  materially  change  the  sounds  heard 
on  auscultation. 

The  treatment  of  such  cases  not  primarily  fatal  should  inchide  o|>inm  narcosis,  hut 
not  stiimdants  intended  to  excite  the  heart  to  extra  activity.  The  operations  justified 
uiuier  these  conditions  are  elsewhere  described.' 

Pcncardill.s,  either  of  i(lioj)athic  or  traumatic  orijfin,  may  j)ro(luce  a  dci;ree  of  disten- 
tion, either  hi/drojH'n'cdnlliiiii  or  pi/ojurintnliiiiii,  callin<;  for  sur<fical  intervention — in 
the  former  ease  with  the  asj)iratinir  needle,  in  the  latter  either  with  the  needle  or  the 
knife.  When  a  i)eriearilium  is  greatly  distended  with  fluid  there  is  marked  change  in 
the  }K)sition  of  the  apex  beat,  Avith  embarra.ssnient  of  heart  action,  accompanied  l)y 
distress  and  distention  of  tiie  veins  of  the  upper  part  of  the  body,  as  well  as  much  altera- 
tion of  the  ordinary  physical  signs,  the  area  oi  dulness  being  corresj)on(lingly  enlarged 
and  the  lung  sounds  l)eing  lost  over  the  area  occupied  by  the  distended  sac.  (Jreat 
distention,  with  marked  invcortlial  trouble  and  distress  of  heart  and  luner  function, 
always  recjuires  pamcnitr.s-t.s. 

Paracrufr.si.s-  prnrurdii  is  j)erfornied  ordinarily  by  puncturing  (a  ])reviously  sterilized 
area)  3  to  5  Cm.  to  the  left  of  the  left  border  of  the  sternum,  and  in  the  fifth  intercostal 
space,  with  a  sterilized  needle.  Here  are  found  the  interiud  mammary  artery  and  the 
pleura.  Too  ra])id  withdrawal  of  fiuid  may  lead  to  sjTicope.  It  should,  therefore, 
be  allowed  to  escape  slowly.  Should  it  prove  purulent  it  may  be  incised,  passing  the 
knife-blade  along  the  needle;  or  the  sac  may  be  emptied,  when,  if  fluid  re-collect, 
a  free  incision  should  then  be  made.  Roberts  has  shown  that  recovery  follows  in  at  least 
40  per  cent,  of  cases  of  empyema  of  the  pericardium  thus  treated.  Gauze  drainage  may 
be  ])r()vided,  but  irrigation  of  the  cavity  should  not  be  practised. 

Allingham  has  suggested  to  open  the  pericardium  from  below  by  an  incision  three 
inches  in  length,  carried  along  the  lower  margin  of  the  seventh  left  costal  cartilage, 
to  .separate  the  cartilage  from  the  abdominal  muscles,  pull  outward  and  uj)ward 
the  loAver  surface  of  the  diajihragm,  expose  the  cellular  interval  between  its  attachment 
to  the  cartilages  and  to  the  tip  of  the  sternum,  to  expose  and  enlarge  l)y  blunt  dissection, 
until  there  appears  a  mass  of  fat  which  belongs  above  the  diaphragm  in  the  interval 
between  the  pericardium  behind,  the  sternum  in  front,  and  the  diaphragm  belf)W. 
When  this  is  removed  the  pericardium  is  exposed  and  can  here  be  opened.  Throughout 
the  procetlure  injury  to  the  pericardium  which  lines  the  upper  surface  of  the  diaphragm 
should  be  avoided.  By  this  method  the  pleura  need  not  be  ojx'ned  and  better  drainage 
may  be  secured.     (Dennis.) 

Ahsce.su  ill  the  heart  u-all  is  an  exceedingly  rare  lesion,  usually  accompanying  jno- 
pericardium,  but  occasionally  met  without  it.  It  was  the  writer's  experience  in  one  case, 
in  puncturing  for  what  was  supposed  to  be  a  pyo pericardium,  to  withdraw  pus  and 
give  temporary  relief.  Later  postmortem  examination  showed  that  this  pus  came  from 
a  large  al)scess  in  the  wall  of  the  heart,  which  had  been  thus  entered  by  the  aspirating 
needle  without  immediate  bad  consequences,  but,  on  the  contrary,  with  temporary 
relief. 

THE  LUNGS. 

In  the  fact  that  the  lung  never  completely  fills  the  pleural  cavity  we  find  explanation 
for  the  kindred  fact  that  small  effusions  produce  little  if  any  compression  symjjtoms. 

'  Borchardt  has  collected  83  cases  of  operations  upon  the  heart,  of  which  78  included  heart  suture.  Of  these 
78,  46  died  and  32  recovered.  He  quotes  a  statement  of  Billroth,  made  when  this  surgeon  was  si^ty  years  of 
age:  "Paracentesis  of  the  pericardium  is  an  operation  which,  according  to  my  view,  closely  approaches  to  what 
might  be  considered  a  prostitution  of  surgical  art,  or,  as  some  surgeons  would  call  it,  a  surgical  frivolity,  an 
operation  which  altogether  has  more  interest  for  the  anatomist  than  for  the  physician.  Possibly  a  later  gen- 
eration will  regard  it  differently.  Internal  medicine  is  constantly  becoming  more  surgical,  and  those  physicians 
who  concern  themselves  especially  with  internal  medicine  will  find  themselves  compelled  to  make  the  most 
daring  operation."  The  rapid  advances  made  in  surgery  during  the  past  three  decades  cannot  be  better  illus- 
trated than  by  contrasting  Billroth's  statement  of  a  few  years  ago  with  the  standard  practice  of  today. 


734  SPECIAL  OR  REGIONAL  SURGERY 

Collapse  of  one  lung  after  opening  the  ehest  is  never  complete  if  the  other  lung  l)e  unin- 
jured and  funetionating.  Moreover,  a  partial  eollapse  on  the  affected  side  will  be 
quickly  atoned  for  when  the  pressure  of  the  external  atmosphere  is  taken  off". 

Two  or  three  serious  pathological  conditions  of  the  lung  occasionally  require  surgical 

intervention. 

HYDATIDS  OF  THE  LUNG. 

Hydatids  of  the  lung  have  l)een  mentioned  (see  above).  Seventv-five  per  cent,  of 
these  cases  terminate  fatally  without  surgical  hel]>,  and  in  reality  more  j)rospe('tive 
benefit  can  l)e  offered  l)y  it  than  without  it.  Serious  and  even  fatal  collapse  has 
attended  the  sudden  withdrawal  of  fluid  from  hydatid  cysts  in  this  location.  Asj)iration 
may  be  made\  but  even  this  is  scarcely  less  dangerous  while  it  is  less  satisfactory  than 
free  exposure  and  tlrainage. 

ACTINOMYCOSIS  OF  THE  LUNG. 

Actinomycosis  of  the  lung  may  be  recognized  by  the  sjHitum  and  also  by  the  pus  dis- 
charged fnmi  any  I )rea king-down  caA-ity  within  the  affected  area.  (See  section  on  the 
Pleura.)     If  a  localized  focus  could  be  diagnosticated  or  recognized  after  exposure 

the  jiortion  of  the  lung  thus  involved  might  be  removed, 

ABSCESS  OF  THE  LUNG. 

Abscess  of  the  hmg  is  always  the  result  of  some  local  or  distant  infectious  jirocess. 
The  mechanism  of  production  of  the  multiple  metastatic  abscesses  which  characterize 
pyemia  has  l)een  described  in  the  earlier  portion  of  this  work.  For  such  conditions 
surgery  affords  no  aid.  Circumscribed  abscess  may  be  the  result  of  the  presence  of  a 
foreign  body — /.  e.,  a  bullet  or  a  parasite — or  it  may  result  from  eml)olism  with  infarct, 
in  consequence  of  such  affections  as  ulcerative  endocarditis,  puerperal  septicemia, 
sloughing  fibroid,  an  otitis  media,  or  a  septic  pneimionia  produced  from  any  cause. 
It  may  lie  the  residt  of  extension  from  an  osteomyelitis  of  some  portion  of  the  bony 
wall  of  the  thorax,  which  itself  may  result  either  from  injury  or  from  local  infection. 
Abscess  of  the  lung  is  seen  not  infrequently  in  connection  with  empijema,  and  often  results 
from  suj)purating  tuberculous  broiirhia!  nodes-.  It  maybe  produced,  also,  by  extension 
of  trouble  from  below  the  diaj)hragm,  as  hepatic  abscess,  subphrenic  abscess,  and  the 
like.     It  is  always  a  secondary  rather  than  a  primary  att'ection. 

Such  abscesses  are  to  l)e  recognized  by  the  character  and  offensiveness  of  the  sputum, 
the  pus  discharged  lieing  colored  green  or  brown,  containing  shreds  of  tissue,  wth  masses 
of  bacteria  and  crystals  of  fat.  Some  believe  the  jiresence  of  elastic  fibers  to  be  pathog- 
nomonic. When  pulmonary  abscess  is  diagnosticated  it  is  necessary,  in  addition,  to 
detenuine  whether  multiple  lesions  or  a  circumscribed  collection  are  to  be  dealt  ^\'ith. 
In  the  former  instance  it  is  of  little  avail  to  intervene.  In  the  latter  the  physical  signs 
will  usually  furnish  evidence  of  adhesions  between  the  lung  and  the  chest  wall,  by  whose 
presence  the  operative  procedure  is  simplified. 

The  term  pneunwtomi/  is  applied  to  the  exposure  and  evacuation  of  pus  in  the  lung, 
whether  it  be  found  in  connection  with  an  ordinary  abscess  or  a  suppurating  hydatid 
cyst.  It  is  essentially  a  thoracotomy,  plus  the  added  measure  of  whatever  may  be  done 
to  the  lung  itslf,  and  will  l)e  described  in  connection  with  other  operations  upon  the 
chest. 

If  a  tuberculous  abscess  could  be  located  it  also  might  be  treated  upon  the  same  general 
])rinciples.  Thus  Lane  and  others  have  suggested  early  operations  for  relief  of  tuber- 
culous lesions.  For  obvious  reasons,  however,  the  method  has  not  found  general 
acceptance. 

GANGRENE  OF  THE  LUNG. 

Gangrene  of  the  lung  is  the  terminal  stage  of  a  local  infection,  and  unless  relieved 
may  prove  fatal  to  the  patient.    It  is  due  to  the  causes  above  mentioned  as  producing 


CIIVLOTIKlUAX  735 

ahscess  in  tlic  liitii^,  wliilr  to  tliciii  may  perhaps  he  addcfl  a  IVu  otlnTs,  cspcfiallv  expres- 
sions of  einl)olisni  or  tlironihus  of  the  |)nhnonarv  eireniation  hy  wliich,  the  hlood  snpply 
heiii^  cut  otf,  death  of  tissne  occurs  before  there  is  time  for  phlej^monons  development. 
Thus  it  is  met  with  occasionally  after  tiic  acute  exanthcms  and  the  infectious  fevers  and 
after  violent  pertussis.  When  diii'use  it  is  of  the  miliary  ty|)e.  When  circumscribed 
it  may  he  due  to  more  localized  causes.  In  any  event  it  is  more  frequent  in  the  lower 
portions  of  the  luiifj. 

I'ulmonary  g;an<,M-ene  may  be  recoijnized  by  the  extreme  condili(»n  of  tiie  patient, 
offensive  odor  of  the  breath,  and  expectoration  of  sputum  which  may  at  first  be  frothy 
and  bloody,  but  becomes  raj)idly  purulent  and  finally  necrotic  in  ty|)e.  Meantime, 
the  function  of  the  lun<j  beiiij;  materially  interfered  with,  respiration  is  rapid  and  there 
will  be  more  or  less  coufjh,  ])ain,  and  finally  collapse.  When  the  sj)utum  is  allowed  to 
stand  in  a  test  tube  there  will  form  an  upj)cr  layer,  opaque  and  frothy;  a  middle,  more 
frothy  layer;  while  the  lower  and  denser  portitm  will  be  of  a  dirty  green  color  anfl  contain 
shreds  of  dead  tissue  with  bacteria,  crystals  of  triple  phosphates,  fat  debris,  and  pus. 
.\ccording  to  the  nature  of  the  case  the  cavity  or  the  area  of  dead  lung  may  be  outlined 
by  j)hysical  signs.  There  is  a  form  of  fetid  hronchiths  which  has  been  mistaken  for 
pulmonary  gangrene,  but  the  character  of  the  sjiiituin  and  the  progress  of  the  case  will 
l)e  <|uite  ditt'erent. 

(Jangrenous  areas  of  limited  size  have  in  certain  favorable  cases  cleared  up  and 
the  patients  have  recovered,  but  ordinarily  for  this  condition  surgery  affords  the  only 
pros|)ect  of  relief,  the  operation  being  begun  with  a  thomcotomij  and  completefl  by  the 
removal  of  the  (jancjrenous  lung  tissue.  The  operative  procedure  is  essentially  the  same 
as  that  for  abscess  and  above  described. 

Septic  pneumonia  is  the  term  applied  to  those  forms  of  pneumonitis  which  occur  in 
connection  with  septic  lesions  in  other  parts  of  the  body,  or  with  the  less  typical  forms — 
e.  (J.,  aspiration  pneumonia,  due  to  the  passage  into  the  finer  bronchioles  (jf  material 
from  the  mouth  or  nose.  It  gives  rLse  to  the  same  physical  signs,  though  it  is  j)erhaj)s 
more  often  irregularly  located  than  is  the  consolidation  of  the  ordinary  lof)ar  pneumonia. 
Viewed  in  this  way  it  will  be  regarded  as  a  serious  conqilication  of  various  other  con- 
ditions, many  of  which  are  surgical,  and  it  is  frequently  a  primary  expression  of  infection. 
The  physical  signs  by  which  it  may  be  recognized  are  scarcely  different  from  those  of 
ordinary  pneumonia,  e.xcept  that,  in  addition  to  the  latter,  there  may  be  distinct  expres- 
sions of  general  septic  infection  and  of  profound  toxemia,  and  that  the  disease  may 
progress  to  the  point  of  producing  pulmonary  abscess  or  gangrene.  While  the  milder 
t^jjes  of  septic  pneumonia  are  not  necessarily  fatal,  it  is  always  a  serious  complication, 
and,  as  such,  dreaded  by  the  surgeon.  It  is  not,  however,  essentially  a  surgical  com- 
plication, but  calls  for  the  treatment  generally  given  to  pneumonia,  plus  whatever 
may  be  needed  for  the  primary  condition  behind  it. 


CHYLOTHORAX. 

This  implies  a  collection  in  one  of  the  pleural  cavities,  usually  the  left,  of  fluid  which 
is  practically  unchanged  chyle,  which  has  probably  escaped  from  the  thoracic  duct.  The 
number  of  cases  on  record  is  not  over  fifty,  of  which  about  one-third  have  followed  un- 
recognized injury  with  probable  rupture  of  the  duct.  ■Most  of  these  cases  have  occurred 
in  connection  with  fracture  of  the  s])ine.  The  duct  may  be  opened  by  the  progress  of 
ulcerative  disease,  and  carcinoma  is  often  the  predecessor  of  chylothorax.  Rupture 
may  also  occur  in  connection  with  tuberculous  lymphatics  about  the  course  of  the  duct, 
and  when  the  condition  occurs  in  children  this  is  the  usual  explanation.  It  should  be 
differentiated  from  so-called  chyloid  effusions  into  the  pleural  cavity,  Avhich  are  more 
often  seen  in  connection  with  cancer  than  tuberculosis,  the  fluid  in  this  case  being 
mixed  with  fat  and  degenerated  leukocytes  or  cells.  Pure  chyle  contains  sugar,  while 
chyloid  fluid  contains  but  a  trace  of  it.  The  former  also  is  thicker,  and  compares  with 
the  lattei"as  does  cream  with  skimmed  milk. 

The  prognosis  is  not  usually  favorable.  Nevertheless  recovery  has  ensued  without 
operation.  ]\Iere  pressure  of  the  effusion  may  occlude  the  opening  through  which  it 
occurs  until  the  latter  shall  heal.  W'heri  the  fluid  gives  rise  to  severe  symptoms  the  chest 
should  be  aspirated.  - 


736  SPECIAL  OR  REGIONAL  SURGERY 


HYDROTHORAX;  HEMOTHORAX;  PYOTHORAX. 

Under  these  terms  are  included  the  presence  of  fluid  in  the  pleural  cavity,  between 
the  lung  and  the  chest  wall;  this  fluid,  in  the  first  instance,  being  scrum,  which  may  be 
slightly  admixed  with  pus  and  blood;  in  the  second,  blood;  and  in  the  third,  pus. 

Ilvdrothorax  may  be  a  primary  condition,  the  result  of  pleurisy  with  effusion,  or  of 
pleuropnevnnonia.  It  may  also  occur  as  does  a  similar  collection  in  the  abdomen,  as 
the  result  of  disease  of  the  chest  wall,  the  lung  itself,  or  in  consequence  of  serious  cardiac 
or  renal  <lisease,  with  tendency  to  dropsical  accumulations  in  various  parts  of  the  body. 
Thus  it  is  seen  in  connection  with  tuberculous  disease  or  cancer  of  the  lung,  as  well 
as  cancer  of  the  chest  wall.  There  is,  moreover,  a  miliary  exj)ression  of  tubercidous 
pleuritis  in  which  hydrothorax  is  always  a  complication. 

The  serious  features  of  hydrothorax  result  from  the  compression  which  it  may  make 
upon  a  lung  with  consequent  embarrassment  of  lung  function  and  from  the  possibility 
of  infection  by  pyogenic  organisms  and  the  consequent  conversion  of  a  hydrothorax 
into  a  pyothorax. 

Collections  of  serum  within  the  pleural  cavity  which  manifest  a  kindly  tendency  to 
disappear  by  resorption  do  not  require  surgical  intervention,  but  all  such  accumulations 
which  do  not  quickly  evince  this  tendency  should  be  removed  l)y  the  operation  of  para- 
centesis, which,  applied  to  the  thorax,  is  called  thoraccnicsis,  i.  c,  aspiration  through  the 
hollow  needle.  No  lung  should  be  allowed  to  have  its  capacity  long  reduced  by  com- 
pression. 

Hemothorax  may  be  idiopathic  or  traumatic.  In  the  former  case  it  is  an  expression 
of  malignant  disease,  or  of  advanced  septic  lesions  which  have  permitted  erosion  of  blood- 
vessels and  escape  of  blood.  It  may  also  result  from  rupture  of  an  aneurysm,  and 
will  then  prove  fatal.  It  is  seen  in  surgical  cases  in  connection  with  injuries  to  the 
chest  wall  or  its  contents,  as  in  compound  fracture  of  a  rib  or  perforation  of  a  rib  frag- 
ment into  the  chest,  with  injury  to  the  lung. 

In  case  of  the  sudden  escape  of  fluid  into  the  chest,  with  symptoms  of  collapse  and 
lung  compression,  it  may  be  assumed  that  an  acute  hemothorax  affords  the  explana- 
tion. Fluid  accumulating  rapidly  under  any  circumstance  is  more  likely  to  be  blood 
than  serum.  The  exploring  needle  may  be  relied  on  to  furnish  the  deciding  test,  in 
addition  to  the  ordinary  physical  signs  afforded  by  auscultation  and  percussion. 

Pyothorax  is  frequently  referred  to  as  empyema,  the  latter  term  indicating  a  collection 
of  pus  in  a  previously  existing  cavity,  and,  by  common  consent,  made  to  refer  to  the 
pleural  cavity  unless  some  other  be  mentioned.  Empyema  is  seldom  a  primary  con- 
dition. Generally  it  is  the  result  of  a  hydrothorax,  which  has  become  contaminated 
either  by  direct  or  by  indirect  access  of  germs.  Under  these  circumstances  it  indicates 
the  conversion  of  a  relatively  innocent  collection  of  serum  into  a  collection  of  pus,  with 
all  its  attendant  dangers.  It  may  be  looked  for  in  cases  of  perforating  injury  of  the 
chest,  e.  g.,  compound  fracture  of  the  ribs,  gunshot  wounds,  and  the  like. 

While  returning  the  ordinary  physical  signs  met  with  in  fluid  collections  in  this  location, 
and  being  discoverable  with  the  exploring  needle,  empyema  has  this  additional  feature, 
that  the  pus  may,  when  long  retained  or  accumulated  in  large  amount,  burrow  and 
attempt  to  escape  through  whatever  path  may  offer  least  resistance.  In  this  way  strange 
freaks  will  occur,  as  when  it  escapes  behind  a  mammary  gland  and  pushes  the  latter 
forward,  thus  forming  a  large  retromammary  abscess,  which  requires  not  merely  the 
ordinary  incision,  but  a  thoracotomy  and  ample  drainage  as  well.  It  may  penetrate 
at  other  points  and  thus  escape.  The  most  remarkable  illustration  that  the  writer 
personally  has  known  of  this  travelling  of  pus  was  in  a  colored  man,  in  whom  it  per- 
forated the  diaphragm,  then  separated  the  peritoneum  from  the  abdominal  wall  over  a 
large  area,  collected  in  large  amounts  between  the  peritoneum  and  the  abdomen  in 
front,  and  even  extended  down  into  the  pelvis.  This  man  had  such  a  peculiar  abdomen 
that  he  was  supposed  to  have  dropsy.  When  the  trocar  was  inserted  there  was  a 
discharge  of  over  a  pailful  of  almost  pure  pus. 

In  addition  to  the  ordinary  embarrassment  which  a  considerable  amount  of  pus  thus 
collected  causes,  there  should  be  reckoned  the  peculiar  septic  and  toxic  features,  which 
can  be  easily  accounted  for  by  the  nature  of  the  contained  fluid.     Pyothorax  will  nearly 


CONGEMTM.   M ALPOh'M .\HO.\S  (>F   Till-:   hSorifAdUS  737 

jilwavs  liavc  s«'|)liciMiiic   in  addition  lo  local  IValiircs,  wliicli   i^ivc  it   an  individnalit y  of 
its  own. 

The  o|)fia(ioii.s  |)ia(tisi'(l  for  ri-jicf  ui  tlicsi-  cuiiilitions  arc  disciis-scd  at  the  con- 
clusion of  this  chapter. 

THE  ESOPHACJUS. 

Anatomically,  the  csophai^iis  is  a  iniiscidoinciid)ranons  Inhc  with  downward  pi-ojcction 
into  the  thorax,  its  uppermost  portion  l)lendin<^  with  the  lower  constrictor  of  the  pharynx, 
the  tuhe  proper  hei^innin"^  at  the  level  of  the  cricoid  cartilajfc,  and  op|)osite  the  sixth 
{■ervical  vertebra.  Its  conclusion  opposite  the  tenth  dorsal  vcrti-hra  marks  the  cardiac 
orilice  of  the  stomach.  In  its  u|)|)er  portion  it  is  |)laced  centrally,  then  inclines  a  little 
to  the  left,  and,  at  the  level  of  the  third  dorsal,  lies  ahout  half  an  ineli  to  the  left  of  the 
middle  line.  This  furnishes  the  reason  for  aj)proaehin<j  it  upon  tiie  left  side  in  doing 
external  esophafijotomy.  From  here  it  passes  to  the  middle  line  again  until  opj)osite 
the  ninth  vertebra,  where  it  once  more  inclines  a  little  to  the  left.  It  has  an  antero- 
posterior curve  corn'spondiiifi;  to  the  shapeof  thesj)ine.  Between  it  and  the  trachea,  in 
the  neck,  lies  the  recurrent  laryngeal  nerve.  Its  nervous  supply  is  derived  from  the 
sympathetic  and  the  pneumogastric,  and  its  lymphatics  connect  with  the  mediastinal 
nodes,  the  latter  point  being  of  importance  in  connection  with  cancer  of  theesophagus. 
Its  average  calil)er  is  about  three-quarters  of  an  inch,  save  where  it  is  crosse(l  by  the 
left  bronchus  and  at  the  diaphragmatic  opening.  There  is  also  a  slight  constriction  at 
its  upper  opening. 


CONGENITAL  MALFORMATIONS  OF  THE  ESOPHAGUS. 

Congenital  malformations  include  its  absence,  at  least  throughout  some  of  its  course. 
Connnunication  between  it  and  the  treachea,  so-called  tracheo-esophageal  fistula,  has 
been  noted.  Its  upper  portions,  into  which  may  open  the  incom])letely  closed  branchial 
clefts,  are  also  subject  to  malformations  with  incomplete  obliteration  of  the  latter  and 
consequent  divertieida.  Irregular  dilatation  is  also  occasionally  of  congenital  origin, 
as  well  as  acquired,  in  the  latter  case  being  due  to  fatty  degeneration  of  muscle  fibers. 
These  dilatations  should  be  differentiated  from  those  Avhich  are  mostly  found  on  the 
proximal  side  of  any  constricted  tubular  passage,  and  which  are  produced  by  accumu- 
lation and  distention  from  behind  of  whatever  should  be  ])assed  through  it. 

The  most  connnon  malfonnatious  of  the  esophagus  which  are  not  of  the  stenotic  char- 
acter are  so-called  divrrticula,  which  a])pcar  in  two  forms — namely,  distention  and 
traction,  these  being  both  acquired  forms,  while  congenital  formations  of  this  character 
are  also  occasionally  met. 

Congenital  diverticula  may  appear  any^vhere  along  the  course  of  the  tube,  but  are 
probably  more  common  in  its  upper  portion.  They  constitute  more  or  less  irregular 
tubular  sacs  which  lie  alongside  of  and  parallel  to  the  main  tube.  The  openings  by  which 
they  connect  may  l)e  large  or  small.  These  saccular  defects,  always  small  at  first, 
may  assume  increasing  proportions,  because  of  the  entrance  therein  of  food  and  their 
consequent  distention  by  foreign  material,  as  well  as  by  products  of  decomposition  of 
the  same.  Thus  slowly  and  insensibly  a  very  mild  form  of  such  defect  may  in  time 
a.ssume  serious  proportions. 

The  acquired  diverticula  of  the  distention  i\\)^  are  usually  met  with  in  the  upper  part, 
and  are  practically  hernial  protrusions  of  at  least  the  mucosa  through  the  fibers  consti- 
tuting the  muscular  portion  of  the  tube,  and  cannot  occur  save  by  some  preceding  ])atho- 
logical  change.  Traction  diverticula  are  the  results  of  adhesions  to  breaking  down  lyinph 
nodes  or  other  pathological  conditions,  by  which  the  es(>j)hageal  wall  is  first  pulled  out 
of  position,  then  gradually  saccnlatecl,  and  the  condition  still  further  aggravated  by 
accumulation  therein  of  foreign  material.  The  acquired  diverticula  attain  considerable 
size,  and  when  emptied  one  may  be  astonished  at  the  accumulation  which  has  occurred. 
Such  a  tube  having  been  completely  emptied  may  be  again  filled  by  the  first  food  which 
is  subsequently  taken.  After  being  filled,  the  balance  of  the  food  may  then  pass  into 
the  stomach,  with  partial  or  complete  comfort  or  satisfaction  to  the  patient. 

The  principal  indication  of  an  esophageal  diverticulum,  beside  dysphagia,  is  regurgi- 
47 


738 


SPECIAL  OR  RI'XlIOSAL-SURaKRY 


tation  or  vomiting  of  food.  When  food  wiiich  has  undergone  decomposition  is  occa- 
sionally rejected,  and  when,  at  the  same  time,  the  stomach  is  shown  to  be  not  dilated  and 
not  at  fault,  the  suspicion  of  a  diverticulum  may  be  considered  well  founded.  Its  open- 
ing into  the  esophagus  may  be  so  placed  as  to  always  engage  the  instrument  which  may 
be  passed  down  for  examination,  either  bougie  or  stomach  tube.  Should  this  })e  a  con- 
stant phenomenon  the  diagnosis  may  be  easily  established.  In  such  a  case  it  may  be 
possil)le  to  first  em{)ty  and  then  distend  the  sac  with  food  mixed  with  bismuth  subnitrate, 
or  perhaps  to  inject  it  with  an  emulsion  of  the  same.  If  this  can  be  done,  the  fluoro- 
scope  or  a  good  radiograph  will  show  a  distinct  shadow,  and  in  this  way  a  pictorial 
outline  of  the  condition  may  be  obtained. 

Treatment. — The  treatment  of  these  diverticula  is  of  great  difficulty,  e'specially 
when  the  sac  has  attained  a  size  which  permits  of  retention  of  material.  Sacs  which 
contain  decomjwsing  matter  should  be  emptied  by  the  stomach  tube  and  washed  out  at 
frequent  interval.^.  If  it  be  then  possible  to  pass  the  tube  beyond  them  the  patient  should 
be  fed  through  it,  or  it  may  be  possible  to  place  the  patient  in  the  recumbent  jjosition, 
with  the  head  lower  than  the  })ody,  and  cause  food  or  fluid  to  be  swallowed  in  this  attitude. 
It  will  then  probably  enter  the  stomach  instead  of  the  sac.  Such  measures  as  these 
failing,  and  nothing  else  affording  relief,  operations  are  occasionally  undertaken.     Much 


Fk;.  .511 


Fig.  512 


Diverticulum    freed  from  its  attachments  and 
delivered  from  the  wound.     (Richardson.) 


Shows  the  external  layers  of  the  esophagus 
closed  by  interrupted  Lembert  suture  of  silk. 
(Richardson.) 


will  depend  upon  the  location  of  the  sac,  especially  its  height.  A  diverticulum  in  the 
neck  may  be  more  easily  reached  than  one  in  the  chest,  and  Richardson  and  myself  have 
had  remarkable  success  in  the  relief  of  aggravated  cases  of  this  kind.  Gushing  has 
shown  the  advantage  of  the  administration  of  atropine  before  these  operations,  in  order 
to  limit  the  flow  of  saliva  and  keep  the  ])arts  dry.  The  sac  having  been  exposed  by  a  long 
incision  in  front  of  the  sternomastoid,  it  may  be  filled  with  a  solution  containing  methyl 
blue,  by  which  it  may  be  identified,  or  it  may  be  filled  with  paraffin,  which,  solidifying, 
will  serve  admirably  for  its  identification.  It  then  may  be  attacked  as  would  be  any 
solid  tumor.  The  sac  having  been  identified  and  extirpated  its  opening  into  the  esophagus 
is  then  closed  by  sutures  and  the  neck  wound  cared  for  as  usual,  with  proAision  for 
drainage  (Figs.  511  and  512). 

Traction  (liverticula  may  be  amenable  to  surgical  intervention.  Should  the  esophagus 
be  diverted  by  adhesion  to  an  advancing  aneurysm  nothing  should  be  attempted.  Among 
the  operations  which  may  be  practised  upon  the  thorax  there  may  be  mentioned  a  method 
of  posterior  exposure  and  attack  upon  some  of  these  conditions  which  may  or  may  not 
afford  advantages,  accortling  to  the  nature  and  location  of  the  various  conditions. 

Canlinspasm  (see  chapter  on  the  Stomach)  produces  a  sacculation  of  the  gullet  often 
mistaken  for  diverticulum,  and  requiring  to  be  differentiated  from  it. 


FoUEHis  ii<)i>ii:s  IS  nil':  i:s()i'n.\(ns 


TM) 


3 


FOREIGN  BODIES  IN  THE  ESOPHAGUS. 

Foreign  hodi-'s  may  Ix-  lod^'cd  in  any  |)(trti(»ii  of  the  csoplia^cal  (iil)c  and  cause  a  variety 
of  lr(inl)l(s,  atcordinj;  to  tlieir  size,  slia|)e,  location,  and  nature.  'I'licre  is  scarcely  any 
conceivaMe  ohject  wliicli  may  he  intro- 
duced into  the  mouth  which  has  not 
been  known  to  l)e  impacted  in  the  eso- 
phajjus  and  jmxhice  more  or  less 
serious  symptoms.  Youn^  children, 
inil)eciles,  and  the  insane  luay  suH'er 
unwittinifly  in  this  way,  while  the  coii- 
ilition  is  usually  accidental  and  unin- 
tentional. 

The  accompanying;  fiii;ures  (Fijis. 
513  and  .514),  j)ortrayinfj  in  one  case  a 
jaekstone  lodfjed  in  the  esophagus,  a 
coin  in  the  other,  a  case  of  my  own,  will 
furnish  illustration.s  of  what  has  just 
been  said.  (See  also  page  674.)  The 
young  and  the  insane  may  make  no 
statement  which  will  furnish  a  clue  for 
the  distress  caused  in  atteni])ts  to 
swallow  or  the  actual  impossibilities  of 
the  act.  Inmost  instances,  however, a 
history  of  impaction  and  a  statement 
as  to  the  nature  of  the  foreign  body 
may  be  obtained.  The  .symptoms  |)ro- 
duced  are  those  of  partial  or  complete 
inability  to  swallow,  of  more  or  less 
|)ain    accompanying    the    act,    and    of 

the  regurgitation  often  of  blood  or  of  bloody  mucus.     The  object  may  be  sufficiently 
large  to  produce  dyspnea  and  suffocative  symptoms,  e.  g.,  a  plate  with  false  teeth. 

Fig.  514 


Jaekstone  lodged  in  esophagus.      (Phelps.) 


Coin  lodged  in  e-'sophagiis,  suecessfiill.v  removed  b.v  e.xternal  esopliagotom.v. 

(.SkiaRiani  b.v  Dr.  Pluminer.) 


From  the  Author's  Clinic. 


The  condition  being  suspected  or  made  known,  the  location  of  the  foreign  body  may 
be  determined  by  the  esophageal  bougie  and  by  the  use  of  the  a;-rays.     With  certain 


740 


SPECIAL  OR  RECIOSM.  SURGERY 


irrcifularlv  shaped  ohjects  the  latter  jjrove  a  clesiral)le  liel|),  e.speeiallv  when  irregular 
phites  eoiitainiiig  false  teeth,  or  toys  have  been  passed  into  the  eso[)ha<^us.  They 
alFord  an  indication  not  only  as  to  their  exact  situation  and  emplacement,  but  also  as  to 


Fig.  515 


Horse  hair  probang.  expanded  and  unexpanded. 


Esophageal  forceps. 

the  best  method  of  attack,  that  is,  whether  from  without  or  within.  Considerable  dis- 
tress may  be  }>roduced  by  even  small  particles,  as  chips  from  an  oyster-shell,  small  pieces 
of  fjlass,  and  the  like. 

Treatment. — A  foreign  body  which  produces  the  slightest  discomfort  or  recognizable 
symptoms  should  be  removed.     Only  occasionally  can  this    be  done   by  making  the 

patient  endeavor  to  swallow  some- 
"^'  ^^  thing  else,  tliis  being  too  uncertain 

a  method  of  procedure;  although 
I  have  known  a  peach-stone  im- 
pacted in  the  esophagus  to  be 
pushed  into  the  stomach  by  the 
passage  of  an  esophageal  bougie. 
The  situation  and  the  nature  of 
the  object  l)eing  known,  one  then 
decides  how  best  to  proceed.  The 
available  methods  of  operation  are: 

1.  The  introduction  of  a  bougie  and  the  enforced  passage  of  the  object  into  the 

stomach  (cjuestionable) . 

2.  The  use  of  the  esophageal  snare. 

3.  The  use  of  the  esophageal  forceps  or  similar  means  of  extraction. 

4.  The  more  directly  operative  methods  by  external  incision. 

The  csophagoscopc  is  an  instrument  of  comparatively  recent  device  and  perfection. 
We  owe  it  largely  to  the  ingenuity  of  Mikulicz.  It  is  to  the  esophagus  what  the  endo- 
scope is  to  the  urethra,  and  may  be  regarded  as  essentially  an  enlarged  endoscope.  Its 
introduction  is  comparatively  easy,  but  its  retention  is  distressing  to  the  patient,  so  that 
opptjrtunity  may  thus  not  be  afforded  for  profiting  by  its  use.  The  emj)loyment  of 
cocaine  anesthesia,  and  perhaps  of  morphine  hypodermically,  will  sometimes  enable  it  to 
be  used  satisfactorily.  It  may  also  be  used  for  exploratory  purposes  previous  to  com- 
mencing a  formal  operation  under  general  anesthesia.  There  are  furnished  Avith  the 
instrument  itself  forceps  and  extractors,  by  which  it  may  be  possible,  when  the  object 
is  once  seen,  to  grasp  and  withdraw  it.  The  use  of  the  esophagoscope  is,  moreover, 
not  limited  to  these  lesions,  since  it  can  be  used  in  revealing  the  character  of  strictures, 
small  wounds,  diverticular  openings,  and  the  like.  Endeavors  may  be  first  made  to 
locate  the  body  by  those  possessing  such  an  instrument  and  expert  in  its  use. 

The  esophageal  snare  is  a  simple  instrument  which,  after  being  introduced,  is  shortened 
in  such  a  way  as  to  cause  to  protrude  a  basket-like  meshwork  of  bristles  in  which,  as  the 
instrument  is  withdrawn,  a  small  object  may  be  entangled  and  so  withdrawn.  In  the 
same  way  an  ingeniously  made  eoin  catcher  is  furnished,  which,  in  cases  of  impacted 
coins  or  similar  shaped  objects  in  the  esophagus,  may  be  introduced  beyond  them  and 


h'l  I'Ti/a-:  OF  Tin:  hsorifAais  741 

(Irmi  witlidniw  II,  llic  dhjcct  l»i-iiiir  caiif^lit  in  ;i  iiiiiiiiitiirr  cnKlIc,  I'njiii  wliicli  it  caniiot 
c'.sc'jii)e  until  l)r<)n<f|jt  u|)  into  the  |)liarvnx.  Ivs()|)lia«feal  forceps  are  made  with  lon<j 
l)hi(les,  curved  hke  all  tlii'  insfrnnients  used  within  the  pharynx,  and  serving,'  adniirahly 
i'or  ifraspintij  objects  impacted  hi<,'h  in  the  tuhe  (Fij^s.  ol")  and  oKi). 

Dislodffcment  hein^  im|)ossil)le  hy  either  of  the  above-mentioned  e\|)edients,  recourse 
may  i)e  had  to  the  ojieration  of  crffnutl  r.soplKU/otoiiiij.  This  ma\  recjuire  to  he  done  as 
an  emer<fency  measure,  l)Ut  is  practically  always  indicated  when  an  impactecl  ohject 
eaiuiot  he  otherwise  removed.  A  dan<fcrous  location  for  a  forei<;n  hodv  in  the  eso|)ha<;us 
is  at  a  distance  of  about  nine  inches  from  the  upper  incisor  tooth,  at  which  point  it  will 
he  located  directly  behind  the  arch  of  the  aorta,  at  which  level  ulceration  would  perhaps 
result  disastrously,  as  Richardson  has  shown.  The  operation  was  devised  by  (iour- 
sault,  in  177^5,  and  has  jiroved  a  satisfactory  surf!;ical  measure.  It  is  jn-rformed  uj)on  tlu; 
left  side  of  the  neck.  The  incision  is  made  alon<^  the  anterior  marj^in  of  the  sterno- 
cleidomastoid from  the  middle  of  the  neck  downward.  The  larynx  and  trachea  are 
separated  to  the  inner  side,  the  muscles  and  the  larf^e  vessels  to  the  outer  side,  the  omo- 
hyoid divided,  th(>  descendens  noni  and  the  recurrent  laryn^real  nerves,  which  lie  in  the 
(groove  between  th(>  trachea  and  the  gullet,  are  j)rotected  from  injury,  and  the  esophageal 
tube  thus  exposed.  The  surgeon  will  feel  more  secure  in  opening  it  if  he  now  pass 
downward  through  the  mouth  a  bougie  or  instrument  upon  whose  beak  or  tip  he  may 
cut  downi.  The  esophagus  being  opened,  the  margins  of  the  woimd  are  secured  by 
sutures  which  serve  as  retractors,  and  the  interior  of  the  tube  is  then  subjected  to 
the  nece.ssary  mani|)ulation.  Even  now  it  may  not  be  an  easv  matter  to  dislodge  a 
j)ointed  object,  which  may  have  become  partially  im|)acted.  Thus  it  may  be  dislodged 
at  first  by  pushing  it  down  a  short  distance  and  turning  it,  the  direction  having  been 
already  indicated  by  an  .zvray  pic-turc.  The  manipulation  should  be  as  gentle  as  possible. 
Extraction  having  been  accomplished,  the  esophageal  wound  is  closed  by  the  sutures 
introduced  for  traction  purposes.  Over  this  the  external  wound  is  closed,  with  suitable 
jirovision  for  drainage,  as  it  is  almost  certain  to  have  been  infected  during  the  jirocedure. 
In  rare  cases  it  has  been  necessary  to  combine  a  gastrotomy  with  this  operation,  in  order 
that  by  combined  manipulation  a  peculiarly  shaped  object  may  be  dislorlged. 

Gasfrofomt/  will  be  necessary  in  but  few  instances,  as,  for  instance,  when  an  o})ject 
known  to  be  one  which  cannot  pass  through  the  ])ylorus  has  been  dislodged  into  the 
stomach  by  pressure  from  above — as  plates  containing  false  teeth,  and  various  similar 
objects.  It  will  ])robably  be  safer  to  open  the  stomach  and  remove  the  object  than  to 
leave  a  patient  to  his  otherwise  uncertain  fate.  On  the  other  hand  objects  which  are 
sure  to  be  in  time  dissolved  or  disintegrated  by  the  stomach  juices  may  be  allowed  to 
remain  to  await  this  event. 


WOUNDS  OF  THE  ESOPHAGUS. 

Wounds  of  the  esophagus  occurring  in  other  ways  than  those  above  indicated  may 
be  the  result  of  gunshot  and  various  perforating  injuries.  The  tube  may  be  also  partially 
cut  across  in  so-called  cut-throat. 

Any  external  \vound  of  the  esophagus  which  can  be  recognized  shoidd  be  closed  with 
sutures,  and  the  parts  brought  together,  if  possible,  Avith  provision  for  drainage.  Those 
lacerated  wounds  constituting  some  forms  of  cut-throat,  however,  permit  of  very  little 
in  this  direction,  for  when  seen  they  are  too  infected.  Through  an  esojihageal  opening 
thus  inflicted  the  patient  may  be  fed  for  a  time  by  a  tube,  the  wound  being  left  to  close 
later  by  granulation  or  by  a  secondary  operation.  When  the  esophagus  has  l)een 
anywise  injured  it  would  be  better  to  abstain  from  feeding  or  else  to  introduce  food 
through  an  esophageal  tube. 


RUPTURE   OF  THE   ESOPHAGUS. 

Rupture  of  the  esophagus  has  been  known  to  occur  in  consequence  of  severe  vomiting, 
there  being  some  twenty-five  cases  of  this  character  now  on  record.  (Dennis.)  A  tear 
is  rarely  comj)lete,  but  it  may  be  followed  by  hernia  and  formation  of  a  diverticulum. 
The  accident  will  be  indicated  by  violent  pain  following  severe  vomiting  in  connection 


742  SPECIAL  OR  Ri:(!I()S.\L  SllidERY 

with  an  effort  to  (lislo(l<>;e  a  foreign  body.  There  will  he  more  or  less  shock  and  jx-rhaps 
eoUapse,  witii  escape  of  blood.  Emphysema  of  the  neck  and  upper  part  of  the  chest 
may  result  and  the  injury  ])rove  fatal.  The  condition  being  suspected,  it  would  be 
advisable  to  do  an  external  esophagotomy  or  else  to  carefully  introduce  a  stomach 
tube  and  leave  it  in  situ. 


PERFORATION  OF  THE  ESOPHAGUS. 

Perforation — i.  c,  rupture  wiihoni  traumaii.sm — may  result  from  the  existence  of 
ulcers  or  from  the  advance  of  malignant  disease.  It  may  occur  in  either  direction. 
Thus  while  the  mediastinum  may  l)e  infected  from  entrance  of  septic  material  into  it 
the  direction  may  be  reversed  and  an  abscess  or  other  lesion  of  the  surrounding  tissues 
may  evacuate  itself  into  the  esophagus.  Should  this  ])rove  to  be  an  aneurysm  the 
patient  will  die  with  uncontrollable  escape  of  blood.  Th(>  treatment  of  such  a  case, 
if  any  be  permitted,  will  depend  entirely  on  the  nature  of  the  exciting  cause.  Perfora- 
tion has  also  followed  injudicious  use  of  bougies  when  exploring  or  treating  strictures 
(especially  cancerous)  of  the  esophagus. 

ESOPHAGISMUS. 

Esophagismus,  or  spasmodic  contraction  of  the  esophagus,  is  usually  an  expression 
of  hvsteria,  or  else  is  a  reflex  spasmodic  effect  due  to  the  presenc-e  of  some  neighboring 
irritation.  In  the  esophagus,  as  in  the  urethra,  there  maybe  spasmodic  stricture,  which 
will  afford  considerable  obstruction.  Thus  I  have  seen  it  as  a  functional  neurosis,  aljso- 
lutely  without  explanation,  in  an  apparently  healthy  workingman.  It  is  noticed  also 
in  connection  wdth  hemorrhoids  and  with  hepatic  lesions.  It  is  seen  in  pregnancy,  and 
a  certain  degree  of  it  will  complicate  many  cases  of  gastric  ulcer,  gastritis,  or  esophagitis 
such  as  is  produced  by  swallowing  mild  caustics.  While  producing  dysphagia  and 
oljstructive  phencmiena  "it  is  intermittent  and  interposes  little  real  obstacle  to  the  passage 
of  a  full-sized  bougie  or  tube.  It  is  frequently  accompanied  in  the  hysterical  by  globus 
hvstericus,  and  by  regurgitation  of  whatever  food  the  patient  attempts  to  swallow. 

The  local  treatment  consists  of  dilatation  by  the  passage  of  full-sized  instruments 
at  frequent  intervals.  If  a  neurosis  the  patient  may  require  other  treatment,  addressed 
<Mther  to  the  nervous  system  or  to  any  well-marked  constitutional  condition. 

STRICTURE    OF    THE    ESOPHAGUS. 

Stricture  of  the  esophagus  has  an  etiology  pracfically  identical  with  that  which  pertains 
to  stricture  of  any  other  passage  of  the  body-  It  may  be  due  to  extrinsic  or  intrinsic 
inffuence.  Among  the  former  may  be  mentioned  the  presence  of  tumors,  either  benign 
or  malignant,  or  of  cicatricial  tissue,  while  among  the  latter  should  be  mentioned  the 
injuries  resulting  from  the  presence  of  foreign  bodies,  the  extensive  ulcerations  due  to 
the  swallowing  of  various  caustic  fluids,  and  the  cicatricial  contraction  which  may 
folknv  other  lesions  like  ulceration.  Those  cases  w^hich  are  due  to  serious  congenital 
defects  will  usually  die  early.  Of  the  ulcerative  lesions  which  lead  to  stricture  the  most 
common  are  the  cancerous.  Syphilitic  and  tuberculous  ulcerations  may  occasionally 
produce  the  same  effect.  By  far  the  most  common  causes  are  the  traumatic,  which  are 
connected  either  with  foreign  bodies  or  with  the  unfortunate  accidental  use  of  caustics. 

Esophageal  strictures  are  recognized  by  the  difficulty  in  swallowing  which  they  profluce 
and  the  later  dilatation  of  the  esophagus  above,  w^hich  is  the  frequent  result  ()f  their 
long  existence.  The  degree  of  difficulty  ex])erienced  by  the  patient  in  deglutition  is 
to  a  considerable  degree  a  measure  of  the  extent  of  contraction.  It  may  be  nearly 
always  assumed  that  such  a  stricture  as  is  produced  by  the  swallowing  of  caustic  fluids 
will  leave  a  tortuously  contracted  passage-way,  and  the  instrument  passed  for  its  recog- 
nition, while  arrested  in  its  upper  portion,  may  give  little  or  no  correct  idea  as  to  the 
arrangement  below.  In  some  instances  it  may  be  possible  here,  as  in  the  case  of  diver- 
ticula? to  introduce  sufficient  bismuth  emulsion  into  the  esophagus  to  make  it  cause  a 


HTRICTl  HI-:  OF   TJfK  KSOl'IIAcrs 


1A\\ 


shadow  ill  an  .r-ray  picture,  and  in  this  way  to  y(\\v  pictorial  inl'oruialicjii  not  otherwise 
attainai)l('. 

The  surf^eon  should  (hstinf;;iiish  hetween  hysterical  spasm  or  eso|)ha<jisnius  and  eiea- 
trieial  stenosis.  The  former  will  offer  hut  little  obstacle  to  the  jjassafje  of  a  fidl-sized 
boiifiie.  In  fact  it  will  he  frecjiiently  liencHfed,  usnally  cnred  hy  it,  while  in  tiie  latter 
instance  this  is  almost  impossible. 

¥\g.  ")17  shows  the  j)ossil)ilities  in  a  case  of  actual  obstruction,  and  how  different 
such  a  eoiulition  is  from  mere  esophaijismus  or  ^dobus  hystericus.  It  has  been  recently 
shown,  es])ecially  by  Dennis,  that  duriu-,'  (tr  just  after  ty|)h(iid  fever,  ulcers  occur  iii 
the    esopha<^us     which    may     pro- 


Fi«;.  517 


518 


K^^ 


Stricture  of  the  esophagus. 
(Dennis.) 


c 


^ 


duee  serious  stenosis.  At  present 
writinfj  I  have  under  observation 
a  little  <;irl  of  nine  years  who  has 
an  e.xtreme  condition  of  this  kind. 
It  is  with  difficulty  that  she  can 
.swallow  fluid  nourishment,  and 
she  was  so  nearly  starved  that  her 
life  was  only  saved  l)y  a  gastrot- 
omy.  Those  congenital  defects 
which  may  j)roduce  esophageal 
stricture  are  usually  of  such  a 
serious  and  extensive  character 
as  to  afford  no  opportunity  for 
relief. 

The  location  and  caliber  of  these 
strictures  may  be  ascertained  by 
the  use  of  esophageal  bougies,  such 
as  represented  in  Fig.  518.  These 
are  made  of  various  sizes,  and  are 
fastened  upon  the  end  of  a  flexible 
rubber  handle,  which  affords  a 
degree  of  elasticity  in  manipula- 
tion. They  should  be  vsed  with 
care  and  caution,  as  minor  de- 
grees of  injury  produced  by  them 
may  cause  a  spreading  infection, 
while  still  more  harm  may  be  done 
by  rupture  of  an  ulcerated  area,  or 
perhaps  the  perforation  of  an  aneu- 
rysm. 

The  patient  should  sit  before 
the  surgeon,  with  the  head  thrown 
backward,  the  mouth  comfortably 
widely  opened,  while  the  surgeon, 
standing,  introduces  the  left  fore- 
finger into  the  pharynx  and  with 
it  depresses  the  tongue  and  guides 
the  tip  of  the  instrument,  be  it 
bougie  or  tube,  along  this  finger, 
which  serves  as  a  guide.  Unruly 
or  hysterical  patients  will  not  only 
gag,  but  may  attempt  to  bite  the 
operator's  finger.  To  prevent  such 
accidents  a  metal  thimble  is  made, 
which,  being  inserted  between  the 

teeth,  protects  the  finger,  but  makes  the  manipulation  more  awkward.  Should  the 
patient  show  any  tendency  to  folly  of  this  kind,  it  should  be  remembered  that  when 
the  finger  is  forced  back  into  the  pharynx  the  mouth  is  instinctively  opened.  If  necessary, 
at  the  same  time,  the  nostrils  may  be  grasped  and  held  closed,  in  which  case  the  patient 
is  sure  to  open  the  mouth  widely  and  thvs  release  the  finger.   After  the  tip  of  the  instru- 


Esophageal 
bougies. 


744  SPECIAL  OR  REGIONAL  SURGERY 

ment  is  engaged  in  the  pliiirviix  it  sometimes  assists  in  the  nianipiihition  if  the  patient's, 
head  be  now  tij)ped  a  Httle  forward,     "^rhis  nianipnlatioii  is  not  very  (hti'erent  from  that 
by  whieh  a  small  and  long  flexible  rubber  tube  may  be  inserted  through  the  nostril  into 
the  stomaeh  for  the  purj)ose  of  feeding,  as  is  frequently  done  with  the  insane  who  refuse 
to  eat,  or  may  be  done  in  the  presenee  of  certain  diseased  conditions. 

The  intent  in  this  exploration  is  to  determine  the  distance  from  the  upper  incisor  teeth 
of  the  obstruction,  as  well  as  its  caliber.  When  the  instrument  is  withdrawn  the  surgeon 
marks  the  location  of  the  teeth  Ijy  grasping  it  at  this  point  with  the  thumb,  and  the 
distance  is  measured  off  afterward  so  that  it  may  be  read  in  inches  if  desired.  The 
caliber  is  determined  l)y  the  success  or  non-success  met  with  in  passing  an  instrument 
of  given  diameter.  The  size  with  which  the  attempt  should  be  made  may  be  determined 
largely  by  the  history  and  statement  of  the  patient.  With  a  patient  who  cannot  swallow 
no  ordinary  bougie  should  be  expected  to  pass,  while  a  small  solid  instrument  might 
produce  a  {)erforation.  Flexible  bougies  are  also  provided  by  the  instrument  makers, 
made  as  are  the  silk  catheters,  some  of  them  being  loaded  with  small  shot  in  order  to 
give  them  a  certain  degree  of  weight.  A  small,  soft,  flexible  instrument  may  be  thus 
passed  when  the  ordinary  probang  would  fail.  Here,  as  in  the  urethra,  an  olivary 
l)ougie  may  pass,  after  which  the  same  sort  of  resistance  will  be  offered  upon  its  with- 
drawal. In  this  case  the  stricture  is  passed  twice,  going  and  coming.  A  slight  degree 
of  constriction  is  met  opposite  the  cricoid  cartilage  at  the  entrance  to  the  esophagus. 
This  should  not  be  mistaken  for  a  pathological  condition.  Information  may  be 
afforded  by  material  l)rought  up  by  the  instrument,  such  as  shreds  of  tissue,  blood, 
etc.  A  small  bougie  coated  with  sponge  may  be  used  for  the  purpose  of  retaining  and 
bringing  back  such  material  as  it  may  engage. 

It  will  be  of  assistance  to  let  the  patients  dissolve  in  the  mouth  a  tablet  containing  a 
little  cocaine  and  swallow  it,  or  to  spray  or  gargle  the  pharynx  with  a  weak  solution. 
It  prevents  the  gagging  and  discomfort  of  an  operation  whieh  otherwise  is  almost  painless. 


ESOPHAGEAL   HEMORRHAGE. 

Esophageal  hemorrhage  occurs  esjx'cially  in  connection  with  cirrhosis  of  the  liver. 
Stockton  and  others  have  called  attention  to  a  peculiar  varicose  condition  of  the  esopha- 
geal veins  in  certain  of  these  cases,  and  the  pcjssibility  of  repeated  hemorrhages  which 
may  terminate  fatally.     The  same  is  true  of  obstructive  jaundice  with  Riedel  liver. 


CANCER  OF  THE  ESOPHAGUS. 

Cancer  of  the  esophagus  may  be  either  primary  f)r  secondary,  and  may  be  either 
sarcoma  or  carcinoma.  Its  first  expression  will  be  idcerative  or  stenotic,  according  as 
it  originates  on  the  inner  surface  or  not.  Sooner  or  later  it  will  produce  stricture,  with 
the  ordinary  evidences  thereof,  and  is  to  be  detected  in  the  same  way.  Cancer  is  usually 
of  the  carcinomatous  type  or  squamous  epithelioma.  The  disease  is  more  common  near 
the  lower  than  the  upper  end  of  the  canal.  The  disease  spreads  and  involves  the  adjoin- 
ing lymphatics,  as  well  as  various  other  structures.  In  addition  to  the  ordinary  evidences 
of  stricture  it  is  accompanied  by  a  certain  degree  of  pain,  which  is  likely  to  be  referred  to 
the  interscajndar  region  or  the  back  of  the  neck.  The  emaciation  which  always  accom- 
panies it  is  not  merely  an  expression  of  the  disease  itself,  but  of  the  starvation  which 
stricture  in  time  produces.  Frequent  expulsion  of  bloody  mucus  or  shreds  is  extremely 
indicative. 

Esophageal  cancer  admits  only  of  esophagectomy,  as  a  very  imusual  method  of  relief, 
or  gastrostomy,  Avhich  is  a  palliative  measure  intended  to  prevent  death  from  starvation, 
but  not  affording  exemption  from  the  advance  of  the  disease. 


OPERATIONS   UPOS    TIIK  EHOPIIMWS  745 

OPERATIONS  UPON  THE  ESOPHAGUS. 

Operations  ii|Ktn  the  csoiiliatjjcal  canal  include: 

1.  Dilatation; 

2.  Internal  (\s()|)lia<i;otoniy; 

3.  External  eso|)lia<,'otoiny; 

4.  Ksoj)lia<^ectoniy. 

1.  nihifdtion  is  practised  ordinarily  with  olivary  f)r  conical-tipped  lM)n<jies.  The 
t'ornicr  are  Msualiy  metal  or  ivory  tips  fastened  to  a  firmer  handle,  while  the  latt<'r  are 
fashioned  like  silk  catheters  havintf  more  or  less  conical  tips.  These  are  introduced 
until  they  are  en>fai^ed  within  the  stricture,  after  which  the  amount  of  |)ressure  or  force 
used  should  he  <]fraduated  to  the  character  of  the  trouble,  the  density  of  the  tissues,  and 
the  tolerance  of  the  patient.  Daily  dilatation  may  he  practised  either  for  the  prevention 
or  relief  of  strictures  followinfif  cicatrices  due  to  caustic  fluids  and  the  like.  A  small 
passanje  may  in  time  he  stretched  up  to  nearly  the  normal  diameter,  after  which  instru- 
ments may  he  passed  at  refjular  intervals,  as  the  tendency  to  recontraction  is  inevit- 
able. 'I'hese  methods  of  dilatation  have  taken  the  j)lace  of  more  complicated  mechanical 
|)rocedures  j)erformed  with  instruments  like  those  intended  for  use  in  the  urethra.  The 
writer  has,  however,  in  one  or  two  instances  used  with  advanta<i;e  the  Otis  dilating 
urethrotome  in  cicatricial  strictures  of  the  jzinllet. 

2.  Internal  csnphngotomij  is  j)ractised  either  with  instruments  carrying  concealed 
blades,  like  those  used  within  the  urethra,  or  by  a  method  suggested  by  Abbe,  where  the 
stomach  is  first  opened,  and  a  retrograde  dividsion  effected,  or  at  least  a  small  bougie 
is  pushed  upward  from  beneath.  When  its  tij)  is  felt  in  the  mouth  there  is  firmly  attached 
to  it  a  strong  silk  thread  which,  as  the  instrument  is  withdrawn,  is  brought  down  into 
the  stomach  and  then  out  through  the  stomach  opening.  With  one  hand  in  the  stomach 
and  the  other  in  the  mouth  this  thread  is  then  manij)ulated  in  sucli  a  way  as  to  saw 
through  the  strictured  pa.ssage.  It  is  well,  should  the  surgeon  use  silk  in  this  way  as  he 
would  use  a  Gigli  saw,  to  pass  it  through  a  piece  of  rubber  tubing,  both  above  and  below, 
in  order  that  its  sawing  effect  may  be  limited  to  the  esophagus  proper.  This  is  a  j)ro- 
cedure  which  should  be  done  with  great  precaution.  The  operator  should  stop  at  short 
intervals,  and,  by  using  a  bougie,  satisfy  himself  whether  the  strictured  passage  has  been 
enlarged.  When  the  flesired  result  has  been  attained  the  thread  is  withdrawn,  the 
stomach  and  abdominal  wounds  closed,  and  dilatation  resorted  to  every  day  f)r  two  in 
order  that  the  benefit  gained  may  be  maintained. 

The  use  of  the  esophago.scope  may  permit  the  exposure  of  a  cicatricial  band  or  an 
annular  stricture,  so  placed  that  it  may  be  divided  l)y  a  fine  knife  directed  through  the 
tube.  Whatever  cutting  is  done  in  this  region  should  be  done  cautiously,  so  as  to  avoid 
injuring  adjoining  structures. 

3.  External  esophar/otnmy  is  easily  performed  for  the  removal  of  foreign  bodies.  When 
done  from  below  it  may  be  combined  with  a  gastrotomy,  the  cardiac  end  of  the  esophagus 
being  thus  exposed  and  exploring  instruments  or  those  intended  for  either  removal  of 
foreign  material  or  division  of  stricture  being  thus  introduced.  After  the  measure  is 
complete  the  stomach  is  first  closed  and  then  the  abdomen. 

4.  Esopharjeetnvii)  is  an  operation  imdertaken  from  without,  and  is  seldom  performed 
for  other  purposes  than  for  the  removal  of  malignant  growths.  A  cancer  of  the  e.so])hagus 
should  be  seen  early  and  be  favorably  located  in  order  to  be  amenable  to  such  a  radical 
measure,  yet  cases  of  this  kind  have  been  successful.  Too  often,  however,  they  are 
done  too  late.  The  esophagus  is  exposed  by  the  same  incision  as  that  described  for 
esophagotomy,  namely,  on  the  left  side  along  the  anterior  border  of  the  sternomastoid, 
the  vessels  and  nerves  being  retracted  to  either  side  in  such  a  way  as  to  permit  its  clear 
exposure.  The  portion  to  be  removed  is  then  isolated  by  blunt  dissection  and  resected. 
This  leaves  two  ends  of  the  canal,  which  can  usually  be  brought  together  by  sutures, 
after  the  fashion  of  an  end-to-end  intestinal  anastcmiosis.  The  j^rincipal  difficulty  met 
with  will  be  adhesions  and  infiltration  caused  by  extension  of  disease,  and  these  of 
themselves  in  well-marked  cases  would  be  contra-indications  to  operation. 

Transthoracic  Resection  of  the  Esophagus.— Bryant  and  others  have  shown  how 
the  est)phagus  may  be  exposed  from  the  posterior  aspect  of  the  thorax  by  a  posterior 
thoracotomy,  made  in  the  third  and  fifth  intercostal  spaces,  where,  by  resection  of  the 


746  SPECIAL  OR  REGIONAL  SURGERY 

ribs  and  dissection,  the  esopliaffus  may  he  exjjosed  Ix-hind  (lie  liihnn  of  the  hnig.  Tiie 
azygos  vein  which  crosses  it  at  about  this  level  should  be  either  retracted  or  divided 
after  a  double  ligation.  Experimentation  has  shown  that  it  is  j)ossible  at  this  point  to 
stretch  the  tube  in  such  a  way  as  to  permit  of  restoration  of  its'  caliber,  if  but  a  small 
amount  have  been  removed,  but  great  care  should  be  exercised,  otherwise  tension  would 
be  extreme.  Because  of  the  doubt  regarding  the  success  of  such  a  resection  Mikulicz 
has  suggested  the  following  procedure  of  rxfcnializaflon  of  the  csophagii.s':  After  exposure 
the  distal  end  of  the  esophagus  is  closed  and  drop])ed  back.  An  opening  is  next  made 
along  the  anterior  border  of  the  sternomastoitl,  where  the  (\sophagus  is  exposed,  pulled 
up  and  out  of  its  situation — i.  c,  dislocated — antl  brought  out  through  the  upper  o])en- 
ing,  which  can  be  done  because  of  its  loose  connective-tissue  surroundings.  A  third 
incision  is  then  made  over  the  second  intercostal  space  in  front,  where  a  bridge  of  skin 
is  lifted  up,  the  esophagus  drawn  down  beneath  it  and  fastened,  the  intent  being  to 
connect  this  opening  with  the  stomach  through  a  gastric  fistula  by  means  of  some  special 
a])paratus,  thus  making  it  possible  to  again  feed  the  patient  through  the  mouth.  The 
incisions  in  the  back  are  closed  by  layer  sutures.  The  principal  ol)jection  to  this  method 
is  that  the  passage  of  fluid  through  the  exicrnaJizrd  portion  of  the  esojjhagus  would 
have  to  be  accomplished  by  massaging  the  part  and  forcing  it  down  through  the  tube. 
Sauerbruch  and  others  have  shown  that  in  animals  at  least  it  is  possible  to  make 
a  transdiaphragmatic  anastomosis  of  the  stomach  and  eso])hagus.  By  much  the  same 
method  as  that  last  above  described,  i.  e.,  through  a  posterior  opening,  the  esophagus 
can  be  exposed  near  its  lower  end,  resected,  and  then  turned  into  an  opening  in  the 
stomach,  the  latter  having  been  brought  up  through  an  opening  in  the  diaphragm.  It 
is  hardly  necessary  to  go  into  details  of  this  operation  here,  since  the  occasions  which 
would  justify  it  are  almost  as  rare  as  the  individuals  who  could  be  entrusted  with  its 
performance. 

OPERATIONS  UPON  THE  THORAX. 

Exploratorij  puncture,  either  of  the  pericardial  sac  or  of  a  ])leural  cavity,  is  an  exceed- 
ingly simple  matter,  the  ordinary  hypotlermic  needle  sufficing  for  many  instances,  while 
in  some  cases  the  contained  fluid  will  be  too  thick  to  flow  through  a  finer  needle  and 
will  necessitate  the  use  of  a  larger  one.  Such  needles  are  furnished,  with  so-called  ex- 
ploring syringes,  and  their  use  is  a  convenient  preliminary  to  the  use  of  the  aspirator — 
i.  e.,  fJioraccutesi.i — or  open  division — ?'.  e.,  tJwracofomij.  It  is  essential  that  both  the 
patient's  integument,  the  instrument,  and  the  operator's  hands  be  absolutely  clean. 
When  several  points  are  explored  at  one  time  and  fluid  is  foimd  at  but  one  it  is  well 
to  indicate  this  with  a  little  nitrate  of  silver  or  tincture  of  iodine,  which  will  make  a  tem- 
porary mark.  Thoracentesis  implies  a  withdrawal  t)f  fluid  through  a  hollow  needle, 
which  will  make  a  small  puncture  that  will  promptly  close,  a  vacuum  apparatus  of 
some  kind  being  attached  to  it.  The  needle  may  be  introduced  at  various  points  to  enter 
either  the  pericardium  or  the  pleura.  Ordinarily  no  harm  pertains  to  exploratory 
puncture  and  but  little  to  withdrawal  of  fluid,  providing  certain  precautions  are  used, 
though  fatal  syncope  has  been  known  to  immediately  follow  it.  Beyond  absolute 
sterilization  the  most  important  feature  is  to  withdraw  fluid  slowly  rather  than  rapidly, 
and  to  desist  so  soon  as  symptoms  of  a  serious  nature  appear,  such  as  faintness  or  collapse. 
When  a  collection  of  fluid  has  existed  for  some  time  in  one  of  the  pleural  cavities 
it  may  have  gradually  so  displaced  the  heart  that  its  too  sudden  withdrawal  may 
permit  a  too  sudden  restoration  to  its  normal  position — so  sudden,  in  fact,  as  to  place 
extra  stress  upon  it  and  perhaps  to  seriously  embarrass  or  com})letely  check  its  action. 
This  is  always  a  matter  requiring  attention.  The  position  of  the  patient  also  should 
be  regarded,  "and  a  patient  who  is  seated  in  a  chair,  in  order  that  fluid  may  gravitate 
to  the  lower  part  of  the  chest  cavity,  should  be  promptly  placed  in  the  recumbent  position 
so  soon  as  alteration  in  pulse  or  coughing  or  serious  embarrassment  of  respiration  are 
noted. 

The  skin  over  the  point  selected  for  puncture  may  be  anesthetized  with  the  freezing 
spray  or  with  a  sterile  cocaine  solution.  The  needle  point  should  be  driven  in  suflSciently 
to  secure  fluid  and  not  such  a  distance  as  to  puncture  the  heart  or  the  lung  within.  The 
better  aspirating  needles  are  provided  with  rounded  points  rather  than  with  sharp  ones, 
in  order  that  scratching  with  a  sharp  end  may  be  thus  avoided.     When  using  a  more 


on:  RAT  loss  I 'POX  'niK  tiiohw  747 

l>luMt  lu'fdlc  of  tliis  (y|H'  il  is  well  (o  iiiakc  ;i  Irilliii^'  piiiictiirc  in  (lie  skin  witii  a  small 
knitV-hladr.  \Vliil(>  tlu-  nioir  elaborate  in.strnnienl  outfits  sold  l)y  the  dealers  are  pleas- 
ing to  use,  fluid  may  he  siphoned  through  a  needle  and  tuhe  with  a  foimtain  syringe 
just  as  in  lavage  of  the  stomach.  ('onse(|uently  it  is  not  necessary  in  emergency  cjuses 
to  have  anything  more  than  a  satistactory  needle,  ('are  should  always  he  given  that 
no  air  is  introduced.  Thus  in  managing  the  last-named  expedient  tlie  tuhe  and  the 
needle  itscH"  should  he  fille(l  with  fluid  hei'ore  the  latter  is  introduced.  Then  the  hag 
may  he  lowered  in  order  that  no  fluid  escape  into  the  chest.  It  is  an  advantage  to  have 
a  piece  of  glass  tubing  connected  with  the  a|)paratus,  in  onlcr  that  the  character  of  the 
fluid  first  withdrawn  may  be  («asily  ascertained.  If  the  patient  begin  to  cough  or  to 
have  a  fe(>ling  of  o{)j)ressi()n  the  operator  should  temporarily  cease,  and  if  symptoms 
are  not  ameliorated  lie  should  withdraw  the  needle,  renewing  the  procedure  a  day  or 
two  later.  A  lung  too  suddenly  forced  to  exj)and  by  removal  of  fluid  may  not  only  give 
distnvss  to  the  ])atient,  but  there  is  a  possibility  of  hemorrhage. 

Thoracotomy. — The  term  thoracotomy  im|)lies  an  incision  made  thidugh  the 
chest  wall,  usually  for  withdrawal  of  fluid,  with  or  without  removal  of  some  portion  of 
its  bony  striu-ture.  'J'horacotomy  performed  for  pericardial  collections  of  flui(l  has  been 
(lescrib(>d.  That  for  removal  of  ordinary  (Mnpyemic  collections  is  usually  a  simj)le 
measure.  It  nuiy  be  practised  und(M"  local  anesthesia.  In  a  general  way  the  extent  of 
the  fluitl  collection  is  made  out  by  percussion,  and  its  character  by  exploratory  puncture. 
The  endeavor  shoidd  be  to  make  the  oj)ening  laterally  and  posteriorly  near  the  lower 
aspect  of  the  cavity  to  be  emptied  in  order  that  it  may  drain  by  ordinary  force  of  gravity 
with  the  patient  in  the  dorsal  position.  Unless  it  be  intended  to  remove  a  portion  of 
rib  the  incision  need  not  be  more  than  one  inch  in  length. 

Ordinarily  the  skin  is  pushed  a  little  one  way  or  the  other  so  that  a  rib  can  be  seen 
underlying  it,  in  order  to  steady  it  for  the  external  incision.  Then  it  is  allowed  to  glide 
back  to  its  normal  position  and  the  knife-blade  is  so  directed  as  to  at  once  enter  the  tho- 
racic cavity.  Only  rarely  is  it  necessary  to  make  a  careful  dissection.  It  is  not  often 
that  vessels  of  importance  wull  be  divitled,  and  one  may  usually  proceed  boldly  with  the 
incision.  It  will  be  promptly  followed  by  appearance  and  usually  by  forcible  expulsion 
of  fluid,  perhaps  even  in  a  jet,  for  which  a  basin  should  be  provided.  In  fresh  cases  this 
fluid  will  be  thin;  in  old  empyemic  cases  there  will  be  so  much  caseous  material  mixed 
therewith  that  it  may  obstruct  the  opening  and  check  escape  of  fiuid.  In  these  cases  it 
may  be  pushed  aside  with  forceps  or  by  the  introduction  of  a  finger.  When  such  material 
is  present,  however,  there  is  need  also  for  its  evacuation,  and  in  such  cases  the  incision 
should  be  extended  and  an  inch  or  more  of  rib  may  be  removed  in  order  to  afford 
sufficient  exit. 

The  objection  above  mentioned  regarding  speedy  evacuation  applies  theoretically 
rather  than  practically  to  this  procedure,  for  when  it  is  necessary  to  open  the  chest  cavity 
widely  it  is  because  the  walls  of  the  cavity  thus  opened  have  already  become  so  thick- 
ened or  stiffened  by  the  disease  process  that  there  is  not  the  danger  of  sudden  change  of 
position  of  the  thorp-cic  viscera  which  obtains  in  the  less  serious  and  more  acute  cases. 

The  fluid  having  been  removed  the  next  question  is  one  of  irrigation.  This  is  only 
rarely  necessary  or  even  justifiable.  Even  in  cases  where  the  evacuated  pus  has  a  more 
or  less  offensive  odor  it  is  found  sufficient  to  remove  it,  while  experience  show's  the 
inadvisability,  sometimes  the  {practical  danger  of  prolonging  the  ])rocediu"e  and  trvirig 
at  this  time  to  wash  out  the  chest  cavity.  If  irrigation  be  practised  it  shoidd  be  with  a 
bland  fluid,  for  antiseptics  are  here  peculiarly  irritating. 

The  third  question  is  one  of  drainage.  In  recent  cases  it  will  often  be  sufficient  to 
insert  some  flexible  material,  like  a  piece  of  oiled  silk  folded  upon  itself,  secured  ex- 
teriuilly  by  a  safety-jiin,  or  stitched  to  the  skin  in  such  a  way  that  it  shall  not  be  lost 
within  the  cavity.  In  the  older  and  more  serious  cases  more  complete  drainage  should 
be  provided.  This  is  usually  ett'ected  with  a  short  piece  of  rubber  tubing,  which  needs 
to  be  amply  secured  against  loss,  either  with  a  large  safety-pin  or  by  being  stitched  to 
the  skin  with  silk  rather  than  with  gut,  lest  the  latter  soften  too  soon.  This  tube  should 
ordinarily  be  quite  short,  in  order  that  it  may  not  irritate  the  pleural  siu'face  of  the 
expanding  lung.  It  is  rarely  necessary  to  make  valve-like  protection  of  the  opening, 
nor  is  it  usually  advisable  to  insert  any  sutures  in  the  external  wound.  These  openings 
in  most  instances  close  too  soon  rather  than  too  slowly. 

The  surgeon  should  avoid  making  the  opening  too  low,  lest  the  diaphragm,  having  been 


74(S  SPECIAL  OR  REGIONAL  SURGERY 

pushed  downward  by  the  accumulation  above  it,  rise  and  cover  the  end  of  the  tube. 
Well-marked  eases  of  empyema  will  often  improve  more  (juiekly  if  a  counter()j)ening  be 
made.  It  is  an  easy  matter  to  introduce  the  end  of  a  lon^  forceps  and  determine  the 
best  point  at  which  to  make  this  opening.  The  forcej)s  being  then  held  at  this  ])oint, 
one  may  easily  cut  down  upon  its  end,  force  it  through,  and  utilize  it  for  drawing  back- 
ward, completely  through  the  chest,  a  long  piece  of  perforated  drainage  tube,  which  per- 
haps may  be  eventually  replaced  by  a  few  stranfls  of  silkworm  gut.  A  very  large  and 
copious  external  dressing  should  be  applied,  and  changed  as  often  as  need  be,  in  order 
to  receive  and  provide  for  such  discharge  as  may  take  ])la("e.  Sometimes  this  will  be 
fjuite  considerable,  and  necessitate,  for  the  first  two  or  three  days,  a  change  every  few 
hours. 

Some  surgeons  have  endeavored  to  make  drainage  more  complete  by  a  vacuum 
irrigating  apparatus,  on  the  Bunsen  pump  principle.  Should  it  be  necessary  to  resort 
to  this  the  more  complicated  older  methods  may  be  supplanted  by  the  simple  procedure, 
illustrated  later  in    this   work,  for  continuous  drainage  or   siphonage   of  the  bladder. 

One  should  never  attack  a  case  of  this  kind  without  being  jirepared  to  rnnove  a 
section  of  one  or  more  ribs.  Indications  for  this  will  be  found  in  the  character  of  the 
contained  fluid,  or  in  the  thickness  of  the  wall  of  the  abscess,  i.  e.,  the  old  j)leural  cavity. 
The  tlifhculty  usually  is  that  these  openings  tend  to  close  too  promj)tly,  and  that, 
especially  in  children,  the  proximity  of  the  ribs  to  each  other  affords  too  small  space  for 
the  maintenance  of  drainage.  When  it  becomes  necessary  to  remove  a  piece  of  one  or 
more  ribs  there  is  little  object  in  trying  to  preserve  the  periosteum,  and  the  operation 
may  be  made  within  a  few  seconds  by  simply  retracting  the  skin  wound  and  the  nniscu- 
lature,  introducing  the  bone-cutting  forceps,  with  which  the  rib  or  ribs  are  divided  at 
j)()ints  one  inch  or  more  apart,  the  intervening  portion  being  promj)tly  lifted  out  with 
forceps  and  cut  away  with  strong  scissors.  The  operation  of  dividing  the  rib  will  often 
so  compress  the  intercostal  arteries  that  there  will  be  little  hemorrhage  from  this  source. 
Should  they  l)leed  too  much  strong  forceps  shoidd  be  used  to  compress  the  lower  edge 
of  the  rib,  and,  by  crushing  it  produce  hemostasis,  as  though  the  artery  were  itself  seized 
with  forceps,  or  the  vessel  itself  may  be  seized  and  secured.  A  special  form  of  forceps 
for  dividing  ribs,  known  as  the  costotome,  has  been  devised  and  has  j^roved  serviceable, 
since  it  is  so  made  as  to  prevent  easy  slipping  of  the  rib  from  the  grasp  of  the  blade. 

The  larger  opening  thus  made  is  treated  in  practically  the  same  way  as  the  smaller. 
Through  it  the  fingers  or  a  blunt  spoon  may  be  inserted  and  any  cheesy  material  lifted 
out,  or  a  sponge  or  gauze  swab  held  in  the  grasp  of  a  long  forceps  may  be  introduced, 
and  with  it  the  cavity  thus  opened  may  be  wiped  out  or  swabbed.  In  this  way  a  con- 
siderable amount  of  caseous  material  or  shreds  of  membrane  may  be  removed.  The 
more  that  can  be  removed  the  better,  since  there  is  so  much  less  to  come  away  later. 
Such  manipulation  is,  however,  sometimes  attended  by  embarrassment  of  respiration, 
and  one  should  use  discretion  in  the  extent  to  which  he  practises  it.  Hemostasis  having 
l)een  secured,  it  will  depend  on  the  case  and  its  extent  whether  any  effort  is  made  to 
partially  close  the  wound  or  whether  it  should  be  left  open.  Even  large  defects  thus 
made  usually  heal  kindly  and  fine  or  careful  suturing  is  rarely  needed. 

The  subsequent  management  of  such  a  case  is  usually  simjile.  After  the  first  few  days 
it  may  be  advisable  to  practise  irrigation.  According  to  the  age  of  the  case  will  be  found 
the  expansile  capacity  of  the  lung.  The  lung  itself  expands  by  relief  of  pressure  and  by 
its  own  inherent  tendencies  and  returning  function.  Again  by  a  process  of  granulation 
it  is  gradually  made  to  attach  itself  to  the  chest  wall  and  is  thus  withdrawn  toward  its 
surface.  The  combination  of  these  agencies  will  usually  in  time  produce  satisfactory 
results.  The  functionating  power  of  the  lung  may  be  determined  by  filling  the  cavity 
with  fluid,  the  patient  lying  upon  the  other  side,  and  then  noticing  the  difl'erence  between 
the  amount  of  fluid  held  in  extreme  inspiration  and  extreme  expiration. 

Thoracoplastic  Operations. — In  old  and  neglected  cases  of  empyema,  especially 
of  tuberculous  type,  the  pleura  itself  becomes  more  or  less  thickened  and  stift'ened, 
and  aft'ords  such  an  obstacle  to  lung  expansion  as  to  justify  more  radical  measures. 
These  have  sometimes  to  be  undertaken  as  secondary  operations,  while  in  other  instances, 
where  there  has  been  sjiontaneous  perforation  and  escape  of  purulent  overflow,  perha]>s 
for  months  or  years,  the  necessity  for  such  measures  may  be  foreseen.  This  necessity 
was  first  appreciated  by  Warren  Stone,  an  American  surgeon,  but  the  procedure  was 
first  formally  placed  before  the  profession  by  Estlander,  of  Helsingfors.     The  principle 


(H'i:ii'.\Tl(>.\S   ll'ON    TIfh'    THORAX 


749 


upon  wliicli  it  ;iM(l  all  siiiiilar  opcralioris  lias  hccti  based  may  Itc  likrnrd  to  tlic  various 

cllorts  wliicli  it  is  necessary  to  make  when  a  person  tries  to  collapse  an  ordinary  barrel 

whose   heads   have   been    knocked   out. 

So  long  as  the  hoojjs  of  the  i)arrel  are  I'"'"-  ^I'J 

intact   the  staves  cause  it  lo  retain    its 

cylindrical  form.    If,  however,  the  hoops 

l)e  divided  it  easily   falls  apart,      in  the 

ease  of  a  human  chest,  the  lun<i;,  having 

been  so  lont^  bound  down,  is  incapable 

of  e\|)ansion,   and   (he  chest   walls  are 

rif^idly    maintained    by    virtue    of    the 

hoop-like  arraiijijement  of  the  ribs.     It 

is  neeessary  then  to  divide  and  remove 

a  section  from   several   of  these   ribs, 

in  order  that  the  wall,  fallinfi;  in,  may 

meet,  at  least  half-way,  the  lun<^,  which 

may  be  expected  to  partially  e.xpaiul  to 

meet  it. 

The  ()ri<j;inal  Estlandcr  operation  has 
been  modified  by  Schede,  and  as  now 
practised  is  made  by  a  long  incision 
passing  oblicjuely  across  the  lateral  as- 
pect of  the  chest,  from  the  origin  of  the 
pectoralis  major,  at  the  level  of  the 
axilla,  to  the  tenth  rib  in  the  posterior 
axillary  line,  and  then  ascending  to 
a  point  betw^een  the  spine  and  the 
scapula.  The  large  flap  thus  outlined 
is  made  to  envelop  all  the  tissues  out- 
side the  ribs.  The  ribs  thus  exposed 
are  resected  from  the  tubercles  forward 
to  their  insertion  into  the  costal  cartil- 
ages. The  large  area  of  the  chest  wall 
thus  exposed  is  then  removed  with  the 
underlying  pleura,  and  all  hemorrhage 

checked.     This  flap  includes  the  periosteum,  the  intercostal  muscles,  the  ribs,  and  the 
pleura,  and  thoroughly  uncovers  the  entire  abscess  cavity.     It  makes  a   formidable 

Fig.  520 


Incision  for  resection  of  thorax.     (Bergmann.) 


Trap-door  thoracotomy.     (Lejars.) 


procedure,  but  is  more  often  life-saving  than  the  reverse.  Over  the  opening  the  skin 
flap  may  be  later  drawn  down  and  tacked  in  place  at  points  sufficiently  near  to  each 
other  to  properly  hold  it  in  place  (Figs.  519  and  520). 


J30 


SPECIAL  OR  RKGIOSAL  SURliERY 


This  ])r(KC{liiri'  may  be  iiiodified  to  suit  tlic  indications  of  any  jjiven  case,  and 
simply  includes  what  may  be  done  in  extreme  cases.  The  surgeon  who  thus  for  the 
first  time  uncovers  such  a  cavity  will  be  surprised  at  its  interior  appearance,  and 
at  the  shrefls  of  tissue  and  de})ris  which  hang  from  its  walls.  The  measure 
thus  described  })roYides  for  collapse  of  the  chest  wall.  Fowler  and  others  have 
shown,  however,  that  even  now  the  principal  obstacle  to  expansion  of  the  lung  is  not 
removed,  and  have  suggested  what  Fowler  has  aptly  described  as  decoriication  of 
flic  lung — namelv,  a  removal  of  its  thickened  pleura  by  a  process  of  dissection  and  strip- 
I)ing,  which   may  be  made  jxirtial  or  complete,   as   circumstances   permit.     In   some 

respects  this  adds  to  the  gravity  of  the 
ii^-  5-1  case  and  will  perhaps  better  be  done  at  a 

second  operation.  Should  it,  hoAvever, 
be  justified  by  the  condition  of  the 
patient  it  is  best  done  in  ccmnection  with 
the  resection  of  the  chest  wall. 

When  decortication  cannot  be  practised 
Fowler  has  advised  that  a  series  of  inci- 
sions be  made,  and  that  by  thus  gridiron- 
ing  the  thickened  membrane  it  may  be 
weakened  or  caused  to  lose  its  inelasticity 
and  thus  a  mild  degree  of  similar  effect 
secured.  Fig.  521  illustrates  the  end  re- 
sult of  such  an  extensive  thoracoplasty. 

Pneumotomy. — This  is  a  term  ap- 
])lied  to  an  attack  upon  the  lung  itself,  it 
having  been  exposed  by  a  thoracotomy. 
It  is  necessary  in  cases  of  gangrene,  ab- 
scess, hydatid  cyst,  and  occasionally  in 
large  bronchiectatic  cavities.  It  is  not 
orclinarily  a  difficult  procedure  when  the 
lung  has  attached  itself  to  the  chest 
wall  in  the  course  of  the  disease  process. 
Here  the  lesion  having  been  located  a  part 
of  one  or  more  ribs  is  removed,  as  may  be 
needed,  thus  exposing  the  lung  surface, 
the  caAnty  is  then  opened  either  with  a 
knife  or  by  dilatation  with  the  blades  of  a 
forceps,  or  preferably  with  the  thermocau- 
tery blade,  by  which  hemorrhage  is  better 
controlled  and  possibilities  of  absorption 
reduced.  If  such  a  cavity  can  be  located  it  may  be  opened  with  a  large  trocar  and 
cannula,  which,  should  be  introduced  with  great  care,  lest  it  be  thrust  too  far,  the 
method  by  incision  being  therefore  preferable.  If  after  opening  the  chest  the  lung  be 
found  non-adherent,  it  depends  on  the  character  of  the  lesion  whether  adhesion  should 
be  provoked  or  the  cavity  itself  attacked.  In  the  former  case  adhesions  may  be  pro- 
duced by  stitching  the  exposed  hmg  surface  to  the  margins  of  the  woimd,  and  wait- 
ing for  siifficient  exudate  to  be  })oured  out  to  ensure  that  the  ]:)leural  cavity  has  been 
hermetically  sealed.  The  same  result  may  be  obtained  more  crudely  by  packing  gauze 
around  the  opening. 

In  case  of  urgency  it  woidd  probably  l)e  best  to  attach  the  lung  to  the  chest  wall  with 
sutures  and  secure  it  there.  This  is  a  comparatively  safe  method  in  dealing  with  hydatid 
cysts,  and  will  give  a  fair  measure  of  success  in  many  other  instanc-es.  The  suppurating 
or  gangrenous  cavity  being  opened  its  contents  should  be  removed,  dead  or  sloughing 
tissue  excised,  and  the  cavity  then  packed  for  drainage  purposes,  the  external  wound 
being  kept  o}:)en  until  it  can  be  safely  allowed  to  close. 

Pneumonectomy,  that  is,  removal  of  a  portion  of  the  lung  substance,  may  be  done  with 
comparative  safety  upon  animals,  but  rarely  upon  hmnan  patients.  It  is  occasionally 
recjuired  in  connection  with  the  removal  of  malignant  tumors  of  the  chest  wall,  to  which 
the  lung  has  affixed  itself.  In  exc  eedingly  rare  instances  it  may  be  justified  for  localized 
tumors  of  the  lung  itself.     It  would  be  ecjiuilly  valuable  for  circumscribed,  primary 


End  result  of  an  extensive  thora'^nplasty.     (Park.) 


I'lih:  A  SI  LI. .\  75J 

tillxM-ciilosis  (»!'  the  liiii;;-,  were  it  jHissihlc  lo  Ywin^wy/r  tliis  in  lime.  'I'liis  :iii  ||;iii;iii 
.surficoii  oiici'  tliouulit  dial  h,.  had  done,  in  (he  case  of  his  (iancrc,  and  proceeded  to 
r(\seet  tli(>  ii|)|)er  lobe  of  one  of  lier  \\\\\\rs.  His  hick  of  success  (piickly  led  lo  liis  own 
siiicith'  a  few  (hiys  later. 

Tlie  hmij  is  exeeedinirly  vascular  and  at  the  same  time  hears  sutures  \vcll.  The 
sutiirinii;,  however,  should  be  Jiccurate  in  oi-dcr  to  prcNcut  secondar\'  hemorrhage  and 
favor  the  process  of  repair. 

Other  operations  may  he  practised  upon  the  chest  wall  for  relief  of  such  conditions  as 
aritU-  o.tfcoinijriiti.s-  of  tin'  rihs  or  .\fcniinii,  nirirs  of  the  ribs,  iiicro.si.s,  and  the  like.  It 
should  be  scarcely  lu'ce.ssary  to  fjive  explicit  directions,  save  that  the  pleural  cavity  should 
never  l)e opened  unl(\ss  (he  pleura  itself  be  involved  in  the  disease.  J^'.very  case  demandiiH'- 
such  operative  relief  should  be  measured  by  its  own  needs,  and  the  ojjerative  procedure 
ada|)ted  to  them.  Necrosed  ])ortions  of  bone  may  b(>  eomj)letely  removed.  The  sup- 
purative and  carious  conditions  lunessitate  rather  a  suUieiently  wide  exposure  from  with- 
out and  then  a  judicious  use  of  the  bone  curette.  One  need  never  hesitate  to  remove 
so  nuich  bon(>  as  is  diseased,  (his  beinj^;  true  even  of  the  sternum. 

THE  THYMUS. 

The  possibility  of  sutl'ocative  and  otlu^r  disturbarnrs  j)r()ceedino;  from  enlargement 
of  the  thymus  has  been  discussed,  as  well  as  the  use  of  long  trachea  tubes  in  cases  of 
this  character  which  call  for  tracheotomy,  as  they  usually  do  if  they  perir.it  of  any 
surgical  intervention.  The  thymus  is  seldom  the  site  of  primary  malignant  disease. 
Certain  acute  lesions  are  due  to  a  peculiar  form  of  hyprrfroplu/  in  the  young,  which 
takes  place  instead  of  that  spontaneous  disaj)pearance  which  should  have  occurred 
during  the  earliest  months  of  infancy.  Its  connection  with  the  .status  //jrnphatirus,  with 
thymii-  asthma,  and  laryngismus  stridulus  has  already  been  mentioned.  While  it  can 
hardly  be  considen^d  absolutely  exempt  from  ordinary  infections  and  the  like  it  never- 
theless is  rarely  involved. 

The  thymus  has  been  removed  by  operation,  usually  with  success.  Should  it  become 
necessary  to  resort  to  such  a  measure  it  should  be  preceded  by  the  removal  of  the  sternum, 
for  only  in  this  way  can  sufficient  exposure  be  obtained,  and  sufficient  opportunity  for 
checking  such  hemorrhage  as  might  residt  from  its  enucleation. 


THE  AxnxA. 

The  axilla  as  a  surgical  region  belongs  as  much  to  the  thorax  as  to  any  part  of  the  body, 
although  none  of  its  diseases  are  peculiar  to  this  area. 

It  is  frecjuently  the  site  of  furuncles  of  local  origin,  which  occasionally  assume  car- 
buneular  type,  and  which  are  expressions  of  local  infection  along  the  hair  follicles  or 
mammary  ducts.  It  is  full  of  lymph  nodes,  through  which  are  filtered  the  lymj)h  streams 
coming  from  the  upper  extremities.  In  this  way  there  are  entangled  therein  septic 
germs,  which  frequently  give  rise  to  small  or  large  pli/rgtuous  proportionate  in  size  to 
the  magnitude  of  the  lesion  beyond  them.  It  takes  but  a  trifling  infection  of  the  finger, 
for  instance,  to  ))rodu(e  such  involvement  of  axillary  lymph  nodes  as  to  make  them 
palpable  under  the  finger.  Such  lymph  nodes  once  genuinely  inflamed  frecjuently 
coalesce,  and  the  resulting  abscess  cavity  may  be  large,  especially  if  neglected.  The 
sooner  these  phlegmons  are  incised  and  cleaned  out  the  better  for  the  patient.  In  order 
to  do  thorough  work  an  anesthetic  is  usually  required. 

In  the  axilla  also  are  frequently  seen  tuhcrruloii.s-  manifestations,  the  residt  of  ])ropa- 
gated  infection  from  some  part  of  the  arm  or  hand.  These  may  be  inv(  Ived  in  a  mixed 
infection  and  quickly  break  down,  or  may  assiune  the  type  of  the  chronically  enlarged 
nodes,  which  imdergo  caseation  and  more  or  less  enca})suIation,  with  such  infiltration 
of  the  surrounding  tissues  that  when  extirpated  considerable  difficulty  is  met  in  the 
dissection. 

In  syphilis,  also,  the  lymph  nodes  become  involved,  frequently  enlarging  to  a  degree 
making  them  palpal)le,  and  sometimes  participating  in  a  mixed  infection  in  such  a  way 
as  to  break  down  into  abscesses. 


arz 


SPECIAL  OR  REGIONAL  SURGERY 


Again,  in  the  axilla  are  occasionally  seen  conspicuous  evidences  of  Ilodr/lcin'.s-  (lhSTa.se. 
Any  disease  of  constitutional  character  which  jjrecipitates  trouble  in  one  axilla  will  cause 
nearly  duplicate  alterations  in  the  other,  whereas  disease  of  local  origin  is  usually  con- 
fined to  one  side. 

Any  |)hlegnionous  cavity  or  tuberculous  lesion  which  has  been  incised  through  the 
axilla  should  be  carefully  cleaned  out  and  then  drained,  lest  tlie  external  incision 
close  before  the  deeper  parts  are  ready  for  it.  Incisions  made  in  the  axilla  should  be 
parallel  with  the  great  vessels  and  nerve  trunks,  by  which  they  are  better  exposed  and 
avoided.  A  wound  made  in  the  axillary  vein  may  be  sutured  or  the  vein  Ije  doubly 
ligatcd.  The  former  is  much  the  better  course,  very  fine  silk  sutures  l)eing  emj)loyed.  In 
some  lesions  where  it  has  not  been  possible  to  discover  the  bleeding  point  the  writer  has 
not  hesitated  to  secure  it  with  the  ends  of  pressure  forceps  and  to  leave  these  forceps 
included  in  the  dressings  for  forty-eight  hours.  He  has  never  seen  harm  result  from 
this  |)r()cedure. 

Finally  the  axilla  is  almost  always  involved  in  cases  of  malignant  disease  of  the  breast, 
of  the  arm  itself,  and  sometimes  of  the  regions  adjoining.     Primary  malignant  disease 

in  this  region  is  rare,  while  second- 
'  "■  •''--  ary  cancer  is  not  unusual.     Accord- 

ing to  the  modern  plan  of  treatment 
of  cancer  there  is  reason  for  scrujni- 
lous  extirpation  of  every  j)article  of 
infected  tissue  and  all  involved 
lymphatics,  and  in  dealing  with 
such  cases  the  surgeon  need  not 
hesitate  to  divide  or  extirpate  the 
pectoral  muscles,  in  order  to  jiermit 
of  thorough  work.  The  disease 
being  present  nothing  can  be  so 
serious  for  the  patient  as  to  allow 
any  particle  of  it  to  remain. 


THE   DIAPHRAGM. 

The  diaphragm  may  show  certain 
concjcnital  dcjerf.s,  C(jnsisting  mainly 
of  fissures  or  openings  which  permit 
displacement  of  viscera,  usually 
from  the  abdomen  below  into  the 
thorax  above.  This  is  often  fatal, 
constituting  a  form  of  diaphrag- 
matic hernia,  which  is  particidarly 
liable  to  strangulation.  Fig.  522 
indicates  a  ease  of  this  kind,  show- 
ing the  hopelessness  of  the  con- 
dition. 

Anatomically  it  is  worth  while  to 
recall  that  the  diaphragm  may  rise 
to  a  level  with  the  third    cartilage 
during   forced  expiration,    and  de- 
scend to  the  level  of  the  fifth  inter- 
costal space  on  the  right  side,  and  a 
little  lower  on  the  left,  during  forced 
inspiration.      When  forced  upward 
by  {pressure  from  below  it  may  rise 
even  higher  than  stated  above.  These 
facts  are  of  surgical  interest  in  considering  the  possibility  of  injury  or  j^erforation  of 
the  diaphragm  in  connection  with  gunshot  and  other  perforating  injuries  to  the  thorax 
or  abdomen. 


Cougeaital  diapliragiuatic  hernia,  with  other  congenital 
defects.      Wood  Museum.      (Dennis.) 


srni)i.\riiir\(iM M ic  on  srni'iiui.Mc  Anschss  753 

l)uij)hnt<iiii(ilii-  p<ini/i/.iis  is  ilic  ncccssnrv  result  ol*  injury  in  the  |tlirciiic  nerve.  It 
may  occur  as  the  result  of  injury  lo  tiie  tlioraeie  viscera,  especially  tliosi-  of  tlie  posterior 
niediastinuiii,  or  injuries  to  the  cervical  or  upper  dorsal  vertebra*,  usually  fractures  or 
dislocations,  followed  hy  asceudinji;  de<jeueratioii  and  involvement  of  tlie  j)Iirenie  nerve 
roots.  l)oul)le  phrenic  paral\-sis  is  in  these  cases  ohviously  fatal,  i'aralysis  of  a  sinfi;le 
side  will  cause  at  li'ast  st'rious  end)arra.ssinent  of  respiration.  An  h\si(  lical  form  of 
diaphra<:;inatic  paralvsis  has  also  been  described. 

I'riiiKiri/  tiniior.s-  are  exceedin<j;ly  rare  in  this  muscular  partition.  .\dvancin<^  j^rowths, 
however,  attach  themselves  to  it  or  jn-rforate  it,  as  nuiy  also  aneurysms. 

Aside  from  the  ordinary  injuries  which  the  diaphraj;in  may  sullVr  from  without,  and 
already  mentioned,  there  are  ])eculiar  forms  of  nipliiir,  the  residt  of  force  applied  from 
below,  usually  at  ri<;;ht  angles  to  the  surface  of  the  body,  this  beini;  ])ermitte(l  on  account 
of  the  dome-like  shai)e  of  the  niusele.  When  thus  ruptured  abdominal  viscera  nuiy  be 
forced  into  the  chest  and  even  out  through  openings  between  the  ribs.  A  gunshot  wound 
of  the  diaphragm  will  be  serious  maiidy  in  proportion  to  other  injuries  involving  the 
viscera  above  or  below  it.  The.se  injuries  produce  no  typical  sym|)toms,  but  are  nearly 
always  accompanied  by  severe  ])ain  radiating  toward  the  shoulders,  with  dys})nea  and 
a  substitution  of  abdominal  for  diaphragmatic  respiration.  When  the  viscera  have  been 
forced  upward  (liey  will  displace  the  heart,  and  this  may  produce  cardiac  symptoms. 
It  is  said  that  the  so-called  "sardonic  grin"  is  still  observed  on  the  faces  of  corpses  who 
came  to  sucKKmi  death  from  some  injury  to  the  diaphragm. 

Thus  diaphragmatic  wounds  are  not  of  themselves  of  serious  import.  When  infer- 
entially  ])resent  they  niay,  therefre,  be  disregarded  .so  long  as  no  serious  symptoms  are 
produced.  On  the  other  hand,  exploratory  celiotomy  should  be  performed  at  any  time, 
should  conditions  seem  to  justify  it. 


SUBDIAPHRAGMATIC   OR   SUBPHRENIC   ABSCESS. 

While  this  is  a  condition  ])ertaining,  strictly  speaking,  to  the  abdominal  cavity,  it 
nevertheless  arises  so  frequently  from  intrathoracic  causes  as  to  justify  its  consideration 
here,  as  well  as  because  of  its  close  relations  to  the  diaphragm.  It  w^as  Volkmann  who, 
in  1879,  first  showed  how  these  abscesses  could  be  successfully  and  surgically  treated. 
The  term  is  applied  to  collections  of  pus  beneath  the  diaphragm,  usually  between  it  and 
the  liver,  which,  however,  may  extend  to  and  later  involve  surrounding  viscera. 

The  rau.srs  may  be  divided  into  those  met  with  above  the  diaphragm  and  those  below\ 
The  former  may  include  emjn'cma,  ])us  having  escaped  beyond  the  normal  ))leural 
limits,  advancing  tuberculous  disease  from  any  of  the  structures  above  the  diai)hragm, 
echinococcus  in  the  lung,  or  suppurative  mcdiastinitis.  From  below  the  diaphragm 
the  infectious  process  may  travel  from  the  direction  of  a  gastric  or  a  duodenal  ulcer, 
hydatid  disease  in  the  liver,  jihlegmon  around  the  liver  or  kidney.  The  contained  pus 
may,  on  culture,  shoAV  the  presence  of  colon  bacilli  or  jineumococci,  as  well  as  the 
ordinary  pyogenic  cocci  and  tul)ercle  bacilli.  If  connectecl  with  hydatid  disease  hooklets 
may  l)e  seen  in  ])us  which  is  not  too  old. 

Sid)phrenic  abscess  may  result  in  large  collections  of  pus,  which  may  travel  a  consider- 
able distance,  separating  the  peritoneum  from  the  diaphragm  and  from  the  lateral 
abdomiiuil  walls,  aj^jiearing  even  low  down  in  the  pelvis.  The  same  is  true  of  esca])ing 
pus  from  a  case  of  empyema.  The  primary  trouble  gives  rise  to  a  localized  peritonitis 
or  perihepatitis,  by  which  are  produced  certain  barriers  that  serve  to  retain  pus  within 
bounds,  and  to  keej)  it  from  spreading  save  as  above  mentioned.  Should  it  be  due  to 
extension  of  abscess  or  disease  within  the  liver  it  may  be  confined  by  adhesions  about  it. 
Fig.  52;}  illustrates  the  relations  which  such  a  collection  may  sustain  to  the  liver  and  the 
diaphragm,  as  well  as  how  the  ojjening  by  which  it  may  be  best  evacuated  should  be 
made  through  the  thoracic  walls.  Even  with  this  condition  jiroduced  by  disease  below 
the  diaphragm  it  is  not  infrequent  to  find  some  collection  of  fluid  or  evidence  of  exudate 
above  it. 

A  study  of  this  condition  will  nearly  always  lead  one  back  to  a  history  of  some  illness 

which  may  furnish  the  explanation  for  the  commencement  of  the  trouble.     Thus,  there 

may  be  obtained  a  history  of  pulnK)nary  tuberculosis,  of  empyema,  of  gastric  ulcer, 

of  gallstone  trouble,  or  of  abscess  in  the  liver  or  in  or  about  the  kidney.     When  the 

48 


754 


SPECIAL  ()U  Ri:(ll()S.\L  SURGERY 


result  of  j)crt'()r;iti(»ii  from  ahovc,  tin-  clirst  wall  may  furiiisli  .si(fn.s  which  will  he  .sufiiciciulv 
indicative. 

The  syuipfoin.s  will  incliide  swelling,  ])aiii,  tenderness,  with  fixation  of  the  liver,  and 
apparent  enlargement  of  its  boimdaries,  because  it  is  jnished  away  from  the  diaphragm. 
The  abdominal  wall  will  frcfiuentlv  be  edematous.  The  ordinary  signs  of  the  presence 
of  |Mis  are  rarely  absent,  including  the  evidences  furnished  by  a  differential  blood  count. 
Diagnosis  is  proved  by  the  use  of  the  exj)loring  needle.  The  disease  is  nearlv  always 
situated  upon  the  right  side.  The  more  distended  the  abscess  cavity  the  less  resj)irat()ry 
murmur  will  be  heard  over  the  lower  j)art  of  the  chest,  while  the  line  of  the  hc|)atie 
dulness  may  be  considerably  above  the  normal.  Sometimes  a  succussion  sound  may  be 
obtained. 

Should  pus  be  withdrawn  from  the  lower  part  of  the  chest  by  the  exploring  needle 
there  might  still  be  doubt  as  to  its  actual  location,  whether  above  or  below  the  diaphragm. 
The  absence  of  cough  and  of  indications  of  pleural  involvement  would  pnne  much  in 
favor  of  the  latter. 

Subphrenic  abscesses  tend  in  time  to  evacuate  themselves.  Thus  they  sometimes 
perforate  the  diaphragm  and  escape  into  the  pleural  cavity,  or  through  a  lung  which 
has  attached  itself  at  its  base,  and  thus  afforded  an  outlet  for  pus  through  the  bronchi 


Absc.  openhi 
PI.  cav. 


Transthoracic  opening  for  subphrenic  abscess.      (Beck.) 


and  the  mouth.  On  the  other  hand,  pus  may  burrow  downward  and  appear  in  the  flank 
or  beneath  the  skin  near  the  liver  and  in  front  of  it.  The  nearer  it  comes  to  the  surface 
the  more  easily  it  is  recognized. 

Treatment. — The  treatment  of  subdiaphragmatic  abscess,  like  that  of  all  other 
abscesses,  consists  in  evacuation  of  the  contained  pus,  Avith  provision  for  drainage. 
In  some  instances  this  may  be  done  with  an  ordinary  trocar  and  cannula,  but  serious 
cases  are  best  treated  by  incision,  with  resection,  if  necessary,  of  a  portion  of  a  rib.  When 
the  chest  wall  is  entered  the  best  place  is  between  the  ninth  and  tenth  ribs  in  the  axillary 
line.  Nevertheless  pus  which  is  presenting  at  any  other  ]i()int  may  be  best  reached  by 
taking  advantage  of  the  indication  thus  afforded.  An  opening  having  l)een  made  the 
cjuestion  of  counteropening  may  be  raised.  This  should  be  decided  in  each  instance 
upon  its  merits.  While  an  opening  made  in  front  does  not  drain  so  well  as  one  placed 
posteriorly  it  may  be  made  to  drain  by  keeping  the  patient  upon  the  side  or  face  for 
a  portion  of  the  ensuing  few  days.  W'hen  it  seems  desirable  to  go  through  the  chest 
wall  it  should  be  incised  carefully,  and  if  the  pleura  has  l)een  opened  before  reaching 
the  abscess,  the  pleural  surfaces  may  be  either  stitched  together  or  ])acke(l;  after 
waiting  a  day  or  two  for  protective  adhesions  to  form  the  abscess  may  then  be  opened. 
The  less  extensive  operations  may  be  performed  with  local  anesthesia.  Rib  resection 
and  extensive  incision  will  usually  require  general  anesthesia. 


Fio.  524 


CHAPTER    X  LI  V. 

TlIK   Bl{lv\S'l\ 
ANOMALIES  OF  THE  BREAST. 

Auia.stia,  or  coniplcle  ;iI)S(Muv  of  one  or  hotli  hrca.st.s,  is  a  rare  defect.  Po/ipnrififin, 
or  the  oeeiirreiue  of  .s-iiprniiinirrari/  hrra.st.s-,  is  more  fre(|iient.'  Tlie.se  iiiav  lie  foiiixl 
on  any  ])()rtion  of  (he  thorax  or  alxlonien,  and  may  constitute  ma.sses  of  triflinij  size  or 
may  hear  considerahle  resemhlance  to  the  normal  l)reast.  A  supernumerary  itreast  lias 
even  been  found  upon  the  thi>>;h.  The  condition  is  to  he  recrarded  as  atavi.stic,  and  a 
return  to  the  j)olymastia  of  animals,  which  j)ro<luce  a  litter  at  one  birth.  Similarly 
absence  of  tlie  nipple,  a mazia,  is  occasionally  seen,  or  more  frequently  polymazia,  the 
occurrence  of  more  than  one  nipple,  either  uj)on  the 
normal  breast  or  in  some  abnormal  position.  Some 
of  these  lesions  are  so  small  as  to  escape  observation, 
or  (o  be  considered  moles  unless  carefully  noted  and 
rec()o;nized  when  found. 

Ordinarily  supernumerary  breasts  are  met  near  the 
middle  line  and  below  the  normal  mammary  glantl. 
A  more  common  condition  is  one  of  defect  of  the 
nipple,  which  fails  to  assume  its  normal  prominence 
and  remains  ill-developed,  so  as  not  to  be  seized  by 
the  infant  in  the  act  of  attempting  to  nurse.  Never- 
theless with  the  physiological  activity  which  occurs 
in  the  breast  at  the  time  of  pregnancy  these  ill- 
developed  nipples  usually  expand  sufficiently  to  fulfil 
their  function,  even  though  imperfectly. 

Hemorrhages  from  the  breast  sometimes  take 
place  idiopathically,  at  others  as  vicarious  eft'orts  at 
menstruation.  There  is  a  peculiar  s^iiipathy  between 
the  pelvic  organs  of  women  and  the  mammary 
glands,  and  the  latter  evince  this  in  more  than  one 
way,.  l)econiing  sometimes  extremely  tender  or  swollen 
at  the  menstrual  period,  or  at  other  times  peculiarly 
sensitive  or  even  neuralgic,  while  at  times  congestion 
will  proceed  to  the  point  of  hemorrhage.  These  c<ni- 
ditions  do  not  require  particular  attention,  but  are 
not  to  be  confused  with  a  bloody  discharge  that  may 
occur  later  in  life,  in  connection  with  certain  forms 
of  malignant  disease  occurring  in  the  interior  of  the 
breast. 

There  exist  the  widest  differences  in  development  of  the  breasts  in  different  individuals. 
The  term  "breast"  is  used  intentionally,  since  the  difference  is  not  so  much  in  the  actual 
glandular  development  as  in  the  surrounding  connective  tissue  and  fat.  Thus  a  jilump 
breast  may  contain  very  little  more  secreting  structure  than  one  ap|)arently  ill-develo{)ed. 
Nowhere  outside  the  uterus  save  in  the  breast  do  such  compensatory  changes  take  place 
under  the  stimulus  of  pregnancy.  In  fact,  a  mammary  gland  in  preparation  for  lacta- 
tion is  a  physiological  adenoma.  At  conclusion  of  lactation  there  is  absorption  and 
atrophy  from  disuse,  usually  not  to  the  original  degree,  although  in  some  instances  the 

'  History  records  interesting  examples  of  the  importance  attached  to  these  conditions.  Thus  the  beautiful 
Anne  Boleyn  fell  under  the  displeasure  of  King  Henry  because  of  a  supernumerary  breast,  and  it  is  said  that 
the  mother  of  the  Roman  Emperor  Alexander  Severus  was  given  the  name  of  Julia  Mamma;  because  of  a  similar 
abnormality. 

(755) 


Idiopathic  hypertrophy  of  breasts  in  a 
girl  of  sixteen.     (Bebee.) 


75G  Sl'KClAL  tJR  UICGIOXAL  SUIiiJERY 

fatty  tissue  disapjH'ars  irregularly  and  leaves  the  breasts  in  quite  different  shape  from  their 
originals.  In  this  way  the  breasts  may  become  exceedingly  pendulous,  so  much  so  as 
to  lead  to  ])ain  and  soreness  from  traction,  and  to  call  for  their  support. 

Idiopathic  /ii//)rftr()phy  of  one  or  both  breasts  is  a  rare  defomiity,  occurring  usually 
in  the  yf)ung,  sometimes  in  girls,  involving  them  to  an  indefinite  degree,  Ijut  in  some 
|)roducing  enormous  overgrowth,  with  corrcs})onding  deformity.  For  such  liyj)ertrophy 
no  known  cause  has  been  assigned.  Fig.  524  illustrates  an  instance  of  this  character 
in  a  young  girl,  occurring  under  the  observation  of  my  colleague,  Dr.  Bebee. 

INJURIES  TO  THE  BREAST. 

These  consist  largely  of  contusion.^  to  which,  from  their  positions,  the  breasts  are  pecu- 
liarly exposed,  and  these  may  be  followed  by  hemorrhage,  by  extensive  ecchymosis,  or 
by  any  of  the  consequences  of  infection.  They  may  also  be  followed  by  more  or  less 
permanent  induration.  The  fact  that  in  the  course  of  time  certain  contusions  of  the 
fjreast  are  followed  by  development  of  cancer  is  incontestable,  although  the  relation 
which  may  exist  between  the  accident  and  the  neoplasm  has  not  yet  been  made  clear. 
The  breasts  are  also  subject  to  the  same  possibilities  of  injury  as  other  parts  of  the 
th(jrax,  which  has  been  considered  in  the  previous  cha])tcr.  The  nipples  are  more  often 
injured  by  efforts  of  the  nursing  infant,  or  by  the  friction  of  ill-fitting  stays  or  rough 
clothing,  than  in  any  other  way.  These  injuries,  at  first  of  a  minor  character,  are  not 
infrequently  followed  by  serious  results,  erysipelas,  septic  infection,  or  tuberculosis 
being  conveyed  thnnigh  trifling  abrasions  thus  inflicted. 

The  nipple  of  a  nursing  woman  once  excoriated,  or  its  surface  broken,  is  kept  constantly 
liable  to  maceration  and  surface  infection.  In  this  way  a  trifling  lesion  may  result 
in  a  linear  ulcer  known  as  a  fissure  ("cracked  nipple"),  or  in  a  more  extensive  involve- 
ment. These  fissured  nipples  are  very  erethistic,  and  great  pain  Is  caused  by  each 
attempt  at  nursing.  On  this  account  the  mother  postpones  the  act  as  long  as  possible, 
and  until  her  l)reast  has  become  overdistended,  the  result  being  injury  to  the  breast 
itself,  with  a  greater  possibility  of  infection  and  of  subsequent  abscess  formation. 

The  slightest  excoriation  of  the  nipple,  under  any  circumstances,  should  lead  to  the 
adoption  of  every  precaution  for  its  cleansing  and  protection.  Both  before  and  after 
nursing  it  should  be  carefully  washed,  while,  after  removal  of  the  child  horn  the  breast, 
it  should  be  carefully  dried  and  dusted  with  dry  boric  acid  or  a  similar  antiseptic.  Any 
abrasion  which  fails  to  heal  should  be  treated  with  silver  nitrate.  More  pronounced 
abrasions  and  ulcers  should  be  cocainized,  then  cauterized,  and  afterward  treated  as 
above.  Finally  in  extreme  cases  it  may  be  necessary  to  discontinue  nursing  and  allow 
the  breast  to  dry.  If  this  policy  l)e  adopted  it  should  l)e  applied  to  both  breasts,  for 
such  is  the  sympathy  between  them  that  the  use  of  one  gland  seems  to  stimulate  the 
other.  The  local  use  of  such  preparations  as  belladonna  ointment,  etc.,  is  to  be  avoided. 
Pressure,  rest,  and  the  care  above  described  afford  more  relief. 

Paget' s  disease  of  the  nipple  implies  an  eczematous  condition,  first  described  by  Paget 
as  a  precursor  of  many  cancers.  It  is  a  more  or  less  chronic  affection,  involves  the 
nipple  and  the  areola,  is  quite  intractable  to  treatment,  gives  more  or  less  discomfort, 
and  is  to  be  dreaded  when  noted.  It  seems  to  sustain  about  the  same  relation  to  later 
cancennis  involvement  as  does  leukoplakia  in  the  mouth  and  on  the  tongue. 

There  is  no  reason  why  any  person  may  not  have  an  attack  of  eczema  alxnit  the  nij)ple, 
but  cases  in  which  the  condition  is  persistent  and  obstinate,  and  especially  in  which  the 
uuflerlying  tissues  gradually  become  infiltrated  or  indurated,  should  be  vicAved  with 
suspicion,  and  should  be  treated  by  eradication  of  the  area  involved,  even  though  this 
may  require  extirpation  of  the  nipple  or  of  the  entire  breast.  When  the  condition  is 
developed  no  ordinary  treatment  will  suffice,  although  a  fair  trial  might  be  given  to 
the  cathode  rays. 

MASTITIS. 

A  true  inflammation  of  the  mammary  gland  may  occur  at  one  of  three  periods: 
(1)  At  birth,  when  the  tiny  breasts  of  the  newborn  infant  secrete  a  milk-like  fluid,  become 
more  or  less  congested  and  tender,  and  when  they  are  unintelligently  treated  by  massage 
or  interference  of  any  kind;  (2)  at  puberty,  when  a  perfectly  natural  turgescence  and 


MASTITIS  757 

oonpjestion  occur,  wliidi,  however,  rarely  |)rocee(l  to  suppuration  unless  iiirected  or 
unless  violence  or  some  indiscreet  treatment  have  heeu  received;  {',i)  durinjf  prifjinmcij 
ami  /(irldlioii,  this  I>ein<^  the  lime  when  mastitis  is  most  common. 

Considerintf  that  the  ni|)ple  alVords  a  numher  ol"  open  paths,  from  iin  area  which  it  is 
didicult  to  keej)  clean,  extendiuf^  into  the  depths  of  inHammahle  tissue,  it  is  strange  that 
infection  throuf^h  the  milk  duets  does  not  occur  in  most  cases.  Such  a  path  of  infection 
alVords  the  e.\|)lanation  for  at  least  a  lar<^e  pro|H)rtion  of  mammary  abscesses.  Aji^ain 
th(>  j)resence  of  excoriations,  abrasions  of  any  kind,  and  es|)ecially  of  dee|)  fissures  which 
are  not  easily  cleansed,  will  account  for  iid'ection  throu<rh  the  lyni|)hatics.  In  these 
two  ways  nearly  all  cases  of  mastitis  and  of  mammary  abscess  are  to  be  e.\|)lained,  and 
both  these  accidents  are  likely  to  occur  during;  pre<rnancv  and  lactation. 

The  conseciuence  of  such  infection  is  nid.shfi.'^,  which  bc<rins  with  painful  induration 
and  local  indications  of  inflanunation,  but  which  may  under  suitable  treatment  uuder«^o 
resolution.  This  failinif,  the  infectious  process  jjroceeds  to  suj)puration,  and  the  cou- 
sequence  is  a  superficial,  deep,  or  retromammary  abscess,  all  but  the  last  named  often 
in  nndtij)le  form.  The  lobular  construction  of  the  breast  permits  the  indej)endent 
occurrence  of  distinctive  supi)uration,  occurrinjf  synchronously  at  several  different  points, 
and  hence  it  may  be  that  a  breast  is  riddled  with  abscesses,  which  form  successively 
or  almost  sinuiltan(>()usly. 

There  is  a  supcrjirial  form,  which  occurs  usually  near  the  nij)ple,  and  in  which  the 
dee])er  structure  of  the  breast  is  scarcely  involved.  This  conies  usually  throu<rh  infection 
of  some  surface  lesion.  Simple  incision  is  usually  sufficient,  and  the  local  lesion  is  thus 
quickly  termiiuited.  Deep  or  iniramammari/  abscess,  single  or  nudtij>le,  is  always 
painful,  sometimes  distressing  and  occasionally  an  extremely  serious  condition.  Occur- 
ring in  a  breast  already  well  developed  and  fatty,  al)seesses  may  form  at  such  depth  as 
to  be  recognized  with  difficulty.  The  surgeon  infers  their  existence  rather  than  dis- 
covers it.  This  is  unfortunate,  for  the  longer  the  delay  the  greater  the  local  disturbance, 
with  a  tendency  to  burrowing,  and  the  worse  are  the  consequences  for  the  ])atient.  It 
is,  therefore,  far  safer  to  early  note  the  minor  signs  of  deep  supjniration  and  to  freely 
incise,  than  it  is  to  wait  for  pus  to  come  toward  the  surface  and  give  its  ordiimry  surface 
indications.  The  amount  of  induration,  sometimes  dense  and  brawny,  which  such 
conditions  will  produce  within  the  breast,  the  size  which  the  latter  may  assume,  and  the 
consequent  suffering  to  the  patient  from  neglected  conditions  of  this  kind,  need  to  be 
seen  to  be  fully  appreciated. 

Reiramammary  abscess  may  be  the  result  of  conditions  not  primary  to  the  breast  itself. 
Thus  the  writer  has  seen  spontaneous  perforation  of  the  thoracic  wall  in  a  case  of 
empyema,  with  escape  of  pus  into  the  loose  cellular  tissue  behind  the  breast,  and  the 
consecjuent  protrusion  forwartl  of  the  latter  until  it  presented  as  an  enormous  tumor. 
Treatment  in  such  cases  would  mean  not  alone  evacuation  of  the  retromammary  col- 
lection, but  emptying  the  pleural  cavity  of  its  acciunulated  fluid. 

An  infected  breast  will  produce  not  only  the  ordinary  local  indications,  but  will  be 
characterized  by  extreme  tenderness,  with  enlargement  of  the  lymph  nodes  in  the  axilla 
and  later  abscess  formation  in  this  location.  In  proportion  to  the  amount  of  pus  thus 
imprisoned,  and  the  virulence  of  the  infecting  organisms,  constitutional  sMuptoms  may 
be  mild  or  extreme. 

Nowhere  is  there  greater  need  for  release  of  an  imprisoned  amount  of  pus  than  under 
these  circumstances,  although  the  incisions  necessary  for  the  jnirposemay  be  sometimes 
multiple  and  deep.  Every  incision  made  for  evacuation  of  a  mammary  abscess  should  be 
placed  radiaUy — i.  e.,  in  a  line  radiating  from  the  ni|)ple — in  order  that  lobules  may  be 
incised  along  their  course,  and  that  neither  they  nor  vessels  be  cut  across  transversely. 
There  is  also  need  for  complete  drainage,  and  several  tubes  may  be  used  for  this  pur- 
pose, being  passed  completely  across  or  beneath  the  breast. 

Chronic  Mastitis. — Chronic  mastitis  may  be  the  termination  of  a  partially  resolved 
acute  process,  or  of  injury,  or  of  ap))arently  unknown  causes,  being  in  these  instances 
of  apparently  spontaneous  origin.  Pathologically  it  comprises  incluration,  with  more 
or  less  infiltration  of  the  interacinous  and  interlobular  tissue,  and  with  some  infiltration 
of  the  other  structures  of  the  breast,  by  which  fixation,  retraction  of  the  ni|)ple,  or  con- 
densation of  the  surrounding  structures  and  adhesion  of  the  overlying  skin  are  produced. 
The  result  may  be  to  produce  either  an  enlargement  or  diminution  in  size  of  the  breast. 
One  or  both  glands  may  be  involved.     It  is  a  disease  usually  of  late  adult  life. 


758  SPECIAL  OR  REGIOXAL  SURGERY 

Breasts  thus  afFecterl  are  (^ften  tender  and  painful,  espeeially  during  menstruation, 
and  u]x)n  pal})atif)n  are  found  to  l)e  irrejiular  in  .sha])e,  more  or  less  nodulated,  extremely 
finn  in  some  easels  and  j)la<es,  and  i)erliaj)s  so  infiltrated  as  to  strongly  simulate  eancer. 
The  changes  which  are  thus  produced  are  slow,  and  it  is  imjK)rtant  to  note  that  the 
iMTiphatics  are  usually  not  enlarged,  and  that  after  attaining  a  certain  degree  the  dis- 
eased condition  becomes  stationary.  The  general  health  usually  does  not  suffer  beyond 
a  certain  point;  at  least  even  in  the  more  chronic  cases  there  is  no  characteristic  cachexia. 
While  the  condition  is  more  fretjuent  in  women  who  have  nursed  it  may  be  met  in  those 
who  have  never  borne  chihlren  nor  have  heen  married. 

Suitable  examination  of  all  these  cases  can  only  be  mafle  with  the  upj^er  portion  of  the 
patient  stri[)ped,  the  l)()dy  in  the  horizf)ntal  ])osition,  and  both  breasts  compared  and 
examined,  first  with  the  flat  hand  in  order  that  differences  of  shape,  size,  mobility,  and 
fixation  may  be  determined.  Subsequently  the  patient  should  be  raised  to  the  sitting 
pf)sition,  the  surgeon  standing  behind  to  examine  each  breast  with  one  hand  and  simul- 
taneously, in  order  that  differences  may  be  more  accurately  noted.  Any  tumor  present 
will  be  more  easily  discovered  with  the  flat  hand  than  with  the  finger-tip,  while  chronic 
influration  will  not  give  the  sensation  given  by  neoplasms.  The  axillfe  should  also  be 
carefully  examined,  as  well  as  the  supraclavicular  regions,  for  evidences  of  l^Tuphatic 
involvement.  When  the  entire  breast  is  involved  diagnosis  is  less  difficult  than  when  one 
or  more  lobules  alone  are  concemefl.  These  constitute  the  painfid  nodular  conditions 
to  which  so  many  names  have  l>een  given  by  different  writers. 

Significant  features  in  their  differentiation  from  cancer  are  the  disproportionate  pain 
and  tenderness,  their  diffuse  leathery  hardness,  and  the  fact  that  both  breasts  are  usually 
similarly  involved,  though  perhajjs  not  to  the  same  extent.  Cancer  is,  on  the  other 
hand,  somewhat  dense  and  confined  to  one  breast,  and  affords  a  sensation  of  infiltration 
of  the  surrounding  tissues,  with  the  j>eculiar  "saddle-skin"  retraction  or  adhesion  of  the 
overlying  skin  and  nipple.  Moreover,  the  growth  is  more  rapid  and  localized,  and  the 
l\Tnphatics  are  involved  in  nearly  every  instance.  Some  of  these  cases  are  so  obscure 
that  diagnosis  previous  to  operation  is  impossible,  while  innocent  lesions  may  gradually 
merge  into  malignant,  and  no  one  can  say  when  the  transition  begins  or  has  begun. 

Treatment. — The  milder  forms  of  chronic  mastitis  gradually  improve  under  the  influ- 
ence of  local  applications  such  as  the  ichthyol-mercurial  ointment,  to  which  menthol 
may  be  added  for  its  soothing  effect.  Pendulous  or  painful  breasts  should  be  sup- 
ported as  much  as  possible.  Otherwise  these  cases  are  best  let  alone — i.  e.,  they  should 
not  be  rubbed  or  massaged.  There  is  usually  a  constitutional  condition  which  is  closely 
related,  and  in  nearly  every  instance  there  Ls  more  or  less  failure  of  elimination.  These 
features  should  be  studied  and  treated  as  they  are  identified.  Finally  there  are  some 
intractal)le  forms  of  innocently  indurated  breast  which  give  so  much  trouble  that  it  is 
f>est  to  remove  them  as  though  they  were  cancerous. 


NEURALGIA   OF   THE   BREAST;  MASTODYNIA. 

Many  women  suffer  frr)m  annfjying  and  })ainful  affections  f)f  the  Ijreast  for  which  no 
sufficient  excuse  Ls  found,  while  f)thers  who  have  small  fibrous  nodules  or  innocent  lobular 
tumors  will  suffer  an  amount  of  pain  which  is  disprojK)rtionate,  and  in  instances  of 
either  tyj^e  we  are  prone  to  point  to  the  neurotic  or  hysterical  features  of  the  case  and 
to  say  that  it  must  be,  at  least  to  a  certain  extent,  neurotic.  Inasmuch  as  these  cases 
usually  occur  in  young  and  otheruise  neurotic  women,  often  of  the  more  impression- 
able type,  it  is  generally  pro]>er  to  consider  them  as  to  some  extent  hysterical,  while  in 
others  there  are  pehic  accompaniments  which  may  perhaps  accoiuit  for  neuralgic  breasts, 
because  of  the  well-known  intimate  relations  between  the  pehnc  organs  and  these  glands. 
In  .some  cases,  again,  are  found  actual  small  tumors,  single  or  multiple,  but  of  innocent 
character.  In  other  cases  there  are  hypersensitive  areas  of  entire  breasts,  to  a  degree 
where  the  patient  cannot  stand  the  slightest  handling.  These  c-ases  are  hyperesthetic, 
even  if  not  hysterical,  and  some  are  unsatisfactory  to  treat.  The  pains  are  more  or 
less  periodical,  and  often  radiate  down  the  arm  or  the  side  of  the  thorax;  this  may  be 
ex})laiiif(l  through  the  intercf)stf)humeral  and  other  nerve  connections. 

Treatment. — The  treatment  of  mastfxlynia  shoulil  include  constitutional,  local,  and 
mitral  measures,  but  of  these  the  local  arc  the  least  ini]M)rtant.     The  excision  i)f  painful 


.\cTi.\().\ryc()siS:  sypuilis  of  tu/-:  hhf.ast  759 

nodules  is  nl'lcii  »lis;i|)|H>iiil iiij;',  llu"  rcinaiiiiii^  scars  Ix'coiniiio;  even  more  sensitive  (lian 
tlie  oritjinal  lesions.  Women  who  under  these  einunislanees  ha\<'  insisted  upon  the 
removal  of  an  entire  hn'ast  have  still  sullered  i'loni  inlereosial  neuralijia  or  other  remain- 
ing; j)ainiiil  conditions,  so  that  their  ultimate  condition  luts  not  been  nnich  im|)rovecl. 
Each  ease  should  he  studied  upon  its  merits,  and  while  (/ue  may  he  benefited  by  some 
pelvic  operation,  or  another  by  Turkish  baths  and  improvement  of  elimination,  others 
are  best  li't  alone,  or  {j^iven  a  minimum  of  dni<;s  with  a  maxinuim  of  {general  and  sexual 
hyij;ieni'. 

TUBERCULOSIS  OF  THE  BREAST. 

I  cannot  aijjri'e  with  writers  like  Fowler,  who  claim  that  tuberculosis  of  the  mammary 
gland  is  extremely  rare.  I  think  it  ncjt  infrequent.  In  the  breast  may  be  noted  the  j)res- 
enee  of  lesions,  either  .separate  or  coalescing,  and  gummas  as  such,  or  l)reaking  down  into 
caseous  masses  or  into  cold  abscesses.  In  connection  with  the  lo<-al  lesions  there  may 
he  more  or  less  involvement,  even  to  ulceration,  of  the  overlying  skin,  with  the  formation 
of  lu|)oid  ulcers,  while  the  axillary  l}iiiphatics  will  be  nearly  always  involved.  In  some 
instances  the  disease  may  have  gone  on  to  suppuration  and  burrowing  of  pus,  with  its 
disehargi',  and  the  existence  of  tuberculous  sinuses;  or  in  others  may  be  seen  results 
of  a  secondary  infection  of  the  remains  of  multi])le  mammary  abscess.  The  condition 
is  most  often  met  with  in  the  young  and  fair,  but  may  be  seen  in  elderly  women.  Around 
the  distinctly  tuberculous  lesions  there  may  be  considerable  tissue  sclerosis.  The 
actual  proportion  of  ciises  is  about  one  of  this  contlition  to  fifty  of  cancer.  Lesions  are 
more  frequent  in  the  outer  quadrant  of  the  breast  than  the  inner,  and  they  occasionally 
produce  retraction  of  the  nipple  or  adhesion  of  the  skin,  above  described,  before  its 
distinct  involvement. 

In  any  of  these  circumstances  secondary  purulent  infection  may  occur,  and  an  acute 
phlegmonous  process  may  seriously  complicate  the  previous  chronic  condition. 

Treatment. — There  is  but  one  satisfactory  method  of  dealing  with  tul)erculous  dis- 
ease of  the  breast — ?'.  e.,  its  extirpation.  The  entire  breast,  or  so  muc  h  of  it  as  nuiy  be 
distinctly  involved,  should  be  extirpated  as  though  it  were  cancerous,  while  the  axilla 
should  be  opened  and  its  contents  cleared  out,  if  it  appear  in  the  slightest  degree  involved. 
INIoreover,  every  other  tuberculous  lesion  in  the  neighborhood  should  be  eradicated, 
either  with  the  knife,  the  scissors,  or  the  sharp  spoon.  After  such  radical  treatment 
results  are  usually  satisfactory. 

ACTINOMYCOSIS;  SYPHILIS  OF  THE  BREAST. 

Adinomycofivi  is  not  common  in  this  location ;  nevertheless  tissue  conditions  are  such 
that  it  would  furnish  accessible  and  diagnosticable  features  which  would  be  distinctive, 
at  least  until  some  secondary  infection  had  occurred. 

Syphilis-  appears  in  this  location  in  many  of  its  protean  manifestations.  Chancres 
ahniit  the  nipples  and  on  the  surface  of  the  breast  are  not  uncommon,  the  disease  being 
often  conveyed  from  syphilitic  infants  through  cracked  nipples,  while  many  other 
methods  of  contamination  have  been  reported.  Near  the  nipple  the  chancre  may  not 
have  those  characteristics  which  usually  distinguish  it  upon  the  genitals,  but  may  appear 
rather  as  an  indurated,  intractable  ulcer,  with  firm  base,  accom])anied  by  distinct 
involvement  of  the  axillary  and  supraclavicular  nodes,  and  unless  early  recognized  and 
promptly  treated  as  such  will  so  endure  until  the  occurrence  of  the  first  significant 
secondary  eruption,  whose  appearance  should  dispel  doubt  and  lead  to  radical  treatment. 

There  is  difficulty,  sometimes,  in  distinguishing  between  tuberculous  and  sy])hilitic 
skin  lesions  upon  the  breast,  especially  near  the  nipple.  When  other  methods  fail  the 
therapeutic  test  will  nearly  always  clear  up  the  difficulty.  All  truly  syphilitic  lesions 
here,  as  well  as  elsewhere,  yield  promj)tly  to  well-directed  treatment. 


7G0  SPECIAL  OR  lil'jnoXAL  SURGERY 


TUMORS   OF   THE   BREAST. 


The  mammary  o;land  is  a  frequent  .site  for  tumors,  altli()Uo;h  neoplasms  of  eml)rvonie 
origin  are  not  as  fretjuent  here  as  might  jjerhaps  be  expected.  Nearly  one-fifth  of  all 
tumors  occurring  in  the  body  will  be  found  in  this  location,  while  the  larger  j)rojM)r- 
tion  of  breast  tumors  are  malignant. 

Cysts  abound  in  this  locality,  occurring  in  one  or  both  breasts,  and  singly  or  in 
exceedingly  midtiple  form,  the  latter  being  small  and  containing  but  a  few  drops  of  fluid. 
Their  cystic  contents  are  colorless  and  of  a  serous  consistency,  .sometimes  thick  and 
mucous,  occasionally  discolored,  and  in  rare  instances  almost  like  unchanged  milk. 
In  the  latter  case  the  condition  is  known  as  galartocelc. 

In  an  organ  .so  thoroughly  ])r()yi(led  with  ducts  it  is  easy  to  understand  how  rrfrnfion 
cj/sts  may  readily  occur  from  |)lugging  of  some  duct  and  the  accinnulation  of  secretion 
l)ehind  it.  Should  it  occur  at  a  time  when  milk  is  forming  galactocele  may  be  readily 
explained.  At  other  times  it  is  in  eyery  respect  an  abnormal  deyelopment.  This 
occlusion  of  the  duets  may  be  the  result  of  disease  or  of  injury,  and  is  not  always  com- 
plete, for  it  often  happens  that  from  a  distended  duct  more  or  less  accumulated  material 
may  be  exj^ressed  l)y  gentle  pressure.  In  this  case  it  will  be  found  thick  and  loaded 
with  the  epithelial  cells  which  line  the  ])assages.  These  retention  cysts  are  sjioken  of 
as  serous,  mucous,  or  sanguinolent  (blood  cysts),  according  to  their  contents,  while 
the  lacteal  contain  material  more  or  less  resembling  butter.  True  gahictncclc  seems  to 
l)e  rare.  While  the  original  contents  are  milky  it  is  claimed  that  through  changes 
taking  place  in  the  neigliborhood  induration  and  proliferation  in  the  surrounding 
membrane  may  result,  or  that  mammary  tissue  may  soften  and  break  down  into  pidpy 
detritus. 

Cystic  tumors  in  the  breast  may  be  of  innocent  character,  or  may  assume  all  degrees 
of  malignancy.  A  cyst  whose  lining  membrane  is  smooth,  without  redu])lications  or 
irregularities,  may  be  regarded  as  innocent,  while  the  complete  extirpation  of  its  walls 
will  be  all  that  is  required.  This  may  be  made  more  c(miplete  after  injecting  it  and 
staining  it  with  nu'thyl  blue,  or  filling  it  with  melted  paraffin  in  order  to  occupy  the  place 
of  the  fluid,  which  should  haye  been  drawn  off.  On  the  other  hand,  eyery  cyst  whose 
interior  is  roughened,  or  presents  the  slightest  papillomatous  appearance,  or  which  is 
imiluly  adherent,  or  has  about  it  any  mark  of  infiltration,  calls  not  only  for  its  own  eradi- 
cation, but  for  practically  the  complete  removal  of  the  breast. 

The  signs  of  cystic  tumor  in  the  breast  are  essentially  those  of  any  other  neoplasm,  except 
that  it  is  frequently  possible  to  recognize  its  cystic  character  by  fluctuation.  A  cyst 
ordinarily  presents  as  a  distinct  tumor,  and  when  innocent  is  ci reruns cri bed  and  non- 
adlu'rent,  lacking  the  clinical  eyidences  of  malignancy.  Pain  is  an  uncertain  feature. 
Most  cysts  deyelo])  slowly,  but  a  cyst  deyeloping  suddenly  after  jiarturition  or  during 
lactation,  without  ])reyious  local  inflammatory  changes,  is  probably  a  galactocele.  The 
small  multiple  form  of  cyst,  with  which  one  or  both  breasts  may  be  studded,  is  fre(|uently 
confused  with  chronic  mastitis,  from  which  it  is  difficult  to  sejiarate  it.  The  escape  of 
sebaceous  material  or  of  milky  fluid  from  the  nipple,  or  the  possibility  of  making  it 
appear  by  gentle  j>ressure,  will  probably  afford  the  best  indication.  If  along  with  this 
possibility  the  ni])ple  be  found  idcerated,  or  if  the  extruded  fluid  be  bloody,  complete 
extirpation  of  the  breast  would  be  the  only  suitable  measure. 

Treatment. — The  general  treatment  of  cyst  has  been  indicated.  It  is  a  question 
simply  of  how  extensiyely  the  eradication  should  lie  made.  The  adyice  of  the  older 
text-books  is  misleading,  and  it  is  the  studies  of  yery  recent  years  which  haye  shown 
how  early  the  lining  membrane  of  apparently  innocent  cysts  may  midergo  malignant 
changes,  by  which  the  breast  is  soon  compromised  and  which  necessitate  its  entire 
remoyal.^ 

Of  the  hcnign  tumors  lipomas  in  the  substance  of  the  gland  are  rare,  while  they  may 
frequently  develop  in  its  fatty  surroundings.  Adenoma  and  fibroma,  with  their  various 
combinations,  are  the  most  common  of  the  innocent  tumors,  and  they  constitute  single 

'  It  will  be  a  safe  nile  to  follow  if  it  be  assumed  that  every  cyst  whose  contents  are  bloody,  unless  this  can  be 
traced  to  recent  accident,  and  especially  every  c.vst  whose  interior  is  papillomatous,  is  on  the  liorder-land  of 
maliKnancy,  if  not  maliKiiant  in  character.  .Ml  such  tumors  then  shouKl  be  extirpatetl-  If  they  occur  in  tlie 
breast  a  complete  operation,  as  for  cancer,  should  b  ■  done 


TCMOli'S  OF   77/A'   liRKAST  761 

or  iiiiilli|)l('  iHxliilcs,  locnicd  ill  llic  siihstaiicc  of  the  ^hiiid,  or  in  i"\i(|cii(  (•oiiiiiiiiiiicalioii 
witli  it,  coiislitutiiii^  iiuisscs  of  wcll-iiiarkcd  dciisily,  slow  growth,  iicarlv  ;d\va\s  iiiohilc 
and  iioii-adluMHMit  to  (lie  skin,  caiisiiiii;  ncitlicr  retraction  ot"  tlic  nipple  nor  lvnij)liatic 
involvt'incnt,  and  heinif  l'r('(|U('ntJy  acconi|)ani('(l  hy  a  very  disproportionate  ainonnt  ol" 
pain  and  tenderin'ss,  some  ot"  tlieni  l)ein<^,  in  fact,  e\(Hiisitely  sensitive.  While  tliese 
•frowtlis  are  rare  |)revioiis  to  |)iil)erty  tliey  are  i"re(|iienliy  met  in  <^irls  and  yoim^  women, 
and,  oeenrrinjj;  in  these  neiirolie  snhjects,  tiiey  eausc  eonsiderahle  mental  as  well  us 
|)hysieal  tronl)le.  In  these  patients  tiiere  nuiy  he  foniid  coiiieideiil  pelvic  disorder. 
'rh(>  removal  of  these  sensitive  masses,  which  seems  to  he  plainly  indicated,  is  often 
disappointinjf,  as  the  ri'mainin<i;  scar  may  retain  the  original  hypersensitiveness,  and 
patients  often  snil'er  as  much  as  before  the  operation. 

'I'he  (Milarji'ement  of  the  breast,  which  normally  |)repai-es  it  for  lactation,  is  to  ]>(.'. 
rei;'arded  as  the  development  of  a,  normal  or  plii/xio/ofiicdl  adrnotiia.  Anythinfij  which 
simnlates  this  nnder  otiu'r  conditions  is  abnormal,  and  any  overdevelopment  of  trnc 
mammary  inland  tissue,  when  loeaHzed  and  circiiinsc  ribed,  should  be  refern-d  to  as 
adcuoina.  In  such  tumors  cystic  cluiuges  often  occur,  as  well  a  later  transformation 
into  adenocarcinoma,  something  always  to  be  dreaded.  These  chanires  are  more  likely 
to  take  place  durino^  lactation,  at  which  time  the  blood  .supj)ly  to  the  breast  is  more  free. 
The  development,  then,  of  an,  adenoma  in  f/ie  hrea.sf  of  a  nvrsincj  iroman  should  be 
reo-arded  with  suspicion,  and  unless  benio-n  it  should  be  ref^arded  as  demanding;  removal 
of  the  entire  or<i;an.  These  tumors  also  are  non-adherent  and  lack  the  ordinary  si<fns 
of  maliifiiancy. 

Cancer  of  the  Breast. — Cancer  oeeurs  in  the  breast  more  often  than  anywhere 
else,  and  rr;/Y'///owa  constitutes  about  S5  per  cent,  of  thesemalio;nant  tumors,  the  balance 
being  mostly  sarcomas,  the  remaining  small  number  being  made  uj)  of  endotheliomtis  and 
the  other  rare  forms.  The  most  common  type  of  carcinoma  is  the  so-called  scirrhus, 
in  which  there  is  a  large  amount  of  dense  stroma,  and  which  forms  a  strong  contrast 
with  the  rare  forms  of  rajiidly  growing,  true  soft  cancer — i.  e.,  the  eneephaloid  or  mediil- 
lafji  as  they  used  to  be  called — in  which  the  cancer  cells  ])rolifcrate  with  greater  rapidity 
and  in  which  there  is  a  small  amount  of  stronuv,  so  that  in  consequence  the  tumor  itself 
is  soft  or  almost  gelatinous. 

Sarcoma  of  the  breast  may  assume  either  of  its  well-known  types,  and  is  a  tumor 
seen  in  the  earlier  rather  than  in  the  later  years  of  life.  It  sometimes  grows  rapidly 
and  attains  large  size,  seeming  to  approach  the  surface  more  rapidly  and  readily  than 
ordinary  forms  of  carcinoma.  In  consequence  it  may  be  mistaken  for  abscess.  As 
a  rule,  however,  the  skin  is  not  so  likely  to  be  adherent  to  the  tumor  as  in  carcinoma, 
and  the  lymph  nodes  are  not  so  early  involved,  w^hile  in  a  cut  section  of  the  tumor 
the  fat  is  not  so  disposed  as  in  carcinoma,  where  it  may  be  seen  in  layers,  while  in  the 
former  case  it  has  been  transformed  into  malignant  tissue. 

The  two  ])rinci])al  forms  of  carcinoma  are  the  acinon.s'  and  the  iuhnlar,  in  the  former 
the  cells  being  packed  into  the  alveoli  and  surrounded  with  a  firm  and  adventitious 
stroma,  while  in  the  latter  the  primary  development  seems  to  be  within  the  milk  ducts, 
which  being  first  involved  cause  a  more  multiple  minute  invasion  and  a  less  distendecl 
tumor  formation. 

The  (jeneral  indications  of  cancer  in  the  breast  are  as  follows : 

The  presence  of  tumor,  sometimes  of  regular  and  definite  outline,  sometimes  diffuse 
and  not  easily  outlined. 

Fixation  of  tJiis  tumor  in  the  surrounding  tissues  in  such  a  way  that  it  cannot  be 
moved  without  disturbing  them. 

Fixation  of  the  general  area,  either  to  the  skin  above  or  to  the  pectoral  fascia  below, 
or  both.     This  gives  to  the  part  an  innuobility  in  contrast  with  normal  conditions. 

Retraction  of  the  nipple,  when  the  growth  is  large  or  located  near  it.  This  is  a  feature 
perhaps  not  noticeable  in  the  primary  stages  when  it  is  so  important  to  recognize  the 
disease  if  present. 

Retraction  of  the  overlying  skin,  at  points  if  not  over  a  considerable  area,  giving  it 
a  p(>culiar  "saddle-skin"  or  "])ig-skin"  a])])earance.  This  indication  of  itself  is  always 
suspicious  and  one  which  should  be  noted  if  ])rescnt. 

In  addition  to  the  local  evidences  in  the  breast  the  involrement  of  the  nodes  in  the 
axilla  and  of  the  lymph  vessels  leading  up  toward  it.  These  should  be  carefully  studied, 
the  patient's  arm  being  liehl  loosely  away  from  the  body,  and  scmiewhat  to  the  front, 


762  SPECIAL  OR  REGIONAL  SURGERY 

in  order  to  relax  the  pectoral  muscle.  In  fleshy  .suhjects  it  may  not  he  possible  to  dis- 
cover them  even  if  present.  The  supraclavicular  reojion  should  also  be  examined,  and 
enlargements  may  be  felt  here  or  along  the  cervical  chain. 

In  addition  to  the  above  features  others  which  are  more  indicative,  because  they  point 
to  advanced  disease,  are  the  appearance  in  the  skin  or  just  beneath  it  of  sliot-like 
nodules,  more  or  less  red,  or  of  any  mass  which  causes  the  skin  to  protrude  and  to  have  an 
unnatural  aj)pearance,  usually  one  of  lividity  or  threatening  ulceration.  Pain  w  an 
iinrniiiin  and  rariab/r  feature,  upon  which  little  stress  shouhl  be  laid.  The  laity  have 
incorrect  notions  about  the  constancy  and  significance  of  pain,  and  many  a  woman 
has  deluded  herself  into  the  notion  that  she  had  no  cancer  because  her  tumor  was  not 
painful.  Pam  is  sometimes  pronounced  and  severe,  even  radiating  down  the  arm;  at 
other  times  it  u  absent  until  almost  the  terminal  stage. 

Any  twnor  in  the  breast  which  presents  any  one  of  the  above  characteristics  is  to  be 
regarded  as  at  least  suspicious,  while  the  ocotrrence  of  two  or  more  of  the  above  features 
should  stamp  it  as  malignant,  and  consequently  condemn  it.  This  is  equally  true  of  the 
cancers  which  rarely  appear  in  the  male  breast. 

Cancer  is  supposed  to  be  a  disease  of  middle  and  usually  of  advanced  life.  This, 
again,  is  an  error.  To  be  sure,  carcinoma  is  rare  below  the  age  of  thirty,  and  yet  one 
sees  it  not  infrequently  in  women  much  younger  than  that.  One  of  the  saddest  cases 
I  have  ever  known  was  one  of  carcinoma  of  both  breasts  in  a  young  mother  of  twenty- 
two,  advanced  to  hopeless  condition  because  her  physician  had  held  that  it  could  not 
be  cancer  at  her  age,  and  because  she  had  coincided  with  his  belief,  since  she  had  not 
suffered  pain. 

The  course  of  a  cancer  in  the  breast  depends  on  several  factors.  There  is  a  rapidly 
growing  type  which  tends  to  kill  within  a  few  months,  this  occurring  usually  in  younger 
l)atients.  On  the  other  hand  there  is  a  slowly  growing  type  which  may  last  over  a  period 
of  years.  This  is  the  so-called  atrophic  cancer,  and  its  slow  growth  is  due  to  the  per- 
fection of  the  protection  afforded  around  the  cancerous  masses  by  the  density  of  the 
stroma.  Occurring  in  a  fatty  l^reast  it  leads  to  a  diminution  of  its  total  mass,  even  though 
the  cancerous  features  themselves  be  advancing,  and  this  makes  it  sometimes  hard  to 
convince  patients  that  a  breast  w^hich  is  actually  diminishing  in  size  is  becoming  more 
and  more  seriously  involved.  Cancer  tends  ever  to  advance,  and  sometimes,  as  it  were, 
by  leaps,  the  method  of  invasion  being  usually  one  of  steady  progress  antl  infection  of 
the  adjoining  tissues;  while  metastases  are  to  be  expected  as  the  case  goes  on,  and  occur 
sometimes  in  unexpected  forms.  Thus  in  cancer  of  the  breast  there  is  a  well-known 
metastatic  invasion  of  the  bones,  even  of  the  extremities,  with  the  consequent  liability 
to  so-called  spontaneous  fracture.  In  cases  of  the  latter  the  former  condition  should 
always  be  suspected.  There  is  a  possil)ility  always  of  invasion  of  the  sternum  and  the 
ribs  by  continuity.  It  has  been  shown  that  invasion  of  the  pectoral  muscle,  and  even 
of  the  firm  pectoral  fascia,  was  a  common  result,  and  this  demonstration  has  led  to  the 
adoption  of  the  more  recent  radical  methods  of  removing  both  of  these  structures  along 
with  the  involved  breast.  In  rare  instances  both  sarcoma  and  carcinoma  assume  the 
miliary  type,  and  e^•ince  it  by  a  miliary  invasion  of  the  skin  of  the  thorax  which  becomes 
gradually  infiltrated,  softened,  and  perhaps  finally  ulcerated,  the  involved  skin  thus 
having  the  aspect  of  a  corset  of  diseased  tissue,  and  being  spoken  of  as  "jacket  cancer" 
or  "cancer  en  cuiras.te."  Such  a  condition  may  before  the  patient's  death  involve  the 
entire  circumference  of  the  thorax.  Any  of  these  miliary  expressions  of  malignancy 
stamp  a  case  with  a  ho])eless  aspect.     Cxeneral  miliary  carcinosis  is  also  known  to  occur. 

Nearly  all  cancers  grow  faster  in  the  young.  Other  things  being  equal,  there  is  a 
somewhat  better  prognosis  for  the  condition  in  elderly  people,  and  this  apj)lies  equally 
to  prosjject  of  recurrence  after  removal. 

In  regard  to  the  curability  of  cancer  the  reader  is  again  referred  to  an  earlier  chapter 
on  the  general  subject,  but  doubtless  there  is  a  time  when  if  the  groicth  were  recognized 
and  thoroughly  removed  it  would  not  recur  and  the  patient  might  be  cured.  This  time 
is,  unfortunately,  too  often  past  when  the  case  comes  under  the  observation  of  one  com- 
petent to  deal  with  it.  This  is  due  partly  to  fear  and  ignorance  on  the  part  of  the  ])atient, 
and  unfortimately  too  often  to  failure  on  the  part  of  some  practitioner  to  appreciate 
the  significance  of  the  early  manifestations,  i.  e.,  to  a  failure  in  early  diagnosis. 

Cancer  also  occasionally  occurs  in  the  7nale  breast,  and  I  have  record  of  a  number  of 
fatal  instances  (if  this  kind.     It  is,  however,  (|uite  rare.     It  is  usually  of  the  scir'hus 


TUMORS  OF   THE   likh'AST 


763 


type,  \n\t  iiiiiy  he  tlic  result  of  ('|)i(li('li()iii;i  coimiK'nciii^  al)()iit  (lie  ni[)|)l('  and  spreudins;. 
It  caiiiiot  asstiiiK'  marked  si/e  uillioiit  heeoiiiiiif^  tlioroiiffhly  distinctive,  and  probably 
ulcerating;,  and  tliere  should  be  no  dilliculty  in  diaj^nosis.  It  demands  the  same  radical 
operation  as  euncer  in  the  IVmaie  (Ki^.  fyl!)). 

Treatment.  In  reji^ard  to  the  method  of  treatment  there  is  but  one  which  needs  to 
be  seriously  considered,  all  others  hriiu/  fallarioii.s  and  irrational.  It  in  hii  oiwrative 
rnnoral  alone  that  ereri/  hopeful  ea.sr  should  he  treated  at  the  earliest  possiljle  date.  Patients 
may  dread  the  knife  and  some  men  may  fear  to  use  it.  Nevertheless  the  above  state- 
ment holds  true.  Even  then  cure  is  not  obtained  unless  the  knife  be  used  tliorou<rhly. 
Treatment  by  plasters  is  barbarous  and  unscientific,  as  well  as  uncertain  and  absolutely 
unsur<;ical.  None  of  th(>  popular  rem(>dies  is  of  the  sli<;htest  value.  Treatment  by  the 
R()nt^en  rays  should  be  reserved  for  tlu>  hopeless  cases  or  for  postoperative  protection. 
Kradication  is,  therefore,  the  only  scientific  surgical  relief. 

Ann  growing  tumor  in  the  breast  of  a  woman  irhieh  cannot  he  clearlij  reeocjnized  as 
perfectlif  innocent  demands  operative  removal,  and  the  operation  itself  should  Ix;  made 
thorou<,di  if  success  is  to  be  attained.     In  the  presence,  then,  of  l}iiij)hatic  involvement. 


Fig.  525 


Fi<;.  52C, 


Recurrent  carciuoma  eight  montlis  after  incomplete 
operation  in  a  woman  seventy-five  years  of  age,  sliowin^ 
the  extensive  nodular,  ulcerating  surface  surrounded  by 
cancerous  masses  under  the  skin.  The  edema  of  tlie 
right  arm  from  the  circulatory  obstruction  occasioned  by 
metastatic  growths  about  the  axillary  vessels  is  well 
shown.     (Parker.) 


Cancer  of  male  breast.     (Buffalo  Clinic.) 

of  any  adhesion  or  infiltration  of  the 
overlying  skin,  or  of  the  surrounding 
textures,  or  of  retraction  of  a  nipple, 
or  of  fixation  of  the  breast  upon  its 
base,  operation  should  be  advised 
witliout  any  reference  to  the  question 
of  pain.  Equally  important  is  it  to 
decide  when  not  to  operate.  When 
the    condition    is    dLsseminated,    when 

the  presence  of  cancer  in  any  other  part  of  the  body  can  be  demonstrated,  when  the 
l}Tiiphatics  of  the  neck  are  notably  involved,  when  the  arm  is  already  swollen  from  ob- 
struction to  the  return  circulation,  when  the  skin  presents  numerous  miliary  nodules, 
or  when  from  disturbance  of  the  heart  or  of  respiration— i.  e.,  chronic  cough— it  might 
appear  that  there  is  involvement  of  the  bronchial  nodes,  with  consequent  pneumogas- 
tric  irritation,  then  it  may  be  held  that  the  case  is  so  far  advanced  that  it  is  useless  to 
subject  the  patient  to  the"  risk  entailed  by  operation.  There  are  e.xceptions,  however, 
even  to  this  statement;  such  as  an  evidently  hopeless  case  that  has  reached  the  stage 
of  ulceration,  in  which  discharge  is  offensive  or  hemorrhage  recurring,  when  operation 
may  be  done  for  temporary  atid  with  humane  purposes. 


704  SPECIAL  OR  REdlONAL  SVRdKRY 

Recurrence  is  to  a  largo  extent  inseparably  connected  with  the  matter  of  both  eurh) 
and  thorough  removal.  Only  when  this  can  be  practised  shonld  any  hope  of  radical 
cure  be  offered.  While  the  results  attained  by  modern  methods  are  very  eneouraginji;, 
they  nowise  contradict  this  statement.  The  discreet  operator  will,  therefore,  be  guarded 
in  giving  a  favorable  ])rognosis  or  making  promises.  Fig.  r)2()  illustrates  many  of  the 
sad  features  pertaining  to  recurrence. 


OPERATIONS  UPON  THE  BREAST. 

Every  precaution  having  l)een  taken  the  operator  should  decide  whether  the  operation 
is  to  be  enucleation  of  the  tumor  or  complete  excision  of  the  breast,  with  dissection  of 
the  axilla.  An  evidently  innocent  tumor  of  small  size  may  be  removed,  either  through 
a  straight  incision,  which  should  be  placed  radially,  or  by  raising  a  flap  with  an  ovoid 
incision,  by  which  more  perfect  dissection  is  j)ermitted.  Small  nodules  and  superficial 
growths  may  be  removed  imder  cocaine  anesthesia.  The  first  essential  is  to  leave 
behind  nothing  of  the  mass  which  it  is  desired  to  remove;  the  second  is  exact  hemostasis, 
and  the  third  is  the  closure  of  the  wound.  It  is  possible  to  remove  portions  of  the 
gland  itself,  as  well  as  to  enucleate  tumors  from  within  its  substance.  V-shaj)e(l  incisions 
may  be  coapted  with  sutures,  by  which  the  size  of  the  gland  is  reduced,  but  its  general 
proj)ortions  maintained.  Tumors  situated  posteriorly  may  be  removed  by  making  an 
incision  beneath  the  breast,  around  its  border,  raising  it  from  the  thorax,  and  returning 
it  to  place  after  the  necessary  excision.  It  is  advisable  to  ])rovide  a  small  drain  for 
these  cases,  as  in  the  more  or  less  loose  tissues  of  the  breast  blood  is  likely  to  accumulate, 
and  by  distending  the  wound  to  interfere  with  its  repair. 

Operalions  for  cancer  of  fhe  hreasi  are  jierformed  more  radically  than  a  few  years  ago. 
This  is  due  to  a  more  thorough  knowledge  of  the  pathology  of  the  disease,  and  to  the 
betttT  appreciation  of  the  value  of  thorough  extirpation  of  all  afiected  tissues,  especially 
if  this  can  be  done  early  rather  than  late.  Therefore  the  modern  o|)eration  includes 
not  only  the  removal  of  the  breast  and  of  the  axillary  nodes,  but  of  the  pectoral  fascia 
and  muscle,  the  fatty  tissue  in  the  neighborhood,  and  everything  in  which  the  disease 
may  lurk. 

The  essential  feature,  then,  of  every  case  is  the  removal  of  all  tifis-ue  which  viay  he 
involved.  It  is  therefore  necessary  to  remove  the  skin  covering  the  mauuua,  as  well  as 
the  structures  above  mentioned.  This  is  done  by  elliptical  or  ovoid  incisions,  the  amount 
thus  included  being  sufficient  to  take  in  every  particle  of  skin  which  shows  the  slightest 
possibility  of  infection — i.  e.,  every  nodule  or  dimple  which  may  be  in  any  way  connected 
with  the  primary  disease.  Inasmuch  as  only  in  cases  seen  early  is  it  at  all  safe  to  be  less 
radical  than  just  mentioned  the  pectoral  fascia  and  muscle  should  be  removed.  For 
these  purposes  large  and  long  incisions  arp  necessary,  extending  from  the  anterior 
border  of  the  axilla  down  towanl  the  costochondral  junction,  while  the  lower  part  of 
the  opening  is  divided  and  the  incision  made  elliptical,  in  order  that  the  breast,  with 
its  coverings,  may  be  completely  removed.  The  u])])er  end  should  follow  the  lower  border 
of  the  pectoral  tendon,  or  at  least  be  placed  near  it,  extending  as  far  as  the  insertion  of 
this  tendon,  since  that  portion  belonging  to  the  muscle  excised  should  be  divided  at  its 
insertion  and  removed  with  the  rest  of  the  mass.  The  incisions  then  are  usually  carried 
down  first  to  the  deep  fascia,  and  then  through  this,  in  such  a  way  that  the  underlying 
muscle  may  be  lifted  from  the  thorax  and  detached  therefrom.  The  result  is  that  there 
is  dissected  from  the  chest  wall  a  total  mass  of  gland,  fat,  fascia,  and  muscle,  which  is 
continuous  upward  and  outward  toward  the  axilla,  from  which  the  final  dissection  is 
made.  Then,  commencing  on  the  outer  side  of  the  axilla,  so  much  of  the  pectoral 
tendon  is  divided  as  may  be  necessary;  close  beneath  it  will  be  foimd  the  axillary 
vein,  and  this  is  next  to  be  fre<Ml  from  its  cellular  and  fatty  surroundings.  The  dis- 
section is  now  carried  toward  the  deeper  part  of  the  axilla,  vessels  being  secured  before 
division,  and  the  entire  contents  of  the  axilla  being  carefully  removed  in  one  continuous 
mass.  This  requires  careful  and  sometimes  tedious  dissection,  which  is  made  much 
easier  by  exact  hemostasis.  If  the  greater  part  of  the  great  pectoral  muscle  be  removed, 
complete  exposure  of  the  axilla  is  easier.  When  this  is  not  sufficient,  because  in  the 
uppermost  portion  of  the  axillary  cone  may  be  felt  enlarged  lymjih  nodes,  at  the  level 
of  or  beneath  the  clavicle,  then  the  lesser  pectoral  should  be  divided  at  its  middle,  and 


()i'i:ii'.\Ti().\s  r/'o.v  77//;  iiRi:.\sr 


705 


its  ends  hdd  apart,  this  alVordinjr  a  still  lK'tl«'r  exposure  ol'  llie  axillary  (le|)tlis.  By 
this  measure  tiie  vessels  and  plexuses  may  he  easily  followed  uj)  to  the  level  of  the  emer- 
<;euee  of  tiie  former  fn»m  the  thorax,  es])ecially  if  the  arm  he  held  upward  and  forward, 
much  dependinjf  upon  the  position  in  whi<'h  the  assistant  thus  holds  it. 

Kvervthin>i  which  is  actually  involved  should  he  sacrificed.     This  \\\\\f\\i  even  a|)ply 
to  the  a.\illary  vein,  which  may  be  douhly  li^Mted  and  e.x.sected.     It  will  occasionally 


Fiu.  527 


Diagram  showing  skin-incisions:  triangular  flap  of  skin,  a  h  c.  and  triangular  flap  of  fat.     (Ilalstcd.) 

happen  that  it  is  cut  or  torn  in  some  deep  dissection.  In  this  event,  licfore  resorting 
to  final  double  liii;ation,  an  eflbrt  should  be  made  to  suture  the  opening  with  fine  silk  sutures 
passed  with  a  round  needle,  which  may  be  successfully  done,  or  to  secure  a  small  tear 
within  the  jaws  of  a  curved  hemostat,  may  then  be  left  within  the  dressings  for 
forty-eight  hours  or  longer;  by  this  time  a  clot  will  have  formed  which  will  ))ermit  its 
detachment.     While  much  work  may  thus  be  done  upon  the  axillary  vein  the  writer 

Fig.  528 


Breast  and  pectoral  muscle  completely  separated  irom  thorax;  axilla  exposed.     (Hal.<5ted.) 

nevertheless  has  the  feeling  that  when  a  case  is  advanced  to  such  a  degree  as  to  demand 
this  it  is  scarcely  worth  while,  because  recurrence  is  |)ractically  sure  to  follow.  Never- 
theless in  the  interest  of  general  thoroughness,  if  the  work  has  been  begun,  it  is  usually 
well  to  finish  it  as  conijiletely  as  possible. 

The  operation  as  thus  described  has  been  extended  by  Halsted  to  a  degree  which 
requires  often  much  more  work,  and  which  has  furnished  even  better  results,  since  he 


76f)  SPECIAL  OR  REGIOXAL  SURCERY 

inclucles  in  it,  if  necessary,  the  removal  of  both  peetoral  muscles,  and  even  the  division 
of  the  clavicle  for  better  exposure  of  the  axillary  and  lower  cervical  regions,  and  the  more 
thorough  extirpation  of  involved  lymphatics.  In  other  cases  he  makes  a  vertical  incision 
along  the  ])()stcrior  margin  of  the  sternoniastoid,  exposing  the  junction  of  the  internal 
jugular  and  subclavian  veins,  and  removes  the  supraclavic-uiar  fat  by  a  downward  dis- 
.si'ction  and  the  infraclavicular  fat  by  a  dissection  from  below.  This  is  facilitated  by 
elevating  the  shoulder,  by  which  the  clavicle  can  be  removed  one  inch  or  more  from  the 
first  rib. 

Figs.  527  and  528  illustrate  the  incision  recommended  by  Halsted  and  the  general 
method  of  attack. 

Throughout  these  operations  the  primary  question  is  removal  of  disease,  the  matter 
of  subsequent  closure  of  the  Avound  being  a  secondary  consideration.  Nevertheless  the 
extirpation  being  completed,  there  arises  the  c(uestion  of  how  best  to  close  the  extensive 
defect  thus  created.  This  will  depend  on  its  size  and  u])on  the  amount  of  loose  skin  in 
the  vicinity  furnished  by  the  patient's  general  physique.  With  emaciated  patients, 
whose  skin  is  tightly  drawn,  it  is  not  easy  to  furnish  fla])s,  whereas  in  tliose  who  are  fatty, 
with  flabby  flesh  and  skin,  it  is  easy  to  rearrange  the  latter.  Beck  has  suggested  to 
make  quadrilateral  instead  of  elliptical  incisions,  leaving  a  square  defect,  which  can 
then  be  closed  by  sliding  flaps  from  two  directions.  The  names  of  ^Yarren  and  jNIeyer 
are  also  connected  with  elaborately  desc-ribed  plastic  operations.  Years  before  any  of 
these  were  published  the\ATiter  was  d(jingsimilar  sliding  of  flaps,  but  never  endeavoring 
to  make  them  conform  to  a  single  pattern,  raising  semilunar  flaps,  or  those  of  any 
other  shape,  as  might  best  fill  the  demand,  and  taking  them  from  that  ])ortion  of  the 
thorax,  side,  or  even  the  abdomen,  which  would  seem  best  to  furnish  them.  There  is, 
therefore,  no  one  method  to  be  especially  recommended,  for  every  operator  of  good 
judgment  will  be  able  to  secure  sufficient  integument  from  some  surrounding  loca- 
tion, so  that  it  is  rarely  necessary  to  leave  such  a  wound  uncovered.  In  those 
cases  which  require  an  amount  of  dissection  not  permitting  this  it  is  a  question  if 
operation  be  adA'isable.  Nevertheless  should  it  happen  that  for  some  reason  a  sufficient 
skin  covering  is  not  thus  easily  available,  Thiersch  skin  grafts  may  be  applied  to  any 
uncovered  area  at  the  time  of  terminating  the  operation  or  later,  and  may  be  nearly 
always  relied  upon  for  their  destined  purpose. 

At  least  one  opening  should  be  made  in  the  lateral  flap  in  such  a  location  as  to  drain 
the  axillary  cavity  when  the  patient  is  lying  upon  her  back,  and  through  this  a  drainage 
tube  of  sufficient  size  should  be  inserted.  This  should  rarely  be  left  more  than  forty- 
eight  hours.  Inasmuch  as  there  will  sometimes  be  considerable  tension  upon  flaps 
a  certain  number  of  strong  and  reliable  sutures  (silkworm  or  thread)  should  be  used, 
to  prevent  parting  of  the  wound  margins,  while  long  retention  sutures  may  be  inserted 
if  required.  The  balance  of  the  suturing  may  easily  be  done  with  catgut.  The  intent 
should  be  to  leave  no  dead  spaces.  Any  isolated  mass  of  fat  which  stands  out  by  itself 
after  the  dissection  is  complete  should  be  pared  down  to  the  common  level,  in  order 
that  it  may  not  perish  from  ill-nutrition,  nor  disturb  the  general  level  of  the  adjoining 
surfaces.  It  is  rarely  necessary  to  keep  patients  in  bed  more  than  two  or  three  days 
after  even  extensive  operations  of  this  kind,  but  it  is  necessary  to  ensure  that  ecjuable 
|)ressure  be  made  with  the  dressings,  and  that  the  entire  arm  be  boimd  to  the  side  and 
immobilized  in  such  a  way  that  the  patient  cannot  move  it  nor  disturb  the  dressing. 


(  IIAl'TER    XLV. 

TlIK  .\i;i)()MK.\  AM)  AIJDO.MIXAL  \IS('KI{A. 

GENERAL  CONSIDERATIONS  AND  CONDITIONS. 

TlIA  r  liirjfc  ])()r(i()ii  of  (lie  Iniinaii  body  wliicli  with  its  coiitonts  we  term  flic  ahdonicii 
was  for  a  lout,'  time  Irrm  inr()(/nil(t  to  the  siirtfcon.  Despite  the  sporadic  success  of  such 
men  as  McDowell  and  others  there  was  felt,  until  the  latter  part  of  the  hust  ecntiiry,  a 
universal  and  well-merited  fear  of  intrusion  uj)on  the  |)eritoneal  cavity,  because  of  tlie 
tremendous  probabilities  of  infection  and  fatal  |)eritonitis.  Until  the  memorable 
researches  of  Lister  and  the  introduction  of  an  antiseptic,  later  of  an  asef)tic  technique, 
there  was,  therefore,  the  best  of  reason  for  repirdino;  the  abdominal  cavity  as  a  sanctum 
to  be  entered  only  when  dire  necessity  re(iuired.  In  spite  of  the  complexity  of  its  ana- 
tomical arrani^ements,  as  well  as  the  peculiar  and  widesj)read  ramifications  and  con- 
nections of  its  vessels  and  its  sympaihetic  and  sj)inal  nerves,  with  the  almost  innumerable 
complications  thus  permitted  and  favored,  and  the  resulting  uncertainty  of  symptoms 
and  distant  disturbances  of  function,  the  abdominal  cavity  became,  first,  a  favorite  seat 
for  laboratory  study  and  experiment,  and  then  a  fascinating  field  for  surgical  endeavor. 
Today  this  region  is  invaded  by  the  surgeon  in  a  manner  and  with  a  freedom  which 
would  have  been  criminal  and  unjustifiable  when  the  waiter  of  these  pages  was  a  student; 
and  yet,  while  we  have  in  the  main  lost  our  fear  of  the  peritoneum  and  our  dread  of 
peritonitis,  we  nevertheless  see  the  latter  occur  now  and  again,  as  it  were  as  a  punish- 
ment for  forgetfulness  or  intention,  the  patient  unfortunately  paying  the  penalty  for  the 
errors  of  which  he  is  not  guilty.  Abdominal  surgery  has  now  become  a  specialty 
which  has  attracted  too  many  of  those  not  thoroughly  fitted  by  training  and  by  experience. 
One  hears  today  of  many,  the  older  practitioners  especially,  insisting  that  the  abdomen 
is  too  often  opened;  perhaps  it  would  be  more  just  to  say  that  it  is  opened  by  too  many. 
By  this  expression  is  meant  simply  that  enthusiasm  has  not  always  been  tempered  hy 
discretion,  and  that  this  is  a  department  of  surgery  which  has  been  too  enthusiastically 
cultivated  by  men  who  have  not  waited  to  ripen  their  judgment  or  perfect  their  methods. 
My  own  feeling  is  that  not  merely  large  observation  should  be  regarded  as  an  essential 
preliminary  for  such  work,  but  extensive  experimentation  in  a  surgical  laboratory; 
while  even  here  the  tyro  has  to  learn,  perhaps  by  severe  experience,  that  not  all  human 
beings  can  recover  after  manipulations  which  some  of  the  lower  animals  bear  with 
apparent  impunity.  Previous  experience  as  assistant  to  a  skilled  operator  is  of  the 
greatest  value. 

While  uttering  this  caution  we  must,  at  the  same  time,  candidly  acknowledge  that 
accurate  diagnosis  of  deeply  seated  lesions  is  by  no  means  always  possible,  and  that 
the  tendency,  especially  among  the  practitioners  of  internal  medicine,  has  been,  and 
often  is,  to  waste  valuable  time  in  the  application  of  methods  of  physical  diagnosis,  all 
of  which  are  valuable,  many  extremely  ingenious,  and  yet  which  prove  insufficient 
or  misleading.  To  give  but  one  illustration — cancer  of  the  stomach,  for  instance,  is  a 
disease  absolutely  without  a  special  symptomatology.  If  we  are  to  wait  for  the  develop- 
ment of  a  recognizable  tumor  or  other  features  which  are  unmistakably  significant, 
we  wait  until  the  period  for  successful  surgical  attack  has  nearly  or  quite  elapsed.  Thus 
rather  than  permit  months  of  valuable  time  to  be  wasted,  it  seems  to  the  modern  surgeon 
far  more  humane  to  make  an  early  exploration,  in  order  that  he  may  attack  the  disease 
while  it  has  involved  but  a  minimum  of  tissue. 

The  general  practitioner  has  seen  himself  robbed,  as  it  were,  of  one  part  of  the  body 
after  another,  by  the  ajiplication  of  this  general  principle,  until  there  has  developed  a 
feeling  of  irritation  or  one  even  more  pronounced,  in  certain  cases,  of  rebellion,  as  it 
were,  against  the  cession  of  this  territory  to  the  surgeon ;  but  this  is  wrong,  and  such 
feeling  should  not  exist.     Rather  should  there  take  place  the  heartiest  cooperation 

(767) 


768  SPECIAL  on  UFA  no  SAL  SVRGLRY 

between  physician  and  snrfijeon,  while  the  ()])erative  proeechires  directed  toward  the 
early  rec()<j;nitic)n  ot"  tliesi'  more  or  less  vaj^iie  conditions  shonid  he  re<farded  more  kindly 
and  the  procedures  themselves  rcf^arded  rather  in  the  lif^lit  of  operative  tliera|)eutics. 
A  recoo-nition,  then,  of  the  limitations  of  physical  diaj^nosis,  comhined  with  an  earnest 
desire  to  do  the  fi;reatest  good  to  the  ])atient  at  the  earliest  possible  time,  when  cheerfully 
combined,  and  practised  by  those  of  ripened  ex])erience  and  cultivated  skill,  will  re- 
dound to  the  greatest  credit  of  all  concerned  and  afi'ord  the  greatest  j)rolongation  of 
human  life.  It  is  to  be  hoped  that  the  day  when  tlie  jihysician  shall  charge  the  surgeon 
with  killing  his  patient,  and  the  surgeon  shall  have  it  in  his  ])()wer  to  retort  that  the 
patient  did  not  reach  him  until  he  was  almost  dead  for  lack  of  surgery,  may  soon  jxiss 
away. 

jJiacjno.si.s  of  ahdoiiiinal  disra.srs  rcfjuires,  first  of  all,  a  comprehensive  knowledge  of 
anatomy  and  physiology,  as  well  as  familiarity  with  all  the  methods  of  biochemical  and 
mechanical  research,  on  which  large  volumes  have  been  written,  along  with  a  peculiar 
tact  which  in  some  individuals  amounts  to  a  gift,  and  includes  the  cultivation  alike  of 
the  senses  of  touch  and  sight,  and  the  power  of  analytical  reasoning. 

While  some  of  the  intra-abdominal  lesions  may  be  recognized  within  a  minute  or  two, 
others  defy  a  study  prolonged  over  hours  or  days.  The  general  methods  to  be  applied 
do  not  diif'er  here  from  those  available  elsewhere,  save  that  they  find  perhaps  an  even 
wider  application. 

Tran.spo.sifion  of  the  viscera  is  one  of  the  rare  anatomical  anomalies  with  which  we 
may  at  any  time  meet  most  unexpectedly.  This  applies  cfjually  well  to  the  thorax  and 
to  the  abdomen,  but  the  conditit)n  is  met  with  oftener  in  the  latter.  It  may  be  met  as  a 
sur))rise  or  it  may  be  diagnosticated  before  operation.  In  one  case  upon  which  the  writer 
operated  for  aj)pendicitis  he  found  the  thoracic  viscera  transposed  and  the  heart  upon 
the  right  side.  The  occurrence  is  so  rare  as  to  figure  but  seldom  in  the  consideration  of 
a  given  case,  but  its  possibility  should  not  be  forgotten.  Thus  acute  pain  upon  the  left 
side,  with  other  indications  of  appendicitis,  has  been  known  to  have  an  anatomical  basis 
of  this  character.  It  will  usually  be  easy  to  determine  whether  the  liver  and  the  spleen 
have  changed  places,  and  if  so  it  may  be  expected  to  find  relative  rearrangement  of  all 
the  other  abdominal  contents. 

Inspection  should  be  made  with  the  ])atient  well  ex]M)sed,  in  the  dorsal  position,  divested 
of  clothing,  and  with  fear  and  hypersensitiveness  allayed  as  much  as  possil)le  by  tact, 
and  perhaps  even  by  the  administration  of  some  soothing  remedy.  Ins])ection  should 
concern  not  alone  the  abdomen  but  the  attitude  of  every  })ortion  of  the  body,  the  character 
of  the  breathing,  the  motility  of  the  chest,  the  expression  of  the  face,  the  degree  of  muscle 
spasm,  and  the  fact  whether  pain  impels  the  ])atient  to  move  and  toss  or  to  lie  quietly. 
Any  irregularity  of  al)dominal  contour,  with  or  without  the  legs  flexed,  should  not  fail 
of  observation.  The  cause  of  any  great  increase  in  normal  pro])ortions  should  be 
promptly  sought  and  assigned,  either  to  collection  of  fat  outside  of  the  peritoneal  cavity, 
of  fluid  within  it,  to  gaseous  distention  of  the  bowels,  or  to  the  presence  of  some  intra- 
abdominal growth.  Any  bulging  in  either  side  or  loin  should  also  be  noted,  as  the 
latter  may  be  due  to  some  renal  condition.  The  existence  of  a  distended  bladder  should 
be  recognized,  while  the  appearance  of  the  umbilicus  sometimes  afl'ords  valuable  informa- 
tion, it  being  flattened  in  tumor  cases  or  bulging  and  j)erhaj)s  containing  fluid  in  drop- 
sical conditions  or  tuberculous  peritonitis.  When  the  sui)erflcial  veins  are  enlarged  it 
may  be  felt  that  there  is  deep  obstruction  to  return  circulation,  which  may  be  often 
located  in  the  liver.  When  the  veins  of  the  limbs  show  the  same  result  it  may  be  believed 
that  the  obstruction  is  rather  of  the  general  circulation  than  of  the  hepatic,  and  when 
involving  one  side  alone  a  unilateral  lesion  may  be  expected.  The  coexistence  of 
hemorrhoids  will  indicate  obstruction  to  the  hepatic  return,  while  varicosities  of  the 
external  genitals  would  probably  indicate  it  in  the  general  circulation.  Much  imj)or- 
tance  may  sometimes  attach  to  the  ])resence  or  al)sence  of  the  linea>  albicantes,  or  of  those 
pigmented  areas  which  almost  invariably  indicate  a  ])revious  j^regnancy.  P^'ixatioti  of 
superficial  tissues  or  of  viscera  implies  either  an  infectious  or  a  malignant  process,  while 
recognizable  local  edema  may  point  to  a  suppurative  condition  if  the  disease  be  recent 
and  acute,  or  to  venous  obstruction  if  it  be  old. 

Palpation  will  afford  information  in  proportion  to  the  tactile  sensibility  and  ability 
of  the  observer,  and  the  relaxed,  rigid,  collapsed,  or  distended  condition  of  the  patient's 
abdomen.     It  may  aft'ord  aid  in  one  case  and  little  or  none  in  another.     The  value  of 


(ii:m:i!.\l  ci)\sii)i:i;.\rit)\s  .\\i>  <(i.\ nirio.xs  709 

what  it  iiiav  rcvi'al  is  also  <:;rratly  iiidiKMiccd  hy  (he  |)aiii  ami  tcii(lcriicss  wliidi  its  practise 
may  cause.  Its  value  may  also  he  limited  hy  liy|»erseiisiliveiiess  or  ri-dex  coiitracUoii.s, 
i'rom  w  liicli  some  patients  can  iicnci-  xolimtarily  free  themselves.  So  completely  may  the 
Value  of  |)alpalion  lie  liniilcil  oi-  destroyed  (hat  every  menus  of  |)ro<hieiu<^  relaxation  or 
of  alioiisliiiio- spasm  may  have  to  he  iMi!|)loyed.  \\'lien  these  ;ire  |)r(>seMt  in  lesser  dej^ree 
nolhin«;-  is  more  ellicaeions  than  to  examine  the  patient  just  after  removal  from  a  hot 
l)ath  or  even  while  sul)mi'r<;'ed  in  hot  water.  In  cxli'cme  cases  the  aid  of  coni|tlete 
anestlu'sia  may  have  to  he  souj^hl. 

liniKiniKil  j)(i/j)(ili()n  is  of  special  service  in  examiniii<f  the  rej^ioii  of  the  kichieys  or 
the  loins,  and  may  often  he  advantajfeoiisly  comhined  with  the  fiii<i;er  of  one  hand  in  the 
vajiina  or  rectum.  Special  rij^idity,  like  special  tenderness,  is  always  a  si<fii  of  jrreat 
sijiiiificance.  \Vhen  the  neurotic  or  hysterical  feature  can  he  eliminated  one  may  almost 
hold  to  the  \ic\\  that  it  points  unerrin<jjly  to  somethin<:;  wronjf  within.  Palpation 
should  include  tlii"  reco^iiitiou  of  ahnormal  pulsation  in  the  aorta,  and  determination 
whetlu-r  this  is  liue  to  (he  presence  of  an  overlyiuff  tumor  or  is  one  of  those  cases  in 
which  (he  aorta  pulsates  uiori'  prominently  than  it  ordinarily  should.  Any  ahnormal 
jnilsation  should  hi'  estimated  as  to  its  expansile  or  non-e.xpaiisile  character,  'i'lie  recofi;- 
nition  of  u  hriiit  may  he  supplemented  hy  its  further  identification  with  a  stetlioseoj)e. 
An  intra-ahdomiiial  growth  once  tliseovered,  the  .surgeon  should  ohviously  learn  uhoiit 
it  all  that  he  ean,  regarding  its  real  location,  its  origin,  its  movahility,  its  density,  its 
fluctuation,  etc.;  also  whether  there  is  free  fluid  in  the  ahdominal  cavity.  It  is  not 
infre(|uently  necessary  to  dilVerentiate  tumors  in  the  lower  alxlomen  and  |)elvis  from 
pregnancy,  either  normal  or  ahnormal,  and  one  should  he  familiar  with  the  ordinary 
evidences  of  this  condition,  as  well  as  alert  to  the  ))ossihilities  of  such  a  ease.  The  value 
of  i)al])ation  is  often  enhanced  hy  changing  the  position  of  the  j)atient  from  that  upon 
the  hack  to  the  lateral  or  the  genuj)ectoral  ])osition. 

The  value  of  added  vaginal  and  rectal  examinations  is  sometimes  inestimable,  even 
in  conditions  which  ajjparently  do  not  involve  the  pelvic  organs  proper.  In  cases  of 
ohstruction  of  the  howel,  for  instance,  the  finger  in  the  rectum  may  discover  an  intus- 
susce])tum,  while  in  the  female  every  tumor  of  the  lower  portion  of  the  ahdomen  can 
he  hetter  examined  and  estimated  hy  this  comhined  bimanual  palpation. 

The  value  of  palpation  is  increased  hy  the  addition  of  pcrcn.'i.siun  as  j)art  of  the  pro- 
cedure, although  c(»nditioiis  made  evident  hy  the  latter  are  usually  detectable  by  the 
former.  The  surgeon  will,  however,  rely  but  little  upon  percussion  alone,  although  it  may 
he  possil)le  in  a  large  hernia  to  decide  as  to  the  probable  nature  of  its  contents  by  this  test. 
Auscultation  is  of  es])ecial  value  in  recognizing  fetal  heart  sounds  and  placental  or  aneu- 
rysmal bruit.  Friction  sounds  with  splashing  in  stomach  dilatation,  and  gurgling  sounds 
in  certain  stibdiapliragmatic  abscesses  which  contain  gas,  are  also  discernible  through 
the  stethoscope. 

Mca.siircmcut  afl'ords  ordinarily  small  help,  save  as  one  may  in  this  way  record  the 
|)rogTess  of  a  chronic  or  ino])eral)le  case. 

Iiiliaiion,  by  means  of  carbon  dioxide  or  hydrogen  was  first  suggested,  as  an  aid  in 
abdominal  diagnosis,  by  Ziemssen  in  18S3,  and  was  ajjplicd  especially  to  recognition 
of  j)erforating  wounds  of  the  intestine  by  Senn.  Nevertheless  it  is  but  little  em])loyed, 
except  in  estimation  of  the  degree  of  dilatation  of  the  stomach  or  of  the  lower  bowel, 
as  when,  by  distending  the  colon,  the  kidney  may  be  pushed  backward  toward  the  loin 
and  the  gall-bladder  up  beneath  the  ribs,  the  bulging  thus  produced  settling  the  question 
of  diagnosis  as  between  enlargement  of  one  or  the  other.  Even  this  is  not,  however, 
always  accurate. 

The  a.spiraiing  needle  is  now^  but  rarely  used,  esj)ecially  by  those  most  experienced. 
In  those  instances  where  such  grave  doubt  exists  as  might  indicate  its  use  it  generally 
appears  that  the  welfare  of  the  ])atient  is  hetter  observed  by  an  exploratory  incision 
rather  than  by  puncture  with  a  needle. 

Pulse  and  respiration  nearly  always,  and  temperature  freciuently,  give  information  of 
great  value  in  abdominal  conditions.  A  rising  pulse  or  a  rate  over  112  to  120,  occurring 
during  any  serious  intra-abdominal  condition,  w^ill  stamp  it  as  one  of  considerable 
severity,  the  gravity  being  proportionate  to  the  increase  above  the  figures  just  given.  This 
is  particularly  true  in  acute  ajipendicitis,  with  or  without  prominent  local  symptoms. 
A  rising  pulse  rate,  then,  should  always  he  considered  as  a  warning.  A  very  rapid, 
feeble,  thready  pulse  will  usually  indicate  a  condition  seen  too  late  to  justify  surgery, 
49 


770 


SPECIAL  on  h' /■:(.•  lO.\ A L  SURGERY 


(he  paticni  lK'iii<,'  then  in  a  coiulitioii  of  practical  c()lla|).sc.  Ncvertlioless  if  it  apjx'ar  that 
this  he  due  to  hemorrhage,  either  from  injury  or  by  rupture  of  an  extra-uterine  pregnancy, 
it  may  he  felt  that  so  long  as  the  pulse  is  i)erecptil)le  the  iiulication  is  [jresent. 

Rclipiralioii  is  markedly  affected  in  many  intra-abdominal  diseases.  The  more 
thoracic  it  becomes — i.  c,  the  more  the  abdominal  muscles  are  disused — the  more  it 
bespeaks  a  serious  condition  below  the  diaphragm.  A  rigid  abdominal  wall  accompany- 
ing fr(>([uent  thoracic  respirations  l)es])eaks  a  condition  of  grave  danger.  It  should 
uvwv  be  forgotten  that  some  of  the  acute  diseases,  especially  of  the  lungs^  above  the 
diaphragm,  cause  symjitoms  and  pain  referred  to  the  viscera  below.  Thus  in  the 
early  stages  of  pneumonia  and  of  (lia])hragmatic  pleurisy  there  may  be  thoracic  respira- 
tion', abdominal  spasm,  and  pain  referred  even  below  the  waist  line,  with  strong  sinni- 
lation  of  acute  appendicitis  or  of  localized  or  general  i)eritonitis. 

Trill prrature  is  an  uncertain  feature.  Rapid  elevation  is  usually  of  serious  import, 
but  one  is  constantly  surprised  at  the  revelations  of  an  ()])eration,  or  an  autopsy,  where 
temp(>rature  is  not  significantly  elevated  or  is  even  subnormal.  Small  matters  may 
suddeidy  send  it  up — a  stitch  abscess,  for  instance — and  it  is  often  difficult  to  distinguish 
between  the  ])yrexia  of  intestinal  toxemia  and  that  of  actual  septic  infectitm.^  When 
elevated  temperature  is  intermittent  and  accompanied  l)y  chills  the  surgeon  is  justified 
in  suspecting  the  presence  of  pus,  although  the  reverse  of  this  is  not  true,  and  pu.'i  may 
form  within  the  abdomen  without  causing  chill.',-  or  even  fever.  Intermittent  fever,  with 
tenderness  in  the  upper  abdomen,  points  as  often  to  infection  of  the  biliary  tract,  usually 
with  gallstones,  as  to  all  other  conditions  combined.  Pyrexia  with  chills  and  enlargement 
of  the  liver  may  indicate  hepatic  abscess. 

When  ])ulse,  temperature,  and  respiration  rate  seem  to  keep  ])aee  with  each  other, 
no  matter  what  the  rate  may  be,  they  together  afford  a  fair  indication  as  to  what  is  going 
on.  A  careful  blood  count,  especially  a  differential  count,  will  often  be  of  service,  though 
it  will  occasionally  mislead. 

Tlie  significance  and  imjwrtance  of  pain  in  abdomimU  diseases  are  very  great, 
since  nearly  all  of  them  are  characterized,  at  least  at  some  stage,  l)y  more  ()r  less  suffer- 
ing. Much  value  attaches  to  the  liistory,  when  it  can  be  accurately  obtained,  as  to  the 
suddenness  of  onset,  the  location  and  character  of  the  pain;  as,  for  instance,  whether  it 
could  be  accurately  localized  or  was  diffuse.  Unusual  intensity  of  pain  may  afford  an 
index  to  the  acuteness  of  the  trouble,  but  in  its  location  or  reference  it  niay  be  exceedingly 
misleading.  A  large  proportion  of  ])atients  are  unable  to  descril)e  their  pains  with  suffi- 
cient accuracy,  and  a  neurotic  patient  suffering  severely  will  evince  a  widespread  hyper- 
esthesia which  will  be  dece])tive.  It  should  he  ascertained  whether  previous  an(l  like 
pains  have  ever  been  experienced,  and,  if  so,  where.  The  pains  of  acute  appendicitis, 
for  instance,  are  widely  referred,  and  will  sometimes  be  complained  of  as  intense  in 
the  left  side  or  high  up  in  the  abdomen.  I  have  known  j)atients  to  refuse  oj)eration 
because  they  could  not  be  convinced  that,  with  pain  on  the  left  side,  it  was  ])ossible 
to  have  acute  ai)pendieitis,  while  even  an  ex])erienced  practitioner  may  be  temj)ted  to 
wait  too  long  for  similar  reasons.  Pain,  accompanied  or  followed  by  jaundice,  or  a 
history  of  pain  so  associated  in  time  ]iast,  will  point  significantly  to  the  biliary  passages. 
A  history  of  ])revious  jmins  constantly  associated  with  taking  of  food  will  indicate 
gastric  or  duodenal  ulcer.  Still  pain  is  ])r()bably  more  often  associated  with  mechanical 
rather  than  chemical  conditions.  Pain  arising  from  the  gall-blad<ler  radiates  usually 
toward  the  right  infrascapular  region,  and  with  adhesions  between  the  stomach  and 
the  gall-bladder  pain  is  frequently  referred  to  the  right  shoulder,  while  when  these 
adhesions  are  between  the  stomach  and  the  colon  it  is  more  commonly  referred  to  the 
left  shoulder.  Pains  due  to  kidney  lesions  usually  are  referred  along  the  corresponding 
genitocrural  nerves,  although,  by  association  of  the  renal  nerves  with  the  semilunar 
ganglia  (and  thus  indirectly  with  the  phrenic  and  pneumogastric  nerves)  we  may  hear 
of  shoulder  pains  even  in  these  cases.  In  most  cases  of  acute  appendicitis  the  first 
complaint  of  actual  i)ain  will  be  in  the  umbilical  region,  since  the  appendix  receives 
its  blood  su]5ply  from  the  superior  mesenteric  artery  and  its  nerve  sup])ly  from  branches 
which  accomjKUiy  this  vessel,  which  are  given  off  from  the  s])ine  at  a  higher  level  than 
those  which  sup))ly  the  colon  and  sigmoid.  Thus  the  reflected  })ain  involves  the  tenth 
and  eleventh  dorsal  nerves. 

The  ])ain  of  colicky  affections  is  usually  relieved  by  pressure,  while  that  of  true  inflaia- 
mation  is  made  worse  and  is  continuous.     When  pain  is  accompanied  by  tenesmus  it 


(,i:\hh'.\L   COXSIDhh'ATKtXS   AM)   Coy  l)/'r/( ).\'S  771 

is  ;;(Micr:illy  .su|)|)(i.sc(l  thai  (lie  disi-asc  will  l»c  i'oiiiMJ  in  tlic  lower  lliinl  of  iIk>  iiil<\stiiial 
tra<  I. 

In  this  connection  \vc  may  |)crlia|)s  Ix"  a  little  more  s|)C(i(ic,  and,  follow  in;,^  I  Icminctcr, 
make  onl  a  catalo<i;iu  sonu'wliat  after  the  follow  injf  fashion: 

(liistritis  will  canse  sudden  alxjoininal  |)ain,  with  sensitiveness,  made  worse  \t\  inges- 
tion of  Ihiids,  l>y  wlii<li,  in  all  prohahility,  vomiting'  will  he  |)n)m|)tly  j)rodiieed. 

Dnodenitis  will  canse  constant  pain  and  increa.sed  sensiliveiu'.s.s,  e.sj)eciallv  in  the  ri<i;lit 
liypoeliondriae  ri'^ion,  with  nni(  iis  and  jjerhaps  hlood  in  the  stools. 

Enteritis  eimses  rather  a  colicky  |)ain,  more  widely  referred,  with  a  ^.^-ncral  nn|)leas- 
ant  sensation  oF  |>ressnre,  accompanied  l)y  distention,  diarrhea,  anorexia,  and  tiiirst. 

Colitis  will  produce  more  diarrheie  symptoms,  with  more  accurate  limitation  of  |»ain 
and  tenderness  on  |)ressiire,  while  si<fmoiditis  and  |)roctilis  will  cause  characteristic 
stools,  in  addition  to  the  localized  pain  which  they  prodiu c.  A  chronic  colitis  mav  cause 
backache,  sometimes  (|nite  sharp,  while  the  same  may  he  |)ro(hi(cd  l»v  a  well-marked 
condition  of  enleroptosis. 

The  more  chronic  forms  of  enteric  disorders  cause  irregularly  recurring  pains,  having 
definite  relation  to  errors  in  diet,  exercise,  excitement,  and  environment.  The  mem- 
branous form  of  colitis  nearly  always  j)roduees  abdominal  pain,  referred  along  the  course 
of  the  transverse  ami  descending  colon.  The  complaint  of  pain  and  the  condition  of 
the  stools  will  be  found  to  have  a  close  relationship.  Fecal  impaction  rarelv  produces 
sharp  pain  until  it  ])roceeds  to  the  degree  of  actiuil  obstruction,  but  does  cause  feelings 
of  discomfort  and  distention,  especially  in  the  right  iliac  region,  with  more  or  less 
tenesmus. 

Lead  poisoning  ])rodiU"es  severe  abdominal  pain,  distention,  and  tenderness,  with 
vomiting  and  alternating  constipation  and  diarrhea,  which  may  lead  to  confusion, 
especially  as  a  subject  of  lead  poisoning  may  be  a  sufferer  from  one  or  the  other  acute 
abdominal  conditions.  Of  course,  in  its  chronic  forms  the  characteristic  line  upon  the 
gums  and  the  nature  of  the  occupation  would  aid  in  diagnosis. 

Tubercidosis  of  the  intestines  and  peritoneum  produces  more  or  less  colickv  ])ain, 
especially  in  children,  with  enlarged  mesenteric  nodes;  while  in  consumptive  j)atients 
recurring  alxloniinal  ])ains,  with  alternating  constipation  and  diarrhea,  would  suggest 
secondary  intraperitoneal  involvement. 

The  possibility  of  abdominal  pain  being  caused  by  parasites,  especially  by  tape- 
worms, should  not  be  overlooked. 

The  intestinal  ulceratioi.s  produce  nearly  always  continual  pain,  associated  with 
localized  tenderness  on  pressure.  The  higher  in  the  intestinal  canal  the  ulcer  be  located 
the  more  regularly  will  it  jiroduce  pain  from  one  to  two  honrs  after  eating,  while  the 
lower  the  location  of  the  ulcer  the  more  likely  are  we  to  find  recognizable  bkxnl  in 
the  evacuations.  During  ty])hoid  any  sudden  onset  of  abdominal  pain  associated  with 
bladder  irritability,  and  often  with  pain  in  the  penis,  may  be  regarded  as  indicating 
perforation. 

In  ajjpendicitis  the  i)ain  is  usually  first  referred  to  the  more  central  portion  of  the 
abdomen,  later  becoming  localized  in  the  right  iliac  fossa.  Frequently  the  overlving 
muscles  will  be  already  in  a  condition  of  spasm  before  this  pain  is  localized  beneath  them. 
In  this  disease,  no  matter  where  pain  may  be  referred,  tlie  tenderness  will  usually  be 
felt  and  the  resulting  tumor  detected  in  significant  position.  Constant  mild  ])ain  and 
tenderness  in  ^IcBurney's  region  are  usually  indicative  of  a  chronic  catarrhal  and  more 
or  less  obstructive  aj)pendicitis.  In  the  chronic  and  relapsing  forms  the  pain  is  inter- 
mittent, but  tenderness  is  nearly  always  significantly  located. 

Strangulated  hernias,  when  external,  will  usually  attract  attention  by  their  presence 
without  reference  to  ])ain,  even  though  the  latter  be  referred  to  some  relatively  distant 
part.  Whatever  might  be  characteristic  of  strangulation  will  more  or  less  quickly  merge 
into  symptoms  of  intestinal  obstruction,  but  no  case  presenting  local  indications  should 
escape  detection.  Internal  strangulations  nearly  always  defy  accurate  detection  before 
operation. 

Intestinal  obstruction  from  any  cause,  when  acute,  produces  early  shar])  and  severe 
abdominal  pnm,  sometimes  localized  vaguely,  but  nearly  alwavs  becoming  general,  and 
so  quickly  followed  by  muscle  s])asm  with  distention  and  the  soreness  of  vomiting,  that, 
with  the  accompanying  general  disturbances,  it  lends  little  aid  in  accurate  diagnosis. 

Acute  pancreatitis  of  either  clinical  type  produces  a  pain  which  is  central  and  agonizing 


772  SPECIAL  OH  REGIONAL  SURGERY 

and  is  ((uickly  followed  by  collapse,  with  alxloiiiiiial  ri<i;i(li(y.  'I'he  rcstdtiiitf  pain  and 
tenderness  are  usually  confined  to  the  up])er  abdomen  and  nuiy  bo  expected  at  least  to 
attract  attention  to  this  ])art  of  the  belly. 

Mesenteric  embolism  and  thrombosis  also  ))roduce  intense  j)ain,  wiUi  pronounced 
depression  and  speedy  collapse,  the  eomj)laint  usually  so  wides|)rea(l  as  to  be  sufi;(festive. 

Pain  made  suddenly  worse  by  extra  exertion  or  strainiufj,  as  |)erhaps  in  defecation, 
may  be  due  to  pressure  or  to  rupture  of  some  part  previously  involved.  When  this  is 
complained  of  in  the  lower  bowel  it  is  usually  due  to  some  ulcerative  condition  in  tiie 
rectum. 

Aside  from  conditions  briefly  si)ecified  as  above,  there  may  be  numerous  other  causes 
of  acute  abdominal  pain,  as,  for  instance,  in  connection  with  various  tumors,  either  those 
which  involve  the  bowel,  where  there  is  suddeidy  precipitated  a  condition  of  acute 
obstruction,  or  ovarian  cysts  and  pelvic  or  other  tumors  which  have  under<i;one  a  sudden 
deprivation  of  bU)od  su|)ply,  as  by  twistino;  of  a  pedicle.  In  nearly  all  of  these  instances 
the  previous  existence  of  such  a  tumor  has  been  learned,  or  else  may  be  made  out  by  such 
physical  examination  as  may  be  permitted  with  or  without  anesthesia.  Again  rupture 
of  an  extra-uterine  gestation  may  produce  intense  pain,  followed  by  speedy  collapse  and 
a  eontlitioh  widely  referred.  I  have  been  repeatedly  called  to  operate  for  acute  appendi- 
citis when  the  actual  lesion  was  of  this  character. 

In  qencral,  of  ahdoininal  pain,  it  may  l)e  said  that,  excluding  hysterical  cases,  when 
severe  it  is  usually  an  indication  of  a  more  acute  condition,  while  mild,  chronic 
and  intermittent  jiain,  accompanied  by  nK)re  or  less  tenderness,  indicates  a  chronic 
condition  which  may  not  amount  at  any  given  time  to  an  emergency,  but  which  may 
precipitate  one  that  may  call  for  inunediate  intervention.  The  nearer,  anatomically, 
the  morbid  condition  to' the  stomach  and  the  great  ganglia  the  more  likelihood  there  is 
of  nausea  and  vomiting  of  purely  reflex  character.  When  these  occur  with  conditions 
low  in  the  abdomen  or  pelvis,  vcjmiting  may  be  an  expression  of  obstruction  rather  than 
a  neunjsis,  pregnancy,  of  course,  forming  a  well-marked  exception  to  this  statement. 

In  the  presence  of  severe  [)ain  the  general  practitioner  and  the  surgeon  alike  feel 
inclined,  froui  luunane  motives,  to  do  everything  in  their  power  to  relieve  it.  While, 
on  one  side,  it  is  kind  and  rational  to  give  sufficient  anodyne,  usually  morphine,  to  relieve 
intense  suffering,  it  may  l)e  felt  sometimes  that  the  ])ractise  is  not  to  be  too  widely 
extended  or  commended,  since  by  relief  of  pain  the  significant  feature  of  the  disease  is 
masked,  and  there  may  be  temi)tation  to  wait  longer  than  would  be  advisable.  While 
wavering,  then,  as  between  advice  in  either  direction,  my  own  view  is  that  most  of  these 
cases,  when  symptoms  are  so  severe,  can  be  classified  by  themselves  as  those  justifying 
or  demanding  surgery. 

One  last  caution  m  this  respect  is  needed,  lest  the  inexperienced  regard  the  sudden 
subsidence  of  pain  as  necessarily  a  good  sign.  When  a  patient  who  has  been  suffering 
from  acute  obstruction  or  acute  peritonitis  becomes  sudtlenly  relieved  the  fear  is  rather 
that  the  disease  has  gone  beyond  all  })ossibility  of  helj),  and  that  such  relief  will  soon 
be  followed  l)y  coma  and  death.  Such  cessation  of  pain,  then,  is  not  necessarily  a  favor- 
able indication. 

Localized  tenderness  is  the  next  most  im])ortant  sign  of  value  in  determining  the  loca- 
tion and  nature  of  abdominal  diseases.  The  more  accurately  it  can  be  localized  the 
better,  since  it  permits  us  to  select,  in  all  probability,  one  organ  or  one  location  as  the 
site  of  the  disease.  When  it  is  accompanied  by  radiating  and  diffuse  tenderness  it  may 
be  suggestive  rather  than  indicative. 

Muscle  rigidity  or  spasm  is  the  third  of  the  trio  of  symptoms  which  give  the  surgeon 
his  most  imperative  indications.  Excluding  the  hysterical  and  purely  neurotic  cases 
there  is  no  occasion  for  pronounced  nuiscular  rigidity  save  some  disease  concealed 
beneath  it,  which  produces  these  reflex  ])henomena.  This,  too,  may  be  localized  or 
generalized.  In  the  latter  case  it  may  indicate,  for  instance,  a  general  jieritonitis  or  a 
local  process  tending  to  become  generalized.  Of  the  trio  of  signs  and  symptoms  it  is 
perhaps  the  most  significant  and  reliable. 

Pain,  tenderness,  and  muscle  spasm  constitute  the  tripod  upon  which  the  surgeon  has 
most  to  rely,  and  which  are  never  absent  in  serious  disease,  while  conversely  it  may  be 
said  that  serious  disease  is  rarely  ever  present  without  producing  thern.  These  with 
such  other  i)henomena  as  special  conditions  may  produce — e.  g.,  vomiting,  intestinal 
hemorrhage,  etc. — are  our  |)rincipal  aids  to  diagnosis.     When  present  and  progressive 


(!i:si:ir\L  rrj'iisiQih:  of  midomixal  ()i'i:u.\ri()\s  77;} 

thov  nearly  always  iiidicatc  necessity  tor  siirj^ical  iiilerveiilioii,.  the  most  pronoiiiieecl 
l)ein<j  in  those  instances  where  ahiloniinal  dislentioii  and  collapse  wi(h  (dlier  <frav(! 
features  have  already  taken  the  ease  beyond  the  helj)  even  of  the  surgeon. 

In  more  deliberate  cases  aid  is  also  to  be  obtained  from  examination  of  the  dis(har<fes 
from  the  various  viscera,  and  by  examination,  for  instance,  of  stomach  contents,  as  well 
as  by  dilVerential  blood  count.  All  of  these,  however,  take  time,  and  the  experienced 
surijeon  may  see  clearly  his  indication  to  operate  at  once  rather  than  to  wait  the  time 
which  th(>y  retpiirc.  The  whole  intent  of  (his  paraf^raph,  as,  in  fa<'(,  of  this  section,  is 
/(()/  /(>  tiKikr  Injlii  (>l  the  onliiKiri/  iiiaiiis  oj  dlafpio.si.s-,  hut  lo  iiisisi  upon  Ihr  nrrrs.s-ifij  for 
varlij  (ipprccidtioii  i>j  importdiil  sicfiis  and  amjiplom.s  in  onlir  lliiil  one  nutij  Inioir  irlirn 
it  i.s'  not  sdjc  to  iritit,  sinrr  too  inani/  livr.s'  air  even  voiv  mrri/irrd  to  this  kind  of  drtay. 

GENERAL  TECHNIQUE  OF  ABDOMINAL  OPERATIONS. 

A})doininal section,  generally  called  laparotoniij,  thoujjh  more  projierly  termed  rrliotonn/, 
is  often  begun  as  an  exploratory  measure,  and  then  called  cvploratorij  laparotoinij, 
whose  wisdom  and  safety  may  be  jM'ojierly  explained  to  even  an  ignorant  |)atient,  the 
underlying  intent  being  a  relatively  small  and  safely  made  opening  for  the  purpose 
of  orientation  and  decision.  It  is  with  me  a  rather  favorite  exj)ression  that  the  danger 
of  such  an  operation  is  insignificant,  and  that  the  danger  of  whatever  may  be  re((uired, 
as  revealed  through  tlu*  oj)ening,  is  pr()|)ortionate  to  the  gravity  of  the  condition  thus 
indicated. 

Abdomiiuil  section  having  once  been  decided  upon,  careful  general  and  local  prepara- 
tion .should  be  made,  as  indicated  elsewhere  in  this  book,  if  time  be  afforded.  There 
are,  however,  emergency  eases  in  which  moments  are  valuable  and  when  there  must 
be  omitted  almost  everything  but  the  considerations  of  cleanliness.  More  aiul  more 
I  am  impressed  with  the  value  of  sterilization  of  the  entire  trunk,  l)oth  front  and  rear, 
since  should  necessity  for  posterior  drainage  be  revealed  we  need  not  halt  in  order  to 
disturb  everything  else  and  sterilize  the  skin  of  the  back.  It  is  ])r(>su|)pose(l,  then,  in 
this  j)lace  that  all  the  ordinary  measures  have  been  carried  out  and  that  the  ordinary 
equipment  is  at  hand.  There  should  always  be  a  supply  of  warm,  sterile  water  (112°) 
in  order  that  the  intestines  nuiy  be  protected,  shouhl  it  be  necessary  to  tem]K)rarily  remove 
them  from  the  abdominal  cavity,  and  saline  solution  at  proper  temperature  should  be 
ready  for  irrigation  piu-poses,  if  needed. 

The  ahdomen  may  he  opened  at  any  point,  and  by  incision  in  almost  any  dii'cction. 
Nevertheless  there  are  provisions  which  should  be  observed.  When  there  is  no  s])e(  ial 
reason  for  a  lateral  incision  it  is  to  be  ojiened  in  the  uiiddle  line;  any  incision,  including 
the  umbilical  region,  shoidd  be  made  to  pass  to  the  left  of  the  navel  rather  than  to  the 
right.  There  is  no  reason  why  the  entire  navel  may  not  be  excised.  It  is  a  dldicult 
point  at  which  to  insert  sutures  and  in  most  individuals  is  at  best  an  infec  ted  region. 
Therefore  there  need  be  no  hesitancy  to  include  it  in  an  oval  incision  and  com])letely 
remove  it.  It  is,  furthermore,  a  wise  precaution  to  drop  into  the  uiubilical  region  a  few 
drops  of  tincture  of  iodine  just  before  the  operation,  in  order  the  better  to  sterilize  it. 
It  is  my  custom  to  use  one  knife  for  the  skin  and  then  lay  it  aside  and  employ  another 
for  the  deeper  work,  in  order  tiiat  no  germs  may  be  transplanted  from  the  skin.  The 
surgeon  has  to  cut  deeply  in  fleshy  individuals  before  reaching  the  deep  aponeurosis, 
aiul  sometimes  it  is  necessary  to  pass  through  two  or  three  inches  or  even  more  of  fat. 
This  necessitates  a  long,  superficial  incision.  The  deep  a))oneurosis  being  reached  we 
have  to  either  go  through  or  between  muscle  fibers,  at  least  in  luost  places.  It  is  desir- 
able rather  to  sej)arate  muscle  fibers  longitudinally.  When  opening  in  the  middle,  or 
parallel  to  the  middle  line,  this  may  be  done  with  the  fibers  of  the  rectus,  the  transverse 
tendinous  intersections,  however,  always  requiring  division.  Operating  in  either  iliac 
fcssa,  and  coming  down  upon  the  broad  and  flat  abdominal  muscl(\s,  there  may  be 
adopted  the  so-called  "gridiron  method,"  and,  after  exposing  those  fibers  which  run  at 
a  right  angle  to  the  line  of  incision,  one  may  endeavor  to  sjiread  rather  than  divide  them. 
This  is  done  when  making  the  small  openings  required  in  removing  the  appendix,  or 
in  making  an  artificial  anus.  For  removal  of  considerable  tumors,  or  for  temporary 
diseml)owelling,  large  incisions,  however,  are  required. 

By  suitable  disposition  of  the  patient's  body  much  assistance  and  comfort  are  afforded 


774  S;PECIAL  OR  RECIOXAL  SURGERY 

the  operator.  When  the  ii])per  abdomen,  especially  the  reo;ion  of  the  fi^all-hladder,  is 
to  l)e  attacked,  the  up])er  ])art  of  the  body  shonld  he  raised  with  dorsal  flexion  above 
the  pelvis,  thns  ])ermitting  i>ravitation  away  from  the  liver  and  facilitatinci;  the  retraction 
which  may  be  required.  A<i;ain,  in  operations  n})on  the  pelvic  viscera  the  reverse  position 
was  suggested  by  Trendelenburg,  and  it  is  of  the  greatest  help,  the  pelvis  and  the  limbs 
being  elevated  until  the  body  assumes  a  position  at  an  angle  of  some  45  degrees.  The 
intestines  then  gravitate  toward  the  diaphragm,  and  the  pelvis  is  more  easily  emptied  and 
k(>])t  empty.  When,  liowever,  there  is  no  j^articular  need  for  either  of  these  positions 
the  ordinary  dorsal  position  is  the  l)est.  With  an  operation  begun  in  the  latter  there 
should  be  no  reason  why  ))()sition  may  not  be  changed,  when  tlie  ex])loration  reveals 
nec(\ssity  for  the  same,  and  all  good  modern  operating  tables  are  so  constructed  as  to 
permit  of  this  being  rapidly  done. 

Of  late  the  frans-irr.'<e  ///r/.v/o/;  has  been  received  with  growing  favor.  In  181)0,  Kiistner 
reported  a  number  of  cases  where  he  had  used  a  transverse  supra])ubic  incision  down  to 
the  aponeurosis  solely  for  a  cosmetic  effect,  the  method  being  ado]ited  by  Rapin  about 
the  same  time.  Others  went  farther  and  made  use  of  an  incision  above  the  pubis  and 
parallel  to  it,  carried  down  through  the  aponeurosis,  over  tlie  recti,  with  vertical  sej)ara- 
tion  of  the  muscles,  in  order  to  diminish  the  chances  of  hernia.  The  incision  is  made 
just  below  the  margin  of  the  pubic  hair  or  in  the  natural  fold  of  the  abdomen.  The 
fascia  being  divided  in  one  direction  and  the  muscle  in  another,  there  is  less  tendency 
to  hernial  protrusion,  the  disadvantages  being  that  there  is  limited  sjxice  through  which 
to  work  and  that  more  time  is  recjuired  in  its  performance.  All  vessels  should  be  secured 
so  soon  as  divided.  The  incision  through  the  fascia  may  be  somewhat  curved,  if  neces- 
sary, at  the  outer  edges  of  the  recti,  l)y  which  a  sort  of  horseshoe  flap  may  be  lifted  up 
if  desired.  The  fat  should  not  be  dissected  from  the  surface  Ijeneath.  Scissors  will  be 
required  to  separate  the  aponeurosis  from  the  muscles  in  the  middle  line,  this  separation 
b(>ing  made  high  in  the  same  line.  The  peritoneum  is  opened  in  the  middle  with  the 
usual  vertical  cut.  When  more  room  is  required  the  aponeurosis  should  be  incised 
farther  on  each  side,  outside  of  the  recti.  The  method  finds  its  greatest  serviceability 
in  those  cases  where  not  more  than  four  inches  in  a  thin  woman  and  two  inches  in  a 
fat  woman  of  vertical  separation  of  the  recti  muscles  will  be  recjuired. 

Ordinarily  when  the  ]XM'itoneum  is  reached  there  will  be  no  difficulty  in  recognizing 
it.  It  is  a  membrane  easily  shifted,  both  upon  its  attached  surfaces,  beneath  the  fat, 
and  over  the  bowel  or  whatever  may  cause  it  to  protrude  into  the  wound.  Unless  one 
is  very  sure  of  his  work  he  will,  however,  pick  it  up  very  carefully,  nick  it  slightly,  and 
convince  himself  that  he  has  the  desired  membrane,  and  then  will  dissect  it  with  care, 
since  the  l)owel  beneath  will  lie  closely  in  contact  with  it,  and  might  easily  ])e  wounded 
were  the  o))erator  careless.  The  peritoneum  in  the  ])resence  of  such  disease  as  tuber- 
culous peritonitis  becomes  very  much  thickened,  and  is  then  not  easy  of  recognition. 
Again,  it  is  sometimes  slightly  adherent  in  the  presence  of  recent  exudate,  or  firmly 
adherent  in  the  presence  of  old  disease,  to  the  tumor  or  viscera  beneath.  When  the 
tissues  are  edematous  and  l)ecome  more  so  as  the  })eritoneum  is  approached,  pus  may  be 
foiuid  beneath,  and  extreme  caution  should  be  exercised,  making  at  first  a  small  opening 
through  which  pus  may  escape,  and  endeavoring  not  to  tear  adhesions  apart  nor  thus 
permit  escape  of  pus  into  the  peritoneal  cavity. 

The  true  abdominal  cavity  once  opened,  the  first  endeavor  should  be  to  ascertain  the 
conditions  within.  Through  a  small  opening  this  is  done  with  the  finger.  This  measure, 
trifling  as  it  seems,  requires  a  knowledge  l)()th  of  normal  and  ])ath()logical  anatomy 
which  cannot  he  too  great.  Unless  the  normal  arrangement,  size,  density,  and  location 
of  all  its  contents  is  known  and  the  way  which  they  should  feel  when  healthy  it  will  be 
.somewhat  difficult  to  distinguish  between  health  and  disease.  Again,  unless  the  surgeon 
is  familiar  with  pathological  conditions  he  will  not  know  how  to  interpret  what  he  may 
thus  discover.  Through  a  small  opening  it  can  usually  be  discovered  whether  or  not 
there  is  a  serious  condition  within.  According  to  knowledge  thus  gained  there  may  be 
justification  for  enlarging  a  small  opening  or  closing  it.  One  caution  here  is  of  the 
greatest  importance — an  exploratory  operation  should  never  be  begun  unless  the  oper- 
ator is  provided  with  means  for  meeting  any  indication  which  should  thereby  be 
disclosed,  else  the  patient  would  be  subjected  to  two  ordeals  when  one  should  suffice. 

The  "diagnostic  finger,"  having  once  entered  the  abdominal  cavity,  shoidd  be  used 
with  extreme  gentleness,  especially  in  the  presence  of  adhesions,  which  yield  easily,  and 


(lESERAL  rrj'iiSKiiE  OF  MiDoMiSAL  nr/:/r\r/f).\s  775 

wliicli  may  point  to  tlic  existence  <»!'  a  piinileiit  fcx  iis  in  the  nei^rlihorliood,  as  seareolv 
any  disaster  eonid  he  more  fatal  tlian  to  rnptnre  sncli  a  foens  and  permit  eseaju-  of  its 
contents  in  I'very  directi<»n  l)efoi'e  surj^ical  protection  lias  Ix-en  all'orded.  Mncli  will 
depend  n])on  wlietlier  there  is  reason  to  snspeci  the  presence  of  j)iis,  and  it  is  alwavs  best 
to  proceed  as  thouffh  sncii  a  continj^ency  mi<^ht  ha|)|)eii.  Attain,  adhesions  which  seem 
firm  may  he  met  with  in  the  j)resenee  of  malif^nant  or  nicerative  disease.  In  some 
instances  they  will  ho  so  firm  tliat  siirroundinj;  normal  structnres  will  yield  hefore  they 
part,  or  are  closely  associated  with  a  dense  adhesion  which  will  he  f(tnn<l  a  weakened 
ana  that  will  tear  easily.  The  process  of  se|)aratinfj  adhesions,  then,  shonid  always 
he  condneted  with  extreme  eantion. 

When  the  presence  of  pns  is  suspected  the  adjoiiiin^f  parts  shonid  he  protected  hv 
" wallinj;  olV"  with  <fan/,e.  (ianze  j)ads,  either  of  sufficient  |cn<;th  to  he  secured  with 
forceps  or  provided  with  tapes  for  the  same  j)urpose,  hv  which  their  loss  in  the  ahdoininal 
cavity  may  he  ])revented,  are  now  used  almost  to  the  ex(  lusion  f)f  the  flat  sj)f)n^es  foniierly 
emj)loyed,  for  they  are  more  reliable  when  j)roperly  sterilized.  With  a  sufficient  nuinher 
of  these  spread  out  as  earefully  as  may  he,  a  neat  padding  or  j)rotective  wall  of  ^auze 
is  made  and  formed  around  the  focus  of  disease,  into  which  any  di.seharfje  of  hlood  or 
pus  luay  take  j)lace,  and  hy  means  of  which  contact  of  surfaces  is  prevented.  Sometimes 
a  larrje  amount  of  <;auze  is  needed  for  this  j)ur])ose,  and  when  the  abdomen  is  widely 
ojK'ii  sterile  towels  may  be  use(l.  "^riie  (greatest  care  should  be  ^iven  that  nothing  be 
left  within  the  abdomen  at  the  completion  of  tlie  oj)eration,  and  every  loose  piec<'  of  j,'auze 
should  be  secured  with  force|)s  and  every  towel  accounted  ff)r.  By  this  protective 
"wallino;  off,"  spreading  of  an  infectious  process  may  be  [)revent(>d,  as  also  the  «listri- 
bution  of  infectious  material.  The  gauze  should  be  ehangcd  as  often  as  needed  and 
there  is  often  no  apparent  limit  to  the  amount  that  may  have  to  be  cmj)loyefl.  Advan- 
tageous as  the  process  may  l)e,  it  has  its  disadvantages,  in  that  material  so  employed  is  a 
source  of  irritation  and  is  |)ractieally  a  foreign  body,  intruded  within  the  alxlomen  in 
such  a  way  as  to  have  always  a  dej)ressing  influenee.  This  depression,  however,  is 
but  temporary,  and  is  the  lesser  of  two  evils,  and  in  the  presenee  of  pus  ean  scarcely  be 
avoided.  Instruments,  cs})ecially  the  smaller  f)nes,  should  also  be  counted  before  and 
after  operation,  or  be  so  aeeoiuited  for  that  ncme  may  remain  or  be  lost. 

The  general  indieation  having  been  met,  the  next  (|uestion  is  one  of  loeal  cleanliness  and 
re.sort  to  irrigation.  If  the  protection  above  described  has  been  sufficient  there  will  be 
a  minimum  of  loeal  cleansing  required.  This  may  be  effected  with  hydrogen  dioxide, 
or  with  or  withf)Ut  other  antiseptics,  according  to  the  choice  of  the  operator.  Obviously 
every  focus  of  disease  should  be  as  thoroughly  cleansed  both  of  clotted  blood  and  debris 
or  pus.  When  this  can  be  accom))lished  by  gentle  wi])ing  or  swabbing  it  may  be  suffi- 
cient.    When  this  is  not  possible  irrigation  and  drainage  should  be  provided. 

Irrir/ation  of  tlie  (OxIom'ninI  rariiij  has  been  widely  j)ractised,  and  has  advantages 
as  well  as  disadvantages  which  have  caused  it  to  be  differently  regarded  by  different 
operators.  While  little  hesitation  need  be  felt  about  washing  out  a  well-localize<l  cavity, 
it  is  felt  by  many  that  to  use  a  quantity  of  water  within  the  complicated  peritoneal  cavity 
is  to  more  widely  distribute  that  which  would  best  be  not  disturbed.  On  the  other  hand, 
it  is  maintained  by  some  that  infectious  material  .so  diluted  and  scattered  is  more  easily 
capal)le  of  disposition  by  natural  jirocesses.  The  general  trend  of  opinion  is  that  a 
localized  condition  is  best  treated  by  local  measures,  and  that  general  abdominal  irriga- 
tion should  be  limited  to  cases  of  generalized  infection.  The  temptation  to  use  antiseptic 
solutions  is  very  strong.  Yet  one  must  remember  that  any  .solution,  of  which  a  portion 
must  remain,  used  in  such  a  cavity  and  having  sufficient  strength  to  kill  bacteria,  will 
prove  at  least  profoundly  anfi  perhaps  fatally  toxic  to  the  individuals,  because  the 
peritoneum  is  a  membrane  of  tremendous  potential  capabilities  in  the  matter  of  ab.sorp- 
tion,  and  those  c-hemicals  which  are  toxic  to  germs  are  also  harmful  to  the  human  ti.ssues. 
Strong,  then,  as  the  temptation  may  be  to  use  antiseptics  under  these  circumstances, 
solutions  used  for  the  purpose  should  be  made  extremely  weak  if  we  are  to  do  more 
good  than  harm.  Warm  sterile  water  or  saline  .solution  is  then  the  generally  accepted 
irrigating  fiuid,  while  a  few  use  such  antiseptics  as  acetozone  in  the  strength  of  1  to  1(),0()(), 
or  others  c)f  the  more  harmless  drugs.  In  c-ases  of  tuberculous  peritonitis  exce])tion  may 
be  taken  to  this  and  a  solution  used  which  is  sufficiently  strong  to  have  some  ])ercej)ti))le 
immediate  effect. 

When  general  abdominal  irrigation  is  j)ractise<J  quarts  and  even  gallons  of  fluid  shoulcl 


770  SPECIAL  OR  h'i:(;i()\.\L  sfh'r;/:Ry 

be  used,  auliicieiit  t(j  ucconi[jli.~>li  the  desired  jjiirpu.se.  \  urifui.',  luhes  have  been  devised 
for  the  purpose  of  eonducting  the  fluid  into  the  deej)er  reeesses,  and  yc't  these,  while 
eonvenient,  are  not  essential.  Praetice  varies  somewhat  as  to  whether  to  leave  a  con- 
siderable amount  oi  saline  solution  within  the  abdominal  cavity  or  try  to  free  it  of  all 
fluid.  The  former  practice  is  desirable,  in  theory  at  least,  for  if  readily  absorbed  it 
will  help  in  relieving  shock  and  keeping  tiic  kidneys  active.  In  general  it  may,  however, 
be  said  that  unless  an  isotonic  saline  solution  is  employed  it  is  advisable  to  remove  all 
that  can  conveniently  be  withdrawn  before  closing  tlie  belly. 

The  next  importiint  question  i^  (nic  of  drninacje,  and  here,  again,  men  differ  widely 
in  their  opinions.  A  distinctly  purulent  focus  is  doubtless  always  best  drained.  The 
question  is  argued  rather  with  regard  to  the  matter  of  jxxssible  sj^read  of  infection  or  in 
ca.ses  of  general  doubt.  Drainage  is  always  a  confession  either  of  fear  or  of  impossibility 
of  ideal  removal  of  the  primary  difficulty.  It  certainly  is  less  practised  than  in  years 
gone  by,  but  will  always  find  a  certain  field  of  usefulness.  Thus  after  some  deep, 
extensive  pelvic  operations,  where  the  scjiaration  (jf  adhesions  almost  ensures  a  certain 
amount  of  leakage  of  blood,  one  should  insert  a  glass  or  metal  drain  for  a  few  hours, 
or  a  day  or  two,  and  through  it  aspirate  at  intervals  suf  h  amounts  as  may  accumulate 
in  the  cavity  thus  emptied.  Nearly  all  cases  of  abdcmiinal  traumatism  require  drainage, 
best  applied  posteriorly,  and  practically  all  instances  of  acute  pancreatitis,  whether  puru- 
lent or  otherwise,  will  also  rec|uirc  it,  ])ostcriorly  as  well  as  anteriorly.  All  old  abscess 
cavities  also  demand  drainage,  no  matter  where  locatcfl.  No  case  of  septic  peritonitis, 
general  or  local,  can  be  safely  closed  without  similar  provision.  Drainage  through  the 
cul-de-sac  is  the  best  method  of  all,  when  available. 

Drnitiacjc  mrfhods  include  the  use  of  hard  tubes  made  of  glass,  alcmincm,  or  celluloid, 
perforated  witli  numerous  o|)cnings  through  which  fluid  may  escajx'  i:;t  >  their  interior. 
These  are  used  mainly  for  drainage  of  the  pelvis  through  an  abdf)minal  Wfnmd.  Soft- 
rubber  tulu's  of  varying  sizes  may  be  used  in  many  ways,  either  Ijv  themselves  or  when 
split  longitudinally,  and  made  loosely  Xo  enfold  a  strip  of  gauze,  or  when  lightly  wrapped 
with  gauze  and  covered  with  pcrforatcfl  oiled  silk.  Except  when  it  is  desired  to  drain 
a  gall-bladder  or  some  similar  circumscribed  cavity,  which  can  be  closed  around  the 
tube,  such  tube  should  have  numerous  large  openings  cut  in  it.  Cigarette  flrains  con- 
sist of  small  rolls  of  gauze  wrapped  with  oiled  silk,  tlien  fenestrated  anfl  secured  with  a 
piece  of  catgut  tied  around  it  to  prevent  it  unwrapping. 

Ordinary  al)sorbent  gauze  or  prepared  gauze  may  be  used  by  itself  to  any  rlesired 
extent,  but  when  so  used  it  is  usually  well  to  make  the  amoiuit  sufficient  to  effect  the  pur- 
pose. Thus  a  drain  at  least  one  inch  in  diameter  or  even  exceeding  that  size  will  be 
much  more  effective  than  two  or  three  small  strips.  In  using  this  it  is  well  to  pro- 
tect the  wound  margins  with  strips  of  oiled  silk,  between  which  the  gauze  is  deeply 
pa.ssed,  as  in  this  way  its  aflhesion  to  the  wound  edges  is  prevented,  such  adhesion  being 
undesirable  both  because  it  helps  to  prevent  the  escape  of  fluid  and  causes  pain  when  the 
gauze  is  removed.  In  this  way  it  is  well  to  combine  the  double  purpose  of  drainage,  and 
pressure  to  check  oozing,  by  packing  in  sufficient  gauze  to  accomplish  both.  These 
gauze  drains,  when  well  soakcfl  with  discharge,  are  ea.sily  removed.  Otherwise  they 
frequently  adhere  and  cause  much  discomfort  during  the  act  of  removal.  In  such  a  case 
it  is  an  advantage  to  wet  them  from  the  outside,  perhaps  three  or  four  hours  before 
withdrawing  them.  Even  with  such  a  gauze  drain  there  is  always  the  danger  of  causing 
fecal  fistida  if  it  be  left  too  long  in  ftifii.  It  is,  therefore,  always  undesirable  to  leave 
a  drain,  even  of  this  apparently  innocent  character,  longer  than  absolutely  necessary. 

In  not  a  few  cases  through-and-through  drainage — i.  e.,  by  a  counteropening — will 
be  of  great  value,  this  especially  in  many  cases  of  peri-appenflicular  abscess,  where  pus 
has  collected  behind  the  cecum.  So-called  posterior  drainage  of  the  alidomen  is  also 
advisable  in  cases  of  acute  pancreatitis  or  deep  retroperitoneal  phlegmon.  Here  the 
ojiening  is  made  from  the  back, by  an  incision  two  or  three  inches  in  length,  just  outside 
the  up|)cr  part  of  the  quadratus  lumborum  and  near  the  costovertebral  angle.  In  stout 
individuals  a  distance  of  two  or  three  inches,  or  even  more,  must  be  traversed.  After 
the  more  superficial  incisions  this  opening  may  be  effected  by  blunt  dissection,  and  is 
l)est  done  with  conjoined  manipulation,  f)ne  hand  working  on  the  exterior  and  the  other 
in  the  interior  of  the  abdominal  cavity.  Occasional  necessity  for  such  pf)sterior  drainage 
shows  the  wisrlom  of  the  practice  of  sterilizing  the  back  as  well  as  the  front  of  the  body 
as  part  of  the  preparation  for  operation. 


cj^osiia:  OF  MU)()Mi\.\i.  i.\(isi().\s  777 

Draiiia^i'  having  hri-ii  t'lVcctcd  by  niii-  of  tlit-  al)()Vc  iiictliods,  (lie  Ix'st  of  (ijood  jii(lji;iii('iit 
will  he  called  for  in  determining  how  lontj  it  slioidd  l»e  continncil.  First  of  all,  no  drain 
which  fails  to  etVect  the  purposes  intended  shonld  he  allowed  to  remain,  and  any  drain 
around  rather  than  thronjj;h  which  material  is  dischariijed  may  he  regarded  us  useless 
and  a  uiere  deleterious  foreign  hody.  (Jauze  which  is  sujiposed  to  drain  hy  osmosis 
often  fails,  and  in  some  of  th<\se  drains  it  may  he  well  to  insert  a  few  strands  of  silkworm- 
gut  in  order  that  material  which  is  to  heconic  moistened  may  not  collaj)se  and  adhere, 
thus  destroying  its  own  capillarity.  A  |)elvic  drain  in  a  non-sejjtic  or  hut  slightly  septic 
ease,  inserted  for  removing  escaping  hlood  or  collc<ting  scrum,  may  he  rcmovc(l  in  from 
twelve  to  sixty  hours,  according  to  the  auiount  of  discharge,  which  when  collected 
with  a  syringe  should  he  carefully  estimated.  Any  cavity  which  is  not  filled  at  a  rate 
ftister  than  2  or  8  Cm.  in  an  hour  may  he  regarded  a.s  cai)al)le  of  disi)osing  of  all  the  fluid 
which  may  collect  within  it,  and  every  tuhe  which  is  no  longer  needed  is  an  irritating 
foreign  hody,  whose  lower  end  may  press  U))ou  intestine,  and  even  produce  ulceration 
if  allowed  to  make  pressure  too  long.  ApjUMidicular  ahscesses  usually  rcipiirc  to  drain 
from  two  to  thre(>  or  four  days;  gall-hladders  and  hepatic  ahscesses  for  a  nuich  longer 
time.  In  nearly  all  instances  it  may  he  expected  that  within  from  forty-eight  to  sixty 
hours  after  the  cstahlishment  of  drainage  a  natural  passage  will  he  formed,  hy  exudate 
aiipearing  first  around  the  drain,  and  remaining  after  its  removal,  which  should  serve 
drainage  purjioses  as  would  a  canal.  Sometimes  the  outer  end  f)f  such  a  canal  tends  to 
close  too  quickly,  and  then  with  accumulation  in  the  deejier  part  there  may  come  reten- 
tion, with  later  spontaneous  escape,  or  possihly  rupture  into  the  ahdominal  dej)ths,  which 
mav  he  serious.  In  nearly  every  instance,  however,  a  large  drain  may  he  suhstituted 
within  a  short  time  hy  a  smaller  one  and  final  removal  l)e  thus  acc(nnj)lished.  Any 
localized  cavitv  whose  discharges  are  offensive  or  jHitrcfactive  should  he  cleansed  each 
(lav,  either  with  hydrogen  jieroxide  or  hy  gentle  irrigation,  or  with  a  reasonahly  strong 
antise])tic  solution — iodine,  silver  nitrate,  etc.  "While  no  such  cavity  will  close  until  all 
such  material  has  escajxHl,  it  nevertheless  is  well  to  keep  the  external  ojiening  wide 
open,  in  order  to  hasten  the  whole  process.  This  may  he  accomplished  by  gauze  packing 
or  the  insertion  of  a  short  tube. 

Cavities  which  persist,  with  apparently  permanent  fistulas,  require  more  radical  treat- 
ment, which  will  consist  at  least  of  a  thorough  curetting  and  considerable  enlargement 
of  the  fistulous  opening,  in  order  to  permit  of  this.  Such  a  cavity,  then,  may  be  com- 
fortably packed  with  gauze  for  a  few  days. 

The  use  of  massive  tanqions  and  the  introduction  of  large-sized  pieces  of  gauze  into 
the  alxkmiinal  cavity  have  been  generally  discontinued,  largely  through  the  writings  of 
Morris,  who  stigmatized  such  practice  as  "committing  taxidermy  upon  patients." 

Ahdominal  drainagr  may  be  favored  by  one  other  expedient — /.  e.,  position.  The  peri- 
toneum possesses  unusual  powers  of  absorjition  and  is  callable  of  taking  care  of  morbid 
material  up  to  a  certain  point.  It  has  been  shown  that  the  peritoneum  of  the  upper 
abdomen  especially,  even  that  lining  the  diaphragm,  is  particularly  potent  in  this  direc- 
tion— next  to  it  perhaps  that  of  the  pelvic  cavity.  Sej)tic  processes  in  the  upper 
abdomen  are  then  sometimes  advantageously  dealt  with  by  placing  the  patient  iii 
bed  in  a  position  with  the  pelvis  considerably  elevated  and  the  head  dependent.  This 
is  the  more  valuable  after  irrigation  has  been  practised,  where  there  may  be  considerable 
fiuid  which  may  thus  gravitate.  On  the  contrary,  in  serions  septic  pelvic  infections  it 
is  often  good  practice  to  keep  the  patient  in  the  semisitting  posture,  so  soon  as  sufficiently 
recovered  from  the  anesthetic.  (Fowler.)  These  expedients  are  perhaps  the  niore 
valuable  when  provision  is  made  in  either  one  of  the  dependent  portions  for  drainage, 
gravity  thus  favoring  the  accumulation  of  fluid  where  it  can  be  best  cared  for. 

CLOSURE  OF  ABDOMINAL  INCISIONS. 

In  what  may  be  termed  a  clean  abdominal  operation  it  is  seldom  that  drainage  is  pro- 
vided. Such  cases  are  expected  to  heal  promptly  and  the  wound  to  close  immediately 
and  without  pus  formation.  It  is  only  in  cases  \vh(>re  drainage  has  been  necessitated 
that  there  is  a  really  legitimate  excuse  for  subsequent  yielding  of  the  scar,  and  the 
production  of  posfnpr'rnfirr  vrntrn!  henna.  These  at  least  are  the  ideal  and  theoretically 
correct  notions,  although  it  should  be  acknowledged  that  in  the  practice  of  even  the 


778  SPECIAL  OR  REGIONAL  SURGLRY 

most  coinjK^tent  such  un(l(>sinil)l('  sec|ii('ls  as  ventral  hernia  do  sometimes  oeeur.  Forc- 
seeinij  the  possihiHty  of  their  oceurreiiee  and  reaHziii<>;  tiie  coiKhtioiis  whieli  ])ermit  the 
same,  every  known  precaution  should  he  taken.  The  (juestion  tlien  of  the  method  of 
closure  of  even  a  small  abdominal  wound  is  one  of  <>;reat  im])ortance,  which  has  lon<i; 
entjaged  the  attention  of  the  most  ex])erienced  operators,  who  have  not  yet  united  upon 
what  all  consider  the  ideal  or  perfect  method.  In  general  it  may  be  said  that  fiuiure 
of  each  separate  tissue  layer  comes  nearest  to  this  ideal,  along  with  the  employment  of  a 
suture  material  which  should  serve  its  purpose  sufKciently  long,  and  yet  not  nniiain  as 
a  ])()ssible  future  irritant.  When  time  is  afl'ordcd,  and  there  are  no  contra-indications, 
the  following  may  be  given  as  the  best  directions  in  this  regard:  A  suture  of  the  peri- 
toueal  edges,  with  or  without  the  deep  fascia.  In  or  near  tlie  middle  line  the  posterior 
sheath  of  the  rectus  may  also  be  included  in  this  row.  These  sutun^s  should  ])e  inserted 
with  extreme  care  so  as  not  to  include  any  peritoneum  of  the  bowel  surfaces.  Then 
the  tnuscle  edges  are  brought  together  by  a  second  row,  over  which  tlie  deep  apoururosis 
is  covered  and  brought  together  with  a  third  row.  Rather  than  fail  in  accurate  approxi- 
mation of  this  third  row  it  would  be  better  to  overlap  the  edges  and  fasten  them  together 
in  this  position.  These  sutures  should  be  made  with  hardened  catgut,  of  whose  sterility 
and  durability  there  is  no  question.  It  should  have  been  so  treatccl  that  reliance  may  be 
placed  on  its  remaining  for  at  least  twenty  days.  The  method  with  the  balance^  of  the 
wound  may  depend  to  some  degree  up;)n  its  thickness.  In  individuals  with  fat  abdomi- 
nal walls  it  is  l)etter,  in  order  to  avoid  dead  spaces,  to  insert  oue  or  two  roivs  of  hurled 
sutures,  by  which  the  fatty  surfaces  are  brought  into  contact.  Finally  the  sln'u  marqins 
may  be  approximated,  either  with  a  subcutaneous  chromic  or  silkworm  suture,  or  by 
the  ordinary  continuous  or  interrupted  suture,  which  may  Ijc  made,  according  to  choice, 
of  celluloid  thread  (Pagenstecher's  linen  thread  soaked  in  a  celluloid  solution  and  thus 
made  non-absorbent),  sterile  silk,  or  fine  wire. 

The  nature  and  the  location  of  the  incision  and  the  thickness  of  the  tissues,  along  wilh 
the  degree  of  tension  which  may  l)e  made  upon  them,  will  to  some  extent  deternu'ne 
how  the  more  superficial  stitches  may  be  placed.  The  depressing  effect  of  postoperative 
vonu'ting  may  be  forestalled  by  phicing  another  set  of  three  or  four  mattress  or  quilted 
sutures,  which  may  be  brought  out  at  a  distance  of  two  or  three  inches  froiu  the  incision 
and  guarded  with  shot,  plates,  or  rolls  of  gauze.  These  sutures  have  a  tendency  to 
take  off  tension  from  those  immediately  closing  the  wound  and  are  a  valuable  means  of 
securing  })rimary  union. 

Ordinarily,  as  stated  above,  one  never  drains  the  abdominal  wound  proper.  Never- 
theless if  it  has  been  infected  by  contact  with  gangrenous  or  infectious  material  it  is 
better  to  leave  some  opening  for  escape,  or  else,  as  a  final  precaution,  to  trim  the  surfaces 
which  have  been  exposed  and  bring  into  contact  only  those  which  are  absolutely  fresh 
and  uncontaminated.  In  gunshot  loounds,  for  examj)le,  unless  the  track  of  the  missile 
has  been  cleanly  excised  some  provision  should  be  made  for  drainage  thereof. 

A  further  ])rotection  should  be,  h()W(>ver,  afforded  in  the  dressings,  by  strips  of  plaster 
placed  over  the  deeper  dressings,  by  which  again  tension  is  taken  of!'  the  wound,  and 
still  further  l)y  such  snug  bandaging  and  arrangement  of  compresses  and  dressings  as 
shall  ccjmplete  this  protection. 

There  are  occasions  when  this  procedure,  which  necessarily  consumes  a  little  time, 
cannot  be  completely  carried  out,  and  when  there  must  be  haste  in  order  to  get  the 
jxitient  off  the  table  in  suitable  condition.  In  such  cases  the  operator  usually  contents 
himself  with  the  applicatitm  of  silkworm-gut  sutures,  which  include  the  whole  thickness 
of  the  abdominal  wall,  or  the  use  of  secondary  sutures,  which  can  be  tightened  and 
utilized  later.  As  Binnie  has  said:  "Inexperienced  surgeons,  after  c()m])leting  a  pro- 
longed o])eration  on  an  exhausted  individual,  sometimes  forget  that  it  is  better  to  have 
a  postoperative  hernia  in  a  living  patient  than  a  ])erfectly  closed  wound  in  a  corpse." 


AFTER-TREATMENT  OF  ABDOMINAL  OPERATIONS. 

While  in  the  general  principles  regarding  the  after-treatment  of  abdoiuinal  cases  prac- 
titioners are  well  agreed,  the  world  over,  they  differ  so  in  regard  to  minor  points  that  it 
is  difficult  to  give  explicit  directions  which  shall  be  ac<e])tal)le  to  all.  Much  will  depend 
upon  whether  the  patient  has  had  suitable  j)reliminary  preparation.     If,  for  instance. 


M'TKi:   TRi:.\TME\T  OF   A /!!)<  i.\U  \  M.   OI'hh'AT/t  >\S  770 

the  Ixiwcls  Iiavc  hrcii  tlinroii^lily  emptied  there  iiee<l  he  no  haste  to  jMhiiiiiistiT  hixatives, 
as  thoiit,Hi  this  had  not  heeii  the  case.  In  many  instances  where  tliis  |)re(anti(ni  has  heen 
iie;i;h'ete(l  catharsis  is,  after  operation,  the  most  important  consith-ration,  and  vet  this 
may  he  difhcidt  to  secure,  the  (hllii  idty  heinj;  enhanced  hy  the  fact  tliat  an  inchvichial 
just  openited  on  and  extremely  tender  finds  it  (hlhciih  to  {jive  natural  assistance  to  the 
process  of  defecation.  'I'he  matter  is  particuhirly  comphcated  hy  the  (hincuMv  of 
seleetin<j  jin  active  catluirtic  \vIm(  li  may  he  retained  \>\  a  sensitive  stonuich.  ( )ne  of 
the  ifreatest  needs  of  the  sur^jeon,  as  well  as  of  the  physician,  is  a  suitahle  medicament 
of  active  cathartic  properties  which  can  1h'  satisfactorily  administered  with  a  hy|)odermic 
syrin<j[e.     Xothini;  of  this  kind  is  as  yet  known. 

It  is  tjood  j)ractice  in  many  cases  to  throw  into  the  intestine,  tlirou<jh  a  hue  nc<-(llccon- 
iKMted  with  a  lar<je  syriufje,  a  considerahle  (juantity  of  saturated  solution  of  Kpsom  salt 
before  closini;  the  ahdoinen.  This  j)laces  it  where  it  will  not  he  rejected  by  an  irritable 
stomach,  and  where  it  must  have  the  desired  effet  t.  The  needle  .so  used  sh(»uld  be 
carefully  introduced,  in  a  very  oblicjue  direction  ;  while  should  the  minute  j)uncture  bleed 
or  seem  to  leak  it  may  be  incluiled  in  a  suture  or  lifjature  loop,  which  shoidd  take  u|)  the 
peritoneal  coat  only.  In  addition  to  this,  an  occasional  exj)edieiit,  the  writer  usually 
adnu'nisters,  before  the  jiatient  leaves  the  tal)le,  a  subcutaneous  injection  of  J,j  (Jr.  of 
eserine  suljjhate,  th(>  active  ])rinciple  of  Calabar  bean,  this  l)ein<;  a  powerful  stimulaiit  to 
the  muscular  coat  of  the  intestine.  The  bowels  should  be  thonnighly  emptied  in  the 
easiest  manner  after  every  operation. 

The  next  question  is  one  of  pain.  Patients  should  not  be  allowed  to  suffer  when  mor- 
phine is  at  hand,  and  this  would  always  be  true  were  it  not  that  morphine  has,  at  times, 
undesirable  eflfects,  both  in  checking  intestinal  activity  and  in  "locking  up  the  secretions." 
Moreover,  it  frequently  nauseates.  On  the  other  hand,  patients  who  have  imdergone 
serious  operations  need  to  be  kept  absolutely  quiet,  and  to  be  prevented  from  tossing  and 
moving  themselves  in  bed.  Some  expedient  then  is  called  for  in  many  cases,  and  one 
may,  if  he  choose,  begin  with  the  milder  of  these — such,  for  example,  as  the  adminis- 
tration of  2  Gm.  each  of  chloral  and  sodium  bromide,  with  or  without  chloretone, 
in  a  little  saline  solution  or  sterile  water,  thrown  high  in  the  rectum.  When  pain  is  not 
severe  this  is  frequently  sufficient  to  soothe  and  allay,  and  often  to  })roduce  sleep.  It 
reduces  or  prevents  the  nausea  with  which  many  patients  stiffer.  This,  too,  nuiy  be 
given  before  the  patient  leaves  the  table.  Such  an  enema,  with  or  without  asafetida  or 
other  soothing  drugs,  may  be  repeated  as  often  as  indicated,  and  does  much  to  quiet 
a  rebellious  stomach. 

It  is  assumed  here  that  the  reader  is  already  familiar  with  the  precautions  advised 
before  the  administration  of  anesthetics  and  that  it  is  now  simply  a  cjuestion  of  after- 
treatment.  (See  Chapter  XX.)  My  own  advice  is  not  to  withhold  morphine  in 
those  cases  which  seem  to  require  it,  remembering,  at  the  same  time,  that  suitable 
management  of  the  stomach  is  required.  It  is  inadvisable  to  permit  the  patient  to  take 
any  fluid  in  the  stomach  for  several  hours,  for  even  plain  water  will  upset  a  stomach 
which  has  seemed  to  be  perfectly  calm  and  controllab'le.  According  to  the  degree  of 
nausea  and  discomfort  should  the  stomach  be  used,  the  patient's  need  for  fluids  being 
supplied  by  more  or  less  copious  saline  enemas.  So  soon  as  the  stomach  becomes  quiet 
ice  pellets  or  small  qiumtities  of  water,  as  hot  as  can  be  liorne,  may  be  used,  the  latter 
frequently  proving  the  more  acceptable. 

Until  the  bowels  are  freely  moved  whatever  food  may  l)e  administered  should  l)e  fluid, 
anfl,  under  most  circinnstances,  not  more  than  forty-eight  hours  should  elapse  after  any 
operation  before  the  intestinal  canal  is  emptied.  Milder  degrees  of  naii.sra  may  be  treated 
l)v  the  use  of  milk  of  magnesia,  of  small  doses  of  orthoform,  or  by  a  mixture  which  the 
writer  is  fond  of  using,  in  each  dose  of  which  the  patient  receives  0.02  of  cocaine,  one 
minim  of  carbolic  acid,  and  one  or  two  minims  of  dilute  hydrocyanic  acid,  in  a  small 
amount  of  water.     I  have  found  this  in  many  instances  very  soothing. 

The  affrr-manar/cntnif  of  many  of  these  cases  includes  also  the  treatment  of  .'ihorJ: 
and  collapse,  which  have  been  considered  in  a  previous  chapter.  It  should  include, 
also,  suitable  attention  to  the  bladder,  and  a  catheter  should  be  used  within  the  first  ten 
or  twelve  hours  if  no  urine  be  passed,  and  as  often  thereafter  as  may  be  necessary. 
Catheterization  should  be  conducted  with  the  same  precautions  as  indicated  at  any  other 
time.  Other  details  of  after-treatment,  such  as  the  removal  of  drainage  materials, 
change  in  position  of  the  patient,  etc.,  have  been  discussed.     Stitches  of  chromic  catgut 


7S()  SPECIAL  OR  REGIONAL  SURGERY 

need  iKj  further  attention,  wliile  tliose  of  silk  (jr  thread  will  need  removal.  It  is  to  be 
emphasized  that  the  great  danger  of  the  so-ealled  siiich-hole  abscefsses  eomes  not  so  much 
from  the  material  first  employed  as  from  faikire  to  protect  it  and  guard  it  against  the 
possil)ility  of  subsequent  infection.  Non-absorbable  sutures  in  the  abdominal  wall 
are  usually  allowed  to  remain  from  ten  to  twelve  days,  but  any  stitch  which  is  seen  to 
fail  in  accom[)lishment  of  its  purposes  should  be  immediately  removed,  as  should  also 
stitches  aroiuid  wliich  a  drop  of  jhis  is  seen  to  be  esca])iiig. 

Certain  abdominal  wounds,  especially  in  fleshy  individuals,  seem  to  heal  perfectly, 
then  part  a  little  and  give  vent  to  material  which  is  hardly  pus,  but  a|)pcars  more  like 
lifjucfied  or  altered  fat.  Such,  in  effect,  it  often  is,  and  the  condition  imjjlics  a  necrosis 
of  a  certain  amount  of  fatty  tissue,  with  its  liquefaction  and  escape  instead  of  al)sorption. 
In  this  way  a  small  cavity  will  be  left  which  should  heal  by  granulation,  and  this  may  be 
hastened  by  the  use  of  mild  nitrate  of  silver  solution. 

A  ]iatient  having  been  removed  from  the  operating  table  in  a  satisfactory  condition  the 
])rincipid  danger  is  that  of  internal  hrmorrJingr,  which,  th()Ugh  fortunately  rare,  is  dis- 
turbing when  it  does  occur.  In  fact,  severe  abdominal  hemorrhage  is  one  of  the  most 
serious  of  surgical  accidents,  either  j)rimary  or  secondary.  It  may  oc-cur  from  wounds 
of  all  descriptions,  as  the  result  of  erosion,  p<'rhaps  of  a  foreign  body,  even  of  a  drainage 
tube,  from  the  sli])ping  of  a  ligature,  from  reaction  after  shoc-k,  the  heart  recovering  its 
vigor  and  j)imi|)ing  blf)od  out  from  the  vessels  which  had  not  ])reviously  oozed.  In  other 
instances,  of  course,  it  may  be  the  result  of  rupture  f)f  an  abdominal  aneurysm  or  the 
twisting  of  the  pedicle  of  an  alxlominal  tumor.  Constitutional  causes  which  contribute 
toward  it  are  jaundice,  both  with  or  without  accompanying  cholemia  (mentioned  more 
particularly  in  the  section  on  the  Biliary  Passages),  hemophilia,  scurvy,  and  that  form 
of  myelogenous  leukemia  ff)r  which  splenectomy  has  been  occasionally  performed. 
In  all  these  cases  the  patients  are  abnormally  prone  to  l)leed  freely.  When  this  con- 
dition is  susj)ected  it  is  well  to  determine  the  coagidation  time  of  tlie  blood.  If  this  be 
over  six  minutes  the  calcium  salts,  with  iron  and  fruit  acids,  should  be  administered 
some  time  previous  to  operation. 

The  most  important  symptoms  of  postoperative  or  internal  ahdounnul  hemorrhages 
are  rising  pulse,  with  fall  in  temperature,  pallor,  and  that  marked  reduction  of  blood 
pressure  which  gives  rise  to  the  ordinary  symptoms  of  shock  or  collapse,  along  with 
extreme  restlessness  and  disturl)ance  of  vision  or  almost  complete  l)lindness.  When 
there  has  been  any  notable  collection  of  blood  within  the  abdomen  there  may  be  found 
dulness  on  percussion  over  the  flanks.  Richardson  has  spoken  of  the  nursi-'s  duty  and 
the  surgeon's  duty  imder  these  conditions,  the  former  l)eing  to  recognize  the  indications 
of  increasing  shock  and  alteration  in  pulse  rate,  the  latter  being  to  adopt  every  expedient 
for  the  checking  of  hemorrhage,  including,  in  many  cases,  prompt  re-opening  of  the 
abd(jmen.  The  more  promptly  this  measure  is  instituted  when  denuuuied  the  greater 
the  probability  of  saving  the  patient. 

The  principal  danger  after  all  alidominal  operations,  next  to  the  possibility  of  hemor- 
rhage, which  rarely  occurs,  is  that  of  peritonitis,  a  danger  so  imminent  in  the  pre- 
antiseptic  era  as  to  have  made  the  abdomen  an  almost  sacred  cavity,  Init  one  which  is 
now  almost  abolished  by  perfection  of  asejitic  technique,  yet  calling  for  never-ending 
care  and  attention  to  detail,  and  occurring  occasionally  in  s|)ite  of  all  the  precautions 
which  the  most  experienced  and  conscientious  operator  can  take.  This  condition  is 
to  be  feared  when  vomiting  c-f)ntinues  or  comes  on  afresh,  and  in  the  presence  of  tym- 
panites, with  a  steadily  rising  pulse.  The  first  appearance  of  these  threatening  signs 
will  l)e  always  a  w'arning,  although  not  invariably  an  indication  of  danger,  since  the 
condition  producing  them  may  be  averted  by  catharsis  or  by  meeting  some  special 
indication.  Septic  peritonitis,  the  great  dread  of  the  abdominal  surgeon,  an<l  prac-tically 
the  only  form  with  which  he  as  such  has  to  deal,  will  be  considered  by  itself  a  little  later. 
Yet  it  is  always  a  question  whether  it  is  advisable,  even  in  these  cases,  to  administer 
powerful  cathartics  which  provoke  undu?  intestinal  motion  and  favor  the  distribution 
of  infection.  While  it  is  true  that  o|)ium  masks  symptouis  and  leads  to  erroneous  con- 
clusions the  same  is  frequently  true  of  cathartics.  From  them  a  really  oljstnicted  or 
really  jjaralyzed  bowel  suffers  harm  rather  than  good.  They  are  too  sparingly  absorbed, 
and  if  al)sorl)ed  their  effect  is  bad.  It  is  much  better  in  these  cases  to  wash  out  the 
stomach  with  a  weak  soda  solution,  and  then  keep  it  empty,  emptying  the  lower  bowel 
by  the  same  means,  and  thus  placing  as  much  as  possible  of  the  intestinal  tul)e  at  rest. 


J.\./(/i'l/:s  OF    Till-:   MihUMIS M.    WM.L  7,S| 

Willi  fniiii  lOIH)  to  L'OOO  ( "c.  sulinc  soliilinn  iiilrndiicrd  liciicalli  llic  .skin  cadi  Iwciilv- 
foiir  ludirs  patients  can  \n-  kept  rioin  .starving'  loi'  a  siidicicnt  k-n^'tli  of  time  to  pcriiiil 
of  other  trealiiieiit  lor  tlie  condition. 


INJURIES  OF  THE  ABDOMINAL  WALL. 

Contusions.  Conlnsions  of  tlic  alxloniinal  wall  may  l)c  followed  l)\-  serious  eoii.sc- 
(|nenccs,  even  tlion^di  they  liav*-  llie  appearance  of  l»ein<f  lri(lin<f.  Tlie  injury  tliat  may 
1)1'  done  implicates  not  alone  the  ahdomina!  wail  proper,  hut  the  viscera  beneath.  A 
l)l()\v  upon  the  aixlomen,  followed  hy  immediate  collapse  of  temporary  character  (as  tlie 
history  of  n)aiiy  a  prize  fi<fht  has  shown),  indicates  a  sudden  reduction  of  blood  pressure, 
the  nausea  and  other  features  being  due  to  the  mechanism  of  the  semilunar  ganglia 
and  the  sympathetic  nerves. 

Contusions  of  the  abdominal  walls  alone  are  serious  largely  in  |)i-o])oilion  as  tliev  are 
followed  by  cxtrardsatiou  or  /initdioiiui,  since  from  failure  of  absor|)tion  of  the  latter  there 
may  result  a  c-yst,  or  jjossibly  an  abs<'ess  should  local  infection  occur.  In  either  event 
evacuation  and  suitable  local  treatment  are  demanded.  But  any  blow,  even  without 
penetration,  nuiy  give  rise  to  serious  disturbances  within  the  al)domen.  Tims,  as 
Uichardson  has  said,  tlie  hollow  viscera  are  lial)le  to  rupture,  witli  extra va.sat ion,  the 
solid  to  fracture  witii  hemorriuige,  wiiile  lacerations  of  the  omentum  or  mesentery  may 
|)roduce  immediate  hemorrhage  and  subsequent  |K)s.sibility  of  intestinal  obstruction. 
When  extrava.'^ation  has  occurred  distention  and  the  ordiiuiry  evidences  of  peritonitis 
supervene.  Wlien  tlie  spleen  or  liver  has  been  torn  or  crushed  there  will  Ije  oijtained 
evidences  of  extensive  internal  liemorrhage. 

Of  the  holloiv  viscera  much  will  depend  upon  tlie  degree  of  their  fulness — especially 
with  fluid.  In  a  small  tear  there  may  l)e  eversion  of  the  mucosa,  wliicli  mav  hinder 
or  even  prevent  extravasation.  Escape  of  infectious  material  into  the  cavity  of  tlie 
lesser  omentum  may  jiroduce  local  peritonitis,  with  subsequent  development  of  what  is 
practically  a  subpli rente  abscess.  When  the  patient  vomits  blood  it  shows  that  there 
has  been  ruptui'e  of  the  gastric  mucosa.  Intestinal  ru])ture  will  be  made  known  hy  rapid 
distention  and  the  ordinary  evidences  of  acute  peritonitis.  These  injuries  rarely  lead 
to  vomiting  of  l)lood,  but  when  occurring  loAV  in  the  bowel  may  lea<l  to  tlie  occurrence 
of  bloody  stools.  Rupture  of  the  spleen  or  pancreas  is  rarely  diagnosticated  |jrevious  to 
exj)loration,  save  as  a  severe  alxlominai  injury.  It  is  not  so  likely  to  lead  to  ra])id  peri- 
tonitis. Rupture  of  the  liver  ])ermits  of  more  or  less  escape  of  l)ile,  a.s  well  a.s  of  i)l(jod, 
and  ruj)ture  (jf  the  gall-l)iad(ler  permits  the  free  emptying  of  bile  into  the  upj)er  abdomen. 
As  tliis  is  usually  harmless,  in  otherwise  healthy  individuals,  the  injury  is  not  neces- 
sarily so  serious  as  might  appear.  In  such  a  case  the  resulting  jieritonitis  will  probably 
be  local  rather  than  general. 

In  this  connection  may  be  considered  ruptures  of  the  kidneij,  which  are  ])roduced  l)v 
similar  injuries  to  those  under  consideration,  and  which  may  ])ermit  escape  of  urine  or 
blood  into  the  abdominal  cavity,  as  well  as  the  apjjearance  of  Ijlood  in  the  urine.  While 
tliese  will  Ix-  considered  in  anotlier  place  tlie  j)ossiljility  of  tlieir  com})licating  abtlominal 
injuries  cannot  be  overlooked. 

Cuusiderab/e  laceration  tvill  predispose  to  subsequent  hernias,  either  direct  or  indirect, 
in  the  latter  ease  by  absorption  following  injury.  The  more  serious  consequences  of 
abdominal  contusions — i.  e.,  the  deeji  hemorrhages  and  lacerations  of  viscera — may 
then  include  all  degrees  of  such  injury,  from  trifling  sul>peritoneal  ecehymosis  to  extensive 
ruptures  of  such  organs  as  tlie  kidney  or  liver,  or  ])erhaps  multiple  jicrforations  of  stomach 
and  bowel.  These  decj)  injuries  will  be  considered  liy  tliemselves  when  dealing  with 
special  organs.  It  is  sufficient  here  to  indicate  their  jjossibility  and  U)  warn  that  every 
severe  contusion  of  the  abdomen  which  is  followed  by  local  syni])toiiis,  or  those  which  are 
grave  and  progressive,  may  at  any  time  demand  exploratonj  section,  which  should  be 
made  early  rather  than  late.  It  is  advisable  to  jiass  a  catheter  to  make  sure  that  there 
is  no  blood  mixed  with  the  urine,  and  to  make  a  rectal  examination  in  order  to  discover 
blood  should  it  have  escaped. 

Penetrating  wounds  of  all  descriptions,  punctured,  incised,  and  gunshot,  are  again  of 
importance  largely  in  proportion  to  the  damage  done  to  intestines  and  great  vessels. 
Some  of  these  injuries  are  so  evidently  superflcial  that  exploration  may  be  abstained 


782  SPECIAL  OR  REGIONAL  SURGERY 

from,  hilt  rvrr//  pnirfratltu/  icoiind  ir/iicli  has  trnlij  pcnH rated  is  to  be  treated  eitlier 
as  they  are  treated  on  the  hattle-field,  hy  mere  insjK'clioii  and  occhision,  or  hv  careful 
exploration  under  all  asej)tie  precautions.  WJtai  the  operator  would  do  deliljerately 
mail  not  he  'what  he  can  do  in  an  emeryeneij,  Jmt  if  he  cannot  reach  one  extreme  he  would 
best  be  content  loith  the  other. 

Abdominal  contusion  has  been  found  by  Makin  to  be  the  cause  of  about  70  j)er  cent, 
of  the  cases  of  intestinal  rupture  which  have  followed  sudden  or  sharp  blows,  while  the 
other  30  per  cent,  have  been  due  to  the  passage  over  the  abtlomen  of  heavy  objects. 
Le  Conte  has  well  summed  it  up  in  the  following  words:  "If  the  force  be  circumscribed, 
and  of  high  velocity  and  of  small  inertia,  such  as  a  kick  or  blow  from  some  rapidly  moviii"- 
object,  crushing  of  the  intestine  is  more  likely  to  occur;  while  if  the  force  be  diffuse, 
as  from  a  slowly  moving,  ponderous  object  of  considerable  inertia  {e.  (j.,  a  wagon  wheel), 
the  belly  is  more  apt  to  be  torn  at  one  of  its  fixed  i)oints  or  the  mesentery  injured.  Thus 
out  of  ()1  cases  of  horse-kicks  of  the  abdomen  in  59  intestinal  ru|)ture  occurred.  When 
the  abdominal  muscles  have  been  braced  in  expectation  of  a  blow  less  harm  results 
than  when  it  has  been  suddenly  inflicted  upon  a  relaxed  musculature."  Crile  has  shown 
that  the  more  specialized  and  abundant  the  nerve  supply  to  a  given  viscus  the  more 
will  it  contribute  to  the  jiroduction  of  shock  when  injured. 

Pain  is  not  always  an  immediate  symptom.  It  may  be  tlelayed  for  hours,  or  ]X)ssil)ly 
even  for  days.  When  intestinal  rui)ture  has  occurred  pain  is  most  often  referred  to  the 
central  portion  of  the  abdomen.  In  rupture  of  the  spleen  it  is  ccjmplained  of  in  the  left 
side,  while  when  the  kidneys  have  been  ruptured  jjain  follows  the  course  of  the  ureters  to 
the  genitals  and  there  is  usually  retraction  of  the  testicle. 

INIuscle  rigidity  is  a  sign  of  equal  diagnostic  value  with  pain,  and  immobilization 
of  the  abdominal  wall  nearly  always  indicates  intestinal  rupture.  The  facial  expression 
is  also  of  importance,  it  being  in  the  more  severe  cases  almost  distinctive.  A  steadily 
rising  pulse  is  always  a  bad  sign,  usually  indicating  a  developing  peritonitis.  Vomiting, 
if  long  continued,  after  a  patient  has  rallied  from  the  immediate  shock,  is  considered 
of  itself  to  justify  operation.     The  same  is  true  of  paralysis  of  peristalsis. 

Such  injuries  to  the  abdominal  walls  proper  may  divide  imj^ortant  vessels,  such  as 
the  epigastric,  and  give  rise  to  hemorrhage  which  may  be  internal  rather  than  external. 
The  first  and  most  important  danger  of  hemorrhage  having  been  passed  or  being  avoided, 
the  next  and  always  urgent  risk  is  of  infection.  This  may  come  from  non-])enetrating 
injuries,  as  well  as  th(jse  which  open  a  wide  path  into  the  interior,  and  it  is  sometiiues 
the  small  punctures  which  prove  most  disastrous. 

From  any  wounded  abdomen  there  may  protrude  omentum,  intestine,  or  portions  of 
some  other  abdominal  viscus,  while  extensive  abdouiinal  incisions  permit  more  or  less 
evisceration.  There  are  cases  on  record  of  jiregnant  wouien  being  injured  by  the  horn 
of  an  infuriated  animal  and  having  the  entire  abdomen,  as  well  as  the  ])regiumt  uterus, 
ripped  open,  everything  thus  escaping.  The  omentum  is  the  most  likely  to  escape 
tlu-ough  small  openings  of  all  the  abdominal  contents,  and  this  is  fortunate  for  the 
])aticnt  for  reasons  to  be  mentioned  in  connection  with  the  omentum  and  the 
peritoneum. 

When  the  nature  or  the  apjiearance  of  the  wound  make  a  complete  perforation  of 
the  abdominal  wall  probable  it  will  always  be  safer  to  be  satisfied  regarding  deeper 
conditions.  The  parts  having  been  thoroughly  sterilized  the  ordinary  probe  is  rarely 
sufficient,  the  best  method  of  orientation  being  the  sterile  finger.  Its  use  nuiy  require 
enlargement  of  the  incision,  and  this  should  always  be  nuide.  Such  an  opening  being 
made  and  proving  insufficient  should  be  enlarged  to  any  desired  extent.  Possibly  a 
deep  condition  will  be  thereby  revealed,  which  will  make  it  ex])edient  to  open  the  abdo- 
men freely  in  the  middle  line,  and  to  deliberately  practise  one  of  the  many  expedients 
called  for  in  such  an  emergency,  such  as  ligation  of  vessels,  intcstiiud  suture,  removal 
of  a  foreign  body,  and  the  like.  The  indication  once  met  the  incisions  are  closed,  an 
infected  wound  being  suitably  drained. 

In  general  it  may  be  said  that  laparotomy  is  the  wiser  course  in  nearly  every  instance, 
and  that  it  should  be  done  when  the  surgeon  is  in  actual  doubt  as  to  its  necessity,  it  being 
better  to  give  the  patient  the  benefit  of  the  doubt  and  operate.  In  all  cases  with  serious 
symptoms  it  is  certainly  safer  than  to  wait  for  further  symptoms.  This  will  appear 
advisable  in  view  of  Curtis'  collection  of  116  cases  of  intestinal  rupture  which  were  left 
unoperated,  all  of  which  died. 


riMoh's  OF  Tin:  muximixm.  wall  7,s;; 

Gunshot  Wounds.  In  rc^jnd  in  ^nmsliol  woiiiids  the  |»iiii(i|)lc.s  of  Ircaliiiriil 
ill  civil  life  an-  dilVcn-iil  Iroiii  (liosc  ohtaiiird  in  an  adivc  iiiilitarv  caiiipaijfii.  In  llic 
roniuT  the  |»a(i(Mil  is  iisiiallv  <,nvcii  (Ik-  licst  cliainc  l)V  an  early  exploratory  section,  uilli 
tlioroiit^Ii  cxamlnalion  of  llic  alxloiiiiiial  contents,  done  with  every  useptic  |)recan(ioii 
and  every  means  lor  cnircct  work.     This  is  not  possible  ii|)oii  (he  hattlc-ficKI. 

Foreign  Bodies.  l''orci,un  hodies  are  occasionally  inci  with  in  ihc  aliduniinal  wall, 
'i'hese  may  he  iiitrodiice(i  from  without  l>y  accident  or  desi<f|i,  such  as  needles  or  splinters, 
or  may  ri\snlt  Ironi  the  escape  hy  slow  process  of  some  forei<.jii  body  from  within,  siicli 
as  a  fish-l)on(>,  a  needle,  and  the  like.  Thus  in  an  ahscess  of  the  ahdominal  wall  I  once 
found  a  stick-pin  over  five  inches  lonjj,'  with  a  lar;i;e  ^^lass  head.  'I'his  had  heeii  swallowed 
hy  an  insaiu'  patient,  who,  snl)se(|iiently  recovering;  from  her  mania,  went  home  and 
developeil  this  disturbance  a  year  or  so  after  her  rele;ise  from  the  asylum. 

PHLEGMONS  AND  OTHER  SEPTIC  INVASIONS  OF  THE  ABDOMINAL  WALL. 

.  I /MYv.v.vr.v  may  develop  within  (he  abiloininal  wall,  without  reference  to  deeper  phle<r- 
monous  processes  within.  Thus  they  are  occasionally  seen  after  typhoid  and  the  exan- 
thcnias,  appearino;  perhaps  as  often  in  the  rectus  as  anywhere.  'J''hey  may  at  any  time 
result  from  superlicial  al)rasi;)ns  and  travellinif  infections.  They  may  occur  somedmes 
tus  the  extension  of  sup|)ura(in<j;  bubo,  especially  after  |)ha<^e<lenic  chancroid.  The\'  are 
recognized  by  signs  which  are  usually  uiuuiuivocal,  and  when  once  detected  should 
pruin})tly  be  evacuated. 

Gumnia.s-,  botii  tuberculous  and  syphilitic,  frequently  break  down  and  form  abscesses 
of  mixed  ty])e.  These  may  burrow  deeply  behind  fascial  ])lanes,  and  re(|uire  one  or 
more  counteropenings.  As  the  result  of  a  particularly  virulent  infection  with  the  specific 
organisms  that  ])roduce  it  one  sees,  rarely,  about  the  abdomen  ex[)ressions  of  (jdiKjrcnoiis 
ccUulitis  or  mahgnant  edema,  which  may  spread  here  from  some  adjoining  part  and 
involve  wide  areas.  Abscesses  also  result  from  infection  of  hematomatous  or  other 
eysts,  while  collections  of  pus  arising  in  the  chest,  travelling  far,  may  spread  downward 
along  the  subperitoneal  connective  tissue  and  appear  even  low  within  the  abdomen  or 
externally  upon  it.  Acute  osteomyelitis  of  the  bones  of  the  pelvis,  or  acute  suppurative 
spondi/Iitis,  may  produce  abscesses  which  will  also  involve  the  abdominal  wall,  while 
it  fre([ucntly  sufl'ers  in  the  effort  of  pus  to  burrow  toward  the  surface,  as  in  large 
pcrinrphritic  collections  and  the  like. 

Enjslpclas  not  iiifre{|uently  involves  the  abdominal  surface,  and,  spreading  deepiv, 
may  produce  suppuration  or  a  virulent  type  of  peritonitis.  The  latter  is  more  likely  to 
occur  in  connection  with  woinids  and  other  injuries. 

Asitle  from  hums  of  the  minor  type,  which  may  involve  large  areas,  there  may  be  seen, 
especially  upon  the  abdomen,  extensive  and  distressing  expressions  of  a;-ray  dermatitis, 
so  called,  followed  by  ulcerations,  perhaps  with  the  later  development  of  epithelioma. 
These  results  of  injudicious  exposure  to  the  cathode  rays  are  always  of  the  most  painful 
and  erethistic  type,  and  most  difficult  to  heal.  Resistant  cases  are  ])robably  best  treated 
by  complete  destruction  of  the  surface  with  knife  or  spoon  and  skin  grafting. 

ITpon  the  abdominal  surface  are  seen  some  of  the  characteristic  expressions  of  (he 
ulcemtive  si/phi/ide  and  of  fuhrrculosis  of  the  skin.  The  former  will  re((uire  ac(ivc 
antispecific  medication  and  the  latter  call  for  the  curette  or  complete  excision.  In  cither 
ca.se  radical  treatment  is  usually  promjjtly  successful. 

Artinomi/rotic  lesions  are  also  seen,  perhaps  as  often  about  the  abdomen  as  anywhere. 
They  are  likely  to  be  mistaken  at  first  for  tuberculous  or  syphilitic  disease,  but  may 
be  (Jifferentiated  by  ap])earances  elsewhere  noted.  They  require  active  eradication, 
combined  with  the  local  and  general  use  of  iodine  and  copper  sulphate. 


TUMORS  OF  THE  ABDOMINAL   WALL. 

The  abdominal  walls  are  not  exempt  from  tuiuors  which  involve  similar  textures  in 
other  j)arts  of  the  body.  About  the  ordinary  hernial  outlets  it  is  advisable  to  proceed 
cautiously  with  any  tumor,  lest  it  may  prove  to  contain  or  to  be  combined  with  a  true 
hernia  in  disguise.     This  is  especially  true  at  the  umbilicus.     Congenital  cysts  in  the 


784  SPECIAL  OR  REGIOXAL  SURGERY 

^vall.s  arc  usually  met  with  alouo;  the  middk'  line,  ami  will  prove  to  I»e  reiiinants  <;f 
evihnjonic  rijatfi,  vitello-intestinal,  uraeluii,  celiiiiococous,  or  deriiKjid.  Cysts  sliould  ije 
distinguished  from  fatty  tumors  and  sometimes  fnjm  hernias.or  from  cold  abscesses. 

Fatfi/  tumors  are  common  in  all  shapes,  locations,  and  sizes.  Among  the  benign  tumors 
frequently  observed  are  the  fibroma.s,  esj)ccially  those  of  the  type  sj)oken  of  in  Cliapter 
XXVI  as  desmoids — /.  c,  those  arising  from  the  dense,  fibrous,  aponeun^ic  tissues, 
growing  slowlv,  being  exceedingly  firm  and  hard  in  character,  intimately  connected 
with  the  fascia  or  aponeurosis,  but  not  with  the  overlying  skin  nor  with  the  viscera 
beneath.  They  are  practically  ])ainlcss,  may  attain  great  size,  and  should  always  be 
removed  while  yet  small,  in  order  that  the  aljdominal  wall  may  not  be  weakened  more 
than  necessary  l)y  taking  away  the  fil)rous  structures  which  especially  give  it  strength. 

The  vascular  tumors  which  call  for  surgery  are  uncommon.  Pigmented  nevi,  h(jwever, 
are  occasionally  met,  and  these  should  always  be  promptly  removed  lest  they  degenerate 
into  meUinosarcomas.  Varices  and  venous  angiomas,  sometimes  of  extensive  dimen- 
sions, are  also  not  infrecjuently  found  here.  Extensive  varicosities  may  have  a  congenital 
cause,  the  decj)  venous  channels  Ix'ing  insufficient,  or  they  may  be  due  to  thrombotic 
occlusion  of  the  abdominal  veins  following  typhoid,  ])ucrperal  fever,  or  injury. 

Primarij  carcinoma  originating  within  or  upon  the  skin,  cpitliclioma  (.f  similar  origin, 
and  sarcoma  arising  from  the  deeper  mcsoblastic  tissues,  may  occur  as  primary  tumors 
of  the  abdominal  wall.  We  may  also  have  cndotliclioma  springing  from  the  peritoneum, 
witli  possible  origin  elsewhere.  Occurring  secondarily  we  may  see  any  of  the  ordinary 
metastatic  expressions  of  any  of  these  forms  of  growth,  as  well  as  those  spreading  by 
continuity,  the  most  frequent  example  of  the  latter  being  so-called  cancer  en  cuirassc 
following  cancer  of  the  breast. 

Finally,  for  those  enormous  overdeveloj)ments  of  fat  and  ccmnective  tissue  which 
accompany  exceedingly  pendulous  alKlomens,  such  as  most  ccunnuMily  folhnv  ]>regnancy 
or  clepliantiasis,  the  surgeon  has  occasionally  to  excise  large  areas,  closing  the  defects 
thus  made  by  numerous  tiers  of  buried  with  strong  superficial  and  retention  sutures. 

THROMBOSIS  AND  EMBOLISM  FOLLOWING  ABDOMINAL  OPERATIONS. 

It  is  well  known  that  these  conditions  occasionally  follow  parturition  and  then  lead 
to  sudden  death.  A  similar  condition  is  now  generally  apprc(  iatcd  as  occasionally  fol- 
lowing abdominal  operation,  and  sometimes  leading  to  the  same  fatal  result.  It  has 
been  said  that  thrombophlebitis  follows  alxnit  ;j  per  cent,  of  abdominal  sections.  It 
occurs  oftencr  in  the  left  than  in  tl'e  right  leg,  and  its  etiology  is  obscure.  It  begins 
with  jmiii  in  the  calf  and  groin,  the  leg  rapidly  swelling  and  tlicn  becoming  edematous. 
Various  writers  have  called  attention  to  the  occurrence  of  jjleurisy  and  pneumonia  during 
convalescence  from  appendectomy,  and  ascribe  them  to  the  presence  of  small  emboli 
detached  from  the  thrombi  forme<l  around  the  immediate  site  of  the  operation. 

Two  rather  opposite  theories  ])revail  at  present  regarding  the  condition — one  that  it 
starts  as  a  phle!)itis  due  to  infection  at  the  time  of  the  ojjcration,  the  other  that  throm- 
bosis is  the  primary  lesion  and  therefore  res]X)nsible  for  the  phlebitis.  Clark  and 
others  have  contended  that  injury  to  the  epigastric  veins,  by  retracting  and  holding 
ojjen  abdominal  incisi(jns  during  ])rotracte(l  (jj)erations,  is  the  cause  of  the  trouble. 

It  would  seem  rational  to  holil  that  mechanical  vitjlence  to  the  vessel  walls,  at  or  about 
the  site  of  the  operation,  is  the  actual  exciting  cause  in  non-septic  cases.  On  th(M)ther 
hand,  the  cases  of  infectious  type  should  be  accounted  for  either  by  local  infection  or 
as  an  expression  of  toxemia  such  as  we  see  when  similar  thrombophlebitis  occurs  during 
the  course  of  typhoid  fevers  and  the  like. 

Years  ago,  Agnew,  for  instance,  stated  that  after  operations  in  which  nnich  blood 
has  been  lost  there  is  always  more  or  less  tendency  to  the  formation  of  coagula,  but 
certainly  the  majority  of  these  operations  today  are  accompanied  by  very  little  lo.ss  of 
blood.  Embolic  ])leurisy  and  j)neumonia  may  apjx-ar  without  preliminary  symptoms, 
while  abdominal  thrombophlebitis  rarely  shows  itself  until  at  least  the  end  of  the  first 
week  and  sometimes  not  until  the  fourth  week  after  operation,  and  then  more  often  in  the 
left  than  in  the  right  leg. 

In  the  treatment  of  these  cases  palpation  and  massage  are  to  he  strongly  avoided, 
lest  thrombi  l)e  dislodged  and  thereby  produce  pulmonary  infarcts.  Rest  and  sorbe- 
facient  ointments  constitute  the  best  treatment. 


CHAPTER    XLVI. 
THE  PERITONEUM  AND  ITS  DISE.VSES. 

Wehk  tlic  |)crit()ii('Uiii  sprciid  iij)()ii  a  flat  siiri'jicc  it  would  Ix-  t'oniid  to  (-(jiial  in 
area  that  of  the  skin  wliicli  covers  the  body.  In  man  it  is  a  closed  sac;  in  woman  it  is 
exposed  to  exterior  contamination  tlirouifli  the  Fallopian  tul)es  l)y  way  of  the  uterus 
and  vagina.  Hence  the  frecpiency  with  which  infections  of  the  latter  are  transmitted 
to  the  memhrane  itself,  'riiickened  in  some  places,  or  du|)licated,  for  the  purpose  of 
formin<^  li<j;aments  and  membranous  visceral  suj)i)orts,  it  is  usually  thin,  connected  with 
the  structures  which  it  lines  or  covers  by  a  more  or  less  delicate,  cobweb-like  connective 
tissue.  In  some  of  its  duplications  relatively  Vdr^a  amounts  of  fat  may  be  collected. 
While  freely  suj)plied  with  bloodvessels  it  may  be  regarded  as  an  enormous  lymj)h  sac, 
its  capabilities  of  absorption  being  relatively  immense.  It  is  because  of  this  that  human 
beings  esca|)e  many  of  the  j)ossil)ly  fatal  consetiuences  of  infection.  Along  it  infectious 
processes  travel,  sometimes  with  wonderful  rai)iciity,  while  again  it  throws  out  exudates 
and  rapidly  walls  off  a  serious  disturbance,  imprisoning  it,  as  it  were,  and  often  effect- 
ually. Fluid  may  escape  fnjm  it  (fluid  exudate)  with  great  ra])idity,  or  it  may  exude  a 
fluid  rich  in  fibrin  which  rajjidly  accumulates  and  forms  a  dense,  firm  exudate  that 
serves  to  bind  surfaces  together  and  is  often  the  surgeon's  best  friend.  In  fact,  the 
surgeon  looks  for  a  minimum  and  desirable  amount  of  this  exudate  to  ensure  the  result 
of  whatever  sutures  he  may  pass  through  the  peritoneum  and  the  tissues  which  it  covers. 
Thus  after  an  ordinary  intestinal  suture  it  is  expected  that  within  some  six  hours  the 
exudate  thus  formed  will  be  of  itself  almost  sufficient  for  the  purpose  of  safety. 

Peritoneum  is  said  to  possess  the  power  of  absorbing  from  4  to  8  per  cent,  of  the  weight 
of  the  individual  within  an  hour,  but  this  only  under  normal  circumstances,  since  inflam- 
mation or  previous  lesions  delay  or  interfere  with  the  process.  Increased  peristalsis 
hastens  it,  the  reverse  being  also  true.  On  the  other  hand,  conditions  may  be  easily 
reversed,  and  the  presence  of  sugar  or  glycerin  within  the  peritoneal  cavity  causes  a 
diluting  fluid  to  be  thrown  into  it  at  about  the  same  rate.  It  is  by  virtue  of  a  firm,  fibrin- 
ous exudate  that  foreign  materials,  e.  cj.,  ligatures,  sutures,  and  even  larger  substances, 
are  encapsulated,  those  which  are  ca{)able  of  disintegration  finally  disappearing  from 
within  this  investment.  Occasional  instances  are  on  record  of  instruments,  sponges, 
or  pieces  of  gauze  being  left  within  the  peritoneal  cavity,  in  consequence  of  inadvertence 
during  or  when  concluding  an  operation.  Such  bodies  tis  these  often  encapsulate  in 
this  way  and  have  been  foimd  years  after  at  postmortem  examination,  or  have  been  slowly 
extruded  during  life  by  natural  ])rocesses.  Such  unfortunate  occurrences  as  the  latter 
afford  the  greatest  reason  for  care  during  all  such  operations. 


PERITONITIS. 

The  term  peritonitis  has  been  made  to  cover  so  many  conditions,  of  widely  differing 
pathological  character,  that  it  is  intended  here  to  consider  only  those  which  have  a  prac- 
tical interest  for  the  surgeon.  It  is  unfair  both  to  terminology  and  pathology  to  include 
under  the  same  name  conditions  that  may  be  brought  about  slowly,  or  without  any  parti- 
cipation of  bacteria,  with  those  which  are  due  solely  to  bacterial  invasion.  No  attempt 
will  be  made  here  to  go  into  a  minute  or  complete  classification  of  the  various  conditions 
included  by  different  writers  under  this  name.  For  instance,  th^y  have  spoken  of  an 
idiopathic  form  of  peritonitis,  thus  confessing  by  use  of  this  adjective  ignorance  of  the 
etiology  of  the  condition.  The  surgeon  has  neither  use  for  such  an  expression  nor  belief 
in  such  a  possibility.  The  thickening  of  the  peritoneum  which  may  result  from  the 
proximity  of  an  old  hemorrhage,  or  the  irritation  produced  by  the  circulating  fluids 
in  cases  of  Bright's  disease,  is  for  him  an  entirely  different  entity,  and  is  neither  an 
idiopathic  form  nor  peritonitis  itself, 

50  (  785 ) 


780  SPECIAL  OR  REinoSAL  SURGERY 

For  siirgiral  purjioses  we  mention  especially  the  following  forms: 

A.  Consecutive; 

B.  Traumatic; 
(".   Perforative; 

D.  Tuberculous; 

E.  Malignant; 

F.  Intra-uterine  and  infantile. 

Forms  A,  B,  and  C  may  merge  into  one  another  or  be  confused  from  the  beginning, 
or  thev  may  themselves  be  ((Jiisecutive  to  D,  while  E,  the  malignant  form,  is  hardly 
a  distinct  ty])e,  but  rather  a  jK-ritoneal  exj^ression  of  a  more  widespread  general  condition. 

Again  writers  have  endeavored  to  make  tlistinctions  by  the  use  of  such  terms  as  "viru- 
lent," "se])tic,"  "putrid,"  between  which,  however,  no  lines  can  be  clearly  drawn  nor 
sharp  distinctions  made.  They  depend  to  some  extent  on  the  nature  of  the  bacterial 
invasion,  and  again  uyxju  the  actual  virulence  of  the  bacteria  involved.  The  most 
distinctive  tvix*  of  surgical  j)eritonitis  is  the  tuherculou.i,  which  is  usually  relatively  slow 
and  recognizable  as  such,  but  as  between  the  cases  produced  by  spreading  erysipelas, 
gonorrhea,  intestinal  perforation  or  postoperative  infection  one  can  make  few,  if  any, 
distinctions  which  are  serviceable  or  useful. 

Anatomically  considered  there  are  two  types  of  great  ini])()rtance — the  rinmnscrihed 
or  local  and  the  general  or  diffuse — prognosis  depending  in  no  small  degree  u}X)n  the 
extent  of  limitation  of  the  active  process,  while  at  any  time  the  former  may  merge  into 
the  latter.  Consecutive  peritonitis  may  include  that  which  is  the  result  of  direct  exten- 
sion, as  from  erysipelas,  appendicitis,  acute  cholecystitis,  pyosalpinx,  or  other  acute 
infections  Avhich  have  spread  to  and  involve  this  membrane.  Under  this  head  also 
mav  be  included  those  cases  due  to  thrombosis  or  embolism,  of  mesenteric  or  other 
vessels,  which  lead  to  speedy  gangrene  of  a  part  or  all  of  the  intestine. 

Traumatic  peritonitis  refers  rather  to  those  cases  where  infection  has  been  carried 
directlv  inward  from  the  exterior.  Traumatic  peritonitis  may  be  the  result  of  extension 
f)f  the  same  conditions  which  produce  the  first,  the  consecutive  form,  or  only  occur  more 
directlv,  as,  for  instance,  those  cases  produced  by  rupture  oi  the  stomach  or  duodenum 
after  ulcerations  of  the  same,  or  ])erf()ration  of  typhoidal  ulcers,  actual  rupture  and 
escajX'  of  the  contents  of  a  sui)j)urating  gall-bladder,  a])pendix,  tube,  or  any  other  col- 
lection of  pus,  or  perforation  due  to  the  gradual  extension  of  tuberculous,  syphilitic, 
or  malignant  disease,  with  final  rupture  of  a  viscus. 

The  nature  of  the  bacterial  invasion  is  of  more  interest  to  the  jiathologist  than  to  the 
surgeon  as  such.  In  general,  however,  it  may  be  said  that,  in  addition  to  the  ordinary 
j)vogenic  organisms,  the  colon  bacilli  are  j^erhaps  the  most  frequently  to  blame,  while 
the  more  putrid  types  are  the  result  of  actual  escape  of  bacteria  from  the  intestine,  as 
through  a  perforated  appendix,  and  the  addition  of  a  mixed  tyj)e  to  one  which  began 
])erhaps  as  a  simple  one.  Thus  in  the  so-called  putrid  forms  multi|)le  Iwicterial  con- 
tamination is  usually  discovered  upon  making  cultures.  The  pneum(Koccus,  the  capsule 
bacillus,  and  the  gonococcus  are  also  not  infrequently  found,  in  cases  of  peritonitis 
whose  nattn-e  and  origin  will  be  suggested  by  the  discovery  of  the  particular  germ 
involved  ill  each  case. 

SymptOins. — While  varying  much  in  time  and  intensity,  and  even  completely  chang- 
ing their  tyi)e  during  the  successive  stages  of  the  disease,  there  are,  nevertheless,  certain 
cardinal  symptoms  which  are  universally  recognized  in  cases  of  surgical  peritonitis. 
These  include  vomiting,  pain,  tenderness,  with  more  or  less  shock,  followetl  sooner  or 
later  bv  abdominal  sjxism  and  distention,  Avhile  to  these  symptoms  there  is  sure  to  be 
adfled  Ijfjwel  obstruction  of  some  type  VNhich  becomes,  toward  the  end,  perhaps  the 
most  |)rofound  feature,  and  which  may  even  mask  the  significance  of  other  symjjtoms. 
According  as  the  lesion  is  localized  or  generalized  pain  may  be  referred  to  a  particular 
area  or  may  be  general  and  intense.  Local  pain,  with  tenderness,  usually  implies, 
at  least  at  first,  a  localized  lesion,  and  is  not  so  likely  to  be  accompanied  by  vomiting 
as  the  more  diffuse  form.  Depression  is  found  to  corres|X)nd  largely  to  the  type  and 
degree  of  sepsis,  while  collapse  is  a  prf)minent  feature  in  the  more  severe  cases.  The 
pain,  which  is  sometimes  intense,  subsides,  and  it  should  be  emphasized  that  a  speedy 
sul)sidence  is  not  necessarily  a  favorable  symptom.  It  too  often  marks  the  transition 
of  an  ordinarilv  acute  case  into  one  of  intensely  septic  or  even  jnttrid  type.  Tenderness 
mav  \)e  acute  and  localized,  or  diftuse  and  only  evoked  on  deep  pressure.     One  of  the 


Phh'/Toxiris  787 

iiio.sl  .^i;i;lli(i(•;lIl(  .syiii|)tniiis  is  (iIx/oihiiki/  nr/it/ili/,  wliidi  persists  lliroiiojliont  tlu"  active 
state  of  the  disease,  and  wliieli,  wlieii  followed  or  aecoiiipaiiied  hy  iiieteorisiii,  inav  to 
s()iiu>  extent  mask  and  ohseure  all  conditions  within,  if  the  patient  he  not  seeji  until 
this  statue  is  reached  diaj^nosis  can  he  made  only  hy  history  and  conjecture,  for  it  is  almost 
impossihle  to  delermine  anythiii}^  i)y  palpation. 

T  nil  j)c  rat  lire  is  an  uncertain  factor.  It  sometimes  rises  high  at  first,  and  then  falls, 
while  if  it  fall  too  low  the  |)rognosis  is  seri()U.s.  The  pul.w  al.so  show'.s  very  irregular 
variation.s,  usually  rising,  however,  as  the  disease  becomes  more  severe,  and  heing  often 
almost  uneouutahle  at  the  end.  A  comhination  of  rising  pulse  and  falling  temperature 
is  of  serious  import. 

In  addition  to  the  roinitiiKj,  which  is  a  ])ronounce<l  early  feature  of  the  disease,  we 
liave,  as  howel  ohstruction  comes  on,  an  added  jcrni  cluirartn-  to  the  vomitus,  wliich 
sometimes  is  most  characteristic  of  complete  ohstruction.  This  ohstruction  is  due  in 
part  to  toxic  jjaralysis  of  the  nuiscular  coat  of  the  howels,  and  in  })art  to  the  result  of 
adhesions  or  fixations  hy  which  how^el  motility  is  completely  prevented.  Thus  in  many 
instances  of  peritonitis  following  acute  ajjpendicitis  there  are  loops  of  intestine  glued 
together  by  exudate  in  such  a  way  as  to  practically  occlude  or  disable  them. 

The  depression,  shock,  and  final  collaj)se  of  the  disease  are  characteristic,  as  is  al.so 
the  jnrinl  appearance,  the  cheeks  becoming  discolored  and  the  orbits  hollowed  out,  so 
that  the  eyes  early  sink  l)ack.  Other  exj)ressions  of  diminished  l)lo()d  ])ressure  are  not 
lacking — coldness  of  the  extremities;  cold,  clammy  persj)iration;  lividity  of  the  skin, 
and  the  like. 

AVhile  this  is  a  |)icture  of  the  most  conmion  expressions  of  acute  septic  or  surgical 
jjeritonitis,  it  is  occasionally  found  that  conditions  equally  serious  arise  w'ithout  such 
marked  symjitoms,  and  that  the  patients  become  rapidly  worse,  finally  dying,  who  neither 
vomit  continuously  nor  show  extreme  meteorism  nor  abdominal  rigidity.  Such  cases 
are  thereby  stamped  as  those  of  more  extreme  toxicity,  where  systemic  reaction  is 
j)aralyzed  almost  from  the  outset,  and  are  accordingly  the  more  hopeless  on  that  account. 

Ordinarily  it  is  not  difficult  to  recognize  the  onset  and  the  cour.se  of  j)eritonitis  in 
surgical  cases.  The  condition  may  be  confounded  with  one  of  septic  intoxication  from 
st)me  focus  which  has  not  involved  the  j)eritoneum;  otherwise  difi'erentiation  is  rarely 
difficult.  The  occurrence  of  such  a  condition  does  not  necessarily  indicate  faulty  tech- 
nique on  the  part  of  an  operator,  as  the  condition  is  too  often  present  when  the  surgeon 
begins  his  work.  On  the  other  hand,  it  too  often  follows  faulty  technique  and  con- 
stitutes the  strongest  argument  for  vigilance  both  in  preparation,  performance,  and 
after-treatment. 

Treatment. — But  little  will  be  said  here  about  non-operative  treatment,  although  first 
it  should  be  emphasized  that  treatment  in  the  past  was  too  often  of  the  non-operative 
type.  Many  cases  of  ])eritonitis  could  be  saved  by  operation  were  it  j)erformetl  while 
the  infection  is  still  localized,  but  this  is  at  a  period  when  they  too  rarely  reach  the 
surgeon's  hands,  he  being  called  in  as  such  when  the  inefficacy  of  drug  treatment  has  been 
already  demonstrated.  Without  denying  that  the  surgeon  is  not  blameless  in  all  these 
res])ects,  blame  should,  nevertheless,  be  placed  where  it  properly  belongs,  at  the  door 
of  the  man  who  fails  to  recognize  and  carry  out  plain  surgical  principles. 

The  opium  treatment  for  peritonitis,  with  which  the  name  of  Clark  will  always  be 
associated,  was  introduced  at  a  time  when  many  things  were  considered  as  peritonitis 
which  were  not  necessarily  such.  It  was  furthermore  an  advance  on  previous  methods 
and  gave  better  results.  That,  however,  is  no  excuse  for  adhering  to  it  when  better  means 
are  at  hand.  On  the  other  hand  it  must  not  be  denied  that  much  can  be  done  medicinally 
to  give  comfort  and  meet  certain  indications.  In  spite  of  the  many  disadvantages  attach- 
ing to  the  use  of  opiates  it  seems  unnatural  to  let  patients  suffer  as  they  would  without 
them.  It  is  justifiable,  then,  to  use  them  in  cases  which  are  hopeless,  or  in  those  Avhich 
refuse  operation ;  but  given  indiscriminately  and  early  they  often  mask  symptoms  which, 
if  properly  ap])reciated,  would  lead  to  early  diagnosis,  and,  it  is  to  be  hoped,  early  opera- 
tive relief.  Views  also  differ  regarding  catharsis.  It  is  a  great  disadvantage  to  permit 
the  intestines  to  retain  fecal  matter  for  days  and  add  a  consequent  copremia  to  the  other 
features  of  the  disease.  On  the  other  hand,  intestinal  activity  tends  to  disseminate 
infection,  and  is,  consequently,  most  undesirable.  If  at  the  outset  the  intestinal  canal 
could  be  emptied  and  then  left  at  rest  it  would  best  meet  the  somewhat  contrary 
indications. 


788  SPECIAL  OR  REGIONAL  SURGERY 

Orditiarily,  however,  it  i.s  of  small  advantage  to  keep  honiharding  the  stomach  with 
repeated  doses  of  hixatives  whieli  are  more  often  rejected  than  retained,  and  which  have 
little  efi'ect. 

One  of  the  most  distressing  features  is  vomitin(j,  and  here  it  is  well  to  follow  Berg's 
suggestion  and  test  the  vomitus  with  litmus  paper.  If  it  be  found  alkaline  small  doses  of 
morjihine  sliould  be  given,  each  with  a  drop  or  two  of  aromatic  sulphuric  acid,  in  a  little 
choy)ped  ice.  If  it  l)e  found  acid  small  doses  of  milk  of  magnesia  are  advised  or  some  such 
preparation,  with  minute  doses  of  mor})hine,  frequently  repeated.  The  greatest  relief 
in  these  cases,  where  the  Ufjper  bowel  is  emi)tying  itself  into  the  stomach,  will  be 
obtained  from  lavage.  In  the  same  way  tympanites  and  meteorism  are  best  treated 
by  passing  a  rectal  tube  high,  leaving  it  in  place,  and  utilizing  it  for  lavage  of  the  bowel, 
using  warm  water  with  a  little  sodium  salicylate.  Not  the  least  distressing  feature 
of  such  a  case  is  the  reflex  hiccough  which  is  produced  by  diaphragmatic  spasm,  since 
the  phrenic  nerve  distributes  sensitive  fibers  as  well  to  the  })eritoneuni.  For  this  there 
is  no  really  effective  remedy.  Small  doses  of  Siberian  musk,  with  or  without  morphine, 
beneath  the  skin  will  sometimes  quickly  relieve  it.  Depression  and  lowered  blood  press- 
ure are  best  treated  by  adrenalin  and  digitalis,  rather  than  by  strychnine,  which  stimu- 
lates i^eristalsis.  Fever,  when  high,  should  be  treated  by  cold  sponging  rather  than 
by  antipyretics.  The  kidneys  should  be  kept  active,  if  necessary  by  hypodermoclj^sis, 
and  the  skin  equally  so  by  hot-air  baths,  as  through  both  of  these  emunctories  much 
elimination  may  be  effected.  The  question  of  catharsis  comes ; up  again  in  considering 
what  can  be  done  to  improve  elimination  of  ])tomains  by  watery  stools,  but  these  are 
hard  to  secure;  it  is,  after  all,  questionable  whether  their  effectiveness  in  this  regard  has 
not  been  greatly  over-rated.  Richardson,  for  instance,  is  inclined  to  believe  that  cases 
reported  as  cured  by  free  catharsis  would,  in  all  probability,  have  recovered  without  it, 
it  being  doubtful  whether  the  really  infectious  element  be  present. 

Surgical  treatmrnt  of  peritonitis  includes  a  recognition  of  the  cause,  and,  if  possible, 
its  removal.  Richardson  has  grouped  in  the  following  suggestive  manner  the  indica- 
tions for  operative  intervention  in  the  early  stages,  when  cases  are  not  without  hope: 

General  pain,  becoming  local;  or  local,  becoming  general,  according  to  cause; 

Tenderness,  showing  the  same  indications; 

Abdominal  rigidity; 

Green  vomitus; 

Rising  pulse  and  temperature; 

Diminished  peristalsis  without  too  much  shock. 
On  the  other  hand,  in  cases  of  fully  (leveloj)ed  peritonitis,  where  the  surgeon  may  still 
consider  the  possibility  of  intervention,  but  where  prognosis  is  far  less  favorable,  the 
conditions  include: 

Lessening  or  vanishing  pain  ; 

More  general  tenderness. 

(treat  distention,  replacing  rigidity; 

Excessive  dark  or  fecal  vomitus; 

Obstipation ; 

Rapid  and  feeble  pulse; 

Pain  extremely  severe; 

Low  temperature  and  the  ordinary  evidences  of  reduced  blood  pressure. 
In  such  cases  the  decision  rests  largely  upon  the  degree  of  collapse.  To  operate  upon  a 
moribund  patient  is  hopeless  and  brings  discredit  upon  surgery.  Before  o])erating 
upon  any  serious  case  of  this  kind  the  circumstances  should  be  fully  explained  to  those 
concerned,  and  they  should  be  impressed  with  the  fact  that  should  the  patient  die  he 
dies  not  in  consequence  of  the  operation  hut  in  spite  of  it. 

The  operation  itself  will  in  a  large  measure  depend  upon  what  can  be  learned  of  the 
etiology  of  the  disease  and  the  diffuseness  of  the  residting  infectior^.  To  reach  a  localized 
focus  the  incision  may  be  made  at  any  point  which  will  best  afford  access;  but  in  dealing 
with  a  generalized  process  the  middle  line,  and  an  extensive  incision,  will  ordinarily 
afford  the  best  opportunity  for  doing  whatever  is  necessary. 

The  preliminari/  incinon  may  be  made  short,  as  for  exploratory  purposes.  Unless 
a  loo])  of  distendecl  bowel  be  at  once  blown  into  the  opening  there  will  be  prompt  escape 
of  fluid,  whose  character  will  reveal  much  of  what  has  gone  wrong  within.  If  reasonably 
clear   the  operator   is   fortunate.     If  it  be  purulent  he  has  to  combat  a  most  serious 


PEUITOMTIS  789 

coiulition;  if  it  he  oft'oii.sivc,  it  is  prohahly  tluc  to  contamination  from  a  septic  abscess 
or  from  intestinal  gases,  while  if  tlie  fluid  he  nondescript  and  contain  ll<)atin<f  {)articles 
of  fecal  matter  there  is  an  intestinal  or  oastric  perforation.  So  soon  as  one  comes  upon 
fixation  or  adhesion  of  viscera  he  will  hnd  lymph,  in  condition  of  fjreater  or  less  ()r<raiii- 
zation.  Inside  the  nnisscs  thus  hound  toii;etlicr  he  will  prohahly  find  the  ^^Tcatest  centre 
of  pernicious  activity. 

The  more  one  sees  of  these  intra-abdominal  conditions  the  more  respect  he,  as  a  sur- 
geon, feels  for  the  omcnhnn.  0\\\y  recently  have  surgeons  learned  to  appreciate  the 
kindly  activities  of  this  duplicature  of  the  peritoneum,  with  its  slight  or  heavy  load  of 
contained  fat.  It  manifi\sts  a  tendency  which  may  be  almost  regarded  as  a  sagacity 
or  instinct  for  shifting  itself  toward  a  local  focus  of  infection,  and  there  throwing  out 
lymph  by  which  it  becomes  attached  and  hel])s  to  form  a  i)rotective  barrier  that  ()ften 
is  most  elfective.  Were  it  not  for  this  tendency  many  cases  of  acute  ap])endicitis,  for 
instance,  which  now  recover  would  be  lost  during  the  early  days  of  the  attack,  in  conse- 
quence of  a  (|uickly  disseminated  infection.  Thus  a  gangrenous  appendix,  or  hernia,  or 
gall-bladder,  is  frequently  .so  wrapped  up  in  a  i)rotective  layer  of  omentum  that  the  oper- 
ator has  first  to  detach  this,  or  go  through  it,  before  he  comes  ujk)!!  the  actual  site  of  the 
trouble.  Some  such  disposition  of  the  omentum,  then,  may  be  easily  discovered  (luring 
the  earliest  moments  of  his  exploration,  and  if  later  he  conclude  to  remove  a  portion  of 
it,  because  of  actual  or  impending  gangrene,  he  neverthele.ss  sacrifices  it  with  a  feeling 
of  regret  because  of  the  good  it  has  already  done. 

The  further  treatment  of  these  cases  is  essentially  a  matter  of  what  can  be  done  to 
remove  the  exciting  cause.  Questions  of  gravest  import,  and  often  difficult  of  immediate 
decision,  will  present  in  nearly  every  case;  as,  for  instance,  whether  to  resect  a  portion 
of  intestine,  to  remove  a  gall-bladder,  to  hunt  for  an  appendix  when  embarrassed  with 
the  difficulty  of  the  effort  ami  necessity  for  widely  separating  intestinal  coils,  or  of  the 
treatment  of  distended  bowel,  Avhich  it  may  perhaps  be  impossible  to  restore  to  place, 
of  extensive  and  complete  flushing  of  the  abdominal  cavity,  or  of  mere  local  cleanliness. 
And  after  these  questions  have  been  decided,  and  action  taken,  there  comes  still  the 
question  of  drainage,  with  the  wisdom  of  or  necessity  for  counteropening,  as  in  the  loin 
or  in  the  cul-de-sac,  and  the  character  of  drain  to  be  used.  As  to  what  should  be 
attempted  in  general  there  will  rarely  be  much  room  for  doubt.  As  to  how  best  to  ac- 
complish it  should  be  decided  according  to  the  training,  the  experience,  and  the  oppor- 
tunities of  the  operator,  and  the  nature  of  the  environment.  When  the  entire  peritoneal 
cavity  is  invaded,  and  flooded  with  more  or  less  infectious  material  the  more  thoroughly 
it  can  be  washed  out  the  better.  At  the  same  time  to  do  this  with  any  degree  of  even 
apparent  thoroughness  requires  practical  evisceration  of  the  patient,  and  an  amount  of 
time  spent  and  shock  produced  by  handling  the  viscera,  which  are  exceedingly  depressing 
and  may  of  themselves  be  more' than  can  be  borne.  The  meteorism,  which  is  so  con- 
spicuous a  feature  of  most  of  these  cases,  means  the  distention  of  the  bowel  to  such 
a  degree  that  when  once  the  intestines  lie  u]X)n  the  surface  of  the  body  they  can  usually 
be  restored  with  the  greatest  difficulty;  and  this  would  raise  the  question  of  the  desir- 
ability of  either  one  or  more  punctures,  through  which  gas  should  be  allowed  to  escape, 
or  a  sufficiently  wide  opening,  with  the  introduction  of  a  Monk  tube,  and  the  complete 
emptying  both  of  gas  and  putrefying  fecal  matter.  The  latter  is  certainly  in  theory  the 
mucli  more  desirable  measure,  if  the  patient's  condition  will  only  justify  it.  Probably 
after  pelvic  drainage  the  Fowler  semi-sitting  ]X)sture  in  bed  would  be  desirable,  while 
after  high  drainage  the  Trendelenburg  position,  with  the  pelvis  higher  than  the  thorax, 
would  be  preferable. 

If  free  abdominal  irrigaiion  is  to  be  practised  a  large  quantity  of  warm  sterile  saline 
solution  should  be  used,  to  which  may  be  added  perhaps  a  small  proportion  of  aceto- 
zone  or  of  mercury  bichloride.  The"  silver  salts  also  make  equally  effective  and  less 
irritating  fluid,  the  nitrate  being  used  in  the  proportion  of  1  to  10,000,  or  the  citrate  or 
lactate  in  proportion  of  1  to  500  or  1  to  1 000.  These  metallic  salts  will  coagulate  the 
albuminoid  fluids  and  give  to  the  peritoneum  an  opaque  appearance,  which,  however, 
need  cause  no  alarm. 

Another  question  of  importance  is  that  of  enferosUsmij.  In  some  of  these  cases  the  acute 
bowel  obstruction  is  the  most  predominating  and  distressing  late  feature,  and  an  enter- 
ostomy may  be  attempted,  even  though  it  be  known  it  will  serve  but  a  temporary  purpose, 
in  order  to  relieve  distress.    There  never  can  be  more  than  sentimental  objection  to  it, 


790  SPECIAL  OR  REGIONAL  SURGERY 

in  STK-h  oases,  witli  the  ])()ssil)ility  of  sonietliino;  more  than  mere  temporary  relief.  It 
can  be  effected  under  local  cocaine  anesthesia,  by  attacliinj;  to  tli(>  i)arietal  peritoneum 
the  first  looj)  of  distended  small  intestine  tiiat  presents,  and,  after  firmly  fixiuff  it  in  j)lace, 
makino-  a  small  oj)enin<i;,  and  then  preferably  insertini2;  a  <;'lass  or  other  tube  for  better 
<h'ainat2,"e  purposes. 

These  constitute  the  j)recautions  to  be  folhnved  and  the  advice  to  be  giyen  in  cases 
of  septic  or  surgical  peritonitis.  How  successful  they  may  be,  or  how  satisfactory  the 
termination  of  the  case,  cannot  be  foretold  by  statistics  nor  by  reports  of  cases  in  the 
hands  of  others.  Success  will  depend  in  large  measure  upon  the  early  or  late  period 
at  which  the  case  is  thus  treated,  and  upon  the  general  surgical  discretion  and  experience 
of  the  operator.  It  is  |)robable  that  disappointment  will  result  more  often  than  success. 
Nevertheless  every  life  thus  saved  is  one  snatched  from  a  certainly  fatal  termination 
without  it,  and  if  successful  but  once  in  ten  times  one  life  has  thereby  been  saved  that 
may  be  worth  saving,  without  sa\ing  the  other  nine.  While  I  would  advise  to  make 
the  attempt  in  any  case  which  offers  a  reasonable  prosjiect  of  success,  caution  should 
be  used  against  doing  it  without  a  fidl  understanding  with  those  concerned  that  it  is 
an  effort  in  the  right  direction,  concerning  which  no  ]irf)mise  can  be  made;  death  results 
not  from  the  operation  so  much  as  in  spite  of  it. 

Summarizing,  briefly,  the  best  methods  of  treating  a  diffuse  septic  peritonitis  we  may 
agree  with  Le  Conte,^  that  they  consist  of  the  following  measures:  The  least  possible 
handling  of  jxn'itoneal  contents,  the  elimination  of  time-consuming  ])rocedures,  most 
perfect  drainage  of  the  pelvis  by  a  special  suprapubic  opening,  as  well  as  free  drainage 
through  the  operative  incision,  the  semi-sitting  posture  of  the  patient  after  its  conclusion, 
the  prevention  of  peristaltic  movements  by  withholding  all  fluids  by  the  mouth,  and 
perhaps  by  small  amounts  of  opium,  and  the  absorption  of  large  quantities  of  water 
through  the  rectum,  by  which  there  may  be  produced  a  reversal  of  the  current  in  the 
lymphatics  of  the  peritoneum,  making  it  a  secreting  rather  than  an  absorbing  surface 
and  increasing  urinary  secretion.  It  is  inexpedient  to  waste  time  sponging  peritoneal 
sin-fac(\s  or  wi|)ing  away  lymph,  for  danger  of  septic  absor])ti()n  is  increased  rather  than 
diminished.  Patients  with  diffuse  se))tic  ])eritonitis  bear  brief  o])erations  fairly  well, 
but  prolonged  ones  badly;  therefore  a  minimum  amount  of  work  should  be  done. 

One  of  the  most  valuable  ])rocedures  in  carrying  out  the  above  advice  is  INIurphy's 
method  of  ftlowlij  introducittg  large  qitanfifieft  of  waier  into  the  rrctwm.  The  rectal  tube 
used  for  the  purpose  ends  with  a  sort  of  nozzle  containing  three  or  four  openings,  and 
the  reservoir  containing  the  solution  is  elevated  but  a  few  inches  above  the  level  of  the 
bed,  the  intent  being  that  it  shall  simply  trickle  into  the  bowel  no  faster  than  absorp- 
tion can  occur.  In  this  way  from  a  pint  to  a  quart  may  be  absorbed  each  hour,  the 
])ressure  being  continuous,  and  the  flow  so  regulated  that  no  accumulation  of  fluid  takes 
place  in  the  bowel.  Murphy  claims  that  by  this  method  the  lymph  current  in  the 
peritoneal  lymphatics  is  so  reversed  that  the  peritoneum  is  bathed  with  free  discharge 
and  that  this  should  be  afforded  escape  by  suitable  drainage  methods,  coupled  with 
Fowler's  (the  sitting)  j)osture. 

TUBERCULOUS  PERITONITIS. 

Acute  or  chronic  tuhercuJn.si.^  of  the  peritoneum  assumes  usually,  first,  the  miliary 
form,  after  which,  in  the  slow  cases,  infiltration  and  great  thickening  occur  to  such  an 
extent  as  to  alter  the  appearance,  texture,  and  behavior  of  the  jjcritoneum  itself.  It 
is  rarely  a  primary  condition,  but  is  usually  secondary  to  some  other  tuberculous 
focus,  which  may  be  one  or  more  of  the  mesenteric  nodes,  these  being  involved  in  con- 
sequence of  infection  from  the  alimentary  canal;  or  the  peritoneum  may  be  easily  infected 
either  from  the  genito-urinary  tract  or  directly  from  the  intestine.  In  children,  the 
most  common  path  of  infection  is  through  the  mesenteric  nodes;  in  females,  through 
the  Fallopian  tubes,  and  in  males,  either  through  the  intestine  or  the  kidneys  or  ureters. 
The  peritoneum,  vmder  these  circumstances,  behaves  very  uuich  as  does  the  j^leura,  in 
the  presence  of  acute  or  chronic  tuberculous  lesions  which  extend  to  and  involve  it. 
Thus  it  may  become  so  thickened,  and  even  "leathery,"  as  to  have  lost  all  its  original 
characteristics,  and  to  appear  more  like  a  dense,  firm  membrane  than  in  its  original 
semblance. 

1  Annals  of  Surgery,  February,  1906. 


TUBERCrWCS  Phh'ITO.VJTiS 


791 


J'criloiirn/  lithcrcti/osis  appears  in  tluvi-  (lillVrciit  types:  A  jiltri)itij)l(istir  tvpc, 
cluinictcri/A'd  I'spociallv  1)V  ac Illusions;  an  ulrcratin-  (uid  ■s-niiirtiiiic.s-  (ihsolniclij  .suppnra- 
tiir  form,  marked  always  hy  the  j)resen('o  of  pus  and  ])yoid;  and  an  (tscitic  tvjx-,  cliarac- 
terized  l)y  leakage  of  inereasinji;  amounts  of  serum  and  the  (levelo|>ment  of  ^vell-nlarked 
ascites. 

The  first,  or  jihniiopldstir,  is  a  locahzed  lesion,  and  leads  to  tlie  formation  of  d(>nso 
adhesions,  as,  for  instance,  between  a  1^'allopian  ti'he  and  the  ])elvic  walls  or  the  other 
\  iscera.  As  the  (hs(\ise  spreads  all  the  tissues  become  matted  together  in  a  muss  which 
renders  them  almost  indistin<,niishal)le,  fre(juently  much  rescmhiinjr  niali<]fnant  disease. 
In  some  instances  it  may  be  })ossible  to  remove  the  entire  affected  area.  At  other  times 
it  is  best  to  let  it  alone. 

The  ii/rrrafirr  jorm  is  characterized  by  more  p;(.n(>ral  symptoms  of  cons])icuous  febrile 
type.  It  produces  rapid  loss  of  streuffth  and  wei<fht,  fre(iuentiy  attended  with  evidences 
of  intestinal  ulceration  and  with  abdominal  tenderness  and  pain.  A  certain  |)roportion 
of  these  cases  justify  exploration,  th()U<;-h  Init  few  of  them  will  be  foimd  favorably  dis- 
posed for  radical  surgical  measures. 

The  a.sritir  ti/pr  is  characterized  by  rapid  accumulation  of  fluid,  with  accompanyinfT 
malaise  and  debility.  As  the  abdomen  distends  and  the  diai)hrai:;m  is  jiushed  upward 
resj)iration  becomes  more  difficidt  and  ra])id.  A  certain  proiniftirw  of  flir  umhilinis 
also  characterizes  many  of  these  cases.  Their  course  is  not  so  febrile,  but  it  may  be 
|)ossible,  especially  in  the  early  stajres,  to  make  out  some  eularwement  of  mesenteric 
nodes,  or  involvement  of  the  viscera,  which  will  aid  in  diatjnosis.  It  is  most  common  in 
children,  but  it  may  be  met  with  at  any  age.  In  general  such  a  collection  of  fluid,  which 
cannot  be  accounted  for  by  recognizable  disease  of  the  heart,  liver,  or  kidneys  niav  be 
sus|)C(tc(l  to  be  tuberculous. 

Treatment. — Treatment  of  tuberculous  peritonitis  should  be  snrgical  when  possible. 
This  statement  is  based  i:>artly  upon  the  fact  that  it  is  so  commonly  a  secondary  condition. 
Such  treatment  will  depend,  in  large  measure,  upon  the  extent  to  which  it  may  be  p()ssil)le 
to  remove  any  exciting  foci  of  the  disease;  but  experience  shows  that  even  this  is  not 
always  necessary  to  bring  about  a  cure,  as  in  those  cases  of  the  ascitic  \y\)0  where  it  is 
desirable  only  to  wash  out  the  abdominal  cavity  and  close  it  again,  this  simple  jirocedure 
seeming  to  suffice. 

It  is  the  cases  of  the  ascitic  fijpc  which  seem  most  benefited  by  incision  and  irrigation, 
usiudly  without  drainage,  and  it  is  these  which  are  perhajis  as  hopeless  as  any  under 
non-operative  treatment.  It  was  Van  de  Warker,  of  Syracuse,  who,  in  1883,  first  recog- 
nized the  value  of  sim{)le  irrigation  in  these  eases,  and  while  at  present  we  find  it  impos- 
sible to  explain  the  benefit  whic-h  so  often  and  so  rapidly  accrues,  the  measure  is  univer- 
sally recognized  as  that  offering  the  most  hope.  This,  like  every  other  surgical  procedure, 
should  be  ])ractised  early  rather  than  late,  preferal)ly  so  soon  as  diagnosis  is  made,  or, 
when  this  is  difficult,  it  should  be  made  a  part  of  an  exj)loratorv  operation  intended 
partly  for  diagnostic  jnirposes.  The  measure  itself  is  simple.  A  small  opening  in 
the  middle  line,  l)etween  the  pubis  and  the  umbilicus,  permits  free  escape  of  all  contained 
fluid,  which  shoidd  be  facilitated  by  changing  the  jiosition  of  the  patient,  thus  preventing 
plugging  of  the  opening  by  presenting  bowel.  Every  drop  which  can  escape  having  been 
removed,  the  abdomen  is  then  flushed  repeatedly  with  either  warm  saline  solution  or  a 
plain  watery  solution  of  acetozone,  1  to  1000,  or  silver  lactate  or  citrate,  in  the  same 
proportion  or  a  little  stronger.  My  own  preference  has  always  been  for  the  latter,  and 
with  a  silver  solution  I  have  obtained  a  large  degree  of  success.  There  is  no  objection  to 
leaving  a  small  amount  of  either  of  these  fluids  in  the  abdominal  cavity — i.  e.,  no  more 
than  an  ordinary  effort  to  empty  it  before  closing  the  wound.  An  incision  one  inch  long, 
made  for  this  purpose,  will  serve  nearly  every  indication.  Through  it  the  parietal 
peritoneum,  as  well  as  that  covering  numerous  loops  of  intestine,  can  be  inspected,  and 
through  it  also  a  finger  may  be  inserted  for  exploratory  purposes,  for  the  detection  of 
mesenteric  nodular  disease  or  of  any  other  focus.  Should  any  serious  local  condition 
be  revealed  which  might  be  benefited  by  radical  measures,  this  would  be  the  time  to 
practise  them. 

Before  closing  the  wound  margins  it  would  be  well  to  thoroughly  disinfect  them,  for 
over  them  has  flowed  infectetl  fluid,  and  we  sometimes  see  tuberculous  foci  develop  at 
this  point.  This  fact  explains  also  the  disadvantage  obtaining  in  these  cases  of  making 
drainage  oj)enings.     They  serve  their  purpose  admirably  for  a  short  time,  but,  becoming 


7<)2  SPECIAL  OR  REdlOXAL  SURGERY 

thus  infectetl,  lead  to  the  cstahhshnient  of  tuhcrculoiis  fistuhis  and  sinuses,  which  may 
call  for  subsequent  operation.  Fecal  fistula  may  even  he  a  more  remote  consequence. 
As  the  peritoneum  is  approached  it  will  he  found  more  or  less  altered,  and  there  may 
even  be  observed  bowel  or  omentum  adherent  behind  it;  therefore  caution  must  be 
observed. 

A  final  caution  should  also  be  given  in  order  that  we  may  avoid  mistaking  that  form  of 
ascites  which  is  frequently  seen  in  connection  with  cancer  of  the  abdominal  viscera 
extended  to  the  peritoneum,  and  particularly  that  form  spoken  of  as  miUary  carcinofiVi  or 
miliari/  sarcomatcms,  for  a  tuberculous  collection.  While  surgeons  are  occasionally 
deceived,  one  will  usually  find  much  in  the  history  of  the  case,  and  in  the  results  of  local 
examination,  which  may  save  making  this  error,  if  it  be  so  regarded;  but,  in  effect,  the 
()j)ening  and  the  evacuation  will  give  relief,  even  though  this  character  of  the  disease 
makes  it  less  amenable  to  help  from  any  such  source. 


CHAPTER     XLVTT. 

INJURIES  AND  SUK(;iCAL  DISEASES  OF  THE  STOMACH. 

CONGENITAL  MALFORMATIONS  OF  THE  STOMACH. 

These  nialforumtions  arc  (jiiitc  rare,  at  least  those  raising;  the  (juestion  of  possible 
surgical  remedy.  Transposition  does  not  recjuire  relief,  nor  does  a  stomach  ahnor- 
mally  small  allow  it.  More  or  less  nieno.ns  of  tlir  pijJorus  as  a  congenital  defect  has 
been  observed,  but  it  is  extremely  rare.  Along  with  it  is  often  associated  a  certain  hyper- 
trophy of  the  stomach  muscle.  Ilonr-gla.ss  (Icj'onnitij  may  be  of  congenital  or  accjuired 
origin.  The  latter  two  conditions  permit  of  easy  surgical  remedy.  Pyloric  stenosis 
may  be  atoned  for  by  gastro-enterostomy  or  treated  directly  by  a  plastic  operation, 
while  the  hour-glass  stomach  ])ermits  of  an  anastomotic  rearrangement,  either  of  its 
dilated  portions  with  each  other  or  with  the  bowel  below. 

The  acquired  malformations  are  connected  with  the  consequences  of  ulceration  and 
stricture.  They  include  more  or  less  complete  stenosis,  cither  cicatricial  or  malignant, 
various  forms  and  types  of  gastroptosis  and  gastric  dilatation,  in  which  sometimes  enor- 
mous degrees  of  distention  are  produced,  with  disturbed  or  practically  destroyed  stomach 
digestion.  These  cases  will  be  considered  by  themselves  a  little  later,  along  with  their 
surgical  relief. 

The  anaiomical  relations  of  the  nerves  supplying  the  stomach  are  worthy  of  the  sur- 
geon's especial  consideration.  Its  sympathetic  nerve  suj^ply  is  in  particular  and  intimate 
relation  with  the  seventh,  eighth,  and  ninth  spinal  roots,  by  which  we  account  for  the 
tenderness  of  the  overlying  surface  in  ulcer  of  the  stomach,  and  the  pain  which  is  often 
referred  to  the  region  of  the  left  shoulder-blade.  When  the  stomach  is  adherent  to  the 
gall-bladder,  in  cases  of  biliary  calculi,  the  pain  is  often  referred  to  the  right  shoulder, 
but  so  soon  as  the  pylorus  becomes  entangled  and  bound  down  pain  is  referred  also  to 
the  left  side  as  well. 

HOUR-GLASS  STOMACH. 

Hour-glass  stomach  is  now  more  common,  and  is  to  be  attributed  more  to  residts  of 
pathological  conditions  than  to  any  congenital  anomaly,  it  being  now  well  established 
that  it  is  usually  the  result  of  perigastric  adhesions  of  chronic  ulceration,  with  cicatricial 
constriction,  as  well  perhaps  of  subsequent  malignant  implantation.  Cancerous  infil- 
tration may  produce  the  so-called  ''leather-bottle"  stomach.  Moynihan  suggests,  among 
other  methods  of  diagnosis,  the  passage  of  a  stomach  tube  and  lavage  with  a  quantity 
of  fluid.  If  there  be  loss  of  a  certain  amount  of  this,  when  it  is  returned,  it  will  indicate 
that  a  portion  has  escaped  into  the  distal  sac  of  the  stomach.  Again  if  the  stomach  be 
washed  until  the  fluid  returns  clear,  and  then  if  there  suddenly  comes  an  amount  of 
offensive  fluid,  or  if  the  stomach  be  washed  clean,  the  tube  withdrawn  and  passed  again 
a  few  moments  later,  and  if  then  offensive  fluid  escape,  the  facts  can  be  best  explained 
on  the  hypothesis  of  an  hour-glass  constriction.  "Paradoxical  dilatation"  may  also 
be  noted,  i.  e.,  the  fact  that  palpation  will  still  elicit  a  splashing  sound  after  a  stomach 
tube  has  been  passed  and  while  the  organ  is  apparently  empty. 

Moynihan  has  suggested  still  another  method  of  recognition.  The  area  of  stomach 
resonance  being  outlined,  a  Seidlitz  powder  in  two  halves  is  then  administered.  After 
about  tw^enty  or  thirty  seconds  great  increase  in  resonance  of  the  upper  part  of  the 
stomach  will  be  found,  while  the  lower  part  remains  unaltered.  If  now  a  bulky  pouch 
can  be  felt  or  outlined  the  fliagnosis  is  determined,  as  the  increase  in  resonance  occurs  in 
the  distended  cardiac  segment. 

The  method  of  treating  an  hour-glass  stomach  will  consist  either,  in  selected  cases,  of 
a  plastic  operation  by  which  an  incision  made  in  one  direction  is  closed  in  the  opposite, 

(  793 ) 


794  SPECIAL  OR  REGIONAL  SURGERY 

i.  e.,  a  measure  like  that  j^raotised  at  tlie  pylorus  for  benign  stricture,  or  else  the  separate 
sacs  of  the  stomach  must  he  luiited  \)y  iin  auastouiotic  oj)euiug  aud  a  (jastrogastrostomy 
thus  performed. 

FOREIGN  BODIES   IN   THE   STOMACH. 

These  are  most  commonly  those  which  have  been  swallowed,  either  by  design  or 
through  inadvertence,  and  may  consist  of  almost  all  imaginable  substances.  In  those 
animals  that  have  the  constant  habit  of  licking  their  own  fur  or  that  of  others,  and 
thus  scraping  off  a  quantity  of  hair,  hair-balls  in  the  stomach  are  frequently  formed, 
and,  as  may  be  seen  in  museums,  these  sometimes  obtain  relatively  enormous  size — 
a  foot  or  more  in  diameter.  IIair-l)alls  in  the  human  being  are  of  rare  occurrence, 
and  are  the  result  of  the  habit  of  chewing  the  hair,  observed  in  some  hysterical  or  insane 
patients.  There  are  several  instances  now  on  record  of  successful  removal  of  such 
liair-balls  from  human  stomachs.  Artificial  denture.t,  partial  or  complete,  are  not 
infrecjuently  passed  into  the  stomach,  sometimes  during  sieej).  In  dealing  with  a  case 
of  this  character  extreme  caution  should  be  exercised,  because  many  individuals  have 
deceived  themselves,  or  have  been  deceived,  and  the  missing  teeth  supposed  to  have 
been  swallowed  have  been  found  in  some  place  where  they  have  been  mislaid  and  for- 
gotten. Cliildreu  have  a  habit  of  swallowing  almost  anything  left  loose  in  the  mouth, 
and  all  sorts  of  toys  and  small  playthings  have  flisaj^peared  into  their  stomachs,  some- 
times causing  death,  ami  occasionally  passing  through  the  alimentary  canal.  The 
insane  sometimes  show  a  maniacal  tendency  to  swallow  foreign  bodies,  such  as  nails 
or  anything  else  which  they  can  get  into  the  mouth.  Hysterical  patients  and  museum 
freaks  evince  the  same  habit,  and  it  is  wonderful  how  tolerant  the  stomach  becomes 
in  some  of  these  individuals,  and  what  objects  seem  to  pass  the  pylorus  and  escape 
externally  without  doing  serious  harm.  Still,  sooner  or  later  nearly  every  one  of  these 
individuals  comes  to  grief.  Thus  from  one  patient  at  the  Erie  County  Hospital,  in 
Buffalo,  Gaylord  removed  an  astonishing  amount  of  junk,  including  nails,  screws, 
pieces  of  glass,  knife-blades,  and  tiie  like.  As  a  general  rule,  any  reasonably  smooth 
ol)ject  which  can  pass  through  the  esophagus  may  also  pass  through  the  })ylonis. 

Symptoms. — The  sym|)toms  produced  by  these  foreign  bodies  will  vary  according 
to  their  size,  number,  and  character.  A  hair-ball  may  lie  for  a  long  time  within  the 
stomach,  producing  few  symptoms,  and  none  by  which  it  may  be  recognized.  So  long 
as  no  perforation  of  the  entire  thickness  of  the  stomach  walls  occur,  nor  any  infection 
which  may  produce  a  local  peritonitis,  the  disturbances  they  set  up  may  be  limited  to 
those  included  under  the  name  "dyspepsia."  So  soon,  however,  as  pain,  tenderness, 
or  septic  indications,  or  those  of  local  peritonitis  supervene,  the  abdomen  should  be 
promptly  opened.  Today  we  have  the  cathode  rays  as  an  aid  in  diagnosis,  which  will 
clear  up  doubt  in  most  instances,  and  afford  a  definite  indication  for  ojx-ration.  Never- 
theless a  negative  result  does  not  necessarily  imj^ly  that  no  foreign  body  is  present. 

Treatment. — The  operation  indicated  is  ga.sfrofomi/,  i.  c,  ojiening  of  the  stomach 
at  a  suitable  or  convenient  point,  removal  of  the  foreign  body  or  bodies,  and  the  com- 
plete closure  of  the  wound  as  well  as  of  the  abdominal  incision,  without  drainage.  If 
due  care  be  maintained  throughout,  and  the  element  of  previous  infection  be  excluded, 
prognosis  is  good.  When  perforation  with  local  peritonitis,  and  perhaps  abscess,  has 
already  occurred,  there  is  a  local  indication  as  to  exactly  where  to  open;  one  should 
then  complete  the  operation  with  the  establishment  of  suitable  drainage. 


WOUNDS  OF  THE  STOMACH,  INCLUDING  RUPTURE. 

As  already  indicated,  the  stomach  may  be  ruptured,  especially  if  weakened  by  previous 
disease,  by  severe  abdominal  contusion.  It  is  subject  to  all  j)ossible  wounds  by  perfora- 
tion, either  gunshot  or  by  puncture.  As  it  is  more  protected  than  the  bowel  below  it  is 
less  liable  to  perforating  injuries.  Much  will  depend  upon  the  nature  and  the  extent  of 
the  injury.  A  small  perforation  may  be  protected  by  prolapse  of  the  mucosa  in  such  a 
way  that  little  escape  of  contents  takes  place.  On  the  other  hand  it  may  be  extensive, 
and  nearly  the  entire  gastric  contents  may  be  poured  out  into  the  upper  abdomen.  The 
location  of  the  stomach  lesion  by  no  means  necessarily  corresponds  to  that  of  the 


DILATATIOS  OF   THE  STOMACH  795 

ahdomliuil  wall,  this  hciiiii;  particularly  true  in  n^iiiisliot  cases.  Extravasation  dcpenfls  in 
amount  and  rapidity  upon  the  stomach  contents  and  their  fluidity.  If  the  posterior  wall 
alone  he  injured  it  will  empty  rather  into  the  cavity  of  the  lesser  omentum.  Stomach 
injury  may  always  he  dia<fnostieated  it',  alter  abdominal  injury,  the  vomited  matter 
contains  blood.  'i'he  pain  is  usually  severe  and  involves  ;fenerally  the  entire  uj)per 
ahdomen.  In  proportion  as  the  lesion  lies  near  the  (lia|)hrajrm  the  breathing  may  be 
allecti'd.  ('ollapse  is  Jisually  j)rompt  and  may  be  due  to  hemorrha<j;c  from  a  vessel  of 
considerable  size.  Pain,  rollajm',  and  liniKtfniir.sis  vousthuW  indications  for  the  |)rom|)test 
possible  openin<i^  of  the  abdomen  and  investigation,  with  suitable  suture  of  the  stomach 
wound,  toilet  of  the  peritoneal  cavity,  and  drainage,  which  should  be  |)osterior  as 
well  as  anterior.  Hvery  ragged  or  eonijjromised  margin  of  a  stonuieh  wound,  esju'cially 
gunshot,  should  be  neatly  excised,  and  sutures  a|)plied  in  such  a  way  as  to  onlv  bring 
clean  and  fresh  surfaces  together.  An  external  opening  of  snificient  length  should  be 
made  to  permit  easy  and  complete  withdrawal  of  the  entire  stomach,  and  a  c(Mnj)lete 
search  ovi'r  both  its  surfaces  in  order  that  no  lesion  may  escape  detection.  If  the 
opening  made  into  the  stomach  be  sufficiently  large  to  permit,  it  would  be  best  to  thor- 
oughly empty  its  contents  and  gently  wipe  it  out,  in  order  that  it  may  be  left  not  only 
empty  but  clean.  Should  the  puncture  be  very  small  it  would  be  well  to  pass  a  stoma(.'h 
tube  from  above  and  wash  out  the  stomach,  protecting  the  o])eiiing  by  ))ads  aiul  ])ressure, 
and  thus  preventing  contamination  of  the  peritoneum. 

While  (ippairutlj/  spontaneous  rnpturr,  i.  e.,  without  ])revious  ulcer  or  disease,  is  most 
rare,  there  are  a  few  eases  on  record  where  patients  have  been  seized  with  intense 
paroxysmal  pain  and  have  died  more  or  less  quickly,  and  where  the  condition  has  been 
found  with  little  or  nothing  to  explain  it.  Immediate  operation  might  jxhssibly  have 
saved  some  of  these  had  the  possibility  of  its  occurrence  been  recognized.  Perjoraiion 
from  unikin  may  also  occur,  as  it  is  known  to  have  happened  in  the  eases  of  sword  or 
knife  swallowers. 

Sufiirr  of  the  sfomaeh  is  practised  in  exactly  the  same  way  in  these  cases  as  for  other 
|)urj)oses  and  the  method  will  be  described  later,  along  witli  the  other  operations  upon 
this  viseus. 

TUBERCULOSIS  AND   SYPHILIS   OF  THE   STOMACH. 

The  gastric  mucosa  presents  a  remarkable  contrast  to  that  of  the  intestinal  tract, 
the  latter  being  exceedingly  likely  to  succumb  to  tuberctdous  infection,  which  is  exceed- 
ingly rare  in  the  former.  Primary  tuberculous  ulceration  of  the  stomach,  then,  is  most 
imusual.  When  tuberculous  ulcers  are  foimd  there  they  are  usually  the  result  of  a  sec- 
ondary or  perforating  process.  Such  ulcers  may  attain  great  size,  as  in  one  case  reported 
by  Simmonds  where  the  ulcerated  area  measured  foiu-  by  eight  inches,  yet  ])ro(luced  no 
symj)toms  during  life.  This  would  correspond  almost  to  a  hipus  of  the  gastric  nuicosa. 
Tuberculous  gummas  are  even  more  rare,  and,  occurring  in  the  stomach,  are  patho- 
logical curiosities  rather  than  surgical  possibilities. 

Sijphili.s  of  the  stomach  is  met  with  either  as  gumma  or  ulcer,  the  latter  leading  almost 
inevitably  to  more  or  less  stricture  as  recovery  follows  suitable  treatment.  Although 
it  is  claimed  that  10  per  cent,  of  cases  of  chronic  ulcer  of  the  stomach  have  suffered 
from  syphilis  at  some  time,  it  by  no  means  follows  that  such  idcers  are  to  be  considered 
as  of  genuinely  syphilitic  origin,  as  a  syphilitic  patient  is  not  exemjit  from  other  stomach 
conditions.  However,  symptoms  of  gastric  ulcer,  associated  with  actual  manifestations 
of  syj)hilis,  might  well  indicate  associated  syphilitic  lesions  and  would  probably  yield, 
with  the  others,  to  suitable  treatment. 

Lesions  of  either  character,  which  do  not  subside  under  proj^er  medical  treatment, 
and  which  require  a  surgical  operation,  would  be  equally  benefited  by  it  whether  of  one 
of  these  types  or  of  the  other. 


DILATATION  OF  THE   STOMACH. 

The  acute  form  of  gastric  dilatation  was  described  by  Fagge  in  1872,  the  chief 
.symptoms  being  excessive  vomiting  and  anuria,  and  the  disease  proving  fatal  within 
three  days,  the  dilatation  being  enormous.     For  a  condition  occurring  as  rapidly  and 


796  SPECIAL  OR  REGIONAL  SURGERY 

progressively  as  this  does  there  is  as  yet  no  satisfactory  exjiUuiation,  careful  autopsy  failing 
to  disclose  a  sufficient  reason.  It  has  been  known  in  at  least  twelve  instances  to  follow 
surgical  ojjeration,  four  only  of  which  were  upon  the  abdomen,  and  none  of  them  upon 
the  stomach  proper,  in  all  instances  the  patients  apparently  progressing  favorably.  The 
stomach  becomes  rapidly  and  enormously  distended,  and  bent  upon  itself  with  a  sharp 
kink  in  the  lesser  curvature.  Thus  it  seems  to  occupy  the  entire  upper  abdomen.  Two 
factors  at  least  seem  to  assist  in  the  condition:  A  paresis  of  the  gastric  musculature, 
and  the  fact  that  as  it  becomes  distended  it  itself  protluces  obstruction  of  the  duodenum, 
and  thus  aggravates  the  primary  condition. 

It  has  been  suggested  that  these  acute  cases  of  po.<iioprmtive  dilaiaiion  are  closely  con- 
nected with  certain  cases  of  ileus  antl  obstruction  after  abdominal  operations,  the  dila- 
tation once  initiated  tending  to  more  and  more  obstruct  the  duodenum,  as  well  as  cause 
upwartl  })ressure  on  the  diaphragm  and  embarrassment  of  the  heart's  action.  Hence 
the  value  of  the  stomach  tube  in  treatment  of  such  conditions. 

Symptoms. — The  symptoms  are  usually  sudden  and  fulminating,  beginning  with 
intense  pain,  which  finally  involves  the  entire  abdomen.  Vomiting  comes  early  and 
persists,  the  vomited  fluid  being  greenish  in  color  and  large  in  amount,  changing  later 
to  a  brownish  color  and  having  an  offensive  odor.  The  act  of  vomiting  is  passive  rather 
than  active  or  violent.  In  spite  of  it  the  stomach  never  seems  to  empty  itself.  The 
outline  of  the  dilated  stomach  may  be  seen  through  the  abdominal  wall,  bulging  being 
often  extreme.  With  the  passage  of  the  stomach  tube  there  may  be  escape  of  a  large 
amount  of  gas  as  well  as  of  fluid.  Thirst  is  intolerable  and  never  satisfied.  The  amount 
of  urine  is  almost  always  reduced  and  sometimes  aniu'ia  is  practically  complete. 

Treatment. — The  treatment  is  too  often  ineft'ectual,  since  the  condition  itself  is  lethal 
almost  from  the  beginning.  Early  and  frequent  lavage,  or  perhaps  leaving  the  stomach 
tube  in  place,  would  be  indicated.  It  might  be  practicable  to  pass  a  small  tube  through 
the  nostril  and  leave  it,  as  is  done  with  the  insane.  Gastrostomy  would  be  theoretically 
indicated,  could  it  be  done  sufficiently  early.  The  same  is  perhaps  true  of  gastro- 
enterostomy, although  it  has  never  had  a  fair  trial,  these  cases  coming  to  the  surgeon 
too  late  to  permit  of  nuu-h  helj). 

Chronic  Dilatation  of  the  Stomach.— Chronic  dilatation  of  the  stomach,  often 
spoken  of  as  (jasirecia.sis,  is  a  frequent  complication  of  various  other  conditions,  being 
essentially  a  consequence  rather  than  a  primary  condition.     It  may  be  due  to: 

1.  Pyloric  stenosis  or  its  equivalent  in  the  first  part  of  the  duodenum: 

(a)  From  cicatricial  processes  following  ulcers  of  the  pyloric  region ; 

{h)  From  perigastritis  with  cancer  of  the  stomach; 

{(•)  From  pylorospasm  and  hypertrophy  continuing  after  recovery  from  ulcer, 

and  including  more  or  less  thickening  of  the  biliary  region; 
{d)  From  neoplasms  outside  the  pylorus  proper; 
(f)  From  cancer  of  the  })yloric  end  of  the  stomach ; 
(/)  From  pressure  upon  the  duodenum  by  pancreatic  lesions; 
(9)  From  the  results  of  gallstones  ulcerating  and  causing  great  local  disturbances ; 
(/()  From  displacement  of  the  pylorus,  due  either  to  falling  of  the  stomach  or 

dragging  of  an  attached  but  movable  right  kidney. 

2.  A  dilatation  due  to  old  lesions  which  have  subsided,  the  atonic  stretching  not  having 
been  repaired. 

It  will  be  seen,  then,  that  the  condition  may  be  met  as  a  sequel  to  many  different 
pathological  processes.  As  such,  therefore,  it  has  no  constant  etiology  nor  necessarily 
distinctive  features.  In  general  it  is  recognized  by  tardiness  in  escape  of  gastric  contents, 
associated  with  vomiting,  the  vomitus  being  distinctive,  consisting  often  of  old  and 
undigested  food,  orperha])sof  food  which  has  rested  in  the  stomach  until  jnitrefaction  has 
occurred.  The  vomitus  also  contains  evidences  of  fermentation,  with  sarciuje  and  yeast 
cells  and  much  mucus.  In  cases  of  ulcer  it  is  usually  very  sour,  owing  to  excess  of  free 
hydrochloric  acid.  When  due  to  cancer  the  acid  is  usually  due  to  excess  of  lactic  acid, 
while  hydrochloric  acid  may  be  nearly  or  totally  absent.  Even  if  vomiting  does  not  occur 
after  ingestion  of  food,  heaviness  and  discomfort,  with  much  eructation  of  gas,  are  pro- 
duced. Constipation  and  diminished  urine  secretion  are  almost  invariable  accompani- 
ments. Wlien  the  obstruction  is  of  the  mechanical  ty])e  a  visible  peristaltic  wave  can 
often  be  seen  and  felt,  and  this  is  a  sign  which  should  be  regarded  as  always  indicating 
operation. 


GASTROProsiS  797 

Patients  i^radiially  lose  (Icsli  and  Ix-coinc  anemic  and  nm  down,  snll'erinir  tVoin  what 
lias  been  often  va<iiieiy  called  indi<j;estion,  tlieir  lives  sometimes  heinif  terminated  by 
starvation,  oeeasionally  by  j^astric  tetany.  Tlie  (jiiestion  of  diaffnosis  can  usually  be 
settled  by  luiving  the  patient  swallow  the  dissolved  se|)arate  |)arts  of  a  Seidlitz  powder, 
one  after  the  other,  when  the  carbon  dioxide  released  within  the  stomach  will  cause 
it  to  balloon  up  and  assume-  that  shape  and  position  which  tin-  amount  of  its  dilatation 
permits. 

Gu.stric  dikitaiion  ichich  does  not  (juick/i/  yield  to  lavage  and  suitable  medication  is  of 
itselj  always  an  indication  for  operation.  When  accompanied  by  a  tumor,  especially  if  this 
move  and  chanoe  position  with  the  stomach,  a  cancerous  condition  may  be  assumed, 
which,  while  not  j)erniittin<i|;  a  cure,  may  nevertheless  be  ameliorated  by  a  gastro- 
enterostomy. In  the  absence  of  actual  cancerous  conditions  the  surgical  treatment 
of  chronic  dilatation  is  exceedingly  satisfactory. 

'^J'his  surgical  treatment  consists  in  the  apj)licati()n  of  one  at  least  of  the  following 
expedients : 

1.  Local  relief  of  mechanical  pyloric  obstruction,  as  by  any  one  of  the  })yloroplastic 

methods ; 

2.  Gastroplication,  by  which  the  capacity  of  the  stomach  is  materially  reduced; 

3.  Gastro-enterostomy,  by  which  mechanical  obstruction  is  atoned  for    by  a  free 

outlet,  ])rovi<le(l  at  a  point  where  gravity  as  well  as  peristalsis  shall  assist  in 

completely  emptying  the  viscus. 
The  methods  in  vogue  a  few  years  ago  for  o])cning  the  stomach  and  merely  stretching 
the  pyloric  outlet  have  been  supplanted  by  other  plastic  operations  which  have  proved 
more  satisfactory  because  of  the  greater  permanency  of  their  results. 


GASTROPTOSIS. 

The  dow'nward  displacement  of  the  stomach,  to  which  the  term  gastroptosis  has 
been  given,  implies  not  only  more  or  less  actual  dilatation,  but  also  a  stretching  or 
lengthening  of  the  upper  attachments  and  peritoneal  folds  which  should  hold  the  stomach 
up  in  place.  When  these  yield  and  the  stomach  is  thus  ])ermitted  to  droj),  more  or  less 
obstruction  of  the  pylorus  and  kinking  of  the  duodenum  are  apt  to  occur.  The  condition 
regarded  surgically  is  not  essentially  different  from  that  of  chronic  dilatation.  When 
the  stomach  is  distended  with  carbon  dioxide  its  normal  position  may  be  easily  recog- 
nized, while,  at  the  same  time,  it  is  determined  that  it  is  perha])s  but  little  dilated. 

The  causes  which  lead  to  this  condition,  aside  from  those  which  affect  the  stomach 
proper,  include  tight  lacing,  by  which  the  supporting  viscera  are  forced  downward  and 
the  stomach  permitted  to  fall  with  them.  In  addition  to  such  a  cause  any  previous 
disease  by  which  the  abdominal  viscera  have  been  affectetl  or  ligaments  weakened  woidd 
be  of  more  or  less  effect.  The  condition  leads  sooner  or  later  to  one  of  dilatation,  and 
always  merges  into  it.  Its  symptoms  are  those  of  dilatation,  only  in  milder  degree. 
On  account  of  the  dragging  upon  the  upper  sup])orts  patients  frequently  complain  of 
intense  lumbago,  and  they  nearly  always  become  neurasthenic. 

Treatment. — The  ordinary  routine  treatment  failing  to  give  relief,  one  may,  in  mild 
cases,  adopt  an  external  mechanical  treatment,  consisting  of  a  suitable  abdominal 
bandage  which  should  press  the  viscera  up  from  beneath,  and  thus  relieve  splanchnic 
congestion  and  weight. 

Mechanical  support  failing  and  symptoms  persisting,  the  surgeon  is  able  to  afford  relief 
by  gastropexy,  first  suggested  by  Duret,  and  consisting  of  an  exposure  of  the  stomach 
through  the  middle  line  and  its  fixation  to  the  anterior  abdominal  wall.  This,  however, 
has  its  theoretical  disadvantages,  since  it  might  be  followed  l)y  symptoms  similar  to 
those  resulting  from  pathological  adhesions.  The  method  has  been  more  or  less  modi- 
fied, sutures  being  passed  through  the  gastrohepatic  omentum  and  gastrophrenic  liga- 
ment in  such  a  wav  as  to  bring  them  into  close  contact  and  looking  to  their  complete 
union.  Thus,  Beyer,  of  Philadelphia,  has  reported  four  cases  apparently  successfully 
operated  upon  in  this  fashion.  Bier  has  added  four  others,  all  of  which  seem  to  afford 
much  encouragement  to  operative  treatment  of  gastroptosis.  Furthermore,  Coffey  has 
modified  the  technique  in  such  a  way  as  to  include  a  sort  of  suspension  of   the  stomach 


79S  SPECIAL  OR  REGIONAL  SURGERY 

by  inakhij;  a  lianunock  out  of  the  great  omentum.  He  did  this  by  stitching  the  oiiK-utiun 
to  the  alxloniMial  {K'ritoneiiiii,  about  one  inch  above  the  unibiUcus,  with  a  transverse  row 
of  sutures  about  one  inch  apart. 


GASTRIC  TETANY. 

Ciastrie  tetany  has  but  relatively  small  interest  for  the  surgeon,  save  as  it  may  com- 
plicate some  of  his  results  or  prevent  his  endeavor  to  secure  them.  The  condition 
is  usually  characterized  by  peculiar,  ilisturbed  sensation  in  the  extremities,  with  a  feeling 
of  coldness  or  numbness  in  the  limbs,  and  drowsiness,  vertigo,  and  disproportionate 
weakness  after  exercise.  Somewhat  severe  attacks  are  sometimes  precipitated  by  lavage, 
and  are  then  begun  with  a  complaint  of  formication,  foUow^ed  by  tetanic  contraction  of 
the  muscles  of  the  extremities.  Instead  of  tonic  spasm  the  muscles  may  be  in  more  or 
less  constant  motion.  The  muscles  of  the  face,  neck,  and  abdomen  are  also  invtjlved. 
The  facial  expression  changes,  and  patients  may  complain  of  loss  of  vision.  During 
these  paroxysms  they  may  even  nuitter  or  s])eak  unintelligibly.  Chvostek  some  time  ago 
showeil  how  to  produce  these  spasms,  when  the  contlition  is  present,  by  tapping  over 
the  facial  nerve  just  at  its  exit  from  the  cranium,  and  Trousseau  demonstrated  that 
during  the  attack  the  paroxysms  may  be  produced  at  will  by  compressing  the  afi'ected 
parts  in  such  a  way  as  to  impede  venous  or  arterial  circulation  through  them.  Some 
of  these  spasmodic  attacks  are  accompanied  by  severe  pain,  while  spasm  is  usually 
made  less  painful  by  gently  yet  forcibly  overcoming  it  by  pressure.  The  condition  is 
essentially  toxic,  usually  autotoxic,  and  yet,  inasmuch  as  it  may  complicate  the  best 
eti'orts  of  the  surgeon  or  comjilicate  the  case  upon  which  he  would  wish  to  operate,  it 
is  deserving  of  this  brief  description  here,  largely  in  order  that  it  may  not  be  mistaken 
for  true  tetanus  or  be  misinterpreted  in  any  other  way. 


CARDIOSPASM. 

This  is  a  term  recently  suggested  by  ^Mikulicz  for  a  peculiar  contraction  of  the  lower 
end  of  the  esophagus  and  the  cardiac  orifice  of  the  stomach,  which  is  occasionally  met 
with,  and  until  fully  described  by  him  was  somewhat  misuiulerstootl.  In  consecjuence 
of  the  spasmodic  stricture  thus  produced  there  occurs  dilatation  of  the  esophagus  above 
and  formation  of  a  sac,  which  may  be  discovered  by  the  bougie  or  tube,  or  by  a 
good  radiogram,  after  having  been  filled  with  a  weak  bismuth  emulsion.  Such  saccu- 
lation had  always  been  previously  regarded  as  due  to  esophageal  diverticulum,  which  it 
greatly  simulates  at  first  and  in  time  practically  becomes.  It  is  due  either  to  jirimary 
and  unexplained  spasm  of  the  muscular  coat  at  this  level,  or  to  a  ]>rimary  atony  for 
the  esophageal  muscle  above  the  stricture.  It  has  been  ascribed  also  to  paralysis  of  the 
circular  fibers  and  spasm  of  the  cardia,  due  to  vagus  involvement  and  to  primary 
es()j)hagitis.     The  view  that  it  is  of  congenital  origin  can  scarcely  be  sustained. 

Symptoms. — The  sym]itoms  and  signs  |)roducetl  are  not  widely  different  from  those 
of  a  capacious  diverticulum.  It  is  difficult,  often  impossible,  to  pass  a  stomach  tube  into 
the  stomach,  it  being  diverted  into  the  upj)er  cavity.  The  patient  moreover,  vomits 
material  which  is  undigested  and  more  or  less  putrefactive,  and,  at  the  same  time,  without 
evidences  of  actual  stomach  disease.  Such  a  sac  may  hold  even  two  pints,  and  thus 
it  will  be  seen  how^  much  material  may  be  vomited  or  washed  out  by  lavage  which, 
at  the  same  time,  never  entered  the  stomach.  Should  it  be  possible  to  enter  the  stomach 
the  two  sets  of  contents  will  be  found  quite  different. 

Treatment. — While  more  or  less  benefit  and  relief  may  be  obtained  from  frequent 
washing  of  the  abdominal  sac  thus  produced  the  real  cure  will  only  come,  as  shown  by 
Mikulicz,  from  opening  of  the  stomach  and  dilatation  of  its  constricted  upper  orifice. 


GASTRIC  ULCER  799 


PYLORIC  STENOSIS. 

Krdiictioii  ill  ciilihcr  of  llic  pyloric  o|)(Miiii<j;,  ;mionii(iii<f  in  cxtrciiic  cases  to  absolute 
closure,  may  he  met  witli  at  various  a<:;es  and  i'ollowiu}:;  various  couditious. 

A  couiijeiiital  stenosis  has  heen  ohserved,  jilthou<fh  very  inl"re(|ueutly.' 

Pyloric  conslrirtion  jolloiviiKj  ricatncial  coiUrarfiou  of  healed  ulcers  is  {)erha|)S  the 
most  common  non-malijinant  form.  This  rarely  j)roceeds  to  absolute  closure,  hut  is 
fre(|uently  suflicient  to  lead  to  dilatation. 

('oiiversely  any  condition  of  the  stomach  which  draj^s  it  out  of  sliajx-  and  leads  to  kink 
or  ahrupt  an>:;ulation  near  the  pylorus  may  lead  to  early  j)ostural  and  later  to  actual 
structural  contraction. 

'I'he  pressure  or  alteration  of  shape  j)rodnced  hy  neoplasms,  i-ithcr  within  the  sub- 
stance of  the  stomacii  or  more  frecjuently  without,  will  cause  more  or  less  irregular  con- 
traction of  the  ])yloric  end  amomiting  to  })yl()ric  stricture. 

By  old  adlir.s'ions  similar  conditions  are  ])roduced,  while  a  definite  form  of  .spastic 
contraction,  corresponding  much  to  eardiosj)saui  just  described,  will  cause  more  or 
less  j)yloric  obstruction. 

Finally  inali(jnaut  tumors  involving  the  pyloric  region  invariably  spread  to  the  j)ylorie 
ring,  and  not  oidy  infiltrate  it  but  cause  it  to  l)ecome  inflexil)le  and  diminislu'd  in  size, 
to  a  degret>  finally  amounting  to  almost  complete  or  to  al)solute  obstruction. 

Symptoms. — No  matter  what  the  cause  the  sym])toms  are  essentially  the  same, 
in  that  they  produce  dilatation  of  the  stomach  and  fretjuent  vomiting.  According  to 
the  cause  there  will  also  be  a  history  of  pain  and  hemorrhage,  suggesting  ulcer,  or  of 
biliary  colic,  denoting  perigastric  adhesions,  or  of  pancreatic  disease,  accounting  for 
adhesion  of  the  duodenum  and  displacement  of  the  pylorus.  The  discovery  of  tumor 
or  the  results  of  examination  of  stomach  contents  may  also  suggest  or  corroborate  the 
diagnosis  of  cancer. 

The  essential  feature  being  the  failure  of  the  gastric  contents  to  ])ass  onward  into 
the  bowel,  and  their  accunudation  in  the  stomach  or  rejection  by  vomiting,  the  condition 
will  be  seen  to  have  a  purely  mechanical  as  well  as  a  pathological  aspect.  The  case, 
therefore,  must  ])e  extreme  in  w^hich  a  mechanical  remedy  wdll  not  afford  at  least 
temporary  relief. 

Surgical  Treatment. — This  remedy  obviously  is  either  to  overcome  the  stricture 
by  dilatation,  or  ])lastic  operation  upon  the  region  involved,  or  to  form  a  new  opening 
by  which  the  stomach  shall  connect  with  the  upper  intestine — i.  e.,  (jastro-enterostomy. 
The  latter  luis  gradually  su])])lanted  the  former  in  the  choice  and  in  the  hands  of  most 
surgeons,  although  occasionally  a  case  may  be  met  w^liich  invites  the  performance  of 
a  pyloroplasty,  by  either  the  lieinecke-Mikulicz  or  the  Finney  operations,  which  will 
be  described  later.  In  the  absence  of  malignant  disease  few  serious  operations  give 
more  satisfactory  results  than  do  these. 

GASTRIC  ULCER. 

During  the  past  few  years  the  studies  of  internists,  of  pathologists,  and  of  surgeons 
ha\e  all  served  to  show  that  gastric  ulcer  in  any  form  is  a  more  common  lesion  than  was 
suspected  l)y  the  previous  generation.  At  first  it  nearly  always  comes  imder  the  care 
of  the  internist,  but  too  often,  becoming  chronic,  it  is  too  long  continued  under  his 
care  imtil  a  serious,  ])erhaps  almost  fatal,  hemorrhage  makes  operative  relief  more  dan- 
gerous, if  not  impossil)le,  or  until  a  chronic  ulcer  has  degenerated  into  a  cancer,  and  this 
is  permitted  to  go  on  until  the  patient  pays  with  his  life  the  penalty  for  such  inattention. 

Ulcers  in  the  gastric  mucosa  vary  from  a  simple  fissure  (such  as  may  be  seen  in  the 
mucosa  of  the  lip  or  the  anus)  to  extensive  and  deep  ulcerations,  which  weaken  the 

'  Fiske  (Annals  of  Surgery,  July,  1906)  states  that  there  are  at  present  on  record  121  cases  of  hypertrophic 
stenosis  of  the  pylorus  in  infants.  The  three  theories  advanced  to  account  for  the  condition  as  occurring  before 
birth  presuppose  either  a  true  malformation  with  muscular  hypertrophy,  a  secondary  hypertrophy  due  to 
prenatal  pyloric  spasm,  or  a  spastic  condition  of  the  pyloric  region  without  definite  gross  anatomical  lesion. 
None  of  these  theories  satisfies  the  condition  in  any  but  a  small  proportion  of  cases,  although  either  of  them 
doubtless  is  or  may  be  correct  in  certain  instances;  71  of  these  cases  have  now  been  operated  upon,  of  which 
33  died,  gastro-enterostomy  giving  57  per  cent,  of  recoveries  and  pyloroplasty  54  percent. 


goo  SPECIAL  OR  REGIONAL  SURGERY 

stomach  structure  in  sjiite  of  protective  infiltration  and  even  adhesions,  until  a  final 
perforation  may  terminate  the  c-a,se,  either  bv  hemorrhaj^'c  or  septic  peritonitis.  While 
surgical  teachiiio;  has  of  late  pointed  more  and  more  definitely  to  the  importance  of  ulcers 
resulting  from  simj)le  erosions,  or  apparently  mere  abrasions  which  have  not  been 
a{)preciated,  most  pathologists  and  surgeons  fail  t(j  realize  that  even  from  so  trifling  a 
surface  alarming  hemorrhages  may  occur.  Such  lesions  appear  upon  the  postmortem 
table  to  be  minute  and  unimportant,  but,  occurring  during  life,  they  have  an  importance 
of  their  own. 

Gastric  ulcers,  then,  should  be  referred  to  as  erosions,  as  simple  or  complicated  ulcers, 
and  as  ulcerating  cancers,  in  addition  to  which  there  may  be  mentioned  the  rare  lesions 
produced  by  tuberculosis  and  syphilis.  These  ulcers  are  always  to  be  regarded  seriously, 
because  in  their  milder  expressions  they  cause  pain  and  various  forms  of  dyspepsia  and 
indigesti(jn,  while  their  more  serious  conseciuences  include  hemorrhage,  which  may  be 
fatal,  and  perforation,  which  is  essentially  so  unless  surgical  intervention  be  ])rompt 
and  complete. 

Sjnnptoms. — The  symptoms  and  discomforts  which  they  produce  include  pain, 
wliich  is  nearly  always  most  pronounced  within  a  short  time  after  the  ingestion  of  food, 
and  which  may  be  accompanied  by  local  tenderness  more  or  less  constant.  As  the 
case  progresses,  with  the  pain  usually  comes  vomiting,  by  which  the  former  is  relieved, 
the  vomitus  nearly  always  containing  excess  of  hydrochloric  acid  and  sometimes  fresh 
or  old  blood.  The  pain  of  gastric  ulcer  is  usually  referred  to  the  back.  The  indigestion 
and  the  frequent  vomiting  together  are  sufficient  to  produce  a  well-marked  anemia, 
which  is  more  ])ronounced  when  nuich  blood  is  lost.  Blood  may  not  be  vomited  but 
escape  intcj  the  duodenum,  and  will  then  give  to  the  stools  a  tarry  character,  which  should 
always  be  looked  for  and  identified  when  discovered.  The  greater  the  loss  of  blood  in 
either  direction  the  more  pronounced  will  be  the  anemia.  Pain,  vomiting,  and  evidence 
of  loss  of  blood  constitute  the  most  distinctive  features  of  gastric  ulcer.  When  these  are 
accompanied  by  tenderness  in  the  epigastrium,  and  by  pain  in  the  back,  the  diagnosis 
is  almost  complete.  In  the  more  chronic  cases  there  may  have  already  occurred  con- 
traction of  the  pylorus  and  consequent  dilatation  of  the  stomach.  Thus  symptoms 
of  the  latter  may  be  added  to  those  of  the  pre\ious  condition.^ 

The  two  ever-present  and  alarming  dangers  are  those  of  hemorrhage  and  perforation. 
Serious  hemorrhage  {permits  the  escaj^e  by  the  mouth  of  large  quantities  of  bright,  fresh 
blood,  with  a  corresponding  degree  of  shock  or  collapse,  and  depression.  Perforation 
is  indicated  by  sudden  onset  of  intense  j)ain,  with  collapse,  rapidly  spreading  tenderness, 
with  abdominal  rigidity  and  increasing  distention.  In  other  wordy  the  sijmptovvs 
of  perforation  are  those  of  acute  local  peritonitis  of  abrupt  origin. 

In  either  of  these  events  the  paramount  indication  is  for  prompt  intervention,  unless 
the  patient  is  already  too  weak  to  withstand  the  shock  of  any  operation.  In  one  case 
this  will  consist  of  gastro-enterostomy,  with  or  without  a  gastrotomy  for  the  purpose 
of  discovering  the  bleeding  vessel  and  making  local  hemostasis.  In  the  other  it  will 
consist  of  free  incision,  c-omplete  toilet  of  the  peritoneum,  with  removal  of  all  escaped 
material,  and  local  attention  to  the  site  of  the  perforation,  doing  there  whatever  may  be 
needed. 

Treatment. — Should  the  surgeon  see  a  case  of  gastric  hemorrhage  due  to  ulcer 
after  the  apparent  cessation  of  the  active  loss  of  blood  he  may  easily  decide  to  wait  for 
a  few  days  until  the  patient  has  in  some  degree  recovered  strength  and  atoned  for  such 
loss.  On  the  other  hand  if  he  see  the  case  during  its  active  stage  he  need  not  hesi- 
tate to  open  the  abdomen,  withdraw  the  stomach,  open  it  sufficiently  for  exploration, 
and  then  attack  the  source  of  hemorrhage,  be  it  large  or  small,  in  such  manner  as  he 
may  see  fit — either  with  the  actual  cautery,  with  a  sharp  spoon,  with  complete  excision 
of  the  ulcerated  area  and  union  of  its  bf)rders  bysuture,  or  by  merely  including  a  bleeding 
vessel  in  a  loop  of  suture,  adflressing  himself  at  once  to  the  formation  of  an  anastomosis, 
preferably  posterior,  between  the  stomach  and  the  uppermost  k)op  of  the  small  intestine. 
This  procedure,  which  is  wise  in  all  instances,  would  be  imperative  in  nearly  all  save 
those  perhaps  where  an  ulcerated  area  could  be  cleanly  excised  and  its  margins  neatly 
sutured.     Should  it  prove  that  suture  of  the  stomach  wall  were  impracticable  its  edges 

1  In  doubtful  cases  accompanied  by  pain  it  will  sometimes  be  of  value  to  try  the  effect  of  orthoform  in  14  Gm. 
doses,  to  see  if  it  will  relieve  it.  This  remedy  will  not  anesthetize  nerve  enflings  which  are  protected  by  skin 
or  mucous  membrane.     The  fact,  then,  that  it  affords  relief  implies  an  ulcerated  or  exposed  area. 


CANCint  OF   Till':  STOMACH  sui 

iniji'lit  I>c  r;i.s(('iu'tl  to  (liusc  of  (he  :il)(l(iinin:il  woiiimI,  a  ^aslrostoinv  tluis  ri'siiltiiig, 
which  cdiild  l)c  hitcT  closed  hy  aiiothiT  o|H'iatioii. 

For  ptrjoration  the  siirjfooii  iiii<;ht  have  to  rely,  in  eiiierj^eiiey,  on  a  ;:;a.stro-enterostoniy 
as  a  relieroj)eninj]i;,  aceoin])anie(l  by  local  <^au/e  tainj)onaffe;  the  ])ointot"  |)erl"oralioii  could 
not  l)c  made  accessihle  for  suture,  hut  one  should  prefer  suture  for  all  cases  that  lu'i-niit 
of  it.  In  these  cases  a  coiisiderahlc  margin  should  he  enh)lded  and  included  within 
the  i^rasp  of  the  suture,  or  else  the  niar;;ins  shoidd  he  coiupletely  excised  until  healthy 
tissue  is  reathed.  In  rare  instances  it  has  heen  feasihie  to  fit  into  a  perforation  a 
drainaji'c  tid)e,  or  to  ])ack  about  it  a  <^auze  strip  which  should  conduct  from  the  .stomach 
cavity  directly  to  the  ahdominal  wound.  The  (|uestiou  of  r.vri.s'ion  of  the  riifirc  ulrcmlcd 
area  should  rest  entirely  upon  the  possibility  of  repairin*:;  the  defect  hy  sutures,  and  this 
will  tlepend  in  larj^e  de<i;ree  upon  the  location  of  the  ulcer  and  the  freedom  with  which 
the  stomach  can  he  manipulated,  especially  with  which  it  can  he  withdrawn  into  the 
Wound. 

Practically  every  case  of  pcrh»ration  thus  operated  will  demand  posterior  as  well  as 
anterior  drainage.  Aside  from  the  treatment  of  the  stomach  itself  the  <2;e!ieral  |)eritoneal 
cavity  needs  the  same  thorou<>ime.ss  of  cleansin<>;  and  the  same  cari'  in  every  manipu- 
lation that  would  he  given  in  a  case  of  well-marked  peritonitis  already  established. 

GASTRIC  FISTULAS. 

This  term  has  reference  es])ecially  to  external  ji.stiilov.s  openings,  which  are  an  exceed- 
ing rarity  save  as  relics  of  injury  or  of  operation.  They  have  l)een  known  to  occur 
spontaneously  by  perforation  of  an  idcerated  and  adherent  stomach,  such  perforations 
occurring  either  in  direct  line  or  irregularly  in  the  direction  of  least  resistance.  Trau- 
matic /isluld.s-  result  usually  from  gunshot  or  stab  wounds,  or  are  due  to  incomplete  union 
of  an  opening  deliberately  made.  In  any  event  they  permit  of  the  esea])e  of  more  or 
less  of  the  stomach  contents.  Their  tendency  is  usually  toward  s])ontaneous  repair, 
but  this  is  often  so  slow  or  so  incomplete  that  it  needs  to  be  hastened  by  stimulation  of 
the  fistulous  tract  with  silver  nitrate,  the  actual  cautery,  curetting,  or  by  a  complete 
resceti(jn  of  the  entire  tissue  involved,  and  a  neat  reimion  with  suture. 

Intra-abdoininal  gastric  fistulas  residt  usiudly  from  ])erforation  of  gallstones  or  the 
escape  of  foreign  bodies.  Produced  in  this  way  they  empty  usually,  though  not  always, 
into  some  neighboring  portion  of  the  intestinal  canal. 


TUMORS   OF   THE   STOMACH. 

Benign  tumors  are  occasionally  found  in  the  stomach,  and  are  most  often  of  the 
adenomatous  type.  Papillomatous  growths  into  the  stomach  have  also  heen  observed. 
Beneath  the  peritoneum,  or  in  the  submucous  tissue  near  the  pylorus,  fatty  tumors 
have  also  been  seen.  INIyomas  of  mixed  type  have  been  described,  and  cysts  have  been 
met  in  the  walls  of  the  stomach.  These  have  rarely  attained  a  size  larger  than  a  hen's 
egg.  All  of  these  non-malignant  tumors  are  of  pathologic-al  rather  than  surgical  interest. 
Every  one  of  them,  however,  will  admit  of  successful  surgical  remedy  when  once  recog- 
nized, operation  consisting  of  excision,  with  suitable  suturing. 

CANCER    OF    THE    STOMACH. 

Carcrnoma  is  perhajis  as  fre(|uently  seen  in  the  stomacli  as  in  any  part  of  the  body, 
the  breast  ])ossibly  excepted.  In  about  three-fifths  of  the  cases  it  involves  the  pyloric 
region,  in  one-tenth  of  them  the  cardiac  end,  the  balance  occurring  in  the  intermetliate 
part.  It  is  usually  of  the  roimd-cell  or  scirrhous  variety,  and  is  generally  supposed 
to  be  a  disease  of  adult  or  advanced  life.  While  this  is  generally  true  there  have  been 
exceptions.  It  is  occasionally  met  in  the  young,  and  has  been  reported  even  in  early 
childhood.  True  sarcoma  of  the  stomach  is  exceedingly  rare.  It  spreads  especially 
in  the  submucous  tissue  and  eWnces  a  tendency  to  involve  especially  the  lesser  curvature. 

The  duodenum  evinces  an  extraordinary  immunity  from  malignant  disease,  even 
51 


S02  SPECIAL  OR  REGIUS  A  L  SLRUERY 

that  involving  the  pyloric  region.  When  the  pyloric  end  is  involved  the  lesion  is  fre- 
(piently  complicated  by  adhesions,  which  are  present  in  considerably  more  than  half 
of  the  cases.  The  lymj)h  nodes  of  the  adjoining  mesentery  are  nearly  ahvays  involved, 
j)ractically  ahvays  in  cases  which  come  to  the  surgeon  for  oj)eration.  As  the  disease 
advances  it  spreads  in  several  directions,  and  adjoining  viscera  may  be  involved,  or 
even  those  at  considerable  distance,  while  metastases  to  other  parts  of  the  body  are 
connnon.  It  is  somewhat  more  common  in  males  than  females.  In  ])r()])ortion  as  the 
pyloric  ring  itself  becomes  infiltrated  and  involved  pyloric  obstruction  is  an  early  feature, 
with  the  inevitable  gastric  dilatation  and  greater  frequency  of  vomiting.  Pathologists 
and  surgeons  rre  learning  that  the  most  frequent  cause  of  gastric  cancer  is  gastric  ulcer, 
and  recent  investigations  are  to  the  effect  that  in  at  least  80  per  cent,  of  cases  there 
has  been  ulceration  which  has  been  followed  by  this  malignant  change.  This  affords 
additional  reason,  then,  for  regarding  gastric  ulcer  as  a  surgical  disease  and  operating 
upon  it  early  and  l)efore  such  transition  has  occurred. 

Symptoms. — As  repeatedly  emphasized  throughout  this  work  cancer  is  a  disease 
without  a  pathognomonic  symptomatologij.  For  this  reason  it  is  rarely  diagnosticated 
in  its  early  stage,  the  symptoms  which  it  produces  being  those  of  indigestion  or 
dyspepsia. 

The  most  distinctive  features  met  with  in  gastric  cancer  are  pain,  vomiting,  more  or 
less  dilatation,  and  presence  of  tumor.  Pain  is  an  early  and  constant  symptom,  the 
complaint  at  first  being  of  hea\iness  and  oppression,  made  worse  after  the  ingestion 
of  food,  and  later  referred  to  as  actual  pain,  which  may  be  limited  or  may  radiate  to  either 
side  or  to  the  back.  Much  Avill  depend  li])on  whether  the  cancer  develop  from  the  site 
of  a  previous  gastric  ulcer  or  independently. 

Individual  complaints  are  variant  regarding  the  intensity  antl  reference  of  this  pain. 
In  large  measure  it  is  due  to  the  formation  of  adhesions,  and  its  reference  will  depend 
much  upon   their  location. 

Vomiting  is  an  equally  constant  and  perhaps  even  more  important  symptom,  being 
met  in  nine-tenths  of  the  cases.  When  the  growth  involves  the  pyloric  end  the  vomitus 
is  copious  in  amount,  while  the  intervals  between  attacks  of  vomiting  are  relatively 
long.  When  the  more  central  areas  of  the  stomach  are  affected  and  its  capacity  is  thus 
reduced  vomiting  is  more  frequent,  usually  following  soon  after  taking  of  food,  and  the 
amount  of  vomitus  is  consecjuently  less.  In  general  the  character  of  the  vomited  material 
depends  upon  the  length  of  time  it  has  been  retained,  upon  the  possible  presence  of  bile 
or  blood,  the  ])resence  of  small  amounts  of  blood  giving  to  it  a  somewhat  characteristic 
apjjearance,  indicated  by  the  term  "coffee-grounds."  As  the  ulceration  proceeds  the 
amount  of  blood  may  be  increased,  and  it  may  even  come  up  fresh  and  red.  The  degree 
of  actual  ulceration  will  be  indicated  by  the  odor  and  the  more  or  less  putrefactive 
character  of  the  materials  ejected. 

Too  much  reliance  has  been  placed  upon  examination  of  the  stomach  contents.  The 
amount  of  hydrochloric  acid  present  therein  depends  in  large  measure  upon  the  area 
involved.  The  same  is  true  of  pepsin.  The  glands  which  produce  these  digestive 
materials  are  found  especially  in  the  more  central  area,  and  when  this  is  involved  their 
amoimts  will  be  much  reduced,  whereas  as  long  as  these  are  free  they  are  not  necessarily 
so  affected.  The  presence  or  absence,  then,  of  hydrochloric  acid  may  prove  most  mis- 
leading. The  Oppler-Boas  bacilli  are  perhaps  of  more  significance,  but  even  here 
the  surgeon  is  often  deceived.  I  regret  thus  to  appear  to  belittle  the  significance  of 
features  upon  which  internists  place  so  much  reliance,  but  I  have  so  frequently  seen 
their  unreliability  that  I  think  it  is  a  sad  error  to  wait  for  weeks  in  order  to  make  a 
diagnosis  by  means  of  material  secured  through  a  stomach  tube. 

McCosh  believes  that  for  diagnosiic  pur})oses  the  stagnation  test  is  of  greater  value 
than  any  examination  of  stomach  contents.  This  consists  simply  in  the  discovery  by 
lavage  of  food  within  the  stomach  when  it  shoidd  have  left  it.  Thus  an  ordinary 
meal  should  pass  out  of  the  stomach  within  five  hours,  but  if  after  six  hours  undi- 
gested food  still  remains  there  it  denotes  sluggishness  of  digestion.  Food  remaining 
ten  hours  makes  positive  the  fact  of  stagnation.  This  being  once  established  it  should 
be  determined  whether  it  is  from  atony,  spasm,  pyloric  stenosis,  peritoneal  adhesions 
which  kink  the  opening,  or  cancer.  In  all  of  these  except  the  first,  surgical  intervention 
is  necessarv. 


CANCER  OF   rilE  STOMACH  SOo 

Tumor  in  ihe  stomach  region,  in  connection  with  .symptoms  already  mentioned,  is 
corr()l)()rativc.  In  nearly  every  case  it  can  be  felt  sooner  or  later.  Too  many  have 
waited,  however,  for  this  corroborative  sym|)toni  before  considerintf  the  case  a  surgical 
one,  or  even  one  of  nnniistakabic  cancer.  Anyone  can  make  a  diaifiiosis  when  he  can 
discover  the  tumor.  What  is  needed  is  reco(i;nition  of  the  condition  before  it  has  advanced 
to  that  sta<>;e.  When  it  escapes  detection  it  is  usually  because  it  is  situated  in  the  pos- 
terior stomach  wall,  high  up,  or  else  because  the  abdomen  is  enormously  fat.  The  tumor 
when  felt  will  be  found  firm  and  usually  tender,  sometimes  regular  in  outline,  sometimes 
quite  the  reverse,  usually  movable,  but  occasionally  firmly  attached  either  to  the 
abdominal  wall  or  to  the  viscera,  usually  the  liver.  Such  a  tumor,  changing  its  position 
with  the  change  in  sha|)e  of  the  stomach  produced  by  its  inflation  with  carbonic  dioxide, 
may  be  regarded  as  almost  certainly  a  cancer  of  this  organ.  One  rarely  detects  lymi)h- 
atic  involvement  through  the  abdominal  wall,  but  in  many  instances  it  may  be  noted 
at  the  root  of  the  neck.  Thv  tumor  usually  rises  or  falls  with  respiration.  Occasionally 
it  will  not  be  discovered  until  the  stomach  has  been  washed  out  and  completely  em|)tic(l. 

However,  further  aids  to  diagnosis  may  be  furnished,  for  instance,  by  the  discovery 
of  cancer  cells  in  the  vomitus  or  washings,  by  the  presence  of  adventitious  materials, 
such  as  lactic  acid,  whose  especial  significance  is  rather  that  of  stagnation  and  motor 
paresis. 

It  is  of  great  importance,  when  possible,  to  decide  as  between  ulcer  and  actual  cancer. 
In  general  the  following  aids  to  diagnosis  may  be  considered:  Ulcer  is  a  disease  of  the 
earlier  years  of  life,  cancer  rather  of  the  later;  in  ulcer  the  pain  is  direct  and  boring 
(extending  to  the  l)ack),  in  cancer  it  may  be  widely  referred  to  the  shoulders ;  in  ulcer  the 
vomited  blood  is  usually  fresh,  in  cancer  it  furnishes  the  so-called  "coffee-grounds;" 
in  ulcer  there  is  ordinarily  no  tumor  present,  in  cancer  this  is  a  late  but  sure  sign ;  the 
history  of  a  case  of  ulcer  will  often  be  a  long  one,  that  of  a  case  of  cancer  is  rarely  long, 
but  steadily  progressive;  in  ulcer  there  may  be  distinct  anemia,  whereas  in  cancer  it 
assumes  rather  the  type  of  a  peculiar  cachexia;  and  the  free  hydrochloric  acid  which 
is  increased  in  ulcer  is  usually  diminished  or  absent  in  cancer.* 

The  question  in  cases  of  gastric  ulcers  is  whether  they  have  yet  advanced  to  actual  malig- 
nancy. Probably  no  surgeon  has  ever  attacked  a  case  of  gastric  cancer  which  has  not 
been  under  treatment  for  a  time  for  so-called  "dyspepsia  or  indigestion,"  perhaps  with 
a  more  definite  diagnosis.  Too  many  internists  have  waited  for  the  discovery  of  a  tumor 
before  thinking  of  surgery.  It  is  the  business  and  the  duty  of  every  surgeon  to  impress 
upon  the  profession  that  the  only  way  to  treat  cancer  svccessfully  is  to  treat  it  radically, 
and  the  only  ivay  to  do  tJm  is  to  operate  early.  This  applies  equally  well  to  the  viscera 
or  to  the  external  portions  of  the  body.  Gastric  cancer  is  essentially  a  surgical  disease, 
and  could  it  be  recognized  early  and  treated  radically  it  could  often  be  cured. 

What  are  we  to  do  then  in  the  absence  of  early  and  indicative  symptoms?  The  fol- 
lowing rule  may  be  laid  down  as  one  to  which  there  is  no  excej^tion:  A  well-founded 
suspicion  of  cancer  of  the  stomach,  (or  of  any  part  of  the  alimentary  canal)  justifies  an 
exploratory  operation  for  its  detection  and  recognition,  which  then  should  he  extended 
into  an  operation  for  its  complete  removal  should  circumstances  justify  it.  If  this  rule 
were  followed  we  would  not  hear  of  cases  of  this  description  remaining  for  months  or 
years  under  drug  treatment,  and  then  perhaps  being  finally  turned  over  to  the  surgeon 
for  relief  of  pyloric  obstruction  at  a  ]:)eriod  when  strength  Is  so  reduced  that  no  operation 
should  be  seriously  considered. 

Gastric  cancer  is,  then,  at  least  in  its  earlier  stages,  a  surgical  disease.  How  is  it  to  be 
recognized?  By  exploratory  incision  when  there  is  serious  doubt  as  to  the  nature  of 
dyspepsia  or  indigestion  which  fails  to  promptly  improve  under  suitable  treatment. 
In  an  early  stage  even  this  might  not  be  easy,  especially  for  the  inexperienced.     Never- 

>  Sahli  has  .suggested  what  he  calls  a  desmoid  test  for  free  hydrochloric  acid.  A  small  amount  of  methylene 
blue  is  enclosed  in  a  small  gutta-percha  bag,  and  this  is  tied  by  means  of  a  small  strand  of  raw  catgut. 
This  catgut  will  not  be  affected  by  pancreatic  juices,  and  will  only  dissolve  in  the  stomach  in  case  there  be 
free  hydrochloric  acid  present.  The  fact  of  its  solution  and  the  liberation  of  the  methylene  blue  is  made 
evident  by  the  peculiar  color  given  to  the  urine  in  a  short  time.  If,  therefore,  this  appears  within  an  hour 
or  so  after  the  material  has  been  swallowed  one  maybe  sure  there  is  free  hydrochloric  acid  present  in  the 
stomach.  The  test  is  not  absolutely  accurate,  but  will  often  serve  as  a  fairly  reliable  one  and  a  .substitute 
for  the  more  disagreeable  and  ponderous  method  of  a  test  meal  an<l  lavage.  In  some  respects  it  is  perhaps 
e^en  more  reliable, 


804  SPECIAL  OR  REGIONAL  SURGERY 

thclcss  any  c-aiiccr  of  the  .stoinucli  which  pnxhuc^  (lialinct  disturhaiRcs  of  dij^cstion 
will  have  advanced  to  a  degree  of  infiltration  and  thickening  which  will  permit  of  its 
recognition  by  the  touch  of  a  practised  oj^erator.  The  discovery,  then,  of  thickening 
in  the  stomach  wall  will  imply  the  presence  therein  of  either  an  ulcerated  or  cancerous 
area,  which  will  in  either  event  demand  relief.  In  such  a  case  the  stomach  may  be  opened 
and  the  mucosa  exj)osed  to  sight  and  touch.  Should  the  lesion  prove  to  be  malignant 
the  same  rule  will  a])i)ly  with  greater  force,  with  the  sole  ditt'erence  that  the  area  should 
be  much  larger  and  that  tlie  surgeon  shoidd  keej)  clear  of  suspicious  tissue.  This  may 
necessitate  a  more  or  less  complete  removal  of  a  considerable  jxjrtion  of  the  stomach. 
The  greatest  care  should  be  exercised  in  the  discovery  and  removal  of  all  infected  lymph 
nodes,  which  will  be  found  especially  along  the  curvatures  and  within  the  peritoneal 
fold.  When  retroperitoneal  lymph  involvement  is  discovered  a  hopeless  aspect  is  put 
upon  the  case.  Life  may  be  prolonged  for  two  or  three  years,  even  under  such  circum- 
stances, and  the  patient  is  certainly  entitled  to  whatever  can  be  afforded  him.  If  the 
cancerous  process  has  advanced  to  a  point  or  a  degree  making  radical  removal  impos- 
sible, one  may  at  once  select  the  other  alternative  and  perform  a  gastro-enterostomy  at 
a  i)oint  of  election,  by  which  relief  may  be  afft)rded  for  at  least  a  number  of  months. 

Onlv  by  exploration,  then,  can  it  be  decided  whether  to  attem|)t  a  radical  measure  or 
a  palliative  procedure.  It  is  scarcely  fair  to  cjuote  statistics  in  this  regard,  especially 
any  but  the  most  recent,  as  only  lately  have  these  cases  been  referred  for  early  opera- 
tion. Obviously  the  less  wide  the  removal  the  less  reduced  the  patient,  the  more  favor- 
able is  his  condition  to  Avithstand  operation,  and  the  more  favorable  the  aspect  of  his 
case.  Thus  pylorectomy  before  gastric  dilatation  has  occurred  is  more  promising 
than  pvlorectomv  when  half  the  stomach  is  involved.  In  proportion,  then,  as  these  cases 
are  submitted  to  early  operation,  statistics  will  improve  and  better  results  be  attained, 
while  if  physicians  and  surgeons  can  be  matle  to  cooperate  early  an  ever-growing  number 
of  cases  will  be  seen  and  operated  at  a  favorable  time. 

The  various  ojierations  practised,  including  gastrectomy,  pylorectomy,  etc.,  will  be 
tliscussed  with  the  other  operations  upon  the  stomach. 


PERIGASTRITIS. 

To  this  term  attaches  about  the  same  force  and  significance  as  to  perihepatitis  or  peri- 
splenitis. The  expression  implies  the  consequences  of  a  local  peritonitis,  usually  of 
low  grade,  by  which  adhesions  are  produced  that  may  anchor  the  stomach  in  whole 
or  in  part,  in  any  possible  direction  and  to  any  of  the  surrounding  viscera  or  part  of  the 
alxlominal  wall.  Such  adhesions  are  more  common  at  the  pyloric  end  than  elsewhere. 
Their  causes  may  be  intrinsic  or  extrinsic,  among  the  former  ulceration  and  cancer  being 
by  far  the  more  common ;  among  the  latter  gallstones,  tuberculous  processes,  and  occa- 
sionally the  remote  consequences  of  typhoid  ulceration.  In  the  majority  of  cases  the 
adhesions  thus  produced  are  protective  and  purposive,  although  they  often  constitute  a 
serious  obstacle  to  surgical  work.  While  they  may  be  suspected  in  almost  any  of  the 
conditions  above  named,  they  are  rarely  discovered  or  identified  until  the  abdomen  is 
opened.  Nevertheless,  distention  of  the  stomach  with  gas  and  the  discovery  of  its  irreg- 
ular naovements  or  shape  because  of  fixation  will  afford  good  ground  for  suspicion  as 
to  the  condition  itself.  When  it  can  be  shown  that  these  adhesions  are  producing  pain 
or  discomfort,  as  they  often  do,  operation,  gasirolysis,  affords  the  only  legitimate  and 
reasonably  certain  relief.  Time  sometimes  permits  a  stretching  of  adhesions  or  the 
possible  absorption  and  amelioration  of  symptoms,  but  only  by  surgical  intervention 
can  anything  radical   or  ])rompt  be  offered. 


PHLEGMONOUS  GASTRITIS. 

Under  this  term  is  included  a  suppurative  or  necrotic  inflammation  of  the  stomach 
tvall,  begiiuiing  ])rol)al)ly  in  the  submucosa,  but  extending  in  l)oth  directions.  It  appears 
in  two  forms — the  circumscribed  and  difi"use. 

Symptoms. — The  symptoms  of  the  latter  are  those  of  an  intensely  acute  gastritis 
with  rapid,  almost  inevitably  fatal  course,  beginning  with  severe  pain,  quickly  followed 


OPERATinxS   UPOX   Till-:  ST().\[.\('II  SOo 

!)>•  i'aiiitiu's.s  and  (■()lla|).st',  with  early  voiiiitiiij,',  voiiiiti'd  niattiT  l)(_'iii<f  first  hile-stuiiicd. 
then  coiituiiiinf^  blood.  The  sensation  of  nausea  is  extreme  and  a  conipiaint  of  thirst 
constant.  Frecjuently  there  are  hiccough  and  pecuhar  and  uncontrollable  general  rest- 
lessness. Pain  is,  however,  a  variable  feature,  and  sonic;  cases  are  too  rapidly  necrotic 
to  afford  nnich  pain  or  tenderness.  The  |)ulsc  is  ra|)id,  weak,  and  poor,  and  the  tem- 
jK'rature  usually  runs  high.  After  a  short  time  the  abdomen  m;iy  be  much  distendecj, 
while  symptoms  of  paralytic  ileus  (/.  c,  obstruction),  su|)ervene,  though  occasionally 
there  is  offensive  diarrhea.  A  well-marked  case  of  this  (y|)c  <'omes  on  with  fulminating 
suddeimess,  patients  later  becoming  apathetic  and  dying  in  stupor. 

About  all  this  there  is  nothing  peculiarly  characteristic,  and  similar  .symptoms  might 
be  caused  by  nu-sentcric  thrombus,  by  acute  pancreatitis,  or  acute  gangrenous  chole- 
cystitis. 

Stjiiipfoiiin  of  llir  more  rirctniisrn'hed  form  are  similar  to  those  just  described,  but  of 
less  severity,  'i'he  |)aiii  and  vomiting  appear  suddenly,  but  are  less  intense.  If  time 
be  afforded  for  f(»rmation  of  abscess  a  distinct  tumor  may  l)e  felt.  Aj)j)etite  is  hjst  and 
food  regurgitated.  \  localized  lesion  favorably  placed  might  lead  to  adhesions  and 
circumscribed  collection  of  pus,  assuming  the  subphrenic  or  sf)me  less  typical  form. 
The  |)yloric  end  of  the  stomach  is  UKjre  commonly  involved  in  such  a  process  and  affords 
evidciue  to  the  effect  that  it  begins  as  an  infection,  the  port  of  entry  being  usually  a 
gastric  ulcer. 

Treatment. — Treatment  would  be  surgical  if  any  were  available,  but  has  never 
yet  been  applied  sufficiently  early  to  save  an  acute,  generalized  ca.se.  On  the  other  hand, 
when  the  lesion  has  been  local  and  has  led  to  subsequent  phlegmon,  cases  have  been 
successfully  opened  and  drained. 


OPERATIONS  UPON  THE  STOMACH. 

In  every  instance,  when  time  is  afforded,  certain  jireparations  should  have  been 
made  by  Avhic-h  the  stomach  has  been  put  in  an  ascjitic  condition.  Not  only  should  it 
be  emptied  of  food  in  the  ordinary  sense,  but  it  shoidd  have  been  wa.shed  out  at  least 
once,  and  in  most  instances  repeatedly,  first  with  ck^ansing  lavage  and  then  with  a 
fluid  containing  a  small  proj)ortiou  of  borax,  with  the  intent  that  by  a  mildly  alkaline 
solution  its  contained  mucus  may  be  more  thoroughly  washed  away.  This  alone, 
however,  is  not  sufficient,  for  quantities  of  septic  material  may  be  introduced  by  the 
patient  from  his  nose  and  throat.  Frequent  use  of  the  toothl)riish,  with  a  strong  anti- 
septic powder  or  solution,  and  frequent  rinsing  of  the  mouth  with  a  suitable  anti.septic 
mouth-wash,  should  be  practised  at  frequent  intervals  for  two  or  three  days  before 
such  an  operation.  If  offensive  mucus  be  dropping  from  the  nasopharynx  this  also 
should  be  cleansed  and  sjmiyed.  In  other  words  the  possibility  of  contamination  from 
the  nose  and  mouth  should  be  prcventecl  as  cc)m])letely  as  |K)ssible.* 

Operation  for  Penetrating  Wounds.— When  t\w  stomach  has  been  opened  by 
gunshot,  stab,  or  other  woiuids  it  should  be  closed  at  the  earliest  possible  moment.  The 
operation  intended  for  this  purpose  may  be  sim])lc  or  difficult,  and  may  be  complic'ated 
by  the  fact  of  injuries  to  other  organs.  A  simple  o])ening  is  easily  clcjsed,  when  exposed, 
by  sutures,  of  which  there  should  be  at  least  a  double  row,  the  internal  devoted  entirely 
to  the  mucosa,  whose  edges  should  be  brought  together  and  held  by  a  continuous  chro- 
micizcd  catgut  suture,  with  stitches  at  intervals  sufficiently  short  to  prevent  the  possi- 
bility of  hemorrhage,  and  interrupted  occasionally  to  prevent  puckering.  A  second 
row  of  sutures,  of  fine  silk  or  thread,  is  then  applied,  by  which  the  serous  and  muscular 
coats  are  firmly  a])i)roximated,  c-are  being  taken  that  the  needle  is  not  allowed  to  per- 
forate a  vessel  and  thus  ])rocluce  hemorrhage.  The  stomach  walls  are  .so  thick  that 
two  layers  of  sutures  thus  applied  usually  suffice.     If  thought  advisable  a  third  suture 

•  The  first  deliberate  operation  upon  the  stomach  seems  to  have  been  that  by  Crolius,  in  1602,  for  removal 
of  a  knife,  and  a  similar  operation  was  made  eleven  years  later  by  GOnther.  Up  to  1887,  liowever,  only 
thirteen  such  gastrotomies  had  been  reported.  The  first  unsuccessful  gastrotomy  was  done  by  Sc-dillot  in 
1839;  the  first  sucL'essful  one  by  .Jones,  thirty-five  years  later.  While  pylorectomy  was  suggested  by  Merrien 
in  1810,  it  was  not  actually  performed  until  1879  by  Pean.  Gastro-enterostomy  was  first  done  by  Wolfler 
in  1881.  The  first  operation  for  hemorrhage  from  ga:stric  ulcer  was  performed  by  Mikulicz  in  1889.  It  will 
thus  be  seen  how  recent  is  the  whole  matter  of  moilern  surgical  attack  upon  the  stomach. 


806  SPECIAL  OR  RKGUJSAL  SURdKRY 

may  be  aj)plie(l  after  the  iiiaiiner  of  tlie  .second.  A  rouiul  needle  is  usually  })referable 
to  a  flat  one  with  cutting  edges. 

(ireat  care  should  he  maintained  to  prevent  e.seape  of  .slotnaeh  contents  or  infection  of 
the  peritoneal  eariti/,  if  this  has  not  already  occurred.  In  some  cases  after  exposing 
the  stomach  wound  it  may  be  advisable  to  pass  a  stomach  tube  and  wash  out  the 
stomach,  holding  the  wound  with  a  compress  in  order  that  no  leakage  at  this  point 
can  occur.  Unless  there  is  some  good  reason  for  not  doing  this  it  shoidd  be  the  method 
of  choice.  Two  dangers  particularly  characterize  cases  re<(uiring  (ju.sirorrhaphy:  the 
first  that  of  assuming  that  there  is  but  one  wound  and  failing  to  discover  others  which 
may  co-exist;  the  second  that  of  infection  by  the  stomach  contents  which  have  already 
escaped.  The  first  is  to  be  avoided  by  careful  observation  and  examination;  the 
second  bv  a  careful  toilet  of  the  peritoneum,  both  before  and  after  suturing.  Drainage 
mav  be  provided  according  to  the  necessities  of  the  case. 

Agun.s-hot  «v>;//k/ produces  more  or  less  contusion  of  the  tissues  in  its  immediate  vicinity. 
Liberal  allowances  should  then  be  made  in  suturing  that  gangrene  and  subsequent 
perforation  may  not  occur;  or,  better  still,  when  it  can  be  properly  done,  the  margins  of 
o-unshot  woimds  should  l)c  smoothly  excised  and  fresh  clean  surfaces  thus  brought 
togeth(>r. 

Gastrotomy. — The  stomach  is  opened  for  purposes  of  exploration  or  for  removal 
of  foreign  bodies,  as  may  be  needed,  and  then  promptly  and  completely  closed  when  the 
opening  has  permitted  such  diagnosis  or  removal,  or  after  a  diseased  area  in  its  interior 
has  been  exposed  by  incision.  Such  may  be  the  procedure  in  certain  cases  of  gastric 
ulcer,  where  the  stomach  is  opened,  its  entire  lining  examined  and  the  sharp  spoon  or 
cautery  applied,  with  or  without  linear  suture.  The  stomas  h  is  also  opened  for  dilatation 
of  its  orifices  as  in  cases  of  cardiospasm  or  pyloric  stenosis,  although  the  latter  procedure 
has  o-iven  way  to  anastomotic  methods,  which  are  more  permanent  in  their  results. 

The  stomach  having  been  exposed,  usually  by  a  sufficiently  long  median  incision,  it 
is  brouo-ht  out  and  divided  at  a  point  of  election,  the  incision  being  made  of  sufficient 
length  to  permit  introduction  of  forceps  or  finger,  or  even  of  more  or  less  eversion  of  its 
interior  surface  in  order  that  it  may  be  carefully  inspected.  The  purposes  of  the  opening 
having  been  achieved,  it  is  closed  as  indicated  above,  with  at  least  two  layers  of  sutures. 
A  perfectly  clean  wound  will  scarcely  call  for  drainage.  One  which  has  been  infected 
should  be  protected  in  this  way. 

Gastrotomv  has  also  been  done  in  order  to  permit  of  the  retrograde  division  of  strictures 
of  the  esophagus,  when  it  has  been  imjiossible  to  pass  even  the  smallest  bougie  from 
above.  In  these  cases  it  has  been  occasionally  possible  after  exposing  the  stomach  to 
introduce  a  whalebone  bougie  which,  passing  upward,  may  follow  the  tortuous  passage  and 
be  made  to  appear  in  the  pharynx.  To  its  upper  end  may  then  be  attached,  by  strong 
silk,  the  small  end  of  another  bougie,  and  thus  guide  it  downward  as  the  first  one  is  with- 
drawn. This  procedure  has  been  improved  on  by  Abbe,  who  has  thus  been  able  to 
])ull  down  from  the  mouth  a  stout  piece  of  coarse  silk,  bringing  it  out  through  the  stomach 
opening,  antl  then,  by  a  species  of  sawing  manipulation,  divide  the  tightest  and  densest 
part  of  an  esophageal  stricture  sufficiently  to  permit  of  the  passage  of  some  other  instru- 
ment.    This  having  l)een  accomplished  the  stomach  wound  is  immediately  closed. 

Gastrostomy. — This  term  imjilies  making  an  opening  into  the  stomach  by  which 
its  cavitv  may  be  directly  connected  with  the  exterior  abdominal  surface,  and  the  com- 
munication thus  established  maintained  indefinitely.  The  procedure  itself  is  necessary 
in  eases  of  dense  stricture  or  malignant  disease  of  the  esophagus,  or  the  growth  of  such 
a  tumor  in  its  vicinity  as  shall  occlude  it,  and  thus  cause  slow  starvation  unless  atoned 
for  in  some  manner.  In  one  instance  recently,  where  I  expected  to  do  a  gastrostomy, 
because  the  stomach  itself  had  been  so  destroyed  by  powerful  caustic  that  not  only  was 
the  esophagus  ruined  as  such,  but  the  stomach  decreased  in  size  and  motility,  I  found  the 
stomach  too  immovable  to  permit  of  this  procedure,  and  accordingly  utilized  the  duodenum 
just  beyond  the  pylorus,  thus  making  essentially  a  (hiodennstomij;  the  indications,  how- 
ever, being  the  same  as  for  gastrostomy.  We  have,  in  other  words,  to  effect  a  permanent 
gastric  fistula,  the  older  method  being  to  make  the  most  direct  possible  communication 
between  the  stomach  and  the  surface  of  the  body,  and  then  to  introduce  a  tube,  or 
resort  to  some  similar  expedient  for  preventing  cicatricial  contraction,  and  perhaps 
even  subsequent  closure.  Silver  tubes  were  formerly  used,  whose  openings  were  corked 
and  kept  closed  when  the  tube  was  not  in  use.     In  consequence  of  this  foreign  body  with 


OI'hh'ATfOXS    (fox    Till':   STOMACH 


S()7 


(lie  in-ita(i()ii  it  [irodiiccd  llicrc  \v;i.s  always  more  i>r  less  Icakaji'c  and  (lisccMiilort.  The 
iiioiv  ivcnit  iiuMliods  have  \wv\\  devised  with  an  intent  ol'  niakinjr  a  tunnel  rather  than 
u  (hrect  ()|)enin«i,  thronjjh  wliicli,  as  neech^l,  a  soft  rul)l)er  tube  may  he  introduced,  whose 
wallssliallcolhijjseat  other  times  and  close  themselves,  if  necessary,  with  a  little  assist- 
ance, by  pressure,  thus  j)reventin^  leakajje.  Sometimes  it  is  ]M)ssib"je  to  attain  this  ideal. 
At  other  times  a  rubber  tube  is  worn  a  greater  part  at  least  of  (he  twenty-four  hours. 


Fio.  529 


Fk;.  530 


Gastrostomy:  Witzel's  method.     Tube  in  posit  ion; 
sutures  ready  to  tie.     (Richardson.) 


Gastrostomy:  Witzel's  method.  Tube  in 
position;  sutures  ready  to  close  abdominal  wall. 
(Richardson.) 


Fig.  531 


Gastrostomy  by  Frank's  method:  cone  of  stomach  stitched  into  the  peritoneal  wound.     (Richardson.) 

All  operative  methods  include  fixation  and  consequent  adhesion  of  the  anterior  stomach 
wall  to  the  parietal  peritoneum,  just  below  the  border  of  the  ribs.  Of  the  many  methods 
employed  the  following  will  be  described,  most  of  which  can  be  easily  appreciated  in 
diagram : 

Figs.  529  and  530  illustrate,  for  instance,  Witzel's  method,  where  a  sterile,  soft  rubber 
catheter  is  infolded  in  the  stomach  wall,  and  finally  passed  into  its  cavity  through  the 


SOS 


SPECIAL  OR  RECinXAL  SURGERY 


smallest  opciiiu^,'  tluu  may  sulHcc  for  llic  purpo.st-,  aftrr  whicli  the  outer  layer  of  the 
stomach  is  completely  closed  over  it.  The  stomach  itself  is  stitched  to  the  deep  margins 
of  the  external  wound,  and  these  are  then  closed  without  drainage.  If  everything  has 
been  neatly  done  feeding  may  be  begun  within  a  few  hours.  Care  should  be  exercLsed 
about  ]);issing  into  a  stomach  which  has  long  been  without  much  food  a  quantity  which 
mav  disturb  it,  or  of  a  quality  which  may  distress  it.  A  procedure  very  much  like 
Witzcl's  is  that  described  by  INIarwedel,  who  first  sews  the  stomach  to  the  abdominal 
woimd  after  drawing  it  partly  into  the  woimd,  in  order  to  afford  sufficient  working 
material,  and  then  infolds  the  tube  and  inserts  its  lower  end  through  a  small  opening. 
This  is  pcrha]\s  preferable,  since  the  stomach  being  so  fastened  up  at  once  there  is  no 
possibility  of  leakage  into  the  abdomen. 

Figs.  531,  532  and  533  i1hi<;trate  Frank's  method,  where  the  stomach  is  pulled  uj)  through 
a  sufficiently  long  incision  ami  drawn  out  into  a  cone,  whose  ajjex  is  then  lircnight  out 
through  a  second  small  incision,  parallel  to  the  first  and  at  a  distance  of  an  inch  or  so 
from  it.  Here  an  actual  opening  is  made  into  the  stomach,  while  the  cone  is  fastened 
to  the  skin  here  and  to  the  peritoneum  through  the  other  opening,  which  is  then  completely 
closed.     This  method  cannot  be  applied  to  a  contracted  stomach. 


Fig.  532 


Fig.  533 


dastrostomy  by  Fr.ank'.s  method:  cone  of  stomach  pushed 
tlirough  t lie  second  skin  incision.      (Richardson.) 


Gastrostomy  by  Frank's  metliod:  suture 
of  abtlominal  wound;  stomach  stitched  in 
the  skin  incision.     (Richardson.) 


Cardiospasm.— Operation  for  this  condition  consists  essentially  in  a  gastrotomy 
as  above,  the  ojjcning  licing  made  sufficiently  near  to  the  cardia  in  order  that  either  with 
finger  or  with  suitable  dilating  instrument  passed  ujnvard  from  below,  the  contracted 
cardiac  orifice  may  be  stretched,  or,  if  necessary,  nicked  at  several  ]X)ints,  and  then 
forcibly  dilated.  In  this  latter  jirocedure  great  care  should  be  given  that  stress  lie  dis- 
tributed as  much  as  po.ssible.  If  it  be  practicable  to  introduce  any  dilating  instrument 
a  four-hladtvl  uterine  dilator  wf)uld  probably  be  ideal  for  the  purpose. 

Operations  for  Pyloric  Stenosis. — Among  the  earliest  suggestions  of  a  method 
of  pi/I(ir(i(lii).si.s  was  that  of  I^)rcta,  who  opened  the  stomach  near  the  pyloric  end  and 
dclil)erately  introduced  through  the  constricted  pyloric  ring  a  dilating  instrument, 
fashioned  imich  after  the  shape  of  the  ordinary  glove  stretcher,  which,  in  fact,  might 
be  used  for  such  a  purpose  should  emergency  require.  The  operation  is  simple  and  but 
slightly  dangerous,  but  it  was  found  that  strictures  here  as  elsewhere  tend  to  contract, 
even  after  forcible  dilatation,  and  that  the  method,  while  temporarily  .successful,  was  but 
seldom  permanently  so.  It  was  applicable  only  to  the  cicatricial,  i.  c,  the  non-malignant 
eases.  • 

A  pla.ttw  method  was  then  suggested  independently  by  Ileinecke  and  Mikulicz,  with 
which  their  names  are  often  connected  and  which  is  referred  to  as  pyloroplasty.     It 


OPERA TIOXS   IP(}\   TIIF.   STOMACH 


809 


consists  essentially  ni  inakinj^  a  biiltnulioK   itH-ision  in  one  direction  and  tlien  closing  it 
in  the  opposite,  as  illustrated  in  Figs  534,  535  and  iJ'M'i. 


Fio.  534 


Linear  pyloroplasty.     Seat  riiui  length  of  cut.     ( I'idiard.son.) 
Fig.  S.SS 


Linear  pyloroplasty.    Appearance  of  cut  sutured  transversely.    Two  more  .sutures  to  be  applierl.     (Richardson.) 

Fig.  530 


Pyloroplasty.     Sliape  of  cut  when  more  than  a  linear  incision  is  desirable.      (Richardson.) 


sio 


SPECIAL  OR  RFXnOXAL  SURGERY 


WhcMi  cicatrici;!!  tissue  is  not  too  donsc,  aiul  tlir  parts  not  infiltrated,  it  has  given 
satisfaetorv  results.  Even  here  it  has  l)een  found  to  he  fretiuently  rechiced  in  size  by 
subsequent  contraetion,  and  the  method  suggested  by  Finney  is  more  serviceable. 


Fig.  537 


Fic  538 


Finney's  pyloroplasty:  posterior  suture. 
(Bergrnann.) 


Finney's  pyloroplasty:  anterior  s\ilvirfs  ilrawn  aside; 
incision  made.     (Bergmann.) 


Fin.  539 


Fig.  540 


Finney's  pyloroplasty:  posleiior  suture  of  mucous 
membrane.     (Bergmann.) 


Finney's  pyloroplasty:  anterior  stitches  inserted  but 
not  tied.     (Bergmann.) 


Finuei/'s  pi/loropln.^ti/  consists  in  making  an  anastomotic  opening  l)etween  the  pyloric 
end  of  the  stomach  and  the  first  part  of  the  duodenum,  ^and  will  be  best  appreciated 
from  the  accompanying  illustrations  (Figs.  537,  538,  539,  540  and  541). 


npHRA  Tins' s  rrnx  the  stomm'ii 


811 


Fig.  541 


Tlio  opc'iiiiifj;  can  \)v  iiiatic  as  cxtciisivclv  as  dt'sircd,  and  it  is  not  easy  to  sec  how  it 
can  be  sul)se(|uently  rednccd  (o  a  dciijrec  (li.Sii(lvantufi;eons  to  the  patient. 

Ga.stro-nilrrosfoiini  may  he  needed  in  non-nialifi;naiit  cases,  hecanse  of  fixation  and 
the  imi)ossil)ility  of  hrin<fin<f  the  |)yl()ric  end  of  the  stomach  out  sufficiently  to  make 
operatioti  feasible.  It  will  he  re(|uired  in 
eases  of  cancer  when  pyiorectoniy  is  not 
indicated.  The  method  of  luakiiiji;  ii;astro- 
(Mit(M"ost()my  will  he  described  later. 

Operations  for  Dilatation  of  the  Stom- 
ach. —  (Id.siroplication  consists  of  takin<2; 
a  number  of  "tucks"  in  the  stomach  wall 
and  thus  reducing  its  ca|)acity.  The  pur- 
pose and  the  method  of  the  operation  will 
be  appreciated  by  the  a('comj)anyino;  illus- 
trations. These  ()j)erations  are  mainly  in- 
dicated, however,  in  the  absence  of  pyloric 
stenosis,  for  if  a  free  oi)eninfi;  be  afforded 
from  the  dilated  stomach  into  the  upper 
bowel  the  gastric  enlargement  will  usually 
be  spontaneously  reduced  (Figs.  542  and 
547). 

Gastwpexy  is  a  term  applied  to  fixation 
of  the  stomach  to  the  anterior  abdominal 
wall.  It  has  been  thus  stitched  up  in  a  few  cases  when  greatly  dilated  or  depressed  into 
the  lower  abdomen.  Fig.  548  illustrates  the  method.  The  stomach  has  also  been 
suspended  by  shortening  the  gastrohepatic  and  gastrophrenic  ligaments,  as  illustrated 
in  Fig.  549. 


Finney 


J 


pyloroplasty:  anterior  suture  completed. 
(Bergmann.) 


Fig.  542 


Fio.  543 


Gastroplication.     When  the  threads  a  n',  b  b'  are  drawn  up  a 
fold  is  formed.     (Bircher.) 


Sectional  view  to  show  result  of 
operation. 


Operations  for  Gastric  Ulcer.— In  dealing  surgically  Mith  an  ulcer  of  the  stomach 
the  selection  has  to  be  made  between  anastomosis  and  direct  exposure  of  the  stomach 
wall  'ft'ith  the  performance  of  a  gastrotomy  (r.  e.,  opening  the  stomach)  and  then  dis- 
covering the  site  of  the  ulcer,  either  treating  it  with  the  actual  cautery,  the  curette,  or, 
preferably,  when  this  general  method  is  adopted,  completely  excising  the  involved  area 
and  bringing  the  margins  of  the  wound  thus  made  together  \A'ith  sutures,  which  over 
the  mucosa  only  may  be  of  chromic  gut.  Should  it  seem  advisable  to  excise  the  entire 
thickness  of  the  stomach  wall  it  would  be  better  to  suture  in  two  layers,  making  the  exter- 
nal one  of  thread  or  silk,  while  the  inner  one  may  be  made  of  reliable  chromic  catgut. 
If  this  operation  be  attempted  the  incision  into  the  stomach  should  be  made  sufficiently 
large  to  permit  of  thorough  exploration.  Nothing  being  found  in  the  anterior  wall, 
the  gastrocolic  omentum  should  be  opened  and  the  entire  stomach  palpated  between 


812 


SPECIAL  OR  REGIONAL  SURGERY 


tlu;  ()])eriit<)r'.s  hands.  Any  suspiciously  indurated  s])()t  on  the  j)osterior  wall  may 
then  he  so  manipulated  as  to  he  hrou^ht  int(j  view  throu}i;h  the  anterior  o|)ening.  Other 
surgeons  besides  myself  have  noted  the  occurrence  of  serious  hemorrhage,  which,  upon 
exposure,  must  have  come  from  small  fissures  or  cracks  in  the  mucous  membrane.  In 
fact  the  lesion  which  may  furnish  a  considerable  amount  of  blood  may  thus  be  so  small 
and  concealed  as  to  be  really  difficult  of  exposure.     However,  exploration  should  be 


Fig.  544 


Vui.  545 


Surface  view  of  tlie  result. 


Sectional  view  of  the  result  when  two 
folds  are  turned  in. 


made  as  thoroughly  as  possible.  The  stomach  having  been  opened  and  the  ulcer  found, 
it  should  be  treated  by  one  of  the  above  methods.  If,  on  the  other  hand,  nothing  be 
found  the  surgeon  still  has  the  measure  of  gastro-enterostomy.  Any  ulcer,  however, 
which  is  threatening  perforation  can  usually  be  recognized  by  thesense  of  touch  alone, 
corroboration  feeing  afforded  by  inspection.  An  ulcer  which  is  recognized  and  found 
to  l)e  favorably  situated  may  l)e  completely  excised.  It  has  been  found,  however,  that 
this  ideal  measure  of  local  attack  gives  but  little  better  results  than  does  the  general 

Fig.  546  Vi>..  rA7 


Gastroplication.     (Brandt.) 


Sectional  view  of  tlie  result. 


procedure  of  gastro-enterostomy,  while,  on  the  other  hand,  it  is  less  satisfactory  in  some 
respects  and  seems  to  be  an  equally  if  not  more  dangerous  j^roccdure. 

The  rationale  of  making  an  anastomotic  opening  between  the  stomach  and  the  upper 
end  of  the  l)owel  is  simply  this :  that  thereby  the  stomach  is  given  a  degree  of  physiological 
rest  to  which  it  has  long  been  a  stranger,  and  that  food  may  pass  easily  from  the  stomach 
into  the  upper  bowel  without  irritating  or  aggravating  the  ulcerated  portion,  which  is 


OPERATIONS   UPON   THE  STOAfACII 


813 


Fig.  648 


iisujillv  ;i(    {\\v  |)\l(tric  nid.      It  .sliould   he  uiidiTslood,  (lu'ii,  (luit  ffiislro-cntiTosloiiiy, 

d(»iH'  for  this  ])ur|)(»so,  is  simply  ti  inoiiiis  of  tarrying  out  tlic  iiiiiviTsally  jipplicuhlc  canon 

of  physiological  rest  for  diseased  orjijans 

or  surfatrs.     The  operation  of  inakin<jj 

this     anastomosis     will     he     deserihed 

hi'low. 

Pylorectomy  and  Gastrectomy.— 

A  e(iiii|il(ie  removal  of    the  pylorie   end 

of   the  stomach    is   usually   referred   to 

as  pijIonclDiiii/,  while  still   more   exten- 
sive   extirpation     of    portions     of     the 

stoniaeh  proper   are  spoken   of  as  f/a.v- 

trcciomlcs.     In   a   few   instances   it  has 

been  possible  to  j)raetieally  remove  the 

entire  stomach,    this   having  first  been 

tlone  by  Schlatter.     Such  an  operation 

would  be  si)c)ken  of  as  total  (/a.strcctoini/. 

These  operations  are  done  almost  exclu- 
sively for  removal  of  areas  involved  in 

cancerous  growth.     Obviously  the  more 

extensive   the  growth   the    greater    the 

amount  of  stomach  Avhich  should  be  re- 
moved.    For   some  reason   as  yet   un- 

knowil    cancer  of  the  stomach    rarely 

transgresses  the  pyloric  ring,  and   thus 

the  first  part  of   the  duodenum  usually 

escapes   involvement,   even   though   the 

stomach   be  extensively  diseased.      All 

these     operations,     therefore,     include 

simply  the  removal  of  a  part  termin- 
ating with  the  pyloric  ring  proper.      It 

is  seldom  necessary  to  take  away  any  of 

the  duodenum.     Uemoval  of  the  pylorus 

may  be  also  ap])licable  in  certain  cases 

of  benign   strictures,   where    the   mere 

plastic  o])erations  would  seem  insufficient,  as  well  as  in  the  cases  of  ulcers  encroaching 

upon  the  pyloric  ring  itself. 

For  all  of  these  operations  the  stomach  is  exposed  through  a  median  incision,  or,  if  a 
tumor  presents  distinctly  upon  the  right  side,  the  incision  may  be  made  even  far  to  the 
right  and  near  the  semilunar  line.  Through  an  opening  sufficiently  liberal  the  stomach 
and  the  movable  part  of  the  duodenum  are  withdrawn  and  carefully  examined.  When 
the  pylorus  is  so  fastened  by  dense  adhesions  within  the  abdomen  that  it  cannot  be  with- 
drawn it  is  best  to  abstain  from  this  particidar  procedure,  as  the  mechanical  difficulties 
too  greatly  enhance  its  dangers.  Suitable  clamps,  wdiose  blades  are  j^rotected  with 
soft  rubber,  are  essential  in  order  that  the  duodenum  may  be  clamj)ed  beyond  the  line 
of  its  division,  and  that  the  stomach  as  well  may  be  fixed  between  their  blades,  for  the 
double  purjwse  of  controlling  hemorrhage  and  preventing  escape  of  contents.  The 
omentum  along  the  involved  part  of  the  stomach  should  then  be  carefully  tied  off,  in  a 
series  of  loops,  before  its  vessels  are  cut,  and  one  should  take  great  pains  to  hunt  out 
enlarged  lymph  nodes  and  include  them  in  the  area  to  be  removed,  or  else  make  a 
separate  incision  for  those  that  cannot  be  thus  extirpated.  To  leave  lymph  nodes  which 
are  ]iercej)tibly  involved  in  the  cancerous  process  is  to  invite  the  speediest  possil)le  return 
of  the  disease,  even  though  the  operation  should  be  successful.  The  upper  and  lower 
borders  of  the  stomach  being  thus  freed,  the  surgeon  is  then  at  liberty  to  cut  away  all 
the  diseased  portion,  going  at  least  an  inch  beyond  the  apparent  limit  of  the  disease. 
There  will  result  from  any  such  operation  two  divided  ends  of  the  alimentary  canal, 
i.  e.,  one,  that  of  the  divided  stomach,  much  larger  than  the  other,  which  is  the  upper 
end  of  the  duodenum. 

Two  procedures  are  now  open  to  the  surgeon:  He  may  entirely  close  each  of  these 
openings  w  ith  sutures  and  then  make  a  posterior  gastro-enterostomy,  making  new  open- 


Rovsing's  operation  for  gastroptosis:  V,  stomach;  T'l, 
position  of  the  stomach  before  operation;  U ,  urinary 
bladder;  A'^,  right  kidney;  A,B,C,  silk  sutures;  x,  x, 
scarifications.     (Bergmann.) 


814 


SPECIAL  OR  REGIONAL  SURGERY 


incrs  for  this  purpose,  and  by  the  common  method  described  below,  or  he  may  reduce 
the  size  of  the  stcmc^ch  opening  and  endeavor  to  fit  it  to  that  of  the  duodenum  in  such  a 
wav  as  to  bring  the  two  openings  opposite  each  other,  where  they  are  then  a])proxi- 
maled  as  in  ordinary  end-to-end  resection  of  the  intestine.     The  earlier  operation  of 


Fig.  549 


3=2*< 


Suspension  of  stomach  by  three  rows  of  interrupted  stitches  through  the  gastrohepatic  and  gastrophrenic 
ligaments:  1,  2,  3,  single  stitches  of  the  three  rows.     (Beyea.) 


Fig.  550 


Resection  of  tlif 


Billroth  and  his  followers  was  made  according  to  the  latter  plan.  It  has  been  found 
usually  easier  and  more  successful  to  adopt  the  former  method,  as  it  is  easier  thus  to 
prevent  leakage  and  consequent  infection ;  that  is,  the  majority  of  operators  would  today 
probably  completely  close  the  stomach  and  the  duodenum,  and  proceed  at  once  to  make 
a  posterior  gastrojejunostomy. 


OI'ERATIOSS    I  roX    TllK   STOMACH 


81J 


P'igs.  550,  551  and  552  f^ivc  a  fair  idea  of  tlie  procedure  of  end-to-end  reunion.  The 
edges  of  tlic  mucosa  sliould  t)e  united  with  chroniic  gut,  the  stitches  heing  close  to  each 
other,  to  prevent  leakage  and  to  control  hemorrhage  from  small  vessels.  The  external 
sutures  of  silk  or  thread  should  he  placed  suflicicntly  dee|)  to  afford  a  strong  bond  of 
union,  and,  at  the  same  time,  to  escape  the  mucosa.     Some  difheulty  is  met  here,  for 


Fig.  551 


Resection  of  the  pylorus.     Tin-,  figure  illu-trate.s  tlie  method  of  fitting  the  du(KJenum  to  the  stomach  when  the 
gap  in  the  stom,ach  is  too  large  to  fit  the  duodenum.      (Richardson.) 

Fig.  552 


Resection  of  the  pylorus.     (The  same  as  Fig.  551).     Suture  of  the  stomach  to  the  duodenum  completed. 

(Richardson.) 

the  thin  wall  of  the  duodenum  should  be  attached  to  the  thick  wall  of  the  stomach,  but 
with  care  it  can  be  done.  When  the  divided  stomach  end  has  been  reduced  or  trimmed 
off  in  such  a  way  as  t(j  leave  only  a  portion  to  be  matched  with  the  duodenal  opening, 
there  is  need  for  extreme  care  at  the  corners  and  angles  of  the  suture  margins,  as  here 
tearing  of  stitches  or  separation  by  tension,  perhaps  during  the  act  of  vomiting,  are 
most  likely  to  occur.     Fig.  553  indicates  the  first  of  the  procedures  above  mentioned. 


Sl(i 


SPECIAL  OR  RFAilOXAL  SURGERY 


Fig.  553 


In  ]>ert"(>riniii<x  comphte  ga.stnrfomij  tlic  tanliar  t'lul  of  the  .stcjiiuuh  is  ljrou<^lit  ilown 
and  fitted  to  the  upper  end  of  the  divided  (hiodeninn,  after  removal  of  the  stomach, 
which  will  usually  be  possible  under  favorable  cireumstaneea,  but  which  exj)oses  the 
patient  to  ^jreat  risks  of  tearing  a{)art  reunited  surfaces  by  undue  tension. 

Gastric  Anastomosis. — This  consists  in  makin*;  an  anastomotic  openinc;  between 
the  stiiiiKuli  and  ilu'  uppermost  j)art  of  the  jejuiunn,  the  duodeiuim  ])roper  being  too 
bound  down  in  its  course  to  permit  of  its  utilization  for  this  |)urj)ose.  Gastro-enteros- 
tomy,  then,  should  be  referred  to  as  gaMfojcjuuostomij.  In  brief,  it  consists  in  making 
an  opening  by  which  the  stomach  shall  empty  directly  into  the  uj)per  bowel,  and  while, 
for  this  pm-pose,  one  of  the  uppermost  loops  would  theoretically  suffice,  it  has  been  found 
that  the  shorter  the  loop,  i.  c,  the  |X)rtion  between  the  duodenum  proper  and  the  upjier 
part  of  the  bowel  used  for  this  purjM)se,  the  better  for  the  patient. 

Gastrojejunostomy  is,  first  of  all,  referred  to  as  anterior  or  posterior,  according  to 
whether  a  loop  of  bowel  be  brought  up  in  fn)nt  of  the  omentum  and  around  it,  and 
attached  to  the  anterior  and  ex}K)sed  wall  of  the  stomach,  or  whether  the  lesser  peri- 

tone^d  cavity  be  opened  by  perforating  the  omentum  be- 
hind the  colon  and  below  the  stomach,  so  that  the  jk)S- 
terior  wall  of  the  latter  is  found,  drawn  into  the  wound, 
and  made  accessible  and  utilized  for  the  |jur]>ose.  The 
anterior  operation  is  the  easier  of  performance,  but  the 
posterior  is  far  preferable  in  most  instances.  Should  it  be 
found  that  the  }X)sterior  wall  of  the  stomach  is  far  more 
involved  in  cancerous  infiltration  than  the  anterior,  the 
anterior  operation  shoidd  be  performed. 

Simple  as  is  the  procedure  in  theory  there  arealx)ut  it  one 
or  two  complications  which  were  not  at  first  foreseen.  Per- 
ha])S  the  most  imjxirtant  of  these  is  that  bile  emjitied  into 
the  duodenum  ))asscs  dowuAvard  until  it  has  an  oppor- 
tunity to  escape  thrnugh  the  opening  directly  into  the 
stomach,  usually  in  the  direction  of  least  resistance.  This 
may  then  carry  it  where  it  is  a  most  undesirable  fluid,  and 
prevent  its  passage  onward  into  the  ir.testine,  where  it  is 
phvsiohjgically  needed.  This  circulation  of  bile  luis  been 
sjxjken  of  as  the  "  vicious  circle,"  and  it  is  the  formation 
of  a  vicious  circle  which  hiis  complicated  not  a  few  of  the 
anastomotic  stomach  cases,  and  which  has  engaged  the 
attention  of  not  a  few  clinicians  and  operating  surgeons. 

The  secxjnd  objection  is  that  the  contact  of  stomach  con- 
tents with  the  mucous  membrane  at  a  ]x)int  below  where 
the  bowel  is  normally  prepared  for  it,  and  before  intestinal 
contents  have  been  prepared  l)y  bile  or  materials  alkalinized  by  this  fluid,  sometimes 
leads  to  the  formation  of  ulcer  just  opposite  the  o])ening,  and  this  has  been  referred  to  as 
})epfic  ulcer  of  the  jejunum.  This  is  a  ]x)ssible  though  not  a  frecjuent  complication,  but 
has  added  weight  to  the  other  considerations  regarding  the  best  way  of  performing  anas- 
tomosis. Again,  it  has  been  feared  that  this  anastomotic  opening  would  contract  in  time, 
or  sometimes  completely  close.  This  objection  obtains  especially  with  anastomosis, 
made  with  a  ^Iur|)hy  button,  or  its  ecjuivalent,  and  can  rarely  be  made  against  the 
ordinary  suture  methods.  Again,  if  the  o|)ening  in  the  intestine  be  made  too  long  the 
intestine  itself  may  be  narrowed,  for  too  much  of  the  circumference  of  the  bowel  may 
Ix"  taken  up  in  the  formation  of  the  anastomosis,  and  thus  there  will  be  mechanical 
obstruction  Anth  vicious  circle. 

"Vicious  circle"  produces  symptoms  which  do  not  appear  until  the  lajxsc  of  at  least 
three  days  after  the  operation.  If  vomiting  should  ])ersist  and  retain  a  bilious  character 
it  is  to  be  feared  that  some  com])lication  of  this  kind  has  occurred.  Under  these  circum- 
stances when  lavage  is  practised  a  large  amount  of  fluid  mixed  with  bile,  perhaps  blood, 
may  be  returned. 

Much  depends  also  on  the  exact  location  of  the  attachment  of  the  intestinal  loop  to 
the  stomach.  Other  difficulties  arise  from  possible  twisting  of  the  loop  of  small  intestine, 
or  its  strangulation  bv  being  entangled  beneath  the  liridge  of  the  jejunum,  which  is 


Resection  of  the  pylorus  ac- 
cording to  BiUroth's  second 
method.     (Bergmann.) 


(>rj:h'Ari().\s  crox  riii:  sidmmu 


S17 


always  made  in  fvcry  aiiasUmiosis.  A;j;aiii  llic  small  iiilc.siinc  may  hccoiiii'  incarci'ralcd 
ill  an  iniprrfi'ctly  tiosfd  ()|HMiinfi;  niatle  in  (lie  mesocolon,  ll  will  (Inis  he  seen  that  (lie 
j)().st<.'ri()r  method  has  (hsadvanta<j;('s  which  ni'cd  to  hi'  iidly  a|t|)rcciat('(l.  On  the  other 
iiand  it  has  this  <i;reat  advanta>;'e,  that  it  |)ermits  of  drainage  or  emptyinjf  of  theslomach 
into  the  jcjuimni  hy  <j;ravity,  in  almost  any  ])<)sition  which  the  patient  wonid  onlinarilv 
assnnie,  i-ilher  sitting:;  or  lying.  INlany  operators  have  devised  methods  of  preventin<f 
formation  of  the  vicious  circle. 

Fig.  o5-l  illustrates  how  valves  uiay  form  which  ihere  is  no  sure  method  of  preventing. 
Fig.  555  rej)resents  the  suggestion  of  Brauii,  to  make  a  seeond  anastoniotie  opening 
between  the  small  intestine  above  the  stomach  opening  and  below  it,  hoj)ing  that  in 
this  way  bile,  for  instance,  may  j)ass  directly  through  this  opening,  which  it  will  first 
meet,  into  the  intestine  below,  and  thus  not  |)ass  on  and  into  the  stomach.  Others 
have  divitleil  the  looj)  of  jejunum  after  making  the  second  anastomosis,  in  this  way 
planting  the  efVc-rent  ])ortion  of  the  bowel  in  the  stomach  and  then  planting  the  afl'erent 
jtoi-tion  of  the  bowel  into  the  side  of  the  efferent  |)art.  'J^his  is  (he  so-called  Y-f/d.slro- 
jcjitiio.stoiitij.     lloux  does  nuich  the  same  thing,  save  that  his  metlu^d  is  all  carried  out 


Fio.  554 


Fig.  555 


Formation  of  valves  in  gastro-enterostoniy:  1,  intestinal  valve; 
2,  right-sided  gastro-intestinal  valve.     (Bergmann.) 


Ga,stro-enterostoniy  with  entero-ana.stomo.si.s 
according  to  Braun.     (Bergmann.) 


behind  the  colon  insteatl  of  in  front  of  it.  The  principal  argument  in  favor  of  the  use 
of  the  INIurphy  button,  in  this  procedure,  is  that  vicious  circle  is  less  frecjuent  after  its 
use  than  after  most  of  the  suture  methods,  all  of  which  would  simply  indicate  that  vicious 
circle  is  largely  a  matter  of  valve  formation,  and  that  by  the  time  the  button  is  loosened 
and  passed  on  the  danger  period  seems  to  have  elapsed,  and  the  current  in  the  new 
direction  to  be  well  established.  Nevertheless  the  button  is  noAV  discarded  by  almost 
everyone  in  favor  of  the  suture. 

GastrO-enterOStomy.— Artificial  anastomotic  opening  between  the  cavity  of  the 
stomach  and  .some  ])art  of  the  intestine  below  is  indicated  in  a  number  of  conditions, 
which  have  been  discussed.  It  is  done  mainly,  however,  for  two  good  reascjns:  first, 
to  atone  for  ])yloric  stenosis,  and,  secondly,  to  give  the  stomach  a  more  ])hysiological 
rest  in  cases  of  gastric  ulcer,  ])ermitting  food  to  pass  readily  from  it  into  the  jejunum, 
with  a  minimum  of  gastric  activity  or  disturbance.  This  particular  form  of  anastomosis 
is  but  the  application  to  these  viscera  of  a  general  ]:)rinciple,  which  in  various  ways,  in 
different  parts  of  the  body,  has  constituted  one  of  the  greatest  features  in  the  advance 
of  modern  surgery. 

The  operation  is  practised  in  two  ways.  In  the  nntrn'or  operation  the  highest  acces- 
sible loop  of  small  intestine  is  brought  up  in  front  of  the  omentum,  or  else  the  omentum 
52 


yi8  SPECIAL  OR  REGIOXAL  SCIi(;KRy 

is  fenestrated  in  suc-h  a  way  that  the  bowel  shall  be  brouifht  through  its  window,  and 
then  attached  to  the  anterior  wail  of  the  stomach,  where  the  latter  is  much  more  acces- 
sible. In  this  operation  there  is  less  handling  of  the  stomach  and  bowel,  and,  in  general, 
it  is  easier  of  performance.  Nevertheless  the  bowel  loop  itself  may  become  adherent 
to  the  abdominal  wound  and  give  rise  to  pain,  or  even  obstruction  simulating  the 
vicious  circle.  Volvulus  of  the  jejunum  has  also  followed  it.  Another  objection  is 
that  as  the  patient  gains  flesh  the  weight  of  the  transverse  colon  and  omentum  sometimes 
causes  dragging  upon  the  loop,  which  may  cause  serious  trouble.  The  opening  thus 
made  is  not  where  gravity  will  afford  the  best  drainage  of  the  stomach,  and  it  is  now 
considered  undesirable  in  almost  all  cases  save  those  Avhere  one  is  compelled  to  its  per-, 
f ormance,  either  by  necessity  for  haste,  or  because  the  posterior  wall  of  the  stomac  h  is 
so  involved  in  cancerous  infiltration  as  to  afford  no  suitable  area  for  fixation  and  opening. 
This  method  is  of  use  mainly  in  dealing  with  maUgnant  disease. 

The  posterior  operation  calls  for  all  the  resources  of  a  perfected  technique,  and  takes 
loncrer  in  performance.  Nevertheless  when  once  the  anastomosis  is  safely  effected  it  is 
more  satisfactory. 

The  posterior  operation  alone,  therefore,  will  be  described  at  length  in  this  place, 
and  onlv  that  form  of  it  which  discards  the  anastomotic  loop,  the  Avriter  quite  agreeing 
A\-ith  the  Mayos,  who  have  had  larger  experience  with  this  operation  than  any  other 
surgeons,  and  who  advise  the  direct  attachment  of  the  jejunum,  as  near  as  possible  to 
the  termination  of  the  duodenum,  without  further  complication  by  operative  procedure. 
The  direction  of  active  propulsion  from  the  stomach  comes  from  its  pyloric  end,  the 
lart^er  end  of  the  stomach  being  mainly  for  storage  purposes  and  having  thus  a  forceful 
action;  consequently  the  preferable  site  for  the  stomach  opening  is  on  a  line  with  the 
longitudinal  part  of  the  lesser  curvature,  with  its  lower  end  at  the  bottom  of  the  stomach. 
The  ^lavos  have  abandoned  reversing  the  jejunum  and  now  apply  it  directly  to  the 
posterior  wall  of  the  stomach  from  right  to  left  exactly  as  it  lies  under  normal  condi- 
tions, having  had  better  results  with  this  method  than  with  any  other. 

In  brief  the  operation  is  as  follows :  Incision  is  made  a  little  to  the  right  of  the  median 
line,  the  transverse  colon  is  withdrawn  by  steady  traction  to  the  right  and  upward,  and 
the  mesocolon  made  to  follow  it  until  the  jejunum  comes  into  view.  The  latter  is  then 
grasped  at  a  distance  of  three  or  four  inches  from  its  origin.  When,  now,  it  is  drawn  tight 
the  fold  of  peritoneum  which  covers  the  so-called  ligament  of  Treitz  is  demonstrated;  this 
is  a  small  band  containing  muscle  fibers,  having  its  origin  on  the  transverse  mesocolon 
and  extending  down  to  the  beginning  of  the  jejunum,  thus  acting  as  a  suspensory  ligament. 
It  leads  to  the  base  of  the  vascular  arch  of  the  middle  colic  artery,  and  indicates  the  place 
where  the  mesocolon  should  be  torn  through  in  order  to  expose  the  posterior  wall  of  the 
stomach.  At  this  point,  in  the  least  vascular  area  which  can  be  discovered,  the  meso- 
colon is  first  incised  and  then  torn,  until  a  good  liberal  opening  is  made,  through  which 
the  posterior  wall  of  the  stomach  is  easily  exposed,  and,  later,  drained.  It  should  be 
forced  through  this  opening  by  combined  manipulation  with  one  hand  introduced  above 
it  and  gentlv  urging  it  through  the  opening  where  it  presents.  It  may  be  easily  identified 
bv  its  resemblance  to  its  anterior  surface  in  its  thickness,  the  arrangement  of  its  vessel 
and  the  like.  The  posterior  wall  alone  is  then  secured  and  drawn  through  the  meso- 
colic  window,  in  such  a  way  that  after  the  jejunum  is  attached  to  it  the  anastomotic 
opening  can  be  mafle  at  a  point  one  inch  above  the  greater  curvature  and  ending  at 
the  bottom  of  the  stomach  two  and  a  half  inches  to  the  left  of  the  pylorus.  This  area 
having  been  exposed  and  prepared,  a  considerable  jxjrtion  of  it  is  drawn  into  a  pair 
of  specially  constructed  clamps  (Doyen's  or  ^loynihan's),  whose  blades  are  usually 
protected  with  rubber.  The  Mayos  prefer  to  have  the  handles  lying  to  the  right  and 
to  direct  the  forceps  transversely  to  the  body  axis.  ^loynihan  prefers  to  reverse  this 
direction  and  make  them  point  to  the  right  shoidder.  The  stomach  ])eing  thus  pro- 
tected, and  prevented  from  slip])ing  by  suitable  tightening  of  the  clamj)s,  the  jejunum 
is  similarlv  secured  with  forceps  lying  in  a  direction  parallel  to  the  first,  having  within 
their  grasp  a  portion  of  the  gut  extending  between  points  one  and  a  half  and  three  and  a 
half  inches  from  its  origin.  If  this  be  properly  effected  the  left  low  jioint  of  the  stomach 
lies  in  the  grasp  of  one  pair  of  clamps  and  the  first  part  of  the  jejunum  ui  that  of  the 
other,  and  these  two  portions  should  be  easily  brought  into  close  contact  Avith  each  other. 
A  gauze  pad  having  been  placed  behind  the  clamps  in  order  to  avoid  soiling,  should 
there  be  any  leakage  of  intestinal  contents,  the  clamps  should  now  be  carefully  and 


()l'i:ii'.\TI(>\S    ri><>.\    Till-.    STOMACH 


sin 


uttciitivfly  lu'lil  l)y  an  assistant,  and  tlicir  distal  ends  may  even  he  honnd  t()<,nilicr  in 
siitli  a  way  that,  after  tlu-  sutiirinji;  process  has  once  Ijeffiin,  nothing'  shall  disturb  the 


Kiii.  ."k)0 


Vu:.  r>r>7 


Anterior  wall  of  stomach  graspetl  by  forceps  passed  Mesocolon  lifted  and  posterior  wall  of  stomach  drawn 

through  from  behind.     (Case  of  saddle-ulcer  of  lesser  through  the  opening  made  in  it.     Dotted  lines  show  site 

curvature  near  pylorus.)      (Mayo.)  of  proposed  anaslonKjtic  openings.      (Mayo.) 

Fig.  558 


V  y^ 


'< 


4^^ 


Stomach  and  jejunum  in  tlie  grasp  of  the  large  clamps,  made  ready  for  suturing.     Small  forceps  still 
marking  low  point  of  stomach.      (Mayo.) 


perfect  contact  between  the  surfaces  thus  mutually  applied.     The  first  row  of  sutures, 
usually  of  the  ordinary  continuous  type,  is  made  of  silk  or  thread,  the  serous  and  muscular 


820  SPECIAL  OR  UEUIOSAL  SURCKRY 

coats  being  seized  tmd  united  over  a  line  some  two  inches  in  length,  the  suture  being 
carefully  secured  at  either  end  of  this  line.  Next,  with  a  scalpel,  an  incision  is  made 
through  the  serous  and  muscular  coats,  parallel  to  the  line  of  sutures,  at  a  distance  of 
about  one-ciuarter  of  an  inch,  and  over  a  length  a  triHe  less  than  that  of  the  line  which 
they  occupy.  Here  the  vessels  will  bleed  freely  and  forceps  may  be  momentarily  used 
for  their  securement.  Through  the  opening  thus  made  the  nuiccnis  membrane  will 
i)rolapse.  ]\b)ynihan  especially  has  shown  that  it  is  not  enough  to  merely  incise  this 
membrane  in  the  same  direction  as  the  (jther  coats,  but  tiuit  a  luirrow  elli[>tical  portion 
of  it  should  be  excised,  since  it  tends  to  prolapse.  Therefore  with  knife  or  scissors  a 
strip  of  the  mucosa,  perhaps  a  half-inch  in  width,  should  be  cut  away  from  either  surface, 
thus  widely  opening  into  and  exj)osing  the  interior  respectively  of  the  stomach  and  of 
the  cut.  Extreme  pains  shoidd  now  be  given  to  prevent  both  leakage  and  soiling,  and 
inslruments  used  u])on  the  mucosa  should  be  discarded  after  it  has  been  divided  and 
sutured.  Now  with  reliable  chromicized  catgut  a  vow  of  confimious  sutures  is  applied 
by  which  all  three  coats  of  both  cavities  are  bound  snugly  together,  the  needle  ])assing 
through  six  distinct  layers  as  each  stitch  is  made.  These  sutures  shoukl  be  drawn 
sufHciently  and  secured  at  frc(juent  intervals  so  as  not  only  to  ensure  perfect  application 
but  sufficient  pressure  to  prevent  hemorrhage  when  the  clamps  are  released.  The  lower 
sitle  having  been  first  closed  the  same  character  of  sutures  is  continued  until  the  up})er 
margin  of  the  buttonhole-like  opening  is  thus  completely  closed.  The  fourth  line  of 
sutures,  this  time  of  the  same  material  as  those  used  in  the  first,  is  applied  in  a  similar 
fashion,  and  with  it  the  serous  and  nuiscular  coats  are  accurately  affixed  to  each  other 
in  such  a  way  that  there  can  be  no  leakage.  Two  or  three  extra  sutures  at  either  end  of 
the  line  may  be  inserted  for  greater  security.  The  clamps  are  now  withdrawn,  the 
o-auze  behind  the  anastomotic  opening  is  removed,  and  it  should  be  found  that  the 
smaller  bowel  is  neatly  and  j)erfectly  fastened  to  the  posterior  stomach  wall  and  that  no 
possibility  either  of  hemorrhage  or  of  leakage  remains.  This  being  acconiplished  there 
remains  only  to  tack  the  margins  of  the  mesenteric  opening  to  the  {)osterior  wall  of  the 
stomach,  at  a  distance  sufficient  to  prevent  all  possibility  of  subsequent  constriction  or 
strangulation,  after  which  tlie  i)arts  are  carefully  cleansed,  restored  to  the  abdomen, 
the  colon  and  omentum  dropped  back  and  made  to  cover  them,  and  the  abdominal 
wound  closed  as  usual.       (See  Figs.  55(3,  557  and  558.) 

Such  is  the  operation  with  suture,  which  may  occupy  from  thirty  to  forty  minutes  in 
performance.  It  takes  a  little  longer  than  the  methods  either  with  the  button  or  with 
the  elastic  ligature,  but  seems  to  be  the  method  generally  used.  In  this  method,  as 
stated  at  the  outset,  no  special  ])rovision  is  made  as  against  "vicious  circle,"  because 
it  has  been  found  that  it  is  seldom  tluit  this  impleasant  complication  ensues.  If,  however, 
the  anastomosis  with  the  jejunum  has  Ijcen  made  at  a  point  twelve  inches  (^r  more  beyond 
its  beginning,  there  is  a  likelihood  of  finding  that  vicious  circle  A\'ill  cause  later  compli- 
cations, and  j)erhaps  necessitate  the  performance  of  a  second  anastomotic  opening  in 
the  small  intestine  al)Ove  and  below  the  stomach  opening. 

Of  course  all  the  precautions  mentioned  previously  for  ])revention  of  infection,  such 
as  washing  out  the  stomach  j)revi()us  to  the  operation,  and  ensuring  both  its  emptiness 
and  that  of  the  upper  l)owel,  are  a  part  of  these  procedures  and  cannot  be  safely  neglected 
in  any  of  them. 

Many  an  ingenious  device  for  effecting  the  same  kintl  of  comnumication  between  the 
stomach  and  the  bowel,  or  between  various  ])arts  of  the  alimentary  canal,  has  been  placed 
before  the  profession,  though  but  a  few  will  be  considered  more  in  detail  when  dealing 
with  the  operations  upon  the  intestines  proper.  The  most  prominent  of  them,  and  the 
one  which  has  found  the  most  lasting  favor  in  the  eyes  of  the  profession,  is  the  Murphy 
button,  or  some  similar  expedient,  by  the  use  of  which  time  is  economized  and  the  opera- 
tions in  some  respects  sim])lified.  .\11  devices  of  this  character,  however,  depend  upon 
a  necrotic  process  for  their  eventual  success,  as  the  intent  is  that  parts  compressed 
between  the  halves  of  the  l)utton  shall  first  adhere  and  then  slough,  the  button  falling 
through  the  opening  thus  made  and  passing  on.  But  to  rely  upon  a  necrotic  process 
is  nnich  like  relying  upon  a  criminal  for  tiie  ])erf'ormance  of  a  serious  duty.  The  button, 
therefore,  has  gone  out  of  general  favor  for  purposes  of  gastro-enterostomy,  although 
for  other  intestinal  work  it  is  still  frequently  used. 

McGraw,  of  Detroit,  has  devised  a  different  and  equally  ingenious  method  of  keeping 
surfaces  in  contact  with  each  other  until  adhesion  shall  have  occurred,  and  then  effecting 


(>pi:r.\ti(>\s  (I Pox  the  stomach  ,S21 

a  furlluT  nrcrotic  process  h\  wliicli  (»|KMiiii<f  shall  he  finally  acfoniplislicd.  This  is 
the  so-calli'd  method  with  the  rhistir  li(/(iliirr.  In  many  respects  it  is  simplicit\  ilsell", 
and  permits  of  ready  and  rapid  employment.  ( )ne  needs  especially  a  ronnd  rnhlx'r 
cord,  ahont  2  Mm.  in  diameter,  of  the  pnrest  <fnm  ohtainahle  and  sufhcientlv  I'resh 
to  he  reliable.  The  surfaces  to  he  united  are  first  approximated  hy  a  |)osterior  row  of 
silk  or  thread  sutures  which  shall  include  their  outer  surfaces.  Then  a  lon<;  straif^ht 
needle  armed  with  this  ruhher  cord  i.s  pa.ssed  into  the  intestine  and  out  afjain  at  a  distance 
of  from  .")  to  10  Cm.  An  assistant  now  hol(lin<if  the  intestine,  the  operator  stretches  the 
ruhher  suture  until  it  is  very  thin  and  then  draws  it  rapidly  throuf^h  tiie  howel.  This 
same  step  is  i-e|)eate(l  in  the  ojjposite  dir(>ction  within  the  stomach.  A  stron<i  silk  lif^a- 
ture  is  next  passed  across  and  underneath  th(>  ruhher  between  the  latter  and  the  |)oint 
where  the  stomach  and  the  intestine  are  to  come  tojijether  and  a  single  knot  is  then 
made  in  the  rubber  after  it  has  been  tiijhtly  drawn.  Another  silk  li<:;ature  is  passed 
around  beyond  the  ends  of  the  rubber  liiiaturc  where  they  cro.ss  and  is  here  securely 
tied.  The  rubber  ends  thus  released  are  then  cut  off.  The  orififirud  silk  suture  is  next 
contiiuied  around  in  front  until  the  point  of  its  beginning  is  reached.  In  this  way  the 
rublxM-  ligature  and  the  parts  which  it  includes  are  surrounded  with  an  elongated  ring 
of  silk  sutures,  and  with  this  the  o])eration  is  complete.  Here  it  is  the  continuous 
pressure  of  the  elastic  suture  which  first  shuts  ofl'  the  circulation  and  finally  cuts  its 
way  through  both  coats,  and  jiermits  the  comnniuication  between  the  bowel  and  the 
stomach.  This  method  is  as  applicable  to  other  portions  of  the  alimentary  canal  a.s  to 
the  stomach. 


CHAPTEE    XLVIIl. 

THE  SMALL  INTESTINES. 

CONGENITAL  ANOMALIES  OF  THE  SMALL  INTESTINES. 

The  entire  intestinal  eanal  is  sometimes  too  short  and  sometimes  fails  to  develop 
suffieiently  in  caliber,  or  sections  of  it  may  remain  undeveloped.  None  of  these  (  hanges 
have  interest  or  importance  for  the  surgeon  as  such,  save  those  which  produce  acute  or 
chronic  obstruction  or  conduce  to  acute  inflammatory  affections. 

Intestinal  diverticula  are  usually  of  that  type  described  by  Meckel  and  everywhere 
known  by  his  name.  Aside  from  these  the  others  usually  met  are  irregular  saccu- 
lations or  hernial  protrusions  which  may  be  due  to  previous  disease  or  to  some  congenital 
anomaly  of  structure.  These  are  sometimes  seen  in  multiple  form,  and  in  one  case 
recently  under  my  observation  over  one  hundred  of  them  were  found  scattered  along 
the  intestinal  canal,  but,  inasmuch  as  the  patient  died  practically  of  old  age  without  a 
history  of  serious  previous  disease,  it  could  not  be  ascertained  whether  the  pouches 
were  of  congenital  or  acquired  origin. 

The  genuine  ISIeckel  diverticulum  is  a  relic  of  the  tubular  structure  which  leads  from 
the  primitive  intestine  to  the  vitelline  or  yolk  sac,  and  which  should  persist  until  about 
the  end  of  the  second  month  of  embryonic  life.  After  this  time  it  should  be  completely 
obliterated  and  disappear.  When  this  does  not  happen  there  may  result  a  fecal  fistula 
at  the  navel,  which  is  then  usually  referred  to  as  persistent  omphalomesenteric  duct, 
and  which  implies  a  continuous  passage-way  between  the  skin  and  the  interior  of  the 
bowel. 

When  the  umbilical  portion  alone  persists  there  results  a  small  cyst  on  the  pos- 
terior side  of  the  navel. 

When  the  intestinal  end  alone  persists  a  protrusion  or  sacculation  will  remain  to 
mark  its  site. 

The  duct  may  become  obliterated  and  yet  fail  to  disappear,  thus  leaving  a  fibrous 
cord  w^hich  represents  the  original  omphalomesenteric  structures  and  vessels,  which 
will  be  probably  mistaken  for  an  inflammatory  band  and  may  serve  as  a  later  cause  of 
acute  ol)struction.  If  such  bands  lead  to  the  umbilical  region  their  identity  may  be 
easily  established. 

The  presence  of  Meckel's  diverticulum  may  cause  serious  abdominal  mischief.  It 
may  become  involved  in  a  localized  process  exactly  as  the  appendix  often  does,  which 
may  then  be  referred  to  as  a  diverticulitis,  where  ulceration  and  perforation  may  occur. 
It  may  constitute  the  whole  or  a  portion  of  the  contents  of  a  hernial  sac.  I  have  twice 
found  it  in  inguinal  hernia,  once  in  umbilical  hernia,  and  by  others  it  has  been  reported 
in  all  the  ordinary  hernial  locations.  Porter  has  collected  from  literature  184  cases  in 
which  its  presence  caused  serious  abdominal  crises.  The  condition  itself  is  probably 
present  in  at  least  1  per  cent,  of  mankind,  and  is  stated  by  Halsted  to  be  the  cause  of 
intestinal  obstruction  in  6  per  cent,  of  cases.  In  the  184  collected  cases  above  mentioned 
it  caused  obstruction  in  101.  Out  of  21  cases  of  the  above  collection  it  was  not  only 
found  in  the  hernial  sac,  but  in  all  but  1  was  shown  to  be  the  actual  cause  of  the  trouble. 
In  5  of  these  cases  the  fliverticulum  was  open  at  the  umbilicus.  In  such  a  case  if  the 
opening  be  large  the  gut  wall  might  prolapse  and  thus  form  a  hernia. 

Diverticulitis  has  been  repeatedly  mistaken  for  appendicitis,  its  symptomatology 
not  being  distinctive.     Exact  diagnosis  is  seldom  possible  before  operation. 

On  general  principles,  considering  their  possible  dangers,  it  would  be  well  to  remove 
all  diverticula  which  are  found  in  the  course  of  ordinary  abdominal  operations,  whether 
they  appear  to  be  causing  trouble  at  the  time  or  not. 
(  822  ) 


wot  \i)s  OF  ■rill-:  sMA/j.  i\Ti:sTi\h: 


S23 


\\liil('  llic  avcraj;*'  l('ii;;lli  (»!'  MccktTs  dixcrl iciiliini  is  tlircc  iiidics  i(  iiiav  cxisl  as  a 
mori'  iii|)i)l('-likr  |)n)jc(li()ii,  or  il  may  Ix'  a  free  tiilx-  atlaiiiinif  a  l('ii)i;tli  of  several  iiiclies. 
Its  attached  end  is  usually  lai'tfer  tlian  its  distal 
])()rti()n  and  its  diameter  usually  less  than  tiiat 
of  the  ji;ut  from  which  it  arises.  It  may  he  pro- 
vided with  a  scanty  mesentery  or  may  haufj;  ind(>- 
pendently.  While  ordinarily  its  distal  end  is  free 
it  may  nevertheless  he  continued  as  a  solid  cord 
attached,  as  ahove  mentione(l,  to  the  umhilicus. 
This  cord  frequently  contracts  secondary  adhe- 
sions, and  it  is  under  these  conditions  that  it 
most  often  constricts  the  bowel  by  forming 
a  loop  within  which  tiie  intestine  becomes 
entangled.  Free  diverticula  of  sufficient  length 
are  sometimes  found  tied  in  a  genuine  knot  in 
a  manner  which  is  absolutely  inexplicable,  "^rhere 
are  numerous  ways  by  which  such  a  diverticulum 
may  ])roduce  strangulation  of  the  normal  bowel; 
thus,  by  formation  of  a  ring  in  which  its  own 
free  end  projects,  in  which  is  later  entangled  a 
bowel  loop,  or  by  surrounding  the  pedicle  of  an 
intestinal  looj>  as  might  a  noose.  Again  bowel 
is  sometimes  tightly  drawn  over  such  a  divertic- 
ular band,  just  as  a  shawl  may  be  thrown  over 

the  arm,  obstruction  following  in  the  displaced  bowel.  When  much  contraction  is 
brought  to  bear  the  gut  may  be  so  acutely  bent  as  to  become  occluded.  Finally  the 
bowel  at  the  point  of  origin  of  the  diverticulum  may  undergo  gross  structural  changes, 
the  result  of  long-continued  traction,  which  may  lead  to  cicatricial  narrowing.  More 
indirectly  diverticula  seem  in  some  unknown  way  to  predispose  to  intussusception  at 
their  point  t)f  origin,  or  they  have  been  found  inflated  and  hanging  from  the  intestine 
after  obstructing  it  (Fig.  559). 


Meckel's  diverticulum  still  attached  at 
the  uinbilicu.s  and  producing  obstruction. 
(Lejars.) 


ACQUIRED  MALFORMATIONS  OF  THE  SMALL  INTESTINE. 

Of  acquired  malformations  of  the  small  intestine  we  have  mainly  to  deal  with  those 
which  are  produced  by  injury  or  disease.  Among  the  former  would  be  the  results 
of  violent  contusions  or  of  any  of  the  lacerated,  incised,  or  gunshot  wounds  to  which 
the  bowel  is  so  often  exposed.  Should  recovery  ensue  cicatricial  contraction  is  likely 
to  result.  On  the  other  hand,  such  previous  disease  conditions  as  ulcerations — tuber- 
culous or  typhoidal — or  the  so-called  chronic  catarrhal  or  malignant,  may  in  one  way 
or  another  occlude  and  thus  finally  obstruct  the  lumen  of  the  bowel.  Distention  diver- 
ticula may  also  result,  which  correspond  to  the  traction  diverticula  of  the  esophagus 
alreadv  described. 


WOUNDS  OF  THE  SMALL  INTESTINE. 

The  small  bowel,  like  the  larger  or  the  stomach,  may  be  nij^tured  in  consequence  of 
abdominal  contusions,  the  condition  depending  on  the  nature  of  the  injury,  the  degree 
of  fulness  of  the  bowel  itself,  and  other  obvious  causes.  This  character  of  injurv  has 
been  already  sufficiently  considered  in  dealing  with  rupture  of  the  stomach.  Their 
symptoms  are  not  essentially  different,  neither  are  the  principles  of  ordinary  surgical 
treatment.  Of  all  gunshot  wounds  those  of  the  abdomen  constitute  about  6  per  cent., 
being  more  frecjucnt  than  stab  wounds. 

Gunshot  Wounds. — Gunshot  wounds  of  the  intestine  would  by  themselves  fill  an 
interesting  chapter  in  a  work  on  surgery.  In  such  an  epitome  as  this  they  can  be  given 
but  short  consideration.  The  condition  was  for  centuries  hopeless,  until  the  American 
surgeons  Parkes,  Bull,  and  Senn  took  up  the  subject  and  taught  the  profession  how  to 


g24  SPECIAL  OR  Ri:ainXAL  SURGERY 

more  (|ui(kly  recognize  the  injiirv  as  well  as  to  treat  it.  The  sj)ecial  (huifj^ers  of  all 
punctured  wounds  of  the  bowel,  like  those  of  the  stomach,  are  hemorrhage  and  escajjc 
of  fecal  contents.  The  great  length  of  the  intestinal  tube,  and  its  coiled  arrangement 
within  the  abdominal  cavity,  subject  it  to  the  possibility  of  multiple  punctures,  from  a 
dozen  to  twenty  having  been  inflicted  by  the  passage  of  one  bullet.  The  multiplicity 
of  these  injuries,  therefore,  gives  a  still  more  formidable  character  to  their  presence. 
jNIuch  will  'de])end  upon  the  size  and  velocity  of  the  bullet  and  the  distance  from  which 
it  is  fired.  The  perforated  gunshot  wounds  of  the  abdomen  which  occur  in  civil  life 
are  usually  inflicted  by  a  smaller  bidlet  than  those  occurring  in  actual  warfare,  while, 
at  the  same  time,  the  distance  is  usually  short. 

Gunshot  wounds  are  followed  by  an  ai)parently  dis])roportionate  amount  of  collapse. 
There  is  no  accurate  method  of  recognizing  from  the  exterior  the  amount  of  harm  done 
by  the  passage  of  a  bullet  into  or  through  the  abdominal  cavity.  This  constitutes  one 
of  the  greatest  arguments  in  favor  of  immediate  exploration,  an  argument  which  is 
strengthened  by  the  fact  that  almost  every  penetrating  wound  of  the  abdomen  is  compli- 
cated by  injurv  of  some  abdominal  organ.  The  greatest  danger  attaches  to  perforation 
of  the  transverse  colon  or  of  the  small  intestine,  because  these  are  the  most  movable 
parts  of  the  intestinal  canal.  The  dangerous  wounds  are  those  which  lie  in  the  frontal 
plane.  Bullets  which  pass  through  the  abdomen  obliquely  are  perhaps  less  likely  to 
j)roduce  fatal  result.  Astonishing  differences  prevail  between  the  severity  of  those 
accidents  received  upon  the  field  of  battle  and  in  civil  life.  In  l)attle  men  are  shot  through 
the  abdomen  and  not  conspicuously  disabled,  recovering  sometimes  with  no  other 
treatment  than  antiseptic  occlusion.  It  is  impossible  to  assume  that  the  bowels  have 
not  been  injured,  and  yet  they  recover.  The  fact  thus  stated  best  indicates  the  reason 
for  abstention  from  intervention  on  or  near  the  firing-line  in  battle,  and  its  most  prompt 
and  earlv  ))erformance  when  the  ])atient  is  in  a  well-managed  civil  hospital. 

Ssmaptoms.  — The  symjitoms  of  iufrsfinal  perforation  in  these  cases  are  not  so  j^romjit 
as  when  the  stomach  is  wounded.  Blood  may  occear  in  the  vomitus  or  in  the  stools,  but 
onlv  ordinarily  after  the  expiration  of  a  few  hours.  Should  fecal  matter  be  found  within 
the  external  wound  evidence  would  be  comj^lete,  but  this  is  rarely  the  case.  The  j)r()be 
mav  show  whether  the  aljdominal  wall  has  been  com])letely  perforated  or  not;  beyond 
this  it  will  give  little  information.  By  far  the  l)est  probe  is  the  sterile  finger,  introduced 
through  the  opening  enlarged  for  the  purpose.  With  this  more  distinct  information 
mav  be  gained.  Some  yeare  ago  Senn  proposed  the  method  of  inflating  the  colon  and 
small  intestine  with  hydrogen  gas,  on  the  expectation  that  it  will  escape  through  any 
intestinal  perforation  into  the  abdominal  cavity,  which  it  would  distend,  and  that  then 
bv  inserting  a  small  glass  tube  in  the  abdominal  wound  it  could  be  lighted  and  made 
to  thus  identify  itself  at  the  distal  orifice  of  this  tube;  but  this  method  requires  special 
conveniences  which  are  rarely  at  hand  in  emergency  cases,  and  has  been  practically 
abandoned. 

A  study  of  the  direction  of  the  abdominal  wound  which  may  be  sometimes  made 
from  an  accurate  account  of  the  accident,  and  at  other  times  by  noting  the  location  of 
the  wounds  of  entrance  and  exit,  will  do  much  to  determine  whether  intestines  were 
probablv  in  or  oiit  of  harm's  Avay.  If  it  can  be  established  that  the  bullet  has  probably 
avoided  them  then  some  would  wait  for  the  inception  of  the  first  serious  sign  of  mis<'hief 
before  exploring.  On  the  other  hand,  if  it  should  seem  inevitable  that  such  injury  must 
have  occurred,  or,  Avithout  such  reasoning,  if  the  patient  present  a  serious  condition, 
he  should  l)e  promptly  operated  ludess  practically  moribund. 

The  general  ])rinciples  of  recognition  and  treatment  of  gunshot  wounds  have  been 
considered  in  an  earlier  chapter  and  the  subject  will  not  be  further  considered  here  exce])t 
as  regards  treatment. 

Treatment. — The  principles  of  surgical  treatment  for  gimshot  wound  of  the  intestines 
include  a  free  abdominal  incision,  an  inspection  of  the  entire  length  of  the  intestinal 
canal,  which  can  only  be  made  by  passing  it  through  the  examining  fingers  while  exposed 
to  sight  upon  the  alxlominal  surface,  the  accurate  securement  of  all  bleeding  vessels, 
and  the  closure  of  all  punctures.  Any  portion  whose  blood  su])ply  has  been  so  completely 
cut  off  as  to  threaten  or  produce  gangrene  should  be  removed  by  resection,  with  end- 
tf)-end  or  a  lateral  anastomosis.  The  ])atient  having  been  thus  eviscerated  and  the 
intestinal  viscera  examined,  the  abdominal  cavity  should  be  further  explored,  not  so 
much  to  find  the  missing  bullet  as  to  discover  what  further  harm  mav  have  been  done; 


VLCFAiS  OF    THE   SMAL/.    /.\Ti:STI\J<JS  825 

while  if  sucli  Ik-  rouiid  the  iiidicalioii  should  l)c  met.  'I'licii  -.ihrr  ;in  ('X<'CC(liii<fly  careful 
toilet  oi"  (he  j)erit()ueunj  (he  iu(estiue.s  uiay  he  res(()red,  i(  heiujj;  ot"  course  ussuiiumI  that 
everv  puncture  has  been  fully  recoifiii/,ed  and  |)n)i)eily  su(urc(l  and  secured.  Nearly 
all  of  these  eases  will  call  for  some  alidoininal  draiiia<:;e,  which  may  or  may  iio(  he 
j)os(erior,  as  shall  seem  l)es(. 

Thr  location  oj  the  hullcl  is  a  untllcr  oj  minor  iin portanrc.  Should  it  lie  where  i(  can 
he  easily  i(Ien(ified  and  removed  this  should  he  done.  <  Xherwise  one  should  not  waste 
valuahle  time  in  hunting;-  for  it,  remeuil)erin<f  that  he  is  |)erforniinj^  not  an  autop.sy  but 
an  o|)era(ion. 

ULCERS  OF  THE  SMALL  INTESTINES. 

There  is  no  point  of  the  intestinal  (nbe  betwt^cn  the  |>ylorus  and  the  anus  which  may 
not  l)e  involved  in  an  ulcerative  process,  either  acute,  chrouie,  or  malignant.  Acute 
ulcers  of  the  ui)per  bowel  are  usually  of  ty|)hoidal  origin,  while  those  of  the  lower  bowel 
may  be  due  to  either  typhoid,  tuberculosis,  or  sypiiilis.  .\t  certain  points  ulcers  a.ssume 
somewhat  dis(iuc(ive  cliaracter.  'I'hus  (lu>  acu(e  catarrhal  ulcer,  so  called,  seems  to 
have  a  more  definite  entity  (hau  a  declared  pathology,  it  being  somewhat  difhcult  to 
account  for  its  existence".  The  peculiar  duodenal  ulcers  which  have  been  met  with 
after  operations  or  burns  have  been  elsewhere  discussed,  and  are  to  l)e  regarded  as  of 
an  acutely  toxic  origin.  A  special  type  of  ulcer  of  the  duodenum  has  also  been  noted 
opposite  the  anastomotic  opening  which  is  made  in  the  ordinary  gastro-enterostomy, 
for  whatever  purpose  performed.  This  appears  to  be  due  to  the  outpour  of  the  gastric 
juice  u]X)n  a  surface  not  normally  prepared  for  it,  u]M)n  which  it  acts  as  an  irritant, 
in  time  ])ro<lucing  more  or  less  acute  ulceration.  This  is  the  so-called  peptic  n/rrr  of 
fhr  (Inodcnnm,  an  occasional  com])lication  of  gastro-enterostomy. 

Duodenal  Ulcer.— Duodenal  ulcer  of  a  ty])e  corresponding  to  gastric  ulcer  has  been 
recently  tlctermined  to  be  a  more  frequent  lesion  than  has  been  supposed.  A  series  of 
over  fifty  operations  for  this  contlition,  reported  by  Moynihan,  in  1905,  thus  occurring 
in  the  practice  of  one  surgeon,  will  dispose  of  the  question  as  to  its  great  rarity.  Its 
symptoms  arc  often  so  characteristic  as  to  admit  of  reasonably  easy  diagnosis,  and  it  has, 
therefore,  become  more  and  more  a  matter  of  greatest  interest  to  the  surgeon,  since 
duodenal  like  gastric  ulcer  is  essentially  a  surgical  condition. 

These  ulcers  are  usually  located  in  the  first  portion  f)f  the  duodenum,  i.  e.,  in  at  least  90 
per  cent,  of  cases.  They  may  be  solitary  or  multi|)le,  and  may  be  associated  with  gastric 
ulcers.  In  the  ordinary  postoperative  peptic  ulcer  the  secjuence  of  events  is  usually 
gastric  ulcer,  hyperchlorhvdria,  and  duodenal  lesion.  It  may  occur  at  any  age,  and 
is  the  frequent  cause  of  melena  of  the  newborn  or  of  the  yoimg. 

Symptoms. — Symptoms  of  duodenal  ulcer  include  pain,  hematemesis,  and  melena. 
Pain  may  be  a  vague  uneasiness  or  may  be  severe.  It  is  usually  described  as  of  a  burning 
character,  felt  mainly  in  the  middle  line  or  along  the  right  costal  margin.  It  becomes 
gradually  more  severe  and  may  finally  disable.  It  is  sometimes  described  as  cramp- 
like. When  severe  it  is  referredto  the  right  of  the  middle  line.  In  cases  where  there 
are  adhesions  to  the  liver  or  gall-bladder,  pain  radiates  u])ward  to  the  right  breast,  or 
even  around  the  chest  to  the  back.  The  pain  is  associated,  by  more  or  less  marked 
time  limit,  with  the  ingestion  of  food,  coming  on  from  two  to  four  hours  after  a  meal, 
whereas  that  of  gastric  ulcer  comes  soon  after  eating.  Sometimes  it  is  even  regarded  as 
a  "hunger  pain,"  and  patients  find  that  the  taking  of  a  little  food  will  give  relief.  So 
soon,  however,  as  this  is  digested  pain  returns,  when  they  again  call  for  more  food. 
Hematemesis  and  melena  may  be  present  together  or  either  may  appear  without  the 
other.  Small  quantities  of  blood  in  the  vomitus  is  more  likely  to  attract  attention 
than  consideral)le  (|uautities  in  the  stools.  It  has  been  estimated  that  in  from  25  to 
30  per  cent,  of  acute  cases  hemorrhage  is  frequent,  and  occurs  in  40  per  cent,  of  chronic 
cases.  In  the  stools  blood  is  found  in  ])erhaps  one-half  of  the  instances.  The  amount 
of  blood  may  be  considerable,  even  sufficient  to  produce  faintness.  In  fact,  the  intestine 
has  been  found  full  of  blood  when  the  abdomen  was  opened,  and  Moynihan  has  seen 
even  the  colon  distended  with  blood. 

The  more  serious  romplication.i  of  dtindenal  ulcer,  aside  from  hemorrhage,  are  those 
of  perforation,  cicatricial  contractions  or  stricture  formation  (obstructing  the  bowel  or 


82(5  SPh'CIM.  O/i*  iniCIOXAL  SURdERY 

the  coiniiioii  duct,  (jr  hotli ), /orr//  pcrilitnitls,  caiiccr,  ami  iii(lirrrtly  (fall-bluddcr  or  ]jaii- 
creatic  disease.  Next  to  hemorrhage  i)eri"oration  is  more  likely  to  occur  in  a  duodenal 
than  in  a  gastric  ulcer  and  with  more  disastrous  consequences.  Such  perforation  affords 
a  peculiar  mimicry  of  acute,  gangrenous  appendicitis  which,  as  Moynihan  has  shown, 
is  due  to  the  direction  taken  by  the  extravasated  fluid  down  along  the  right  of  the 
transverse  mesocolon  toward  the  iliac  fo.ssa.  In  fac-t,  the  condition  is  more  likely  to 
be  mistaken  for  one  of  acute  appendicitis  than  for  anything  else. 

With  a  primary  ulcerative  lesion  in  the  duodenum  it  is  easy  to  realize  that  infection 
may  readily  travel  up  the  common  duct,  involving  both  the  pancreas  and  the  biliary 
passages,  while  the  resulting  cholecystitis  will  intensify  and  spread  the  local  peritonitis 
previously  produced,  and  all  combined  will  cement  the  viscera  in  this  region  into  one 
common  mass  in  which  anatomical  identity  is  easily  lost.  A  good  history,  when  obtain- 
able, will  help  very  much  in  diagnosis,  especially  when  the  absence  of  previfnis  gastric 
symptoms  can  be  established.  This,  with  the  symptoms  already  given  above,  and  the 
tenderness  over  the  duodenum,  which  is  rarely  absent,  will  afford  good  basis  for  diagnosis 
in  the  more  chronic  cases.  Duodenal  perforation  may  even  be  mistaken  fcjr  nipture 
of  an  extra-uterine  pregnancy,  as  well  as  for  perforation  of  the  stomach  or  of  the  gall- 
bladder, or,  as  mentioned  above,  of  an  appendix. 

Quite  recently  attention  has  been  called  to  a  condition  of  the  duodenum  resembling 
that  known  as  hour-glass  stomach,  and  produced  in  much  the  same  way.  It  seems  to 
be  the  result  of  cicatricial  contraction  of  an  old  ulcerated  area,  and  may  cause  almost 
complete  constriction.  Hour-glass  duodenum  is  amenable  to  surgery  only,  and  should 
be  treated  cither  by  gastrojejunostomy  or  possibly  by  a  resection  with  end-to-end  suture. 

Treatment. — For  duodenal  ulcer  when  recognized  before  perforation,  there  is  l)ut  one 
treatment,  /.  c,  gasiro-enieroMomji ,  preferably  posterior,  performed  exactly  as  for  gastric 
ulcer,  for  the  same  reason,  and  with  the  same  prospect  of  relief,  inasmuch  as  it  affords 
physiological  rest  for  the  diseased  area.  In  rare  instances  it  may  be  possible  to  .so 
expose  the  duodenum  as  to  make  it  justifiable  to  attack  the  ulcer  directly,  but  the  simplest 
and,  in  general  terms,  the  best  procedure  is  that  just  mentioned. 

For  perforated  ulcer  of  the  duodenum  the  indication  is  not  alone  for  a  gastro-anasto- 
mosis,  but  for  exposure  of  the  site  of  perforation,  removal  of  all  extravasated  material, 
a  most  careful  toilet  of  the  peritoneum,  and  suture  of  the  perforated  area,  this  being  the 
indication  when  possible.  Provision  .should  be  made  for  drainage,  while  at  the  same  time 
affording  a  direct  outlet  from  the  stomach  into  the  first  portion  of  the  jejunum  beyond. 
vShould  the  surgeon  operate  apparently  for  appendicitis  and  discover  that  he  has  to  deal 
with  a  perforated  duodenum  he  should  extend  far  upward  the  incision  made  for  the 
former  purpose,  and,  having  thus  widely  opened  the  abdomen,  should  thus  find  himself 
perhaps  l)etter  provided  with  space  in  which  to  work  tlian  had  lie  opened  at  first  directly 
over  the  duf)denum. 

Typhoidal  Ulcers. — T\-phoi(lal  ulcers  of  the  intestines  have  a  tremendous  surgical 
interest  in  that  they  not  infrequently  lead  to  perforation,  and  that  this  almost  always 
is  fatal  if  let  alone.  It  may  be  possible,  however,  by  prompt  rec(jgnition  of  the  occur- 
rence of  the  perforation  and  by  immediate  intervention  to  cleanse  the  peritoneal  cavity 
of  extravasated  feces  and  close  the  opening  thus  made. 

Sjonptoms. — The  symptoms  of  jierforation  are  at  first  not  unlike  those  of  hemorrhage, 
in  that  shock  is  immediate  and  profound,  and  pain,  usually  intense,  is  produced.  These 
are  quickly  followed  by  abdominal  rigidity,  while  a  blood  count  will  show  a  rapidly 
increasing  and  high  leukocytosis.  To  the  expressions  of  local  peritonitis  are 
quickly  added  those  of  one  which  is  generalized,  with  well-marked  rigidity  and  great 
meteorism. 

The  condition  having  occurred  admits  of  but  one  remedy — namely,  operation.  One 
of  the  latest  collections  of  statistics  includes  63  operations  for  t^'phoid  perforation,  "with 
11  recoveries,  although  probably  today  the  percentage  is  somewluit  better  than  in  1903. 
Operations  to  be  effective  should  he  immediate.  Patients  are  usually  too  profoundly 
collapsed  to  justify  general  anesthesia,  unless  perhaps  this  may  be  secured  with  ethyl 
chloride  or  somnoform.  Many  of  them  have  been  operated  under  local  anesthesia. 
This  has  its  disadvantages,  however,  in  that  it  is  .so  difficult  to  make  free  opening  and 
exploration  or  free  toilet.  Opening  having  been  effected,  the  loops  of  intestine  must 
be  .successively  examined  until  the  site  of  the  perforation  is  discovered.  Here  sutures 
must  be  applied,  if  po.ssible.     Should  the  condition  of  the  bowel  render  it  absolutely 


sTRicniii-:  OF  Till-:  istkstises  s27 

unrcliahlc,  /.  c,  slioiild  it  l)C  hm  cxlciisivcly  <,'aii;j;rciM)ii.s  (o  retain  sutures,  it  sliould  \\v 
hrou^^lil  out  and  an  artilicial  aims  made,  at  least  tor  teui|)()rarv  i)ur|)()ses.  \n  additi(jn 
to  tliese  uieasuri's  tlie  most  careful  toilet  of  tlie  peritoneum  is  needed,  perhaps  inelndin;^ 
extensive  irriijatiou,  unless  it  can  he  shown  that  the  area  eontaininate«|  hv  extravasation 
is  Kxali/.ed  and  shut  olV. 

I\'rj()mtn)u  of  iulx'rculous,  (h/scnlrnc,  rdiicrroiis,  or  oIIut  ulcers  will  cause  svniptoms 
very  much  like  those  of  typhoidal  perforation,  and  the  cjuse  will  ditier  essentially  only 
in  this  respect,  that  in  most  of  the  latter  the  general  condition  of  the  j)atient  will  not 
be  so  extreme,  and  the  danger  of  administering  an  anesthetic  or  of  o|)erating  not  so 
great.     Otherwise-  the  indication,  the  necessity,  and  the  method  do  not  difi"er. 

Tuberculous  Ulcers.— Tuberculous  lesions  of  the  small  intestines  |)roduce  less 
tiestructive  features  than  when  situated  in  the  colon.  Tuberculous  infection  of  the 
intestinal  tract  occurs  more  often  through  the  swallowing  of  infected  sputum,  and, 
C()nse(|uently,  is  a  frecjuent  condition  among  consum])tives.  Such  lesions  in  the  s-mall 
intestines  will  lead  to  infection  of  the  mesenteric  nodes  which,  in  time,  uiay  become 
serious  or  even  fatal,  or  it  may  lead  to  tuberculous  j)eritonitis  with  its  finally  disastrous 
consequences.  As  a  rule,  however,  tuberculous  ulcers  are  not  so  likely  to  perforate, 
this  being  in  large  measure  due  to  the  frequency  with  which  they  contract  adhesions 
or  affix  diseased  surfaces  to  others,  thus  rather  giuirding  against  such  an  accident. 

Symptoms. — Tuberculosis  may  also  a])]>ear  throughout  the  intestinal  tract  in  niiHari/ 
form,  or  we  may  find  tubrrriiloKs  (/iimmas,  either  in  the  folds  of  the  peritoneum  or  sub- 
])eritoneally  in  the  wall  of  the  bowel.  Any  of  these  lesions  may  lead  to  any  of  the  others, 
and  by  the  time  the  case  has  been  diagnosticated  or  has  come  to  operation  or  autopsv  it 
is  sometimes  difficult  to  say  what  was  the  primary  lesion.  Diagnosis  is  made  partly  with 
the  thermometer  and  j)artly  by  inspection  and  ])alpation,  where  one  may  be  able  to  dis- 
cover mesenteric  enlargements  or  the  presence  of  fiuid,  as  it  usually  collects  in  tuberculous 
peritonitis;  and  perhaps  partly  by  the  general  appearance  of  the  stools,  in  which  a 
careful  search  may  possibly,  although  by  no  means  with  certainty,  reveal  the  tulurcle 
bacilli. 

Treatment. — The  treatment  of  such  tuberculous  lesions  is  largely  constitutional. 
When  the  case  assumes  the  aspect  of  tuberculous  peritonitis  much  more  can  be  accom- 
plished by  abdominal  section  and  irrigation,  at  which  time  it  may  be  possible  to  remove 
some  localized  focus  without  thereby  doing  more  harm  than  good.  The  usual  consti- 
tutional measures,  including  oxygen,  are  indicated;  but  there  maybe  difficulty  in  forcing 
hypernutrition  because  of  the  actual  state  of  ulceration.  In  this  case  foods  which  are 
cared  for  by  the  stomach  should  be  given  in  preference.  Such  intestinal  antiseptics  as 
creosote  or  other  remedies  of  its  class  may  also  be  pushed  to  the  point  of  toleration. 

The  other  granulomas'  produced  l)y  either  sifphilis  or  actinomycosis  may  give  rise 
to  ulceration  and  its  consequences  and  sequels,  in  a  way  resembling  those  of  tuberculosis. 
While  the  lesions  they  produce  may  give  rise  to  imcertain  symptoms,  a  diagnosis  can 
hardly  be  made  without  accurate  history  and  without  the  co-existence  of  other  lesions 
in  more  accessible  parts  of  the  body,  by  whose  characterthey  maybe  determined.  Pri- 
mary actinomycosis  of  the  intestinal  tract  is  more  common  than  is  generally  realized. 
As  it  develops  it  tends  to  si)read  to  adjoining  viscera  and  form  tumors  which  later  may 
break  down.  The  debris  thus  resulting  will  be  indicative,  especially  when  the  char- 
acteristic calcareous  particles  are  felt  in  it,  or  the  characteristic  ray  fungus  discovered 
with  the  microscope.     (See  Actinomycosis.) 


STRICTURE  OF  THE  INTESTINES. 

Save  in  rare  instances  where  stricture  may  be  due  to  congenital  defect  the  condition 
is  never  primary,  but  is  secondary  to  some  previous  and  active  disease.  Stricture  proper 
should  be  distinguished  from  obstruction  produced  by  compression  from  without  and 
should  usually  be  made  to  include  those  cases  due  to  intrinsic  disease  of  the  intestinal 
wall.  Here  it  is  in  the  vast  majority  of  cases  either  due  to  cicatricial  contraction, 
following  the  healing  of  some  previous  lesion,  or  else  to  the  infiltration  and  progress 
of  malignant  flisease.  In  the  former  instances  a  great  deal  may  be  accomplished  by 
operation.  In  the  latter  much  will  de])end  U]X)n  the  relative  jx'riod  at  which  the  case 
is  seen  by  the  surgeon. 


828  SPECIAL  OR  REGIONAL  SURGERY 

Symptoms. — The  symptoms  of  stricture  are  those  of  bowel  obstruction.  The  tumor 
which  j)n)(hices  it  may  be  itieiitified  by  palpation,  or  by  the  fecal  impaction,  at  least 
accumulation,  which  is  likely  to  occur  above  it,  which  may  ai)pear  as  a  tumor  and  be 
mistaken  for  it  until  cleared  away  by  suitable  cathartic  measunns.  Ordinarily  the 
surgeon  never  recognizes  stricture  of  the  small  intestines,  then,  save  by  its  obstructive 
features. 

Treatment. — The  treatment  consists  in  what  can  be  done  by  radical  surgical  measures, 
and  this  can  only  be  determined  after  exploratory  abdominal  section. 


TUMORS  OF  THE  SMALL  INTESTINES. 

Benign  tumors  of  the  small  bowel  are  relatively  infrequent,  perhaps  the  most  common 
being  the  lipomas  which  develop  along  the  mesenteric  border,  usually  as  excessive  epi- 
ploic a|)pendages.  But  circumscribed  and  even  pedunculated  li})omas  are  seen  occa- 
sionally in  diis  location  and  are  of  surgical  interest  largely  because,  at  j^oints  where  they 
are  located,  intussusception  is  peculiarly  liable  to  occur.  In  fact,  the  condition  figures 
as  one  of  the  predisposing  causes  of  invagination.  Fibromas  develop  occasionally  in 
the  intestinal  walls  and  adenomas  grow  from  the  glandular  structures  which  abound 
therein.     Other  benign  tumors  are  exceedingly  rare. 

Besides  predisposing  to  intussusception  these  tumors  are  innocent,  save  that  in  time 
they  constrict  or  obstruct  the  lumen  and  produce  one  form  of  stricture  with  obstruction, 
which  will  first  be  chronic  and  then  terminate  acutely  and  fatally  unless  promptly 
relieved. 

All  benign  tumors  of  the  l)owel  should  be  removed  with  the  least  harm  possible  to 
the  bowel  itself,  but  when  a  neat  extirpation  without  reduction  of  intestinal  caliber  is 
not  possible  no  hesitation  should  be  felt  about  resecting  a  suflficient  portion  of  the  gut; 
or  should  this  be  impracticable  in  making  an  anastomosis,  thus  excluding  that  part  of 
the  bowel  involved. 

Cancer  of  the  Bowel. — In  the  small  intestines  by  far  the  most  common  type  of 
malignant  tumor  is  the  round-cell  carcinoma,  epithelioma  rarely  appearing  except  in 
the  lower  part  of  the  rectum,  where  flat  epithelium  is  met.  Adenocarcinoma,  then,  is 
common,  and  sarcoma  relatively  rare,  the  latter  arising,  of  course,  from  mesoblastic 
elements.  A  diagnosis  is  made  l)y  first  noting  symptoms  of  intestinal  obstruction  plus 
certain  added  features  of  cachexia,  lymph  involvement  and  possibly  of  metastasis, 
for  which  a  benign  stricture  would  not  account.  Sometimes  a  tumor  is  easily  felt  within 
the  abdominal  wall;  at  other  times  one  simply  makes  the  general  diagnosis  of  intestinal 
obstruction,  presumably  cancerous,  because  of  age  and  cachexia,  and  leaves  the  rest 
to  be  determined  by  operation.  Cancer  of  the  bowel  will  naturally  si)read  in  the  direc- 
tion of  the  lymphatics  at  the  root  of  the  mesentery,  and  these  will  nearly  always  be 
found  involved.  It  is  fortunate  if  a  case  may  come  to  operation  before  this  invasion  has 
occurred. 

Treatment. — Cancer  of  the  bowel  permits  of  but  two  methods  of  treatment,  one 
excision  of  the  entire  infected  area,  both  of  bowel  and  of  mesentery,  in  cases  not  too 
excessive,  the  other  an  nnasiouiosi,^,  by  which  temporary  relief  at  least  may  be  aft'orded. 
In  all  cases  I  am  strongly  inclined  to  advise  the  use  of  the  .r-rays,  for  a  long  time  after 
operation;  in  favorable  cases  because  it  exerts  a  prophylactic  influence,  in  the  unfavorable 
cases  because  it  nearly  always  relieves  pain  and  retards  growth,  seeming  sometimes 
even  to  disperse  it.  Such  treatment  should  always  be  tempered  by  the  best  of  judgment, 
lest  a;-ray  dermatitis  complicate  or  prevent  it. 


ACUTE  INTESTINAL  OBSTRUCTION;  ILEUS. 

The  somewhat  badly  derived  and  indefinite  term  "ileus,"  in  common  use  abroad, 
is  coming  into  more  fashionable  use  in  the  English-speaking  profession,  which  is  rather 
unfortunate,  for  it  has  not  always  meant  exactly  the  same  thing  in  the  writings  of  dift'erent 
authors.  It  will  be  used,  however,  in  this  chapter  as  practically  synonymous  with  acute 
obstruction  or  strangulation. 


ACUTE  I\TESTIS.\I.  OHSTIWCTIOS ;  ILEUS  ,S20 

Acute  ()l).sti'U('ti()ii  muy  be  classilicd  in  two  ways,  as  to  ty|H'.s  uiid  jis  to  cuu.si's.  For 
till-  first  purpose  the  best  elussifieatioii  is  perhaps  the  simplest,  and,  as  recently  rehearsed 
by  Murphy,  is  as  follows: 

1.  Ad\  uaniic,   includiujj;  those  conditions   which   ;irc  due  to  absence  of  power  of 

|)ropulsioii. 

2.  Dynamic,  where  obstruction  is  (hic  to  excessive  power  or  excessive  conlniction 

of  the  muscular  wall. 
',i.   i\Iechaui<'al,    inchuhni^  all   of   those   conditions   of  stranj^ulatioii   or  ol)turalioii 
which,  in  a  mechanical  way,  impede  the  advance  of  intestinal  contents. 

Conditions  which  |)ermit  the  adynamic  ty|)e  may  include  those  of  spinal  ort(/iii,  those 
interfering  with  mesenteric  tiervc  Hupph/  or  that  of  the  walls  of  the  intestines  (for  instance, 
in  cases  of  fracture  of  the  spine),  or,  a<!;ain,  where  extensive  operations  have  been  |)er- 
formed  on  the  mesentery,  or  where  there  have  been  extensive  wounds.  Thus  in  removal 
of  mesenteric  tumors,  unless  care  is  exercised  in  separating:;  the  mesentery  from  the  tumor 
and  in  li^atinj;-  bloodvessels  without  includinj:;  nerves,  a  j)aralytic  ileus  may  promptly 
result.  (lunsliot  wounds  of  the  chest  or  of  the  spine  may  also  include  itijiinrs  fo  vrrirs, 
by  which  paralysis  of  the  bowel  ensues.  So,  too,  adynamic  ileus  sometimes  results 
through  the  p(tr<ilipin(j  rcfU'xrs  which  follow  strangidation  of  the  (.inentum — as,  for 
instance,  in  a  hernial  sac — or  it  may  be  due  to  biliary  calculus  acting  in  the  same 
way. 

The  dynamic  forms,  as  well  as  the  mechanical,  are  much  more  likely  to  be  charac- 
terized bv  pain  and  violent  symj)toms  than  are  the  ])aralytic.  (iasiric  tetany  is  a  ccMidition 
to  be  differentiated  from  reflex  ileus.  Knormom  distention  of  the  .stomaeh  inunediafely 
after  operation  leads  perhaps  to  a  belief  that  a  patient  has  acute  obstruction  of  the 
intestine,  when  the  fact  is  that  such  a  case  may  be  relieved  by  vomiting  or  ])assage  of  a 
stomach  tube.  Loeal  peritonitis  of  septic  type,  as  well  as  j)eritoneal  traumatism,  tends 
to  weaken  if  not  to  paralyze  peristalsis.  In  general  peritonitis  the  entire  intestinal 
tract  is  involved,  partly  from  reflex  paralysis,  partly  from  inflammation  of  the  intestinal 
wall.  The  embolie  type  of  paralytic  ileus  may  t)c  (lue  either  to  interference  with  nerve 
supply  or  with  blood  suj)ply.  In  thrombophlebitis  symptoms  develop  more  slowly, 
especially  when  this  follows  abscess  of  the  liver  or  spleen.  Here  there  is  not  so  much 
meteorism,  and  the  bowel  may  be  even  nearly  empty,  while  we  have  the  other  symp- 
toms of  pain,  nausea,  and  vomiting.  Borborygmus  is  one  of  the  most  pronounced 
manifestations  of  mechanical  ileus  and  the  stethoscope  will  then  give  much  assistance. 
In  fact  auscultation  of  the  abtlomen,  with  a  recognition  either  of  active  motion  within 
or  of  absence  of  peristalsis,  should  not  be  neglected;  when  one  can  hear  intestinal  waves 
the  condition  is  much  more  likely  to  be  one  of  purely  mechanical  obstruction. 

Classified  by  causes,  we  may  make  out  the  following  well-marked  groups: 

1.  Strangulated  hernia  of  all  varieties,  including  diverticula. 

2.  Intussusccjition. 

3.  Volvulus. 

4.  Ileus  from  fecal  impaction. 

5.  Stricture. 

G.  Intrinsic  neoplasms. 

7.  Extrinsic  neoplasms. 

8.  Gallstones  and  foreign  bodies,  enteroliths,  etc. 

9.  Peritonitis,  with  paralytic  ileus  or  kinking  of  bowel  by  adhesions,  or  both.     This 

condition  is  seen  in  severe  cases  of  appendicitis. 

10.  Bands,  congenital  and  acquired,  recent  and  old. 

11.  Slits  and  apertures  in  the  mesentery  or  omentum. 

12.  Effects  of  contraction   and  intestinal  looping. 

13.  Congenital  causes,  including  diverticula,  unobliterated  omphalomesenteric  and 

hvj)ogastric  remains,  etc. 

1 .  Strangulated  Hernias.— By  far  the  most  connuon  of  all  the  causes  of  acute 
obstruction  are  strangulated  hernias.  These  are,  however,  treated  by  themselves  m  a 
distinct  cha|)ter. 

2.  Intussusception  or  Invagination. — These  terms  imply  a  protrusion  or  prolajise 
of  one  part  of  the  intestine  into  the  lumen  of  an  immediately  adjoining  portion.  This 
is  found  to  be  the  cause  of  perhaps  one-third  of  the  total  number  of  cases.  Enteric 
invaginations  occur  along  any  portion  of  the  small  intestine,  being  more  common  in 


830 


SPECIAL  OR  REGIONAL  SURGERY 


the  lower  portion  and  rare  in  the  ujjpernio.st.  They  seldom  attain  great  length  ant!  are 
often  very  short.  The  ileoeecal  is  the  most  common  variety,  since  obviously  it  is  the 
easiest  of  occurrence,  the  ileum  protruding  into  the  cecum  or  the  ileum  and  cecum 
together  passing  into  the  ascending  colon.  Colic  invagination  may  occur  anywhere 
along  the  large  bowel,  being  again  more  common  near  its  distal  termination.  The 
colon  may  descend  into  the  colon  or  the  sigmoid  into  the  rectum,  even  to  such  an  extent 
as  to  present  at  the  anus  or  ])()ssil)ly  protrude.  Statistics  show  that  the  ileocecal  occurs 
in  44  per  cent.,  the  enteric  in  30  j)er  cent.,  the  colic  in  IS  ])er  cent.,  and  the  ileocolic  in 
8  per  cent,  of  cases. 

While  the  surgeon  is  concernetl  only  with  the  obstructive  form  of  intussusception  it 
is  of  interest  to  know^  that  the  condition  occurs  occasionally  shortly  before  death  and 
is  then  spoken  of  as  the  intussusceptio7i  of  the  dying,  being  usually  due  in  these  cases 
to  irregularity  and  uncertainty  of  peristalsis  during  the  concluding  hours  of  life;  paralysis 
occurring  at  one  portion  of  the  intestinal  tube  and  abnormal  activity  just  above  it. 
These  conditons  are  discovered  at  auto])sy,  and  can  be  recognized  as  such  by  the  absence 
of  exutlate  or  of  any  attempt  either  at  rej^air  or  inflammation.  They  occur  most  com- 
monly in  the  young  and  may  also  be  nndtiple. 
In  direction  intussuscej)tion  is  practically  always 
descending,  although  there  may  be  a  secondary 
and  associated  ascending  movement,  the  latter 
being  unimportant. 

Double  intussusceptions  are  somewhat  com- 
mon, and  triple  or  multiple  have  been  de- 
scribed. 

Cross-section  of  an  invaginated  bowel  will 
show  that  on  each  side  one  must  pass  through 
three  distinct  layers  of  bowel  wall.  That  portion 
which  is  intruded  is  spoken  of  as  the  intu.i.'iufi- 
ceptiim,  while  that  ])ortion  which  receives  the 
latter  is  known  as  the  inius,suscipie7is  (Fig.  560). 
Obviously  Avhen  invagination  occurs  the  mesen- 
tery should  be  drawn  in  with  the  intussuscep- 
tum,  while  traction  upon  it  should  increase 
with  advance  of  the  included  bowel.  This  is 
particularly  often  seen  in  ileocolic  varieties 
where  the  ileum,  with  its  mesentery,  may  travel  the  whole  length  of  the  colon  and  even 
})resent  at  the  anus.  Moreover,  this  may  occur  within  a  relatively  astonishing  short 
time,  and  the  fact  that  the  intussusceptum  may  be  felt  in  the  rectum  within  a  few 
hours  after  the  occurrence  of  the  first  symjjtoms  is  a  fact  not  easily  to  be  exjjlained. 

Causes. — The  causes  of  intussusception  are  obscure,  postmortem  findings  or  even 
the  revelations  of  a  laparotomy  demonstrating  conditions,  but  not  often  affording  explana- 
tions. The  presence  of  tumors,  especially  lipomas,  which  may  even  be  pedunculated 
along  the  small  intestine,  has  been  demonstrated  in  a  number  of  instances,  and  they 
have  been  supposed  to  be  active  factors  in  the  first  disturl)ance.  Everything  points 
to  the  association  of  disordered  intestinal  movements  with  the  mechanical  condition  of 
obstruction,  and  the  former  are  more  frequently  seen  in  the  intestinal  complaints  of  the 
young,  along  with  the  presence  of  masses  of  undigested  food  or  impacted  feces  within 
the  bowel,  or  the  occurrence  of  intestinal  polypi.  The  most  complicated  case  of  ileo- 
cecal invagination  which  ever  came  under  my  notice  was  associated  Avith  the  presence 
of  a  polyp  in  the  ileum.  All  of  these  conditions,  save  the  presence  of  tumors,  pertain 
more  frequently  to  the  young  than  to  the  aged.  The  influence  of  the  ileocecal  valve  is 
also  undeniable,  and  that  at  this  region  parts  are  more  predisposed  to  invagination  than 
elsewhere  is  quite  obvious.  In  at  least  half  of  the  cases  that  have  been  recorded  no 
satisfactory  cause  could  be  shown.  Any  condition  which  causes  severe  intestinal  colic 
mav  give  rise  to  intussusception ;  the  next  most  common  causes  are  paralysis  or  weak- 
eniiig  of  some  part  of  the  bowel,  such  as  may  follow  injury  or  disease,  or  the  presence  of 
tumors,  while  even  the  role  whic-h  they  play  is  not  entirely  explained  (Fig.  5G1). 

That  invagination  will  produce  mechanical  obstruction  is  obvious,  while  the  fact  that 
such  obstruction  is  not  always  nor  necessarily  complete  incites  surprise.  The  orifice 
of  the  intussusceptum  is  distorted,  while  the  included  portion  may  be  greatly  bent  or 


Diagrammatic  section  of  an  intussusception: 
-1,  reflected  tube;  B,  receiving  tube  or  sheath; 
C,  entering  tube. 


Acuri-:  i\Ti-:sT[\.\i.  oustuictios ;  ilfas 


S31 


ciirvrd  ii|)()ii  itsi-lt",  in  additiini  to  which  the  ohstnic'tioii  to  (he  circiiladoii  loads  to  (•oii- 
jjc'stion,  exudation,  aiul  swelling,  and  predisposes  to  aetive  infiainination,  ail  of  whieh 
tend  to  still  further  narrow  the  passaf;e-\vay.  If,  in  addition  to  this,  some  tumor  or  hard- 
ened fecal  mjiiis  he  included  in  the  f^rasp  of  the  bowel  involved  it  may  he  seen  how  com- 
plete sluittin<;oH^^  of  the  intestinal  tube  may  oecur  within  a  few  hours.  Inva<;ination  having 
occurred  tends  (|uickly  to  become  irreducible;  most  commonly  by  the  formation  of 
adhesions,  as  lymph  (|ui(kly  exudis  and  bowel  surfaces  are  by  it  thus  <;lued  tof^ether. 
Such  adhesions  mav  |)crsist  (hrouij;hout  the  whole  involved  lentrth  of  bowel  or  niav  occur 
at  various  scatter(>(l  s|)()ts.  As  pressure  becomes  f^reafer  circulation  of  the  iiiva<finatc(l 
portion  is  impeded  and  fiiuilly  shut  olf,  ^an<freiie  of  the  intussusce[)tum  thus  resultiiiif. 
('ases  oecasioiudly  terminate  favorably  throutjh  this  actual  condition,  the  included  |)ortion 
being  finally  cast  oiY  as  a  slough  and  passing  onward  and  outward.  It  is  on  record,  for  in- 
stance, that  six  feet  of  invagiiuited  bowel  have  thus  been  obtruded  from  the  rectum  after 
haviiigsloughed,  the  patient  eventually  recovering.  While  this  |)ossibility,  then,  is  |)resent 
it  is  never  safe  to  wait  for  it,  and  it  is  to  be  regarded  simply  as  a  happy  accident  when 
it  occurs.  Unless,  then,  a  case  of  intussusception  be  very  early  and  promptly  operated, 
the  included  portion  of  the  bowel  may  be  regarded  as  dangerous  and  unsafe,  unless  upon 

Fi.;.  561 


Invagination  of  ilemu,  cecum,  and  ascending  colon  into  transverse  colon.      One  probe  is  passed  into  the 
appendix,  the  other  into  tlie  invaginated  portion  of  the  ileum.     (Rafinesque.) 


disengagement  it  prove  to  have  been  but  very  slightly  affected.  Even  then  there  is 
danger  of  immediate  recurrence  of  the  previous  condition  because  of  distention  of  the 
bowel  above,  paralysis  of  the  part  disengaged,  and  stretching  of  the  part  below.  In 
proportion  as  obstruction  becomes  more  complete  distention  of  the  bowel  above  the  lesion, 
from  accumulation  and  gas  fortnation,  will  cause  more  and  more  distress,  until  finally 
complete  paralysis  of  the  muscular  coat  and  possibly  eventual  rupture  may  terminate 
the  case. 

In  adtlition  to  the  conditions  above  described,  all  of  which  are  acute,  there  is  known 
also  a  chronic  form  of  intussus-rrption,  whose  whole  course  is  much  sknver  and  less 
severe,  where  symptoms  of  obstruction  never  become  more  than  partial,  but  may 
involve  any  portion  of  the  bowel,  and  with  about  the  same  relative  frequency  as  the 
acute  forms.  Such  a  condition  in  the  rectum,  for  instance,  has  been  mistaken  for 
cancer. 

Symptoms. — The  special  symptoms  by  which  intussusception  may  be  recognized, 
or  at  least  by  which  suspicion  is  aroused,  are,  in  addition  to  those  common  to  all  forms 
of  acute  obstniction,  the  abrupt  onset,  which  may  even  occair  during  sleep,  the  late 
rather  than  the  early  occurrence  of  vomiting,  complaint  of  tenesmus,  the  wave-like  or 
eolicki)  character  of  the  pain,  and  the  fact  that  along  with  the  violent  peristalsis  of  which 
this  colicky  pain  is  an  indication  diarrhea  is  a  common  accompaniment,  the  actual  local 
coj)rostasis  being  masked  by  this  fact.  As  the  lumen  of  the  bowel  becomes  occhuled  and 
fecal  matter  fails  to  pass,  the  evaeuaiions  heccyme  more  bloody  and  contain  little  but  mucus. 
Finally,  almost  pure  blood  may  be  passed.     In  no  other  form  of  obstruction  is  the  passage 


832  SPECIAL  OR  REGIOXAL  SURGERY 

(>l  hlood  ,su  (li.'ifiiirfivr  as  In  lliis.  Urine  elimination  is  hnl  slijflitly  influenced,  and  stnin- 
•jurv  is  an  exceedingly  rare  feature.  INleteorisni  is  also. less  jjronouneed.  The  discovery 
oi  a  tumor  formed  by  the  invagination  will  lend  further  aid  in  diagnosis.  It  may  be  felt 
either  through  the  abdominal  wall  or  by  the  rectum,  and  may  be  noted  in  about  half 
of  the  cases.  It  is  most  frequently  found  in  the  ileocecal  and  colic  varieties,  and  felt 
in  the  rectum  with  the  lower  colic  forms.  In  children  it  is  more  distinct  than  in  adults. 
The  tumor  may  even  take  the  outline  of  the  involved  l)owel,  is  usually  movable,  but 
may  be  fixed.  When  such  a  tumor  is  felt  within  the  rectum  it  may  have  to  be  distin- 
o-uished  from  some  intrinsic  neoplasm  of  the  lower  bowel ;  but  the  history  of  the  case  should 
])rove  satisfving  if  the  j)hysical  examination  leaves  one  in  doubt. 

Treatment. — Spontaneous  cure  of  an  intussusception  by  a  sloughing  process  has  been 
mentioned  above.  Cure  may  also  occur  by  s}X)ntaneous  reduction.  It  would  seem 
possible  also  only  in  recent  cases  and  in  the  enteric  forms.  Cure  may  also  occur  by 
formation  of  a  fecal  fistula,  although  this  is  most  rare. 

3.  Volvulus. — The  term  "volvulus"  implies  some  form  of  twisting  or  of  revolution 
of  a  part  of  the  bowel  upon  itself  or  its  mesenteric  axis,  the  result  Ix-ing  knotting  or  inter- 
twining of  intestinal  coils  to  an  extent  causing  their  ])artial  and  finally  complete  obstruc- 
tion. A  common  site  for  volvulus  is  the  sigmoid  flexure.  Still  no  part  of  the  intestine 
which  hangs  loosely  is  exempt. 

The  most  common  causes  of  volvulvus  are  chronic  constipation  and  fecal  impaction, 
with  distention  and  ptosis.  Intestine  thus  displaced  and  overloaded  becomes  more  or 
less  paralyzed,  its  circulation  more  or  less  impeded,  and  any  twist  which  has  once  occurred 
is  not  likelv  to  right  itself.  The  twisted  loop  having  been  engorged  becomes  distended 
Avith  gases,  and  thus  tends  to  increase  the  difficulty.  In  these  cases  the  bowel  loop  is 
closed  at  both  ends.  Unless  relief  be  afforded  by  o])eration  it  is  a  question  merely  of  how 
soon  the  loop  will  become  gangrenous  from  aggravation  of  every  one  of  the  features 
above  recounted.  Bowel  thus  involved  permits  easy  passage  of  bacteria,  aiifl  thus  to 
the  other  features  are  rapidly  added  a  septic  peritonitis.  The  resulting  abdominal 
distention  niav  appear  early  and  will  become  more  prominent. 

4.  HeUS  from  Fecal  Impaction. — A  condition  of  extreme  coprostasis,  or  fecal 
impaction,  to  a  degree  producing  actual  obstruction,  may  occur  without  necessary 
volvulus  or  twisting  of  any  portion  of  the  bowel.  As  fecal  impaction  increases  the  over- 
loaded bowel  becomes  more  and  more  paralyzed  until  there  may  occur  final  and  complete 
arrest  t)f  ])eristalsis,  with  gradual  development  of  symptoms  of  obstruction.  The  longer 
the  condition  persists  the  less  the  ])rospect  of  restoration  of  peristaltic  movement.  INIore- 
over  the  condition  may  be  complicated  by  the  development  of  ulc-ers  above  the  obstructed 
segment,  known  as  stercoral  ulcers,  due  jiartly  to  gangrene  from  pressure  and  partly  to 
the  chemical  effects  of  long-retained  decomposing  material.  They  may  appear  as 
sloughs  of  the  mucovis  membrane  and  finally  lead  to  perforation. 

This  form  of  ileus  is  more  common  in  the  large  than  in  the  small  intestine,  and 
especially  so  in  the  cecum.  Here  there  is  little  chance  of  retrograde  movement,  Avhile 
fecal  matter  coming  down  from  above  will  continue  to  pack  the  colon,  and  thus  the  cecum 
may  have  to  bear  the  brunt  of  great  ])ressure.  The  amount  of  fecal  matter  which  may 
be  thus  collected  is  sometimes  astonishing,  for  the  bowel  may  dilate  to  the  diameter  of 
six  or  even  ten  inches,  and  contain  many  pounds  of  impacted  feces.  Such  masses  of 
collected  feces  can  usually  be  j^alpated  through  the  abdominal  wall,  and  will  at  least 
indicate  the  location  of  the  jn-incipal  disturbance,  if  not  its  actual  character. 

5.  Strictures. — The  most  common  causes  of  cicatricial  stenosis  in  large  or  small 
intestine  are  the  results  of  cicatricial  contraction  following  recovery  from  local  ulceration 
or  repair  of  injury,  as,  for  instance,  after  reduction  of  a  strangulateil  hernia.  The  exact 
character  of  the  iilcer  does  not  matter.  Any  lesion  which  may  granulate  and  heal  will 
also  contract,  and  the  extent  of  the  stricture  will  be  proportionate  to  the  area  first  involved. 
Should  this  extend  well  around  the  nuicous  membrane  there  may  be  a  distinct  annular 
stric-ture.  Stricture  may  also  result  from  infiltration  and  thickening  in  connection  Avith 
a  more  active  diseased  process,  and  such  a  condition  may  be  multiple.  This  is  particu- 
larly true  in  cancerous  involvement  of  the  l)owel. 

Previous  history  of  the  case  will  shed  nnich  light  on  the  probable  existence  of  intestinal 
stricture.  Thus  a  history  of  tyj)hoid,  of  dysentery,  of  tuberculosis,  or  of  syphilis  will 
be  most  suggestive,  for  in  any  of  these  diseases  there  may  be  luimerous  intestinal 
ulcers.     A  history  of  hernia,  reduced  or  operated,  or  of  injury,  is  also  of  importance, 


PLATE  L 


Enterolith  with  Gallstone  for  a  Nucleus  ;   Removed  by  Enterotomy.      (Richardson.) 

Tliis  i)atient  was  a  man  of  sixty-nine,  witli  symptoms  of  oomplete  intestinal  obstnicfif)n.  There  was  no 
previous  liistory  wliatever  of  gallstone.  The  impaftion  was  liigh  up  in  the  small  intestine.  The  gallstone  was 
removed  by  a  small  linear  cut  which  was  satisfactorily  sutuiefl.  The  patient  died  in  the  course  of  twenty-four 
hours. 


MHTF.    IXThsriXAL  OHSTRUCTIOX ;  ILFAJS  S.'W 

as  also  is  one  ot"  ()|)('ratioii  ii|)(tn  other  viscera,  especiallv  williin  the  pelvis,  the  lower 
howel  heiiiif  often  iiivolveij  in  a  disease  process  within  this  cavity  which  iiiav  have 
left  its  marks. 

Stricture  may  he  recofjjiiized  hy  the  <jfra(lual  course  ol'  the  case  and  by  a  hist(jry  of 
increasing  difficulty  or  of  increasing  c()nsti|)ation.  A  stricture  as  such  is  not  formed 
within  un  hour,  and  in  this  sense  is  the  result  of  a  previous  more  or  less  active  disease. 
This  is  true,  also,  of  cancerous  stricture. 

().  Intrinsic  Neoplasms. — The  jjossihility  of  hoth  innocent  and  nialignaiit  tumors 
occurring  within  the  intestinal  structures  has  already  been  considered.  It  is  obvious 
that  any  such  growth  will  cause  gradiud  ol)struction  by  the  usual  process,  or  mav 
precipitate  by  its  presence  the  occurrence  of  intussuscc|)tion,  of  volvulus,  or  of  some 
kiids^ing  by  which  obstruction  is  suddenly  jmxhiced. 

7.  Extrinsic  Neoplasms,  What  has  been  said  above  aj)|)lies  eciually  well  to  growths 
not  primarily  involving  tlu>  intestine,  but  encroaching  uj)()n  it.  Thus  obstruction  may 
gradually  result  from  retroperitoneal  growths,  or  from  the  impaction  of  a  growing  uterine 
myoma  pressing  uj)on  the  rectum  and  finally  occluding  it.  Also  cancers  growing  in 
various  locations  encroach  upon  and  finally  involve  the  bowel  in  conditions  which  never- 
theless were  originally  quite  extertud  to  it. 

8.  Gallstones. — In  the  section  devoted  to  the  biliary  ])a.ssages  the  accidents  which 
may  occur  during  gallstone  disease  have  been  summarized,  and  it  has  there  been  related 
how  large  ones  may  ulcerate  through  and  dro])  into  the  small  or  even  into  the  large 
intestine.  Enteroliths  may  be  thus  ])r()duced,  which  were  originally  small  gallstones 
that  have  lodged  and  grown  by  accretion  until  they  have  reached  considerable  size,  or 
by  gallstones  which  have  suddenly  entered  the  intestine  by  ulceration  above,  or  by  other 
material  which  may  have  collected  in  some  sacculation  or  diverticulum,  where  it  has 
received  more  or  less  calcareous  deposit  and  has  grown  by  accretion  until  it  produces 
obstruction,  either  by  occlusion  or  by  causing  the  intestine  to  kink.  Other  foreign  bodies 
may  also  produce  obstruction.  Although  it  has  been  generally  held  that  whatever  may 
escaj)e  through  the  pylorus  may  be  evacuated  from  the  rectum,  nevertheless  peculiarly 
shaped  objects  become  entangled  in  such  a  way  as  to  be  checked  in  progress  and 
serve  as  impacted  bodies  upon  which  an  accumulation  may  take  place.     (See  Plate  L.) 

9.  Peritonitis. — While  coprostasis  is  a  feature  of  almost  every  case  of  acute  peri- 
tonitis the  obstruction  referred  to  in  this  paragraph  comes  rather  from  the  adhesion  and 
fixation  of  bowel  from  outpour  of  lymph  than  from  paralysis  and  ileus  in  consequence. 
It  may  be  doubted  whether  acute  peritonitis  is  ever  idiopathic.  As  seen  by  the  surgeon, 
at  least,  it  has  some  point  of  origin  which  furnishes  ample  excuse  for  its  existence.  The 
most  common  cause  in  the  male  is  the  appendix,  and  in  the  female  the  appendix  or  the 
tube.  At  least  one-half  of  the  cases  occurring  in  general  practice  originate  in  one  or 
the  other  of  these  w'ays.  Infection  may  also  easily  spread  from  the  mesenteric  nodes, 
beginning  locally  and  resulting  in  adhesions,  the  disease  spreading  by  a  natural  })r()cess 
until  perhaps  the  w^iole  abdomen  is  finally  involved.  While  healthy  bowel  is  ordinarily 
impervious  to  germs,  when  it  becomes  diseased  germs  may  easily  travel  from  its  interior 
to  its  exterior  and  thus  set  up  peritonitis.  In  this  way  a  purely  mechanical  original 
condition  may  bring  about  a  fatal  septic  peritonitis.  It  is  known  also  that  intestinal 
diverticida  are  subject  to  exactly  the  same  lesions  as  is  that  one  in  })articidar  which  is 
called  the  appendix,  and  the  sym])toms  and  se(|uences  of  the  diverticulitis  may  simulate 
those  of  an  acute  appendicitis.  In  acute  a])])en(licitis  co])rostasis  and  even  aj)j)arently 
fatal  obstruction  are  frequently  met  with.  Their  occurrence  is  to  be  explained  not  alone 
by  toxemic  paralysis  (/.  e.,  toxemic  ileus),  but  by  the  actual  mechanical  impediments 
offered  by  loops  of  bowel  strongly  bound  together  around  the  appendix  in  the  actual 
protective  effort. 

10.  Bands. — Bands  of  tissue  which  may  cause  obstruction  of  the  bowel  are  neither 
necessarily  long  nor  large,  and  one  will  frequently  be  astonished  to  see  how  trifling  a 
tissue  cord  may  produce  intense  disturbance.  The  bands  which  may  be  found  within 
the  abdominal  cavity  under  these  circumstances  include  those  {)roduced  by  jjeritoneal 
adhesions,  where  the  cohering  lymph  has  organized  and  at  the  same  time  stretched, 
such  bands  being  found  to  arise  from  and  connect  with  the  bowels  alone,  to  arise  from 
the  omentum  from  any  other  causes,  particularly  traumatic,  or  to  occur  at  any  ])oint 
within  the  peritoneal  cavity.  They  may  be  single  or  multiple.  When  speaking  of 
Meckel's  diverticulum  it  was  stated  how  it  might  be  mistaken  for  a  band  extending  to 


834 


SPECIAL  OR  REGIOSAL   SURGERY 


Fig.  562 


the  region  of  the  umbilicus,  and  acting  as  one  cause  of  obstruction.  (See  Fig.  559.)  An 
adherent  ajj|>endix  or  tube  tightly  attached  at  its  free  extremity  may  also  act  a,s  a  band, 
and  the  former  is  known  xo  very  frequently  produce  at  least  a  mild  form  of  intestinal 
obstruction,  which  may  at  any  time  assume  acute  pro]M)rtir)ns.  The  pedicle  of  an 
ovarian  or  other  tumor  may  alsf),  if  long,  by  becoming  twisted,  mclude  an  intestinal 
loop  and  thus  ])n)du(i-  otistniction. 

11.  Slits  and  Apertures. — The  mesentery  Ls  the  occasional  site  of  fenestra  which 
apparently  are  of  congenital  origin.  Through  such  o])enings  or  slits  a  loop  of  bowel 
may  easily  ptiss  and  become  strangulated.  The  same  is  true  of  the  omentum.  Ojx'n- 
ings  in  either  of  these  structures  are  perhaps  more  frequently  the  result  i»f  traumatisms. 
Similar  conditions  result  where  omental  or  mesenteric  surfaces  have  united  over  small 
areas,  leaving  jxickets  or  openings  in  \\hich  bowel  might  be  caught.  Quite  a  similar 
condition  results  in  so-called  hernia  of  bowel  into  and  through  the  foramen  of 
Winslow. 

12.  Intestinal   Loops   and   their   Traction    Effects.— These   causes   are    not 

perhaps  independent  of  .^omc  of  th(j.->e  aljovc  mcniiuiicd,  yet  presup|X)se  a  certain  looping 
or  al>normal  festooning  of  intestine,  with  the  further  stretching  tliat  occurs  as  the  result 
of  greater  loading  and  the  final  entanglement  of  such  loops,  or  their  adhesion,  in  such 
a  wav  as  to  become  completely  occluded.  To  this  result  some  local  inflammatory 
process  may  contribute.  The  condition  is  often  met  in  connection  with  pelvic  disease 
of  females.  ^luch  that  may  happen  to  a  loop  of  bowel  which  has  become  attached  to  a 
growing  tumor  during  its  migration,  as  it  gradually  changes  its  shape  and  position, 
may  Ije  imagined. 

13.  Congenital  Defects. — Certain  congenital  defects  predispose  to  acute  obstruction. 
Among  thcaf  are  Ji\crucula,  as  already  mentioned,  which  may  produce  trouble,  either 

by  incomplete  obliteration  and  separation  from  the 
umbilicus,  in  which  event  they  act  as  bands  or  cords, 
or  by  becoming  acutely  inflamed,  then  attaching  them- 
selves and  indirectly  producing  the  same  effects 
(Figs.  ooO  and  5(32).  Even  the  smaller  diverticula 
or  sacculations  which  extend  between  the  folds  of 
the  mesenterv'  may,  when  infected  and  inflamed, 
tliicken  and  cause  angular  bending  of  the  intestine, 
with  consequent  partial  obstruction,  which  later  is 
made  complete  by  the  consequences  of  local  peri- 
tonitis, with  its  dense  incAntable  adhesions.  Statistics 
show  that  acquired  diverticula  occur  twice  as  often  as 
Meckel's,  and  nearly  as  frequently  in  the  small  as  in 
the  large  intestine.  They  are  mostly  of  the  traction 
variety  and  occur  at  the  mesenteric  border,  where 
they  have  close  relation  to  the  bloodvessels,  tlius 
increasing  the  dangers  of  operative  measures  because 
of  possible  gangrene  from  shutting  off  circulation. 
Porter  has  recently  collected  188  cases  of  violent  and 
even  fatal  trouble  thus  produced  within  the  abdom- 
inal ca\-ity,  returning  an  exceedingly  high  death-rate 
after  o|)eration,  which  unfortunately  was  almost  always  done  late.  In  nearly  all  of  these 
cases  the  diverticula  were  found  -«-ithin  the  lower  four  feet  of  the  ileum.  In  one  case 
of  mv  own  an  nnol)liTeratfil  liy]K)gastric  artery  caused  acute  obstruction. 

14.  Postoperative  Obstruction. — Finally  cases  of  postoperative  obstruction  are 
met  with  in  a  way  to  bring  disappointment  and  disaster  when  everything  else  has  seemed 
favorable,  and  constitute  a  clinical  t}-pe  without  any  distinct  padiological  foimdation. 
Most  of  them  are  due  either  to  some"  form  of  paralnic  ileus,  or  else  to  local  or  general 
peritonitis  with  its  c-ombined  sequels  of  paralysis  and  adhesion  by  the  gluing  of  portions 
covered  wnth  exudate.  Some  of  these  cases  vriW  justify  reopening  the  abdomen,  while 
in  other-  tlif  condition  is  absolutely  helple-;-^  bcfaii^f  of  the  septic  element  present. 

General  Symptoms  of  Acute  Intestinal  Obstruction.— Certain  symptoms  and 
signs  characterize  all  cases  of  acute  intestinal  obstruction  and  may  be,  therefore,  included 
as  common  to  each ;  consequently  they  may  be  considered  collectively.     The  cardinal 
indications  are  pain,  voinitinfj,  constipation,  distention,  and  collapse. 
53 


Strangulation  of  bowel  by  a  long  diver- 
ticulum,    (Lejars.) 


.\CITE  ISTKSTISAL  nliSTUrCTIOS ;  ILKUS  835 

I'ltin  iii;iy  lie  tlic  lir.st  iiidicatiun,  and  usually  is  so  in  in\a<^inatit)n,  volvnins,  and 
rni-tlianical  (thstrnctictiis  j^cncrallx .  It  is  usually  of  violent  |)aro.\ysnial  cliaractcr,  con- 
tinuing; at  least  during;  the  earlier  staj,M's,  ra|)i(lly  wearinj;  away  tiie  patient's  stren<;tii, 
diininisliint;  as  distention  increases  and  nerve  endin<;s  heconie  paralyzed. 

roniiliiKj  is  an  early  or  late  tcalure,  aciordinj;  to  tlie  portion  of  the  alimentary  canal 
ohstructed.  The  more  prompt  its  occurrence  |)resuinal)Iy  the  hif^her  in  the  srnall 
l)o\vel  the  det"e(  t.  In  conse(|uence  of  the  remedies  usually  udministered  it  will  he  found 
that  when  nothinij  hut  stomach  contents  are  ejected  it  is  easier  to  produce  fecal  evacua- 
tion from  l)elow,  while  the  <jreater  the  difliculty  in  securing;  a  return  from  the  lower  bowel 
the  lower  the  ohstruction  and  the  more  likely  the  vomited  material  to  become  fecal 
in  character.  X'omitintj;  once  begun  is  usually  continuous  until  relief  is  afforded  or  the 
j)atient    utti-rly  exhausted. 

('i)ustipatiim  or  obstipation  sooner  or  later  characterize  these  cases.  The  tenesmus 
of  intussuscei)ti()n,  with  the  jjassage  of  bloody  mucus,  which  may  occur  in  this  form, 
or  in  volvulus,  for  instance,  does  not  imjjly  that  the  bowel  itself  is  not  obstructed,  nor 
does  the  emj)tying  of  the  larger  bowel  of  an  accumulated  l(jad  necessarily  imj)ly  that 
the  fecal  stream  is  in  motion.  Even  the  passage  of  flatus  usually  is  promptly  shut  off, 
and  it  is  the  gas  which  forms  and  cannot  escape  that  j)roduces  the  distention. 

Distention  gradually  becomes  excessive,  the  abdomen  becoming  ball(M)ned  and  e.\- 
tremelv  tvm|)anitic  on  ))crcussion,  while  its  surface  becomes  shiny  because  so  stretched. 
This  uictcori.siii  is  in  large  degree  due  to  the  formation  of  gas  within  the  bowel  jjroper, 
Init  is  permitted  by  the  additional  features  of  paralysis  of  intestinal  muscle  and  weaken- 
ing of  that  of  the  abdominal  wall.  As  it  increases  the  diaj^liragm  is  pressed  upward 
and  respiration  is  much  imj)eded,  while  even  the  bladder  may  be  compressed  below. 
It  aftV)rds  another  reason  why  fluid  which  is  taken  into  the  stomach  is  quickly  ejected. 

Characteristic  collap.se  comes  on  more  or  less  promptly,  according  to  the  nature  of  the 
exciting  cause,  and  the  date  of  its  occurrence  is  in  some  degree  an  index  of  its  violence. 

In  dealing  with  obstructive  cases  any  history  that  may  bear  upon  the  conditions,  as  of 
j)revious  j)eritonitis,  ap])en(licitis,  of  so-called  dy.spej)sia  which  might  indicate  gallstone 
disease  or  gastric  ulcer,  or  of  pelvic  conditions  which  might  iiulicate  pyosalpinx  or  the 
like,  should  be  obtained.  The  manner  of  onset  should  be  learned,  whether  acute  or 
gradual,  with  the  relative  date  of  the  occurrence  of  pain,  vomiting,  and  stools,  along 
with  their  character,  if  there  be  anything  distinctive  therein.  Past  and  present  history 
being  secured,  the  most  methodical  examination  of  the  body  should  be  made,  including 
the  physiognomy  and  general  conditions,  the  attitude  {e.  g.,  whether  the  knees  are  drawn 
up,  whether  the  patient  is  able  easily  to  turn),  the  type  of  respiration,  and  the  amount 
of  restlessness.  The  character  of  the  abdominal  movements  during  respiration  should 
also  be  noted,  as  well  as  the  presence  of  any  prominence  or  the  indications  of  violent 
peristalsis.  By  palpation  the  degree  and  location  of  greatest  tenderness,  the  presence 
of  nuiscle  spasm  or  of  tumcjr  may  be  learned.  Careful  examination  of  all  the  ordinary 
hernial  outlets  should  be  made  and  the  rectum  and  vagina  explored.  Revelations  thus 
obtained  may  also  prom{)t  a  careful  physical  examination  of  the  chest.  Percussion 
will  show  the  presence  of  free  or  localized  fluid  or  gas,  while  localized  dulness  may 
denote  a  loop  of  intestine  distended  with  fluid  or  impacted  feces.  Auscultation  will 
enable  the  surgeim  to  hear  the  sounds  produced  by  violent  jieristalsis  or  to  note  the 
absence  of  movement  within  the  l)owel.  A  study  of  the  temjjerature  and  the  pulse 
may  reveal  much  in  certain  cases,  especially  the  inflammatory,  and  particularly  in 
appendicitis,  while  the  urine  may  be  examined  for  indican,  and  a  differential  blood 
count  made. 

Meteorism,  constipation,  and  fecal  vomiting  of  themselves  indicate  acute  obstruction, 
but  furnish  no  aid  as  to  the  nature  of  the  exciting  cause.  They  are,  however,  sufficient 
to  indicate  the  wisdom  of  immediate  intervention. 

Pathologically  every  case  of  intestinal  obstruction  has  an  interest  of  its  own.  iS'wr- 
gicalhj,  however,  they  are  readily  grouped  as  a  class  of  cases  in  lohich  operation  should 
always  he  performed  early,  inasnuich  as  it  offers  the  better  prospect  of  relief  and  in 
which  death  is  the  inevitable  spontaneous  termination.  It  can  scarcely  be  imagined 
how  a  more  distressing  case  than  an  acute  strangulation  can  be  allowed  to  go  to  its 
fatal  termination  withcnit  being  offered  the  prospect  of  a  judicious  operation,  if  only 
performed  early.  The  disfavor  with  which  operation  is  received  by  the  general  physi- 
cian, as  well  as  by  laymen,  is  due  to  the  fact  that  too  much  time  is  wasted  with  futile 


336  SPECIAL  OR  REGIOXAL  SURGERY 

drug  tiTHtnieiit,  and  that  the  gohlen  liuurs  when  surgifal  intervention  niiglit  save  are 
allowed  to  })ass  unutilized.  Of  most  of  these  cases  it  may  be  said  that  dying  after  opera- 
tion they  have  died  in  .spite  of  it  ratlier  than  in  conscqwnce  of  it. 

This  is  })articularly  true  with  intussusception  and  volvulus  in  young  children  or 
infants.  Within  six  hours,  in  such  cases,  the  harm  whicii  may  be  done  is  necessarily 
fatal,  and  to  keep  them  for  a  day  or  more,  dosing  them  with  cathartics  or  making 
strenuous  efforts  to  relax  invagination,  is  to  deprive  thcun  of  the  only  measure  which  offers 
them  any  cliunce.  The  disrepute  into  which  operative  treatment  of  these  cases  has  fallen 
in  certain  (quarters  is  due,  then,  solely  to  the  fact  tliat  the  [)hysician  does  not  call  the 
surgeon  early,  because  there  is  a  time  in  the  history  of  nearly  every  one  of  them  when  it 
could  be  saved  were  mechanical  relief  afforded. 

Treatment. — There  are  certain  cases  of  obstruction  by  fecal  impaction  or  lodgement 
of  enteroHths  which  may  be  successfully  treated  by  internal  or  non-operative  means. 
Coidd  these  always  be  diagnosticated  it  would  be  known  when  not  to  operate.  But 
to  wait  until  paralysis  of  the  bowel  has  occurred,  or  gangrene  due  to  stasis,  or  perforation 
have  taken  place,  or  septic  peritonitis  has  set  in,  is  to  wait  far  longer  than  circumstances 
justify  and  reflects  on  those  responsible  for  the  delay  rather  than  on  the  operator  or 
the  operation.     In  general  terms,  acute  intestinal  obstruction  is  always  a  surgical  disease. 

It  is  not  necessary  to  wait  for  accurate  diagnosis — recognition  of  the  exiMence  of  ob- 
struction alone  is  all  that  is  required.  Conditions  rapidly  aggravate  themselves,  and 
strength  is  rapidly  lost,  if  we  wait  for  more  than  distinctive  symptoms.  There  is  no 
'palliative  treatment  save  operation,  and  the  drugs  and  other  harsh  measures  which  are 
often  prescribed  serve  to  intensifij  and  aggravate  rather  than  to  relieve.  Anodynes  given, 
though  administered  with  the  most  humane  intent,  serve  only  to  mask  conditions  and 
lead  to  delay. 

Exploration  once  resolved  upon,  careful  judgment  must  decide  as  to  where  to  place 
the  incision.  If  local  indications  be  present  they  may  be  folloAved.  If  there  be  good 
reason  to  believe  that  the  original  cause  Avas  an  acute  ajipendicitis,  then  the  incision  may 
be  placed  upon  the  right  side.  In  the  absence  of  all  indications  the  surgeon  operates 
most  safely  in  the  middle  line  by  an  incision  below,  above,  or  around  the  umbilicus,  as 
circumstances  may  indicate.  Edema  of  the  subserous  tissue  or  of  the  abdominal  muscles 
indicates  the  presence  of  pus  beneath.  Peritoneum  should  be  sought  and  opened  with 
care,  as  in  the  presence  of  much  distended  bowel  injury  to  the  same  may  easily  occur. 
The  opening  once  made  the  operator  will  be  embarrassed  from  that  time  until  the 
conclusion  of  the  operation  by  the  distention  of  the  bowels — at  least  those  above  the 
obstruction,  and  by  their  being  constantly  in  the  way.  If  a  mechanical  cause  for  obstruc- 
tion l)e  found  it  will  be  noted  that  the  intestine  above  is  more  distended  than  that  below, 
which  latter  may  be  collapsed  and  a])])arently  smaller  than  natural.  Thus  if  a  con- 
stricting band  be  found,  or  an  internal  hernia,  the  removal  of  the  obstructing  cause  will 
permit  of  prompt  restoration  of  equal  gaseous  pressure  between  the  parts  above  and 
below. 

Scarcely  any  surgical  emergency  requires  wiser  discretion  than  do  cases  of  this  kind. 
Bands  may  be  double  ligated  and  divided,  kinks  straightened  out,  twists  untwisted, 
invaginations  withdrawn,  if  this  be  possible  by  reastmable  effort.  On  the  other  hand 
the  surgeon  should  be  ])re])ared  to  find  bowel  which  has  a])parently  lost  its  vitality  or  is 
actually  necrotic,  either  for  a  few  inches  or  for  several  feet,  and  he  will  soon  realize  that 
to  leave  such  gangrenous  masses  within  the  abdomen  is  to  accomplish  naught,  while 
to  remove  them  is  to  subject  the  ])atient  to  a  procedure  longer  and  more  severe  than  he 
can  bear.  He  must,  then,  decide  whether  to  close  the  abdomen  for  form's  sake  and  let 
the  patient  die  a  natural  death,  or  whether  to  undertake  the  risk  of  resection,  or  perhaps 
to  leave  a  considerable  portion  of  the  intestinal  canal  upon  the  outside  of  the  body, 
opening  it  and  establishing  an  artificial  anus  in  the  hope  that  the  sloughing  portion  may 
be  cast  oft",  and  that  the  artificial  anus,  having  served  its  purpose,  may  be  subsequently 
closed  by  another  operation.  Such  cases  live,  though  not  very  often.  Here,  j^erhaps 
as  often  as  anywhere,  can  be  seen  the  most  desperate  expedient  succeed  and  the  most 
trifling  measure  fail. 

Another  question  is  what  to  do  with  distended  and  paralyzed  intestine,  especially  when 
it  appears  impossible  to  restore  it  to  the  abdominal  cavity.  Paralyzed  as  it  is,  it  is 
almost  too  much  to  hope  that  it  may  recover  its  tone,  and  distended  as  it  is,  it  is  practically 
unmanageable.     To  open  it  at  one  point  would  be  to  empty  several  loops,  at  least  of 


AclTl:'  /\'77;.S'77.V,1/.  OliSriU'CTIOX:  llJ:i'X 


837 


<ifiiS  iiiul  prohaltly  of  lliiid  I'l'cal  matter,  all  of  w  liicli  will  liclp.  (  )ii('  caiiiiot  l)Ut  reflect  on 
the  toxic  nature  of  all  fecal  matter  so  retained  and  feel  that  could  it  all  he  evacuated  the 
patient  would,  other  thinj^s  heinif  e(|ual,  i)e  in  vastly  hetter  condition.  And  so  operators 
have  often  made  openinjfs,  takintf  all  possihle  j)recautions  to  prevent  contamination, 
and  have  not  only  evai-utited  a  eonsiderahle  length  of  the  intestinal  canal,  hut,  jus  suggested 
by  Mixter  and  others,  have  washed  it  out. 

A  more  perfect  method,  however,  of  aeeomjjlishing  this  ])urpose  has  been  suggested 
by  Monks,  <)f  Boston,  in  the  use  of  a  large  glass  tube,  from  twenty  to  twenty-foiir  inches 
in  length,  strong  and  with  smooth  ends.  He  has  shown  how,  an  opening  having  been 
made,  say  just  above  the  obstruction,  it  is  possible  by  mHnij)nlating  the  bowel  with  gauze 
patLs  to  draw  it  over  the  tube  (as  shown  in  Fig.  503),  to  an  extent  of  several  feet,  and 

Fi(i.  563 


Method  of  inserting  a  tube  (through  an  enterostomy  opening)  a  considerable  distance  into  the  intestine 
by  drawing  the  intestine  around  it  with  the  help  of  a  piece  of  dry  gauze.  The  tube  used  in  this  case  has 
a  cur\ed  extremity,  the  opening  being  on  the  concavity  of  the  curve.  It  is  shown  entire  at  the  lower  left 
corner  of  the  illustration.  The  longer  the  abdominal  incision  and  the  longer  the  tube  the  greater  the  length  of 
intestine  which  may  be  drawn  upon  it  and  emptied  of  its  contents.      (Monks.) 


to  thus  more  completely  evacuate  it  than  could  be  accomplished  in  any  other  way. 
Monks  is  undoubtedly  entitled  to  priority  for  this  suggestion  over  ]\Ioynihan,  who  has 
elaborately  figured  and  described  it.  All  in  all  this  permits  better  management  and 
more  complete  effect  than  any  other  method.  The  bowel  having  been  emptied,  the 
opening  is  closed  by  the  usual  double  row  of  sutures  and  is  then  easily  dropped  back 
into  the  abdominal  cavity.  Cases  occur  where  this  procedure  might  be  carried  out  at 
two  different  points,  say  above  and  below  the  obstruction. 

What  may  be  done  with  the  obstruction  produced  by  local  and  septic  peritonitis, 
such  as  is  especially  seen  in  acute  cases  of  cholecystitis,  appendicitis,  and  pyosalpinxV 


838  SPECIAL  OR  REGIONAL  SURGERY 

Here  the  surgeon  deals  not  only  with  twisted,  kinked,  and  obstructed  bowel,  tensely 
distended,  but  with  much  infected  lymph  and  per]ia|)s  a  collection  of  pus  and  a  gan- 
grenous aj)pendix.  Such  a  condition  becomes  ai)])alling  and  every  such  case  should 
be  dealt  with  upon  its  merits.  Any  collection  of  pus  should  be  evacuated  and  drained, 
and  it  must  tiien  be  decided  whether  to  endeavor  to  withdraw  cntanglc<l  loops,  disengage 
and  straighten  them  out,  or  to  be  content  with  an  artificial  anus  for  tcni])orary  purposes, 
the  latter  often  being  the  safer  course,  even  though  it  may  lead  to  a  tedious  convalescence 
and  the  necessity  for  subsecjuent  ojjeration.  It  might  even  be  advisable  to  evacuate  pus 
and  remove  a  sloughing  appendix,  if  it  were  easily  found,  and  then  make  an  enterostomy, 
opening  at  some  other  point,  in  order  to  keep  the  two  procedures  and  fields  of  activity 
quite  distinct. 

A  case  may  occasionally  be  seen  where  the  cjuestion  of  affording  some  relief  is  para- 
mount to  every  other  consideration,  and  where,  at  the  same  time,  the  patient's  condition 
is  such  as  to  make  anything  extra-hazardous.  I  have  saved  life  under  conditions  of  this 
kind  by  making  a  simj)le  enterostomy  under  cocaine,  the  intent  being  only  to  attach  a 
loop  of  distended  bowel  to  the  parietal  peritoneum  and  to  o])en  it  then  or  a  little  later, 
thus  establishing  an  artificial  anus.  This  may  be  done  with  local  cocaine  anesthesia. 
I  have  even  seen  the  fecal  fistula  thus  produced  close  spontaneously  in  the  course  of 
time,  and,  while  the  exact  character  of  the  lesion  was  never  known,  have  had  the  satis- 
faction of  thus  saving  a  life  which  I  believe  would  otherwise  have  been  lost. 

One  of  the  most  unfortunate  accidents  that  can  occvir  during  operation  for  acute 
obstruction  is  to  have  the  patient  practically  drown  in  his  own  fecal  vomit.  This  may 
occur  either  on  the  operating  table  or  soon  after  leaving  it.  The  term  implies  simply 
this — that  there  is  regurgitation  of  fecal  matter  into  the  stomach,  and  that  as  this  is 
ejected  by  a  patient  in  his  unconscious  condition  he  is  not  able  to  prevent  its  aspiration 
into  the  trachea,  with  the  occurrence  of  all  that  essentially  constitutes  drowning.  Even 
a  few  ounces  of  fluid  material  drawn  into  the  lungs,  under  these  circumstances,  would  be 
sufficient  to  cause  asphyxia  and  death. 

The  accident  is  to  be  prevented  not  alone  by  Iava</c,  both  before  and  at  the  conclusion 
of  the  operation,  l)ut  by  jilacing  the  patient  upon  his  side  in  such  a  way  that  any  gush  of 
fluid  into  the  mouth  may  escape  from  it  and  not  be  sucked  into  the  lung.  The  amount 
of  fluid  that  may  arise  is  sometimes  astonishing.  The  introduction  of  harmless  fluid, 
under  these  circumstances,  would  be  sufhcient,  but  the  entrance  into  the  lungs  of  a  viscid, 
oft'ensive,  and  septic  fluid,  even  in  small  quantity,  would  quickly  serve  to  induce  a  septic 
pneumonia  if  nothing  else.  The  accident  once  having  occurred,  resuscitation  is  almost 
impossible.  Under  the  relaxation  of  anesthesia  it  may  occur  without  outcry  and  almost 
unsuspected,  and  with  the  patient  on  his  back,  death  may  be  determined  even  Ijefore 
the  attendant  has  noticed  anything  particularly  wrong.  To  prevent  this  accident  tubes 
have  been  devised  having  balloons  around  them  which  can  be  inflated  with  air,  to  the 
desired  degree,  and  the  eso])hagus  thus  be  plugged. 

Hence  it  will  be  seen  that  the  surgeon  should  temper  his  measures  to  the  condition 
of  the  case,  its  exigencies  and  its  surroundings.  Operation,  therefore,  may  be  exceed- 
ingly mild  or  exceedingly  severe,  taxing  the  resources  of  the  best-equi])ped  clinic. 

Strangulations  recognized  from  surface  indications  are  usually  dealt  M'ith  according 
to  standard  indications.  Those  discovered  only  after  abdominal  section  are  to  be  (Jealt 
with  each  on  its  merits. 

CHRONIC  OBSTRUCTION  OF  THE  BOWEL. 

The  expressions  of  chronic  obstruction  are  essentially  those  of  acute,  in  which  they 
usually  terminate,  occurring  meantime  in  milder  degree.  Their  causes  are  nowise 
dift'erent  from  those  tabulated  al)ove. 

Symptoms. — The  symptoms  of  chronic  obstruction  are  those  of  intermittent  colic, 
consti{)ation,  perhaps  with  local  tenderness,  with  change  in  shape  of  the  al)domen  due 
to  the  primary  cause  or  to  intestinal  distention,  and  in  many  instances  with  some  charac- 
teristic appearance  or  shape  of  the  feces.  Thus  the  stools  are  often  loose,  or  scybalous 
masses  when  removed  by  cathartics,  and  these  are  followed  l)y  diarrheal  stools  containing 
many  gaseous  bul)bles.  01)struction  of  the  lower  bowel  will  frequently  cause  the  hard- 
ened fecal  masses  to  assume  a  tape-like  shape.  With  increasing  obstruction  there  is 
increasing  severity  of  symptoms,  until  finally  they  become  acute. 


FIU'AL   F/STl'LA:  AirriFlciAL   ASIS.  ,S30 

Treatment.  Til (•  IrcMtnicnl  ol"  clinmic  obsdMution  is  also  operative,  cillicr  radical 
or  |)ailiali\c.  W'licii  llic  cxciliiifi;  cuiiso  can  not  only  he  detected  on  exploralioii  l)ii( 
rcnioveii,  it  should  he  radical.  11",  however,  this  jx;  not  possible  then  enterostomy  or 
cntero-anastoinosis  oidy  can  he  |)ra(tised.  Thus  in  cancer  ol"  the  rectum  or  siifinoid, 
colostomy  is  the  last  resort.  In  cancer  of  the  howel  ahove  the  sigmoid  anastomosis  may 
relieve  the  ohslruction  and  permit  the  patient  to  linger  until  he  dies  ol"  the  natural  |)ro^res.s 
of  the  disease. 

Here,  as  elsewhere,  o])erati()n  should  not  he  too  lonijj  delayed.  To  wait  for  a  chronic 
ohstruction  to  nierij;e  into  one  of  the  jieutc  forms,  and  then  to  wait  imtil  the  ])atient 
is  morihund,  is  to  have  deliherately  dejirived  him  of  that  whicji  otherwise  mi<flif  have 
prolonged  his  life. 

For  chronic  ()l)stniction  whose  ('aus(>  is  not  easily  revealed  the  hypothesis  of  cancer 
affords  the  most  common  ex|)lanation.  This  may  he  intrinsic  or  extrinsic,  so  far  as  the 
bowel  itself  is  concerned,  the  results  howevcM"  not  differin<ij.  It  matters  hut  little  whether 
cancer  is  jn'odncino;  an  annular  stricture  or  involvin<j;  a  considerable  extent  of  bowel, 
somethin(i;shonl(I  he  done.  When  health  has  i;'ra<lually  failed,  and  ol)structive  symptoms 
have  come  on  slowly,  and  when  distinct  cachexia  is  present  the  ])re;jence  of  cancer 
within  the  abdomen  may  be  suspected.  When  a  distinct  tumor  is  |)al])ahle  or  wlien  (he 
abdomen  (2;ra(hially  fills  with  fluid  there  is  little  doubt.  When  to  these  signs  is  added 
pigmrnfafion  of  the  alxlovthinl  wall  the  diagnosis  may  be  considered  certain.  Fven 
now  exploratory  scMtion  is  justified,  in  the  ho])e  that  some  operative  measure  may  oifer 
comfort  and  at  least  temporary  relief. 

On  the  other  hand,  when  obstructive  symptoms  a])j)ear  and  increase  without  the 
accompaniment  of  other  serious  indications,  it  may  he  lioju'd  that  the  condition  is  benign 
rather  than  malignant.  Ohstruction  Avith  ascites  nuiy  j)ossiI)ly  he  due  to  tuhcrculous 
lesions,  Avhich  are  not  unconunon,  especially  in  children.  The  recognition  of  enlarged 
mesenteric  nodes  would  corroborate  this  diagnosis,  A  history  of  typhoid  fever  or  of 
injuries  or  foreign  bodies  might  confirm  the  theory  of  cicatricial  stenosis.  The  possi- 
bility of  enteroptosis  of  the  colon  and  impaction  of  hardened  fecal  matters  should  not  be 
disregarded    and  that  of  enteroliths,  especially  gallstones,  not  forgotten. 

FECAL  FISTULA;  ARTIFICIAL  ANUS. 

A  fecal  fistula  implies  any  communication  between  the  intestinal  tract  and  the  exterior 
of  the  body  or  one  of  its  other  cavities.  Thus  it  is  possible  to  have  a  rectovaginal  fistida 
as  well  as  a  vesicovaginal.  In  rare  instances  we  may  meet  also  with  intestinal  communi- 
cation with  the  bladder,  the  other  viscera,  or  even  the  pleura  or  lungs. 

Fecal  fistulas  are  always  abnormal  productions,  aiul  result  either  from  congenital 
causes,  previous  injury,  or  disease.  Among  the  traumatic  causes  may  he  mentioned 
penetrations  or  ruptures  of  the  intestines,  injuries  to  the  bowel  occurring  in  the  course 
of  alnlominal  operations  (for  instance,  the  inclusion  of  some  ])artof  the  bowel  wall  within 
a  ligature  or  suture),  while  the  pathological  causes  include  the  ])ossihilities  of  ])erforation 
of  any  form  of  idcerative  lesion,  cancer,  actinomycosis,  or  the  secondary  sloughing  which 
may  follow  apjiendicitis,  or  even  the  pressure  of  a  drainage  tube.  Fistidas  result  also 
from  escape  of  foreign  bodes  (for  instance  enteroliths  or  l)one  fragments),  which  niay 
work  their  way  into  some  other  viscus,  or  out  through  the  abdominal  wall  to  the  body 
surface.  Old  pelvic  and  abdominal  abscesses  also  occasionally  cause  ]x>rforation  and 
fecal  fistulas.  These  fistulous  tracts  may  be  long  or  short,  aiul  direct  or  indirect.  They 
may  also  permit  the  escape  of  a  large  amount  of  fecal  matter  or  the  smallest  appreciable 
amount.  The  majority  of  them  tend  to  close  spontaneously  in  the  course  of  time,  but 
this  time  is  sometimes  so  prolonged  that  a  surgical  operation  is  preferable  to  waiting 
for  natural  processes.  The  communications  may  be  high  in  the  intestinal  canal.  In 
such  a  case  matter  that  escaj^es  will  be  but  partially  digt'sted  and  will  have  the  character 
of  chyme  rather  than  of  feces;  and  patients  suffer  in  consequence,  as  products  of  digestion 
are  not  complete  and  opportunities  for  absorption  have  been  too  limited,  and  they  are 
deprived  of  all  that  should  normally  happen  further  along  in  the  bowel.  In  such  a 
case  there  is  tem])tation  to  operate  much  earlier  than  is  advisable.  Another  form  of 
fistula  results  from  certain  cases  of  strangulated  hernia,  in  consequence  of  necrosis  of 
the  strangulated  loop  of  bowel.     In  fact  this  is  true  of  any  of  the  mechanical  causes 


840  SPECIAL  OR  REGIONAL  SURGERY 

of  acute  obstruction,  where  this  e.\j)e(Heiit  nia}'  he  resorted  to  under  compulsion  and  we 
produce  a  fistuhi  as  an  emergency  measure. 

The  difference  between  intestinal  or  fecal  fistula  and  artificial  anus  is  that  the  former 
is  an  undesirable  and  untoward  event,  w^hereas  the  latter  is  deliberately  produced  by 
operation  practised  for  the  purpose.  Artificial  anus  is  in  the  main  limited  to  cases  of 
cancerous  or  other  hopeless  or  inoperable  obstruction  of  the  lower  bowel,  and  in  such 
case  is  purely  a  palliative  measure.  It  is  made  occasionally  at  the  upper  end  of  the 
colon  in  order  to  give  a  diseased  colon  physiological  rest  and  j^ermit  of  more  j^erfect 
irrigation  of  that  tube,  the  intent  being  to  later  close  the  o])ening.  It  is  an  inevitable 
emergency  measure  in  certain  cases  of  acute  obstruction,  where  the  patient  is  in  no  con- 
dition to  bear  anything  more  extensive  or  prolonged. 

The  operation  for  making  an  artificial  anus,  usually  referred  to  as  enterostomy  or 
colostomy,  will  be  described  below. 

Fecal  fistulas  shoidd  be  treated  largely  according  to  their  causes;  when  they  are  the 
product  of  actinomycotic  or  cancerous  disease  little  can  be  done,  and  perhaps  nothing 
should  be.  On  the  other  hand,  when  resulting  from  traumatism,  from  sloughing  of 
some  portion  of  the  bowel,  or  from  strangulation,  much  can  be  accomplished. 

A  small,  fistulous  tract  shoukl  be  kept  clean  and  stimulated  occasionally  with  silver 
nitrate  or  something  of  the  kind,  and  perhaps  by  introducing  into  it  every  day  a  small 
piece  of  gauze,  which  provokes  the  granulation  process  as  well  as  fills  the  opening. 
It  is  bad  practice,  however,  to  simply  close  the  outer  end  and  let  the  lower  portion  dis- 
tend with  feces.  Much  will  depend  upon  whether  it  now  connects  Avith  the  bowel. 
This  may  be  determined  by  injecting  into  the  fistula  some  methyl  blue  and  then  noting 
the  subsequent  stools.  When  communication  with  the  bowel  is  evidently  free  the  sur- 
geon may  feel  like  making  a  deeper  operation,  perhaps  with  intestinal  suture  or  even 
intestinal  resection,  whereas  if  there  be  little  or  no  actual  fecal  leakage  it  may  be  sufficient 
to  enlarge  the  outer  end  of  the  fistula,  to  thoroughly  scrape  it  A^dth  the  sharp  spoon,  and 
then,  lightly  packing  it,  see  it  close  with  granulations.  A  passage-way  which  is  exceed- 
ingly short  may  be  treated  by  simple  superficial  plastic  operation,  including  freshening 
of  the  entire  margin  of  the  opening  and  the  passage  around  it,  and  a  purse-string  suture, 
with  or  without  a  circular  incision  of  the  skin.  By  drawing  this  suture  tight  the  external 
opening  may  be  closed.  This  is  a  neat  way  in  which  to  dispose  of  a  small  fistulous 
opening  resulting  from  a  previous  enterostomy  or  aj^pendicitis  operation. 

A  rectovaginal  fistula  may  be  closed  by  formal  operation,  similar  to  that  for  closure 
of  a  vesicovaginal  fistula,  based  upon  the  simple  principle  of  freshening  the  edges  of  the 
opening  and  then  holding  them  together  with  suitably  placed  sutures.  A  rectovesical 
fistula  would,  in  most  instances  at  least,  require  a  laparotomy,  with  careful  separation 
of  the  rectum  from  the  bladder,  and  then  a  separate  suture  of  each  opening.  Such  an 
operation  might  be  quite  difficult,  made  so  not  by  its  plan  of  performance  but  by  the 
conditions  which  necessitated  it.  Any  bladder  thus  attacked  should  be  kept  perfectly 
empty  for  several  days  by  the  use  of  a  self-retaining  catheter.  Every  case  of  fecal 
communication  with  any  large  abscess  cavity,  or  through  the  diaphragm,  directly  or 
indirectly,  as  with  a  bronchus,  should  be  treated  on  its  individual  merits,  it  being  a  grave 
question  whether  operation  would  be  indicated  or  not. 

Certain  fecal  fistulas  will  justify  more  formidable  operation,  in  which,  after  opening 
the  abdomen  and  carefully  protecting  its  contents  against  contamination,  the  adhesions 
should  be  separated  entirely  and  that  portion  of  the  bowel  which  is  involved  removed,  • 
making  either  an  end-to-end  suture  or  a  lateral  approximation.  If  this  be  done  it  will 
be  best  also  to  completely  excise  the  old  fistulous  tract  through  the  abdominal  wall,  and  to 
remove  everything  that  was  involved  in  the  previous  condition. 

It  is  possible  to  atone  for  almost  every  opening  of  this  character,  save  those  produced 
by  some  seriously  malignant  disease.  If  such  a  condition  be  the  residt  of  cancerous 
extension  then  it  is  practically  hopeless. 


OPERATIONS  UPON  THE  INTESTINE. 

Intestinal  Suture. — Intestinal  suture  is  by  no  means  a  new  or  modern  operation. 
It  was  spoken  of  by  the  ancient  writers  and  was  evidently  practised  in  the  midtile  ages 
by  the  "Four  Masters"  of  the  School  of  Salernum  and  their  followers.      But  until 


()i'i:i{.\Ti()\s  rro.y  rjiF.  intestine 


841 


it  was  rcducecl  to  a  .science  \)\  tlie  French  snrjfcons,  Joljcrt  and  Lenihert,  during  the 
first  quarter  of  the  past  century,  it  was  always  a  hazardous  measure.  Success  with 
intestinal  suture  depends  upon  exact  liemostasis  of  the  cdojcs  to  he  united  and  their  accu- 
rate a])proxiniation  in  hirers  {i.  c,  mucosa  to  mucosa  and  serous  and  mtiscuUir  coat  to 
its  Hke).  Save  when  haste  coni|)cls,  tliis  accurate  appHcation  is  effected  l)y  two  distinct 
suture  rows,  the  first  or  deeper  (of  liank'ncd  <j;ul)  made  (o  include  the  mucosa  alone,  the 
suture  being  usually  continuous,  hut  knotted  at  intervals,  with  stitches  close  together  and 

Fiii.r.(i4 


Application  of  the  interrupted  Lembert  suture.     (Richardson.) 

drawn  tightly  to  amply  secure  against  leakage  from  the  relatively  large  vessels  of  this 
membrane.  It  is  better  to  apply  this  row  by  itself,  as  any  suture  drawn  through  the 
mucosa  and  out  again  through  the  serous  coat  is  liable  to  contaminate  the  latter,  it  being 
much  better  to  keep  the  contaminated  row  of  sutures  distinct.  The  first  row  having  been 
applied  and  the  surface  carefully  cleansed  the  operator  may  then  coapt  the  balance  of 
the  annular  wound  by  a  continuous  row  of  fine  silk  sutures,  made  to  include  the  serous 
and  muscular  coats  and  to  avoid  the  mucosa.     The  stomach  and  the  colon  are  sufficiently 

Fig.  565 


The  continuous  Lembert  stitch.     (Richardson.) 

thick  to  take  a  row  of  rather  coarse  sutures  for  this  purpose,  but  most  of  the  small  intes- 
tine is  so  thin-walled  that  these  need  to  be  applied  with  caution  as  well  as  with  dexterity. 

Every  row  of  sutures  shoidd  be  so  applied  and  directed  that  the  lumen  of  the  bowel 
be  not  reduced  by  its  presence,  it  being  a  serious  matter  to  greatly  encroach  upon  the 
diameter  of  the  bowel,  since  obstruction  will  thereby  be  favored  and  extra  tension  made 
upon  the  sutures  (Figs.  564  and  565). 

So  many  different  forms  of  intestinal  suture  have  been  devised  that  it  is  useless  to 
attempt  here  to  describe  them  all. 


842  SPECIAL  OR  REGIONAL  SURGERY 

Any  minute  puncture  of  the  bowel  may  be  closed  by  i)ursc-strin<;  suture.  Any  ])er- 
foratiiif];  wovnid  should  be  not  only  first\-arefully  cleansed,  but  also  slif;htly  enlarged, 
cutting  away  its  more  or  less  contused  margins  in  order  that  fresh,  viable  tissue  may  be 
cxi)osed.  This  is  particularly  true  of  gunshot  wounds.  Many  of  the  operations  now 
prMctiscd  include  inversion  of  the  end  of  the  l)owcl,  a  method  illustrated  in  Fig.  560, 
showing  a  method  ecjually  applicable  to  burying  the  stump  after  removing  tlie  appendix, 
closing  the  end  of  a  portion  of  the  small  or  even  the  large  bowel. 

Most  operators  now  use  for  the  mucosa  a  carefully  prepared  and  reliable  chromi- 
cized  catgut,  the  smaller  size  being  preferable,  with  the  ends  cut  short  after  the  knots 
are  tied.  It  is  well  also  to  use  for  intestinal  suture  needles  which  are  round  rather  than 
made  with  cutting  edges,  as  by  the  latter  openings  are  maile  larger  and  vessels  some- 
times cut,  this  requiring  the  insertion  of  extra  sutures  for  their  securement.  Whether 
the  operator  shall  use  curved  or  straight  needles,  and  shall  do  the  work  with  his  fingers 
or  depend  upon  various  forms  of  needle  holders,  is  purely  a  matter  of  choice  and  training. 
Siicrrs.s  or  failure  depend  not  so  much  upon  the  needle  lio/der  as-  upon  the  holder  of  the 
needle,  and  his  care  and  attention  to  detail.  In  the  presence  of  nudtiple  lesions  the 
procedure  may  have  to  be  repeated  to  meet  each  indication. 

Anastomotic  Operations. — For  the  general  application  of  the  principle  of  anas- 
tomosis to  intestinal  work  the  profession  is  largely  indebted  to  Senn.  The  principle 
having  been  once  recognized  will  never  be  rejected,  but  methods  have  already  varied 
nmch  from  those  first  introduced,  and  will  be  improved  by  the  substitution  of  simpler 
|)rocedures  for  the  more  complex. 

In  general  an  anastomotic  opening  may  be  made  between  any  distinct  portions  of 
the  alimentary  canal,  and  almost  any  one  part  may  be  thus,  as  it  were,  connected  up  with 
any  other.  Gastrojejunostomy  has  already  been  described.  Only  under  compulsion 
does  one  thus  connect  the  stomach  with  any  other  part  of  the  alimentary  canal.  From 
the  jejunum  down  to  the  rectum  one  may,  however,  effect  attachments  of  this  kind  at 
any  desired  point.  These  operations  are  in  the  main  done  for  one  of  the  following 
|)urposes: 

(a)  In  cases  of  obstruction  of  the  bowel ; 
{}))  For  the  purpose  of  exclusion  of  a  certain  length ;  or 

(r)  As  a  substitute   for   end-to-end    reunion,   after   resection  of  a  portion  of  the 
bowel. 

The  method  of  performance  will  depend  not  so  much  upon  the  nature  of  the  difficulty 
requiring  the  operation  as  upon  the  comlition  of  the  patient,  the  efjui])ment,  and  the 
oj)erative  skill  of  the  surgeon.  With  a  patient  in  extremely  serious  condition  that  method 
which  may  be  most  quickly  performed  is  obviously  the  best.  When  tinu>  and  method 
are  under  control,  then  that  is  best  which  can  be  most  perfectly  ])erformed  by  the 
o])erator,  or  that  which  he  is  compelled  to  adopt,  as  when,  for  instance,  he  resorts  to  a 
suture  method  because  he  has  no  l)utton  at  hand. 

In  order  to  simplify  the  subject  as  much  as  possible  the  following  methods  alone  will 
be  mentioned  here: 

'i'he  method,  hi/  suture  is  essentially  similar  to  that  described  as  gastro-anastoniosis, 
the  surfaces  which  are  to  be  brought  together  being  properly  ])lace<l,  and  a])proximated, 
first,  by  a  row  of  silk  suture,  the  openings  l)eing  then  made  with  excision  of  a  strip  of 
mxicosa,  and  the  mucosa  being  next  sutured  with  chromic  gut,  first  on  the  further  side, 
then  on  the  near  side  of  the  opening,  after  which  the  serous  membranes  are  accurately 
sutured  around  the  opening  by  continuation  of  the  first  row  of  silk  sutures.  The  actual 
opening  made  for  the  purpose  should  be  at  least  an  inch  in  length,  preferably  an  inch 
and  a  half  or  more,  while  when  the  lower  bowel  is  attached  to  the  colon  such  an  opening 
may  well  have  a  length  of  at  least  2^  inches,  for  if  successful  it  will  be  followed  by  a 
certain  degree  of  cicatricial  contraction  and  will  never  remain  of  its  original  size  (Figs. 
r)(U;,  5(17,  SOS  and  569).  The  suture  may  be  combined  with  the  elastic  ligature,  the 
method  again  being  similar  to  that  for  imiting  the  jejunum  with  the  stomach,  already 
described.  The  rubber  ligature  used  for  the  jiurpose  is  of  the  same  size,  and  there  is  no 
difference  to  be  made  in  the  directions  already  given.  The  elastic  ligature,  however, 
can  not  be  relied  upon  in  emergency  cases  where  it  is  necessary  to  effect  a  communication 
at  once.  It  is  serviceable  only  in  instances  where  there  is  a  leeway  of  at  least  three  or 
four  days.  This  method  has  for  one  of  its  advantages  the  fact  that  in  its  performance 
it  is  not  necessary  to  clamp  or  secure  the  bowel  by  any  instrument,  simply  to  empty  it 


OPJJIiATIOXS  UrOX  THE  IXTESTIXE 


S43 


for  the  moment  witli  the  fiiifjers,  it  not  l)eiM<f  opened  (hirinfi;  the  o|)er;ition  by  anything 
save  the  needle  puncture,  whieli  is  promptly  filled  with  the  ruhher.  It  does  require, 
however,   lliat    the    nihher  used    for   the   purpose  shall    he    rcli;il)l('  and    new,  it    being 


Fr:.  5GG 


Vui.  5G7 


Entero-anastomosis  of  intestinal  loops  which  have 
lieen  resected  and  the  bowel  ends  closed;  the  first  row 
(if  sutures  has  been  applied  and  the  line  of  opening 
indicated.     (Lejars.) 


Suture  of  the  distal  edges  of  the  mucosa. 


Fig.  568 


Fig.  569 


Insertion  of  the  last  (fourth)  row  of  sutures. 
(Lejars.) 


Resection  of  intestine  with  lateral  anastomosis.  Pos- 
terior suture  inserted.  The  free  ends  of  the  bowel  in- 
verted and  sutured.     (Richardson.) 


844 


SPECIAL  OR  REGIOXAL  SURGERY 


unfortunately  the  case  tliat  pure  ruljher  wliieli  will  lust  fur  a  long  time  is  .seldom  found 
in  the  market. 

The  button  method  depends  for  its  success  upon  a  mechanical  device  of  Murphy, 
knowTi  everywhere  as  the  '' Murphy  button,'"  or  upon  one  of  its  modific-ations.     Fig. 

570  illustrates  the  component  parts  of  this  de- 
FiG.  570  vice,  which  is  made  in  various  sizes  and,  in  fact, 

in  various  shapes  for  different  purposes,  though 
the  circular  forms  suffice  for  practically  ail  cases. 
In  Fig.  572  it  is  seen  in  actual  use,  while  Figs. 
573  and  574  illustrate  the  method  of  its  insertion 
and  securement. 

The  underlying  principle  of  the  ]Murphy 
button  is  that  each  half  can  be  inserted  sepa- 
rately and  that  then,  by  pressing  these  halves 
together,  an  opening  is  at  once  afforded  from 
one  part  of  the  bowel  to  the  other.  If  the 
halves  be  pressed  together  with  the  proper  de- 
The  Murphy  button.  gree  of  firmuess   they    produce,  first,   adhesion 

between  considerable  areas  around  their  cir- 
cumference, folloAvt  .1  in  the  course  of  a  few  days  by  a  necrosis  of  the  central  por- 
tion, which  slougJis  because  deprived  of  its  circulation  by  the  pressure.  So  soon 
as  this    separation    or    sloughing  is  complete    the  button  drops    into  the    intestinal 


End-to-end  union  of   intestine  by  means  of  the  Murphy  button:  the  two   portions  of  the  Murphy  button,  lield  in 
position  by  purse-string  sutures,  are  ready  to  be  pressed  together.     (Richardson.) 

canal,  being  completely  loosened,  and  is  now  carried  along  by  peristalsis  and  by  the  fecal 
current  from  above,  its  position  shifting  as  would  that  of  a  scybalous  mass  or  a  fecal 
concretion,  until  it  finally  emerges  from  the  intestinal  tube,  being  passed  from  the  anus. 

Fig.  572 


Union — end  to  end — with  the  Murphy  button. 


How  soon  it  will  thus  appear  will  depend  in  large  measure  upon  the  point  of  the  intes- 
tinal canal  into  which  it  is  thus  intruded.  If  this  be  high  up  it  will  be  slower  in  appear- 
ing. If  low  down  it  may  be  expected  sooner.  While  it  usually  appears  within  ten  days 
or  two  weeks  it  may,  however,  be  longer  retained,  and  in  one  case  of  my  own  was  not 


()i'i:i{.\Ti()\s  c'i'ox  Till-:  i\ti:sti\i<: 


S45 


piisscd  for  three  nioiitlis,  allli()Ui;li  tlie  anastomosis  was  made  witli  tlie  asceiidinji;  colon, 
into  wliieli  it  must  have  dro|)|)ed. 

Fi(^.  573  shows  one  of  tlie  halves  held  in  the  (rrasp  of  ;i  forceps,  heint;  inserted  into  a 
small  huttoidiole  opening  just  large  enough  to  receive  it,  around  which  there  has  been 
j)asse(l  a  buttonhole  or  purse-string  suture  of  silk.  This  portion  once  thus  inserted 
shoidd  not  be  lost  within  the  bowel,  it  being  necessary  to  retain  control  of  it  by  the  for- 
ceps until  its  application  to  the  other  half.     Both  halves  being  inserted  and  brought 

I'lu.  573 


Introduction  of  one-half  of  a  Murphy  button.     (Bergmann.) 

opposite  to  each  other,  as  in  Fig.  574,  the  smaller  is  introduced  into  the  larger,  and  they 
are  then  pressed  together  until  the  included  serous  surfaces  are  brought  into  contact, 
with  sufficient  pressure  inflicted  to  bleach  them,  in  order  that  their  subsequent  necrosis 
may  be  ensured.  A  circular  row  of  sutures  should  now^  be  placed  around  the  surfaces 
thus  a])plied,  in   order  to  more  widely  secure    them  in 

contact.     The  procedure  being   completed  in  this  way,  Fig.  574 

the  parts  are  dropped  back  into  tlie  abdomen  and   the 
abdominal  wountl  closed. 

End-to-end  reunion  can  be  accomplished  by  the  same 
method,  or  the  end  of  the  small  intestine  may  be  applied 
to  the  side  of  the  large,  after  a  method  "which  will  be  best 
understood  by  reference  to  Fig.  571,  it  being  necessary 
here  to  draw  the  squarely  cut  end  of  the  intestine 
around  the  button  with  a  circular  suture,  and,  at  the 
same  time,  to  so  grasp  the  button  that  it  shall  not  recede 
into  and  be  lost  in  the  bowel. 

Small  buttons  have  been  made  for  the  purpose  of 
uniting  the  gall-bladder  to  the  upper  bowel  and  extra 
large  ones  are  made  for  the  large  intestine. 

The  particular  advantage  of  the  button  method  is  the 
shortness  of  the  time  required  for  its  performance,  as  it 
can  be  conducted  in  a  few^  moments  by  one  who  might 
take  four  times  as  many  minutes  in  using  sutures. 
The  disadvantages  attaching  to  it  are  these:  (1)  That  it  depends  for  its  success  upon 
necrosis,  i.  e.,  of  the  part  of  the  bowel  included  within  its  grasp;  (2)  that  it  might 
itself  serve  as  a  foreign  body  and  produce  acute  obstruction,  a  not  unknown  event;  (3) 
that  it  is  not  always  at  hand,  especially  in  emergency  cases,  and  that  to  rely  upon  it  is 
to  be  limited  in  one's  abilities. 

There  is  but  little  question  that,  when  properly  performed,  the  simple  suture  methods 
are  the  best  of  all,  and  the  operator  who  has  never  seen  a  button  used  should  abstain 
from  its  use.  Still  it  has  given  many  good  results.  J\ly  belief  is  that  the  better  the 
surgeon's  judgment,  and  the  more  developed  his  skill,  the  less  he  will  rely  upon  any 


Intestinal  anastomosis  with  a  Mur- 
phy button,  showing  the  halves  in 
position  ready  to  be  pushed  together. 
(Bergniann.) 


846  SPECIAL  OR  REGIOXAL  SURCIKRY 

im-chaiiical  expedient  of  this  cliaratter,  ami  tlie  more  upon  wliat  he  can  accomplish 
with  the  neetlle  in  his  own  finjjers. 

End-io-aidc  anatiiomosis  is  in  no  essential  resj)ect  ditt'erent  from  resection,  only  it  may 
be  done  for  the  purpose  of  exclusion  when  nothing  is  absolutely  removed.  Thus  in 
case  of  cancer  of  tlie  cecum  a  lateral  im})lantation  can  be  made  of  a  lower  loop  of  the 
ileum  upon  the  side  of  the  ascending  colon,  using  for  this  purpose  a  button,  having 
divided  the  ileum  on  the  proximal  side  of  the  ileocecal  valve,  and  turned  in  both  ends  and 
invaginatcd  the  stumps.  Here  one  resects  nothing,  but  makes  a  direct  communication 
between  the  bowel  above  and  Ix'low  the  c-ancer,  sliort-circuiting  the  intestinal  canal,  as 
electricians  would  say,  and  all  for  tlie  ])uri)ose  of  giving  temporary  relief.  Thus  end-to- 
side  or  end-to-end  anastomosis  may  be  made,  according  as  circumstances  dictate,  and, 
if  one  chooses,  with  the  Murphy  button. 

Resection  of  some  portion  of  the  large  or  small  intestine  is  required  under  a  variety  of 
different  circumstances.  Thus  after  certain  injuries,  contusion  and  rupture,  or  numer- 
ous punctures  or  gimshot  perforations,  it  may  be  decided  to  remove  a  considerable  length 
of  bowel  rather  than  be  compelled  to  give  s])ecial  attention  to  a  number  of  distinct  lesions, 
believing  it  a  time-saving  measure,  and,  therefore,  for  the  welfare  of  the  individual. 
The  same  measure  will  be  indicated  when,  either  by  injury  or  disease,  the  blood  supply 
of  anv  portion  of  the  l)owel  is  apparently  comjjromised  or  certainly  shut  ofl".  Here 
necrosis  is  so  certainly  to  be  expected,  or  ])erhaps  has  already  occurred,  in  such  a  way  as 
to  necessitate  removal  of  whatever  length  of  bowel  may  thus  be  involved.  Several  of 
those  cases,  already  mentioned,  which  produce  obstruction  of  the  bowel  will  demand 
resection,  as,  for  instance,  when  reduction  of  an  invagination  is  impossible,  with  gangrene 
threatening.  In  a  few  instances  extensive  gangrene,  precipitated  by  embolism  or  throm- 
bosis of  the  mesenteric  vessels,  has  been  successfully  treated  by  resection  of  considerable 
lengths  of  bowel.  Again,  the  bowel  is  resected  for  closure  of  fecal  fistula  or  artificial 
anus,  as  well  as  for  relief  of  stricture  due  to  various  causes.  Finally,  nearly  all  of  the 
tumors  of  the  intestine  itself,  and  especially  all  of  the  malignant  forms,  will  require 
removal  of  at  least  a  few  inches  of  gut,  save  in  those  cases  where  this  is  shown  to  be  im- 
|)racticable  because  of  the  presence  of  cancer  elsewhere,  in  which  case  it  may  be  sufficient 
to  make  an  anastomosis. 

When  intestinal  resection  is  not  an  emergency  measure  there  should  be  as  much  jirepa- 
ration  as  the  case  will  permit,  including  lavage  of  the  stomach,  the  ingestion  of  sterilized 
food,  the  use  of  antiseptics  and  the  most  thorough  emptying  of  the  bowel  which  can  be 
accomplished.^ 

One  of  the  greatest  difficulties  attendant  upon  the  operation  is  the  avoidance  of  all 
contamination  by  contact  of  peritoneum  with  intestinal  contents.  Against  this  the  most 
minute  }:)recautions  should  be  taken.  This  is  never  an  easy  matter,  and  in  the  presence 
of  distended  bowels  and  the  emergency  of  acute  obstruction  it  sometimes  taxes  every 
resource  at  hand.  A  variety  of  clam])s  have  been  devised  by  different  operators,  the 
intent  being  to  so  clasp  the  bowel  beneath  their  blades  as  to  completely  occhide  it.  These 
blades  are  covered  with  sterilized  rubber  tubing  to  keep  them  from  acting  too  harshly, 
and  it  is  necessary  to  use  pressure  upon  the  handles  with  great  discretion,  lest  permanent 
injury  be  done  to  the  bloodvessels.  The  bloodvessels  of  the  bowel  are  essentially  termi- 
nal, and  the  blood  supply  should  be  kept  sufficient  for  every  part  which  is  not  removed. 
These  vessels  are,  moreover,  numerous  and  relatively  large,  and  hemorrhage  is  not  always 
easy  of  control,  especially  when  damjjs  are  not  at  hand.  As  a  substitute  for  clamps 
tapes  of  sterilized  gauze  may  be  used,  being  tied  around  the  bowel,  or  the  fingers  of  a 
reliable  assistant  may  be  substituted.  Such  use  of  the  fingers  is  not  easy  nor  simple, 
not  only  because  tliey  become  tired  and  relax  their  grasp,  but  since  they  slip  so  easily,  and 
because  the  escape  of  one  drop  of  fecal  matter  may  cause  a  fatal  contamination. 

Resection  of  the  bowel  may  imply  in  one  case  a  removal  of  but  two  or  three  inches  of 
its  length,  while  the  other  extreme  is  not  reached  until  several  feet  of  bowel  have  been 
removed.  I  have  been  able  to  successfully  remove  eight  feet  and  nine  inches  of  intestine, 
the  lower  part  including  the  cecimi  and  a  portion  of  the  ascending  colon,  and  there  are 
now  on  record  nearly  twenty  cases  where  over  200  Cm.  of  bowel  have  been  resected, 
nearly  all  of  them  recovering.     Success  in  this  procedure  depends  partly  upon  the  con- 

i  Sanderson  has  suggested  a  new  method  of  sterilization  of  the  interior  of  the  bowel  at  the  time  of  operation. 
He  injects  a  solution  of  acetozone  through  a  hypodermic  needle,  or,  after  opening  the  bowel,  freely  irrigates 
with  the  same. 


Ol'hh'ATIOXS   VPOX    Tllh:   IXTKSTINE 


S47 


(lilioii  ncccssiiiiiiii};  llic  operation,  as  well  as  the  general  coiMlitioii  of  iIk-  |)aliriit,  l»u(  in 
MO  small  HK-asiiiT  lian<;s  upon  tlic  pfrt'cction  of  tlir  o|)crator's  tt'ciiniiinc 

Whatever  l)e  tlie  coiulition  wliicli  re(jiiires  .sueii  rescclion  it  should  he  nuule  sufhciently 
fxtoiisive  to  eonipletely  include  and  permit  the  total  removal  of  the  diseased  or  injured 
])()rti()n.  The  ahdomina!  incision  should  he  larfje  enoufjh  to  ))ermit  the  delivery  u])on  the 
surfat'c  of  the  hody  of  all  (hat  |)ortion  to  he  removed.  Unless  this  he  done  the  dilliculties 
are  j^rcatly  enhanced.  Save  where  there  is  some  distinct  indication  for  openinj;  elsewiiere, 
this  incision  is  made  in  the  middle  line.  The  com|)romised  howel  havinif  heen  souj^ht 
and  thus  delivered  and  one  havinj;  decided  exactly  where  to  divide  it,  clamps  are  so  placed 
hoth  ahove  and  helow  each  line  of  division  as  to  j)revent  leaka<fe.  I  ndcrneath  the 
howel  to  he  thus  divided  <fau/e  is  j)laced  in  su<'h  a  way  as  to  receive  the  small  amount  of 
dischar<i;e  which  will  escape  from  the  portion  hetween  the  clam|)s.  The  expo.sed  bowel 
surfaces  should  tluii  l)e  thoroughly  cleaned,  the  contaminated  gauze  removed,  fresh 


Fig.  575 


Fig.  576 


I'">n(l-to-en(l  or  circular  anastomosis  by  enterorrhaphy. 
First  row  of  ilistal  sutures  in  serosa.  (Type  of  needle 
differs  from  that  used  in  tliis  country).     (Lejars.) 


Completion  of  last  row  of  suture,s,  begun  as  shown  in 
Fig.  575.     (Lejars.) 


pieces  substituted  for  it,  and  the  other  division  of  bowel  made  in  the  same  way.  \Yhile 
in  some  eases  it  may  be  well  to  tie  ofT  the  mesenteric  border  and  secure  all  its  vessels 
before  dividing  the  bowel,  this  may  at  other  times  be  delayed  until  after  the  division. 
At  all  events  it  is  the  next  step.  Whether  the  mesentery  shall  be  simply  sejxirated  along 
the  intestinal  border  and  tied  oflf  in  small  portions,  one  after  another,  or  whether  a 
triangular  resection  of  a  portion  of  the  mesentery  itself  should  be  made,  securing  the 
larger  vessels  nearer  to  its  root,  will  depend  on  the  nature  of  the  case  and  upon  whether 
the  mesentery  itself  be  involved  in  the  disease.  In  dealing  with  cancer  it  is  often  neces- 
sary to  remove,  at  the  same  time,  every  enlarged  lymphatic.  It  may  be  inferred  that 
no  incision  or  tear,  no  matter  how  short,  can  be  made  in  these  tissues  without  danger  of 
subsequent  hemorrhage  unless  the  parts  be  secured  against  it.     A  series  of  ligatures 


S48 


SPECIAL   OR  REGIOXAL  SURGERY 


and  sutures  is  therefore  called  for  here  which  may  consume  no  small  pro])ortiou  of  the 
entire  time  of  the  operation.     (See  Figs.  575  and  57().) 

All  that  portion  of  bowel  which  has  been  condemned  having  been  removed  and  a 
careful  toilet  of  the  parts  having  been  made  the  surgeon  next  proceeds  to  restore  the 
bowel  lumen.  A  V-shaped  defect  in  the  mesentery  should  be  united  with  sutures.  The 
line  of  former  mesenteric  border  left  after  removal  of  bowel  should  be  not  only  carefully 
protected  with  ligatures,  })Ut  the  whole  margin  should  be  overcast  and  so  folded  in  or 
drawn  together  in  tucks  as  to  make  it  easy  to  bring  the  bowel  ends  together  without  undue 
stress. 

Fig.  577  Fig.  57 


Circular  anastomosis  of  portions  of  the  bowel  Laving  different  lumina.     (Bergmann.) 

The  sutures  by  which  the  divided  bowel  is  restored  should  begin  at  the  mesenteric 
border,  and  every  care  should  be  taken  to  make  the  joint  at  this  point  absolutely  water- 
tight. Suture  methods  have  been  described.  To  unite  bowel  ends  of  the  same  diameter  it 
is  an  easy  matter  to  suture  together  first  the  mucosa  and  then  the  outer  layer,  so  long  as  the 
intestine  is  on  the  outside  of  the  body  and  equally  accessible  on  all  sides  (Fig.  578).  The 
surgeon  is  sometimes  compelled  to  do  this  work  within  the  body  cavity,  as  in  resection 
of  the  rectum  for  cancer.  It  may  be  advisable  to  first  place  a  row  of  sutures  between 
the  serosa  and  muscularis  on  the  further  side  of  the  margins  to  be  united,  then  to  close 
the  mucosa  completely  around,  and  then  to  finish  the  outer  layer  of  sutures.     So  long 


Fig.  579 


Fig.  580 


Isoperistaltic  lateral  apposition. 


Antiperistaltic  lateral  apposition  (bad). 


as  differences  of  size  are  not  conspicuous,  end-to-end  approximation  can  be  made 
almost  an^nvhere.  When,  however,  it  is  necessary  to  attach  small  bowel  to  large, 
the  size  of  the  larger  opening  should  be  reduced  to  fit  the  smaller,  or  one  or  both  ends 
mav  be  closed,  turning  in  the  stump,  as  already  described,  and  then  making  lateral  or 
end-to-side  anastomosis.  Any  such  anastomotic  opening  should  be  so  placed,  and 
bowel  so  directed,  that  there  shall  be  no  interference  in  the  direction  of  the  natural  bowel 
stream,  failure  to  observe  this  precaution  producing  not  only  added  immediate  danger 
but  more  or  less  permanent  obstruction  (Figs.  579  and  5S0J. 


OI'KRATIOSS    ri'OS    Tin-:  IXTJuSTIMC 


849 


All  that  has  hron  said  ahovc  with  rcj^ard  to  the  Murj)hy  button  and  its  use  in  anas- 
tomotic operations  holds  equally  good  here  with  regard  to  its  usefulness  after  resection. 

Numerous  devices,  either  instruments  for  the  purpose  of  holding  the  bowel  together 
while  it  is  sutured,  or  of  afVordiiig  substitutes  for  the  Murphy  button,  have  been  jilarmed 
by  operators  all  over  the  world.  There  are  few  of  them,  however,  which  give  any  better 
results  than  the  simple  methods  above  described,  to  which  I  prefer  to  limit  description 
here  because  of  their  very  simplicity. 

Intestiiuil  suture  or  any  other  method  of  ((unplcting  tlie  resection  having  been  finished, 
a  careful  toilet  of  all  exj)osed  parts  should  be  made,  by  which  bowel  may  be  dropped 
back  into  the  abdominal  cavity  and  the  latter  closed  without  drainage. 

Tlie  s-uh.srqurnf  manaqemcyit  of  these  cases  will  consist  in  two  or  three  days'  starvation, 
in  order  that  ])eristalsis  nuiy  be  reduced  to  a  minimum,  the  ])aticnt  being  meanwhile 
fed  by  the  rectum.  Then  will  come  a  time  when  both  fluid  food,  and  cathartics  a  little 
later,  should  be  gently  and  discriminately  administered.  Any  satisfactory  suture 
method  will  rarely  give  way  after  forty-eight  hours.  Buttons,  on  the  contrary,  may  break 
loose  after  many  days  or  even  weeks,  and  this  fact  affords  another  argument  against 
their  use. 


Fig.  581 


Fig.  5S2 


Enterostomy;  preliminary  fixation  of  a  loop  of  bowel  t( 
the  i)eritoneum.     (Lejars.) 


Enterostomy;  fixation  of  margins  of  opened  gut 
to  skin.     (Lejars.) 


Enterostomy. — Enterostomy  for  establishment  of  fecal  fistula,  or  artificial  amis, 
is  ])erformed  for  relief  purposes  and  sometimes  as  an  emergency  measure.  It  consists  in 
attaching  some  portion  of  the  bowel,  naturally  that  above  the  constriction  or  disease  which 
compels  the  operation,  to  the  parietal  peritoneum  through  a  small  wound  in  the  abdomi- 
nal wall.  When  the  large  intestine  is  opened  for  this  purpose  the  operation  is  usually 
referred  to  as  a  colostomy,  and  this  preferably  is  done  in  the  left  iliac  region.  When  enter- 
ostomy of  the  smaller  bowel  is  ])referable  it  may  be  done  at  any  point  on  the  abdominal 
surface.  Thus  if  through  a  median  incision  a  condition  be  found  necessitating  it  the  bowel 
should  be  attached  at  the  lower  end  of  the  abdominal  opening,  for  here  drainage  will  be 
better  and  contamination  less  likely.  When  enterostomy  is  done  for  acute  obstruction, 
it  is  preferable  to  place  the  opening  in  one  iliac  fossa  or  the  other. 

Enterostomy  consists  essentially  of  the  following  steps:  opening  through  the  abdomen, 
recognition  of  the  parietal  peritoneum,  which  is  seized  with  forceps  on  either  side,  opened 
and  secured  with  these  forceps,  after  which  the  first  tensely  distended  loop  of  bowel  Avhich 
presents  is  taken,  and,  with  a  series  of  fine  sutures  in  a  round  needle,  the  serous  surface  of 
the  gut  is  attached  to  the  margins  of  the  parietal  peritoneum  (Figs.  581  and  5S2).  In  the 
more  desperate  cases  a  portion  of  the  bowel  may  be  brf)ught  out  through  the  Avound  and 
fixed  there  in  such  a  way  that  it  cannot  recede.  If  the  emergency  is  great  the  bowel 
may  be  immediately  punctured,  the  patient  so  placed  and  so  protected  that  fecal  contents 
shall  escape  away  from  the  body  rather  than  over  it.  If  one  can  take  a  little  time  he  may 
wait  a  few  hours  for  the  adhesion  which  is  sure  to  take  place  between  the  peritoneal  sur- 
54 


850  SPECIAL  OR  RhVIONAL  SURCUJIiY 

faces  and  tlie  consctjiu'iit  sliiittiiig  oil'  of  the  abdominal  cavity  from  the  outer  wound.  Thus 
after  twelve  hours  the  surface  of  bowel  exj)ose(l  throujjh  the  wound  may  be  punctured 
either  with  a  knife,  scissors,  or  the  actual  cauterv,  and  this  may  be  done  without  causing 
pain  to  the  patient.  Escape  of  bowel  contents  will  instantly  ensue  after  puncture.  After 
permitting  all  to  escape  that  will,  abundant  })rotection  should  be  |)rovided  for  the  recej)tion 
of  the  discharges,  which  will  continue  at  reduced  rate.  I'hc  best  way  to  do  this  is  to 
pass  into  the  bowel  in  the  ])roper  direction  a  rubber  tube,  as  large  as  it  can  acconnno- 
date,  or  a  glass  tube,  bent  at  an  angle,  which  shall  connect  with  a  flexible  tube,  and 
thus  conduct  away  all  discharge. 

Another  method  of  j)erforming  the  operation  is  to  bring  out  the  loop  of  bowel,  ()])en 
and  emjity  it,  then  to  introduce  a  glass  or  rubber  tube,  around  which  is  snugly  fastened 
the  bowel  margin.  The  intestine  is  then  stitched  in  })lace  and  the  tube  so  arranged  as 
to  conduct  away  all  discharge. 

Just  how  much  may  be  expected  of  such  a  relief  opening  will  (le])end  u])on  the  case. 
These  operations,  es])ecially  for  cancer  of  the  rectum  or  the  lower  bowel,  may  ])rolong 
life  for  two  or  three  years.  An  emergency  opening  into  the  small  bowel  for  relief 
of  acute  obstruction  may  need  to  be  kept  open  for  but  a  few  days,  after  which  the  tube 
may  be  removed  and  the  fecal  fistula  be  allowed  gradually  to  contract.  According 
to  the  case  an  intestinal  resection  may  be  made  or  the  opening  may  be  closed  by  one  of 
the  plastic  methods. 

Appendicostomy. — Aj^pcndicostomy  is  the  more  complete  form  of  carrying  out 
a  suggestion  first  made  by  Hale  White,  of  opening  the  colon  on  the  right  side  in  cases 
of  intractable  colitis.  Gibson  suggested  to  accom])lish  this  by  a  method  similar  to 
Kader's  for  gastrostomy,  making  a  valvular  colostomy  through  which  the  colon  might 
be  irrigated,  without  escajjc  of  feces.  In  1*)02,  Weir,  intending  to  do  this  operation, 
found  the  appendix  rising  so  invitingly  into  the  wound  that  the  inspiration  occurred 
to  him,  and  was  promj)tly  acted  upon,  to  utilize  it  for  the  ])urpose. 

In  performing  the  operation  the  smallest  jx)ssible  incision  should  be  made  through 
which  the  appendix  may  be  delivered,  its  mesenteric  artery  is  tied,  and  its  mesentery 
stripjied  down  to  its  origin.  At  the  latter  the  cecum  is  fastened  to  the  parietal  peritoneum 
by  a  suture  on  either  side,  avoiding  the  appendicular  artery  itself.  The  balance 
of  the  wound  is  then  closed  as  usual,  the  a])])cndix  being  fastened  to  the  lower  angle 
by  suture,  the  protruding  ])art  then  wra])ped  with  gutta-percha  tissue  and  included 
in  the  dressing.  At  the  end  of  two  days  the  external  jjortion  may  be  divided  about  1 
to  4  inches  from  the  skin,  after  which  a  catheter  is  })assed  along  its  lumen  and  the  stump 
tied  around  it.  This  serves  the  double  ])urpose  of  ])reventing  leakage  and  severing 
the  appendix  flush  with  the  skin.  The  catheter  is  introduced  from  2  to  4  inches,  and 
its  external  portion  left  open  to  allow  escape  of  gas,  or  doubled  and  fastened  to  prevent 
leakage,  as  circumstances  may  require.  Irrigation  may  be  begun  on  the  third  or  fourth 
day. 

When  the  aj)])endix  is  used  for  the  pur])ose  of  forming  an  artificial  anus  it  will  be 
probably  in  instances  where  there  is  more  of  the  emergency  element  ])resent,  and  it 
may  be  sufficient  then  to  sim])ly  utilize  it  for  the  purpose  of  anchoring  the  cecum  to  the 
abdominal  wall,  or  with  the  ])urpose  of  dilating  it  after  the  expiration  of  a  few  hours. 
In  other  words,  the  method  may  l)e  modified  to  meet  the  indication. 

It  is  scarcely  necessary  to  devote  space  to  any  other  operative  procedures  upon  the 
small  intestine.  Consecjuently  it  will  sim])ly  be  mentioned  here  that  the  upper  part  .of 
the  jejunum  can  be  used  for  artificial  feeding  and  jcjufio.siomi/  made  to  take  the  place 
of  gastrostomy  under  those  rare  circumstances  which  may  demand  it. 

Upon  the  large  intestine  coloprxi/  may  be  practised,  attaching  it  to  the  anterior 
abdominal  wall  or  to  the  border  of  the  liver  or  the  gastrohejiatic  omentum.  Andrews' 
suggestion  to  attach  the  colon  to  the  k)wer  border  of  the  liver,  after  certain  o|jcrations 
upon  the  biliary  passages,  will  be  described  in  connection  with  the  latter.  In  cases  of 
extreme  dilatation,  with  loss  of  muscular  tone,  etc.,  involving  especially  the  colon,  an 
enter oplication  may  be  practised  corresponding  to  gastroplication,  and  having  the  same 
purpose,  with  a  technique  practically  identical  with  the  other.  Thus  when  the  sigmoid 
flexure  is  so  dilated  as  to  largely  fill  the  abdominal  cavity,  with  an  enormous  S-shape, 
much  can  be  done  by  thus  reducing  its  dimensions,  the  only  objection  being  the  fear 
that  the  causes  which  produced  the  condition  will  conspire  to  reproduce  it  even  after 
enteroplication. 


CHAPTER    XL  IX. 

TUK  Ali'KNDIX  AND  ITS  DISEASES.' 

Anatomy. — I'lic  vcnnitoriu  apiH'iitlix  is  ;iii  cinhryoiiic  relic,  and,  like  all  siicli  remains, 
is  not  iiici'civ  su|)i"rflii()iis,  l)ut  ot'lcn  (roiihlcsonic.  That  at  some  time  it  may  liavc  had 
an  onliiiary  t'uiutioii  is  not  to  he  denied;  that  now,  in  (juadrupeds  at  least,  it  lias  one 
cannot  he  successiiiily  maintained.  Its  past  importance  may,  however,  he  perhajw 
indicated  hy  the  fact  that  in  the  ostrich,  for  instance,  it  is  said  to  assume  a  length  of  six 
feet.  Because  of  its  relatively  wide  variations  in  size,  len<^th,  and  em])lacement,  as  well 
as  because  of  its  mesenteric  and  other  anatomical  arrangements,  its  affections  are  often 
complicated  and  variable  in  the  synij)toms  they  j)roduce.  The  appendix  is,  in  fact,  a 
miniature  intestinal  tube,  having  the  same  structure  as  the  small  intestine,  though  but 
greatly  reduced.  Its  average  length  should  be  <S  to  9  Cm.,  the  shortest  on  record  l)cing 
1  Cm.,  and  the  longest  perhaps  21  Cm.  Its  average  gross  diameter  should  be  that  of 
a  No.  1()  Freiuh  catlu>ter,  but  it  ma)  be  found  1.5  Cm.  in  size.  The  average  diameter 
of  its  lumen  should  be  1  to  3  Mm.  The  appendicular  artery  is  given  off  from  the  right 
colic  braiuh  of  the  ileocolic  artery,  and  it  ordinarily  divides  into  four  or  five  branches, 
according  to  the  length  of  the  a})pendix  and  the  extent  of  its  mesentery.  It  derives 
its  nerve  supply  from  the  superior  uiesenteric  plexus  of  the  sympathetic  ganglia,  which 
itself  is  connected  with  the  right  pneumogastric,  this  fact  exj)laining  many  of  the  reflexes 
accompanying  its  diseases.  In  it  lymph  abounds  and  lymj)h  follicles  are  luuuerous. 
Around  its  neck,  as  art)untl  the  origin  of  every  other  embryonic  canal  (as  Sutton  has 
shown),  is  foimd  a  rullar  of  hjmplioid  H.s.nw  corresponding  in  structure  to  that  seen  in 
the  pharynx.  This  tissue  is  inflammable,  and  succumbs  easily  to  infection.  Hence 
probably  the  ajiparent  ease  with  which  infection  and  gangrene  occur  in  this  locality. 
The  position  of  the  appendix  is  variable,  and  depends  in  effect  on  the  development 
of  the  cecum  and  the  degree  of  its  rotation  during  this  process.  Its  most  frequent  loca- 
tion (40  ))er  cent.)  is  behind  the  cecum.  In  30  i)er  cent,  of  cases  it  occurs  on  its  anterior 
siu'face  or  just  at  its  lower  end.  It  may  lie  as  a  free  pouch  with  a  loose  mesentery, 
movable  in  the  abdominal  cavity,  (jr  it  may  be  essentially  a  retroperitoneal  affair  not  t)nly 

1  The  laity,  as  well  as  i)art  of  the  profession,  having  not  yet  ceased  to  wonder  at  the  great  importance  attacliing 
today  to  appendicitis, when  twenty  years  ago  it  was  practically  unknown,  it  is  worth  while  to  insert  here  the  following 
brief  historical  account:  The  term  "appendicitis"  was  coined  hy  Fitz  for  a  condition  which  had  not  been  hitherto 
unknown,  but  to  which  he  gave  a  classical  description.  That  the  appendix  might  be  i)rimarily  diseased  had  been 
known  for  one  hundred  and  fifty  years;  that  peri-appendicular  abscesses  were  frequent  may  be  seen  by  reference  to 
works  of  the  middle  and  latter  part  of  the  past  century  on  perityjjhlitis  and  perityphlitic  abscess,  Willard  Parker, 
of  New  York,  being  the  most  prominent  writer  of  his  day  upon  this  subject.  In  the  Traiisactions  of  Ihe  Midical 
Societi/  of  the  Slutc  of  New  York  for  1875,  Gouley  reports  a  case  of  so-called  perityphlitic  abscess  due  to  perfora- 
tion of  the  appendix,  with  remarks  upon  its  surgical  treatment.  The  curious  feature  attacliing  to  this  case  was 
that  two  years  previous  to  its  occurrence  the  patient  had  swallowed  one  of  his  teeth.  Although  this  tooth  was  not 
found  at  the  time  Gouley  alluded  to  the  possibility  of  it  or  any  other  small  body  lodging  in  the  appendix  and  finally 
causing  ulceration.  He  referred  also  to  the  ca.se  published  in  1856  by  Dr.  Lewis,  of  New  York,  who  reported  an 
individual  dying  at  the  age  of  eighty-eight,  whose  appendix  was  found  to  contain  one  hundred  and  twenty- 
two  deer  shot,  it  appearing  that  lie  had  Ijeen  exceedingly  fond  of  game;  he  supposed  that  the  shot  found  in  the 
appendix  were  cimtainod  in  meat  which  he  had  eaten.  Lewis  also  referred  to  forty-seven  cases  of  foreign  bodies 
which  he  tabulated,  all  but  one  of  which  died. 

Fitz's  article  ai)peared  in  18SG.  In  it  he  claimed  that  oiieration  should  be  done  much  earlier  than  was  then  the 
custom,  and  he  showe<l  that  34  per  cent,  of  these  cases  died  during  the  first  five  days  of  illness.  But  the  first  real 
operation  for  appendicitis  as  such  was  done  by  Krcmlein,  of  Zurich,  according  to  a  suggestion  made  by  Mikulicz 
in  1884.  The  second  was  done  by  Symonds,  in  lOngland,  in  1885,  this  being  an  interval  operation.  The  first  opera- 
tion in  the  Ignited  States  was  done  by  Hall,  of  New  York,  in  May,  1886,  although  to  Morton,  of  Philadelphia,  the 
credit  must  be  given  of  the  first  operation  in  this  country  on  a  case  deliberately  diagnosticated.  This  was  in 
April,  1887,  Sands  doing  the  next  one  in  December  of  the  same  year. 

McBurney  had  assisted  Sands  in  a  large  number  of  cases,  and  in  1889  published  his  classical  paper  with  an 
account  of  "The  First  Recorded  Case  where  an  .\cutely  Inflamed  .\i)pendix  had  been  Removed  while  Full  of  Pus." 
In  the  same  year  Weir  also  published  an  elaborate  paper,  making  similar  recommendations.  It  is  not  necessary 
to  follow  the  subject  later  than  the  year  1889,  since  to  it  every  surgeon  of  note  has  probably  contributed. 

{  851  ) 


"5152  SPECIAL  OR  Ri:(,I()SAL  SIRCF.UY 

not  free,  but  even  difficult  to  find.  In  direction  it  may  vary  correspondingly.  Tliu.s  it 
may  lie  behind  the  colon,  perhap.s  jx^inting  .straight  upward  toward  the  liver;  it  may 
hang  in  the  pelvis,  it  may  point  toward  the  sacrum,  or  it  may  coil  up  anteriorly;  and, 
according  to  the  extent  and  freedom  of  its  mesentery,  in  any  of  these  locations,  it  may 
cither  be  unattached  and  movable  or  fjuite  bound  down.  Again,  it  may  lie  nearly 
straight  or  it  may  be  kinked,  l)ent,  nr  i oiled.  It  is  necessary  that  the  surgeon  appreciate 
these  possible  variations,  for  they  account  for  vagaries  in  .symptomatology.  In  brief 
it  should  lie  in  the  iliac  fo.ssa,  at  least,  and  to  the  outer  side  of  the  iliac  vessels,  but  it 
mav  hang  over  into  the  pelvis  in  20  to  25  per  cent,  of  cases,  f)r  its  tip  may  rest  in  a  pocket 
or  even  in  a  subcecal  fo.ssa.  In  other  words,  it  may  be  found  in  almost  any  attitude  or 
position,  these  variations  being  explainable  by  peculiarities  of  fetal  development.  Fur- 
thermore it  may  even  have  its  own  diverticula,  as  has  been  recently  shown.  Normally 
it  should  be  practically  empty,  save  perhaps  for  a  little  muddy  mucus.  Very  frequently, 
however,  it  contains  fecal  matter,  and  upon  this  fact  depends  much  of  its  importance. 
If  from  retained  fecal  matter  fecal  concretions  gradually  result,  then  these  become  irri- 
tants and  may  produce  either  appendicular  colic  or  may  predispose  to  acute  infection. 
Upon  the  retention  of  fecal  contents  should  depend  also  a  miniature  peristalsis,  and 
imitation  of  what  goes  on  in  the  intestine  above,  in  the  production  of  a  genuine  appen- 
dicular colic.  How  annoying,  painful,  or  even  disabling  this  may  be  may  be  learned 
from  the  history  of  many  a  patient.  On  the  other  hand  the  appendix  may  become 
gradually  occluded  or  obliterated,  in  whole  or  in  part.  If  this  process  begin  at  its  distal 
end  and  involve  the  entire  tube  it  might  be  considered  a  fortunate  occurrence  for  the 
patient.  If,  however,  it  be  due  to  previous  inflammation,  or  to  subinvolution  of  the 
previous  process,  and  if  fecal  concretions  be  thus  imprisoned,  it  is  hardly  desirable  and 
will  frequently  lead  to  trouble.  More  or  less  occlusion  occurs  in  probably  at  least  one- 
fourth  of  mankind. 

Like  the  bowel  above,  the  appendix  may  suffer  in  various  as  well  as  in  similar  ways. 
Thus  in  it  may  be  seen  pathological  conditions  which  involve  the  bowel  proper.  Tuber- 
culosis and  actinomycosis  may  even  occur  here  as  apparently  primary  lesions,  while 
cysts  have  been  discovered  within  its  walls,  and  such  tumors  as  fibromyomas  or  primary 
adenocarcinomas  are  also  met  here.  I  have  seen  three  or  four  instances  of  primary 
cancer  of  the  appendix,  and  have  now  living  one  patient  from  whom  sLx  years  ago  I 
removed  an  appendix  and  adjoining  portion  of  the  cecum  involved  in  most  distinct 
cancer. 

Again,  the  appendix  participates  in  certain  hernias  and  has  been  found  in  instances 
of  strangulated  or  non-strangulated  inguinal  and  femoral  hernia,  and  has  been  seen 
also  in  cases  of  umbilical  hernia.  T\\ice  I  have  found  it  in  the  inguinal  canal  and  once 
in  the  femoral. 

Furthermore  when  diseased  the  appendix,  like  the  bowel,  may  contract  adhesions 
to  certain  \nscera,  while  it  is  now  well  known  that  it  may  attach  itself  to  the  kidney, 
the  bladder,  the  right  ovary,  the  tubes,  or  the  uterus.  This  is  of  more  than  mere  passing 
interest,  for  by  such  adhesions  cases  are  not  only  surgically  complicated,  but  diagnosis 
is  made  fliflfieult.  because  of  associated  symptoms  prjinting  to  the  organ  thus  involved. 
Foreign  Bodies  in  the  Appendix. — Foreign  bodies  are  occasionally  found.  This 
expression  refers  not  merely  to  the  fecal  concretions  above  mentioned,  whic-h  are 
practically  small  enteroliths.  Thus,  Kelly  has  mentioned  cases  in  which  ordinary  pins 
have  been  found  in  this  location,  two  of  these  cases  being  my  own.  In  one  instance 
I  found  the  appendix  to  contain  a  round-worm  at  least  three  inches  in  length,  and  other 
intestinal  parasites  have  been  found  by  other  observers.  The  laity  have  been  greatly 
impressed  by  the  reputed  frequency  with  which  grape  and  other  seeds  are  found  in  the 
appendix,  these  figuring  in  their  eyes  as  exciting  causes  of  disease.  In  truth  seeds  are 
seldom  found,  that  which  has  been  mistaken  for  them  being  fecal  concretions  of  various 
sizes  and  degrees  of  density.  I  have  foimd  actual  seeds  two  or  three  times,  but  probably 
not  oftener. 

Bacteriology  of  Appendicitis. — Acute  appendicitis  being  essentially  an  acute 
infection  one  inquires  naturally  which  are  the  organisms  most  commonly  involved. 
Answer  to  this  question  should  be  sought  rather  in  the  text-bof)ks  on  pathology,  and 
should  be  summarized  here  by  simply  saWng  that  the  colon  bacillus  is  perhaps  more  often 
found  in  connection  with  these  cases  than  any  other  one  organism.  Streptococci  and 
staphylococci  rank  perhaps  next  in  frequency,  while  the  pneumococcus,  the  capsule 


PLATE   L( 


>y.^A- 


Illustrating  Various  Degrees  of   Involvement  cf  Appendix  Vermiformis.      (Richardson.) 


.4.   Chronic,  recurring. 

B.  Chronic,  much  thickened. 

C.  Acute,  with  necrosis  and  rupture. 


D.  Showing  necrosis  of  mucous  membrane. 

E.  Gangrene  and  perforation,  permitting  fecal  extrava^<ation. 
/'.   Total  gangrene  without  i)erforation. 


THE  Al'l'ESDlX   AM)  ITS  DISK  ASKS  853 

CDccus,  and  all  of  tlir  other  pyotjc'iiif  fonns  may  he  present,  either  as  eontaininations 
or  in  almost  pure  cultures.  The  fauna  and  Mora  of  the  intestinal  tract  afl'ord  am|)le 
opportunities  for  contaminations  with  many  forms  of  microbes.  If  pus  found  here  he 
a  puri"  culture  of  any  one  ort;anism  it  is  most  often  of  the  colon  variety,  which  is  known 
to  vary  nuich  in  virulence,  even  when  occurrinji;  alone.  Mixed  infections,  however, 
are  more  predominant  and  more  serious,  especially  in  proportion  as  tiie  more  active 
pyoji;enic  ori;anisms  apj)ear  in  j^reater  numbers.  The  hacterioloiry  of  appendicitis  is 
then  of  «;reat  patholo<rical  interest,  hut  concerns  the  surgeon  very  slitjhtly,  unless  lie 
have  to  do  with  some  |)cculiar  form,  such  as  pyoeyaneus,  or  a  particularly  virulent 
stn'ptococcus. 

Appendicular  Colic. — Sufficient  has  l)een  said  al)ove  regarding  the  appendi.x  as  a 
miniature  intestine,  its  outlet  guarded  hy  the  little  valve  of  (ierlach,  to  afi'ord  an  ana- 
tomical reason  why  conditions  even  in  the  larger  bowel  should  be  imitated  here.  Some 
writers  have  not  placed  as  nuich  stress  upon  appendicular  colic  as  I  would  here.  (Jne 
sees  many  instances  of  it  if  he  will  only  recognize  it,  the  frequency  of  its  occurrence 
not  only  disturbing  the  comfort  of  patients,  but  keeping  ever  before  their  luinds  the 
necessity  for  operation.  An  absolutely  empty  appendix  will  be  free  from  all  abnormal 
activity  of  this  kind,  but  when  a  little  fecal  matter  has  become  imprisoned,  and  when 
by  its  long  retention  fecal  concretions  have  formed,  they  may  give  rise  to  considerable 
disturbance  without  actually  producing  inflammation,  the  former  being  due  to  the 
spontaneous  eti'ort  of  the  ap|)en(lix  to  expel  them.  This  effort  may  be  excited  by  other 
conditions  in  the  bowel  adjoining,  but  by  itself  it  may  be  the  essentially  relatively  violent 
muscular  effort  which  produces  pain  and  is  followed  by  soreness.  That  not  a  few  cases 
of  acute  ai)pendicitis  commence  with  an  appendicular  colic  is  extremely  probable,  and 
that  it  may  occur  at  frequent  intervals  and  never  pass  the  colicky  stage  is  equally  true. 
Appendicular  colic,  then,  may  be  a  precursor  of  an  iyijectious  appendicitis,  acting  as  a 
predisposing  cause,  or  either  may  occur  independently  of  the  other. 

Indications  of  this  form  of  colic  are  frequent,  viz.,  nagging  pains  in  the  region  of  the 
cecum,  which  may  last  a  few  moments  or  a  few  hours  and  then  subside,  leaving  a  tender- 
ness which  persists  for  a  day  or  two,  after  which  the  patient  seems  to  be  free  for  a  longer 
or  shorter  interval,  to  suffer  again  and  again  in  the  same  way.  These  attacks  may  be 
accompanied  by  some  nausea,  will  be  found  frequently  associated  with  whatever 
may  have  disturbed  ordinary  intestinal  activity,  and  may  even  produce  a  mild  degree  of 
fever,  which  latter  is  partly  due  to  mental  perturbation  and  partly  to  a  mild  degree  of 
toxemia,  the  latter  being  possible  in  connection  with  abnormal  appendicular  activity, 
as  the  appendix  itself  is  a  closed  sac  and  the  very  materials  which  it  is  trying  to  expel 
may  furnish  the  toxins. 

It  is  di^cult  to  distinguish  between  appendicular  colic  and  mild  attacks  of  catarrhal 
aj)])endicitis.  The  transitory  nature  of  the  former  is  its  particular  diagnostic  feature, 
c(Ui|)le(l  with  absence  of  all  lasting  indications. 

The  following  would  seem  the  simplest  working  classification  of  lesions  of  the  appendix. 

f  Catarrhal.      Endo-appendicitis. 
Diffuse.  Parietal  or  interstitial.  .\1?''''P  ^.^  ' 


Intertubular. 
.1.   Acute.  -j  Purulent.    \    lutraniural. 


( )l)literative. 

I  (.  Peri-appendicular. 

I  Any  ot  these  may  lead  to 

I  Gangrenous  or 

[  Perforative  lesions. 

B.  Subacute.  Recurrent  or  relapsing. 

C.  Adhesive  or  ol)literative. 

Almost  any  of  the  above  forms  may  be  associated  with  diseases  of  other  abdominal 
viscera,  as,  for  example,  with  typhoid.  Thus  out  of  119  autopsies  on  typhoid  patients 
19  showed  changes  in  the  appendix  corresponding  to  those  produced  by  the  typhoid 
organisms  in  other  portions  of  the  intestines.  (Kelly.)  Of  3770  autopsies  on  tuberculous 
patients  tuberculous  lesions  were  noted  in  the  appendix  in  44  instances.  The  appendix 
may  also  become  involved  with  any  form  of  ileocolitis,  either  in  the  young  or  in  the 
adult.  Again  an  infection  of  the  right  tube  and  ovary  may  easily  extend  to  and  involve 
the  appendix,  just  as  infection  may  travel  in  the  opposite  direction.     (See  Plate  LI.) 


854  SPECIAL  OR  REGIONAL  SURGERY 

Before  discussing  the  causes  of  this  condition  it  is  aflvisable  to  take  a  comprehensive 
view  of  the  entire  subject  in  its  patholoi^ical  rehitions.  As  Dicuhd'oy  has  shown,  appendi- 
citis is  the  consequence  of  the  transformation  of  tlie  iiollow  conchiit  into  a  closed  cavity, 
whose  length  and  narrowness  make  it  Hable  to  such  changes,  for  which  various  causes 
are  to  be  assigned:  for  example,  the  formation  of  calculi  or  concretions  which  are  quite 
comparable  to  renal  or  biliary  and  which  lead  to  a  true  appendicular  lithiasis.  There 
is  even  reason  to  believe  that  a  calculous  appendicitis  may  be  hereditary  and  belong 
to  the  patrimony  of  gout.  At  other  times  it  is  the  consecpience  of  local  infection, 
followed  by  tumefaction,  and  corresponding  to  obstruction  of  the  Eustachian  or  the 
Falloi)ian  tubes.  Again  it  results  from  slow,  ])rogressive  fibrous  alterations  or  from 
the  strangulations  due  to  twisting  or  formation  of  adhesions.  In  any  event  the  closed 
cavity  varies  in  size  and  shape,  and  <loes  not  necessarily  lead  to  self-destruction  unless 
the  bacteria  thus  pent  up  are  sufficiently  virulent.  At  all  events  the  attack  declares 
itself  only  when  the  cavity  is  actually  closed,  and  it  is  then  that  imprisoned  bacteria, 
previously  harmless,  multiply  and  intensify  their  virulence,  as  they  do  in  a  blocked  loop 
(jf  bowel.  At  times  an  acute  intoxication  from  toxins  is  produced,  and  may  be  so  pro- 
noimccd  that  j)atients  succumb  to  it  almost  before  the  characteristic  lesions,  or  any 
local  peritonitis,  has  become  fairly  outlined.  On  the  other  hand  if  retained  bacteria  be 
but  slightly  virulent,  or  have  been  successfully  concjuered  by  ])hag()cytcs,  or  if  the  canal 
has  become  pervious  again,  the  attack  may  sj^ontaneously  subside,  although  there 
is  great  probability  of  recurrence.  In  many  instances  the  infection  ends  in  ulceration, 
abscess,  gangrene  or  perforation,  all  of  which  may  give  rise  to  peritonitis  of  varying 
extent  and  severity.  Germs  may  traverse  the  walls  of  an  affected  appendix  without 
perforation.  It  may  then  become  the  direct  cause  of  peritonitis,  septicemia,  or  hepatic 
abscess. 

Recurrent  Appendicitis. — Even/  aUdHc  of  appendicitis,  vo  maltrr  how  mild,  pre- 
di.s-pu.se.s-  to  a  rr  pet  it  ion  of  the  trouUe,  in  mihl  or  in  fuJminatinrj  form.  Every  appendix 
once  inflamed  has  had  its  l)lor)d  supply  comjiromised  and  may  break  down  easily  upon 
a  second  attack.  While  not  every  patient  who  has  once  suffered  in  this  way  should 
necessarily  suffer  again,  the  majority  who  have  had  one  attack  may  have  another.  No 
one  can  be  ])ro|)hetic  in  this  regard  and  no  one  may  truly  assert  that  several  mild  attacks 
may  not  be  followed  by  another  most  severe.  That  an  appendix  has  been  once  inflamed 
is  sufficient  to  justify  its  subsequent  removal.  That  it  has  been  several  times  involved 
makes  operation  next  to  imperative.  Even  repeated  attacks  of  appendicular  cf)lic  pre- 
dispose to  trouble  in  this  region.  In  any  a]i})endix  which  has  in  this  way  frequently 
excited  suspicion,  or  which  gives  rise  to  frequently  recurring  though  mild  colicky  pain 
and  local  tenderness,  es])ecially  when  coupled  with  mild  stercoremia,  indications  are 
for  removal.  It  may  be  safely  laid  down,  then,  as  a  rule,  to  which  there  should  be  few 
exceptions,  that  any  appendix  which  causes  frerpientlij  recurrincj  or  almost  continurnis 
trniilJf  should  he  removed. 

Causes. — It  is  impossible  in  any  brief  summary  to  include  all  the  possible  causes  of 
appendicitis.  Those  mentioned  below  are  perhaps  those  most  commonly  recognized 
or  pronounced,  yet  the  list  is  far  from  complete.  First  of  all  it  should  be  remembered 
that  the  disease  occurs  in  a  vestigial  organ,  containing  relatively  considerable  lymplu)id 
tissue,  especially  aromid  its  neck,  that  it  is  comparatively  poorly  su})plied  with  blood, 
and  that  such  tissue  under  such  circumstances  inflames  easily  and  breaks  down  f|uickly. 
Doubtless  the  trouble  in  some  instances  connnences  within  the  tiny  intestinal  tube. 
At  other  times  its  originating  cause  lies  without,  as,  for  instance,  when  its  blood  supply 
is  interfered  with  by  pressure  of  an  overloaded  cecum,  by  tumors,  or  by  violent  intestinal 
activity;  this  especially  in  connection  with  an  appendix  firmly  anchored  and  not  freely- 
movable,  it  being  so  fixed  in  many  instances  that  it  cannot  readjust  itself  easily  to 
varying  conditions.  Thus  an  overloaded  cecum  may  first  press  upon  the  appendix  and 
then  by  violence  of  activity  so  displace  it  that  it  may  easily  succumb.  Again  in  those 
appendices  which  hang  downward  into  the  pelvis  there  is  little  or  no  drainage  by  gravity, 
and  they  may  easily  become  overloaded.  A  movable  kidney  may  also  disturl)  the 
integrity  of  an  ap])endix  in  certain  locations.  Foreign  bodies  frecpientlv  excite  pernicious 
activity,  es])ecially  fecal  concretions,  and  actual  calculi  or  miniature  enteroliths.  Trau- 
matism sustains  a  certain  relation  to  some  cases  of  violent  activity  of  the  ])soas  muscles 
in  athletes,  which  may  upset  the  circulation  of  appendices  which  lie  directly  upon  the 
muscles  involved. 


THE  APPENDIX  AND   ITS  DISEASES  855 

Many  of  the  causes  mentioned  above  are  j)re(lis|)osin(i;  rather  than  actual.  The 
actual  excitini;  causes  of  acute  infection  have  mainly  to  do  with  (/rnii  aciivilij  and  with 
vascular  .s'lipp/i/.  It  is  well  known  that  the  more  virulent  (he  or<raiiisms  the  more  acute 
the  resultiiifi;  in.llanunation,  and  it  is  also  well  known  that  colon  bacilli  and  the  ordinary 
|)yo<i;enic  ort^anisms  vary  in  virulence  within  wide  limits,  and  that  mixed  are  often  more 
acute  than  simple  infections.  Typhoid  bacilli,  tuberculous  bacilli  and  the  like  vary 
in  the  sanu>  way,  and,  in  c()m|)any  with  other  (rerms,  may  easily  li<>;ht  up  seriou.s  dis- 
tnrliancc. 

Complications.  ()f  the  complications  whicli  may  accompany  or  ensue  upon 
a|)pcndicitis  the  most  common  are  those  which  involve  tiie  peritoneum,  either  local  or 
iijeneral.  Acute  j)eritonitis  is  to  be  feared  not  only  because  of  its  autotoxic  expressions, 
but  because  of  the  acute  obstruction  which  it  may  j)r()duce  by  f2;luinfj  intestinal  loops 
together  and  paralyzino;  their  motility.  When  to  more  or  less  widespread  peritonitis 
are  added  jijeneral  sepsis,  with  all  its  possible  com])lications,  and  such  further  local 
cxjiressions  as  cellulitis,  which  may  be  ])ericolic,  sul)j)hrenic,  ])erineal,  or  pelvic,  or 
})hlebitis  which,  involvinfi^  the  portal  system,  would  soon  lead  to  formation  of  hepatic 
abscess,  it  will  be  seen  how  easily  the  case  may  become  serious.  Furthermore  not 
only  may  the  ovary  and  tube  suffer,  but  cystitis  and  nephritis  may  occur  as  toxic  com- 
plications, while  finally,  by  violence  of  the  ulcerative  process,  a  fecal  fistula  may  form. 
This  is  by  no  means  a  complete  list,  but  includes  some  of  the  more  frecjuent  complica- 
tions. 

Symptoms  of  Acute  Appendicitis. — Pain  v^iih  navsea,  iendemcfis,  and  rifjldifi/ 
constitute  the  triad  of  tlu'  most  indicative  early  signs  and  symptoms,  each  of  which  needs 
to  be  considered  l)y  itself. 

Pain. — Pain  is  at  the  same  time  an  important  yet  yarial)le  feature.  In  few  other  acute 
lesions  does  it  vary  as  much  in  degree  and  location.  Generally  it  is  referred  at  first  to 
the  more  central  portion  of  the  abdomen,  as  around  the  navel  or  between  it  and  the  right 
side  of  the  pelvis.  Later  it  may  be  localized  at  some  widely  distant  point,  as,  for  instance, 
far  over  upon  the  left  side.  Such  vagaries  may  be  held  to  be  due  to  peculiarities  of 
emplacement  of  the  appendix,  and  would  indicate  that  the  organ  will  probably  not  be 
foand  in  its  most  common  location,  l)ut  rather  extending  to  the  left  or  hanging  over  into 
the  pelvis.  \Yhen  the  appendix  is  attached  to  or  lies  near  the  bladder  there  may  be 
considerable  pain  in  the  pelvis  and  in  the  bladder.  It  should  be  remembered  that 
the  parietal  peritoneum  is  much  more  sensitive  than  the  visceral,  and  in  proportion  as 
the  lesion  approaches  the  surface  more  exact  information  may  be  gathered  from  location 
of  pain.  Occasionally  it  may  be  referred  to  the  region  of  the  gall-bladder,  or  even  to 
the  chest  above  the  diaphragm.  In  some  instances  it  is  agonizing,  almost  from  the 
outset;  in  others  it  is  never  very  severe.  The  ra])idity  of  the  process  may  be  measm-ed 
to  some  extent  by  the  intensity  and  character  of  the  pain.  When  the  disease  resolves 
slowly  and  kindly  pain  rjraduaUij  subsides,  but  the  sudden  subsidence  of  pain,  especially 
without  equal  improvement  in  other  respects,  is  a  had  rather  than  a  good  sign,  indicating 
probably  that  perforation  has  occurred. 

Tenderness. — Tenderness  is  a  more  constant  and  persistent  and,  therefore,  a  more 
reliable  indication  than  pain,  and,  as  well,  less  misleading.  No  matter  where  the  patient 
may  seem  to  feel  pain  the  actual  tenderness  will  indicate  the  location  of  the  appendix 
itself.  Thus  even  if  pain  on  the  left  side  be  severe,  tenderness  will  not  accompany 
it,  but  will  be  found  centred  at  the  location  of  the  appendix.  This  is  a  fact  of  great 
importance.  In  his  first  |)aper  on  appendicitis  jNIcBurney  showed  that  the  appendix 
is  most  commonly  located  at  a  point  beneath  a  line  drawn  from  the  umbilicus  to  the 
anterior  superior  spine  and  one  and  a  half  or  two  inches  away  from  the  latter.  This 
has  since  been  known  as  McBurney's  point.  To  it,  however,  too  much  importance 
should  not  be  attached,  since  the  appendix  is  often  not  found  under  this  area,  and 
tenderness  may  be  found  at  a  distance  two  or  three  inches  away  from  it.  Over  the 
actually  tender  area  the  skin  will  also  be  hypersensitive,  and  this  intense  hyperesthesia 
is  also  an  indication  of  considerable  value. 

Rigidity  and  Muscle  Spasm. — Rigidity  and  muscle  spasm  are  to  be  carefully  studied,  and 
upon  them  much  reliance  may  be  ]>laced.  With  the  first  onset  of  |)ain  they  may  be  general, 
but  they  usually  become  more  and  more  localized,  unilateral,  and  finally  limited,  save 
ill  those  instances  where  general  peritonitis  has  begun  and  is  spreading.  For  instance, 
Richardson   regards  it  in  this  light:    "Rigidity  with  distinctly  localized  pain  strongly 


856  SPECIAL  OR  REGIONAL  SURGERY 

suggests  iij)])riuli(itis;  with  IVvrr  it  almost  |)r()\('s  it;  witii  tumor  it  I'ully  ('stal)lisli('s  diag- 
nosis." Wlieu  to  ordiiuiry  ahdoiuiiial  rigidity  is  added  actual  nuiscle  sj)asni,  j)rovokod 
by  even  light  palpation,  and  oceurriiig  in  the  rectus  or  one  of  the  fiat  nuiscles  lying  in 
close  relation  to  the  apj)eiidix,  then  a  still  more  important  indication  has  been  obtained. 
When  true  muscle  spasm  involves  all  the  alxlomitial  musculature  general  ])eritonitis 
has  probably  begun. 

Tumor. — "^rhe  presence  of  tumor  in  the  suspected  area  will  nearly  always  be  a  corrobora- 
tive sign,  but  diagnosis  should  not  dc|)en(l  upon  its  ])resencc.  It  is  hardly  to  be  looked 
for  tluring  the  early  hours  or  perhaps  days  of  an  ordinary  attack.  It  niay  be  due  to 
fecal  ini])acti()n  in  the  cecum,  to  outpour  of  exudate,  to  binding  together  of  omentum  and 
intestine,  or  to  the  presence  of  j)us.  If  a  considerable  mass  can  be  detected  within  the 
cecum  during  the  early  hours  of  an  attack  this  should  be  regarded  rather  as  an  expression 
or  co})rostasis  and  impaction,  to  which  the  attack  itself  may  be  due.  Tumor,  there- 
fore, is  significant  when  present,  while  in  some  instances  its  absence  is  still  more  so. 

Vomiting. — Vomiting  is  an  irregular  and  uncertain  feature.  Probably  the  majority 
of  cases  begin  with  nausea  (after  the  Initial  pain)  or  with  vomiting,  either  one  without 
the  other,  or  with  both  combined.  Likely  through  the  course  of  the  disease  vomiting 
may  be  an  occasional  disturbing  element,  though  patients  may  have  no  nausea  whatever. 

Bowels. — The  condition  of  the  bowels  and  their  behavior  will  depend  very  much  upon 
their  actual  state  at  the  moment  of  attack.  Some  attacks  seem  precipitated  by 
violent  intestinal  activity;  here  diarrhea  or  dysentery  will  be  an  early  feature.  Others 
are  precipitated  rather  by  overloading  of  the  cecum;  in  these  cases  constipation  would 
be  a  well-marked  feature.  Bowel  inactivity  is  to  some  extent  an  expression  of  bowel 
paralysis  due  to  toxemia,  w'hich  in  some  instances  is  profound,  in  others  slight. 

Temperatmre, — The  temjierature  is  also  a  variable  and  uncertain  feature.  It  may 
be  normal  at  first  or  veiy  high.  At  any  time  it  may  rise  gradually  or  suddenly,  and 
may  subside  in  the  same  atypical  way.  Taken  by  itself  it  is  an  unreliable  feature. 
When,  however,  temperature  steadily  rises  the  surgeon  may  take  alarm,  and  if  the  pulse 
rate  goes  up  correspondingly  the  case  takes  on  a  serious  aspect.  A  sudden  fall  of 
temperature  is  almost  as  serious  a  feature  as  a  sudden  rise.  A  normal  or  subnormal 
temperature  may  be  seen  when  a  large  amount  of  pus  is  present,  or  but  a  minimum  of 
disturbance  may  be  found  when  operating  upon  a  patient  whose  temperature  is  104°. 

The  Pulse. — The  pulse  is  a  more  reliable  guide  than  any  obtained  with  the  ther- 
mometer, its  rapidity  being  proportionate  to  the  gravity  of  the  disturbance.  A  con- 
stantly ruing  pulse  is  a  serious  indication,  especially  if  accompanied  by  vagaries  of 
temperature.  Some  operators  regard  the  pulse  as  a  sufficient  indication  for  o])eration, 
holding  that  when  it  rises  above  112  operation  should  be  made.  I  hold  this  to  be  a 
good  rule,  but  would  not  have  it  interpreted  as  indicating  that  o})eration  should  not  be 
done  unless  the  pulse  attains  this  figure,  and  believe  that,  no  matter  what  the  other 
conditions,  the  final  indication  has  arrived  when  the  pulse  goes  above  112. 

Abdominal  Distention. — Abdominal  distention  may  be  due  to  gas  formation,  to  con- 
stipation, or  may  indicate  the  paralysis  of  peristalsis.  When  it  becomes  well  marked 
it  is  a  serious  indication,  and  when  toxemia  is  profound  no  sound  whatever  will  be  heard 
within  the  bowels  thus  distended.  It  usually  indicates  the  onset  of  general  })eritonitis. 
It  is  unfortunate  in  more  than  one  respect,  since  intra-abdominal  conditions  are  masked 
by  it  and  operation  complicated,  it  being  sometimes  impossible  to  restore  the  bowel  to 
the  abdomen  without  at  least  partially  emptying  it. 

Jaundice. — Jaundice, when  occurring, is  a  toxic  expression,  possibly  due  to  temporary 
obstruction  of  distended  or  paralyzed  bowels. 

Finally  the  general  appearance  of  the  j)atient  will  be  suggestive,  patients  with  serious 
conditions  having  always  an  anxious  or  haggard  facial  expression,  rarely  moving  them- 
selves easily  or  freely  in  bed,  or  smiling  at  anyone  or  anything,  their  faces  being  perhaps 
somewhat  flushed,  their  expression  and  action  being  apathetic,  while  perhaps  later 
there  will  be  delirium  with  restlessness.  When  the  face  is  pinched,  the  eyes  sunken,  the 
nose  sharp,  the  skin  dusky,  and  respirations  rapid  and  unsatisfying,  as  well  as  of  thoracic 
type,  any  intra-abdominal  infection  may  be  regarded  as  serious  and  unpromising. 

What  shall  be  said  about  the  value  of  the  blood  count  f  It  is  possible  in  nearly  every 
instance  to  make  a  diagnosis  of  appendicitis  without  the  aid  of  the  microscope,  as  well 
as  even  to  judge  of  the  advisability  of  immediate  or  ])ostponed  o])eration.  Nevertheless 
an   intlicative  difl'erential   blood   count,  an  afhrmative  result  of  the  iodine  test,  or  the 


Till-:  .\ppE\i)ix  A\f)  ITS  i)ish'.\s/:s  ^57 

(liscovrrv  ol'  iiulicaii  iii  llir  iiriiic,  may  ail'onl  |)ositi\c  corrolxtralioii  in  cusi's  wlicrc  doubt 
may  have  existed.  In  rcalily,  liowcvcr,  any  case  which  will  furnish  satisfactory  and 
distinct  nvsponscs  to  these  tests  should  he  rccopiized  without  them.  A  leukocyte  count 
above  IJ.OOO,  in  coinu'ction  witli  t)ther  indications,  is  usually  suflicicnt  to  justify  opera- 
tion. .\  very  hi^h  leukocytosis — c.  (/.,  above  24,()()()  is  a  matter  of  <rrcat  importance. 
In  the  more  chronic  cases  the  leukocytosis  is  but  sli<j;ht. 

Diagnosis.  ()b\ious  and  indicative  as  many  cases  of  acute  appendicitis  are  from 
the  outset,  tiiere  are  still  others  when  one  may  l)e  in  serious  (ioul)t,  even  for  sonic  davs, 
either  because  patients  do  not  clearly  state  their  own  sym])toms,  becau-se  of  |)eculiar 
reference  of  |)ain,  or  because  of  the  co-existence  of  complications,  each  of  which  may 
mask  the  other. 

(U)liti.s-  of  a<lults  and  rntrroroliti'i  of  children  will  j)roduce  sometimes  severe  attacks 
of  pain,  with  cramps  and  local  tenderness,  that  may  at  first  mislead.  There  is  a  form 
of  nnicoiiM  rolifi.s-  which  is  now  more  generally  recotj;nized  than  in  time  past,  in  which 
diagnosis  is  sometimes  ([uite  difficult.  The  onset  is  often  sharj),  while  the  rif^ht  iliac 
fossa  may  be  occui)ied  by  an  elonjijated,  resistant,  tender  mass,  showiiifj  fecal  imj)action 
within  the  cecum.  On  the  other  hand  the  same  condition  may  be  met  in  the  left  iliac 
fossa,  and  will  thus  indicate  that  the  sigmoid  is  especially  at  fault.  In  these  conditions 
there  is  often  actual  exudate  around  the  inflamed  bowel,  and  this  may  even  break  down; 
it  is  proper  then  to  speak  of  a  circumscribed  colitis-,  and  there  is  reason  to  think  that  in 
certain  cases  it  arises  from  infection  of  a  diverticulum  from  the  large  bowel.  The  pain 
is  not  infrequently  complained  of  at  the  so-called  ^IcBurney  point.  In  not  a  few 
instances  the  apj)endix  has  been  removed  when  under  perfectly  natural  suspicion,  and 
found  so  slightly  involved  as  to  show  that  the  actual  trouble  was  in  the  cecum  rather  than 
in  the  appendix  itself.  Dieulafoy  believes,  in  fact,  that  formerly  the  cecum  was  made 
too  much  of  and  the  appendix  disregarded,  while  today  these  conditions  are  sometimes 
reversed. 

From  (jallstone  disease  and  cholecystitis  its  symptoms  are  sometimes  quite  difficult  to 
distinguish.  Especially  is  this  true  when  pain  is  not  accurately  localized,  and  when, 
on  the  other  hand,  muscle  spasm  and  tenderness  are  widespread.  The  jirevious  his- 
tory of  the  case  will  give  much  aid  in  this  matter,  while  the  pain  in  gallstone  trouble 
radiates  rather  toward  the  right  shoulder,  in  appendicular  disease  toward  the  uml)ilicus 
or  downward.  When  dulness  on  percussion  shades  directly  into  liver  tlulness  the 
gall-bladder  is  natiu'ally  the  more  to  be  suspected.  When  patients  themselves  cannot 
make  minute  distinctions  in  description  of  pain  and  tenderness  the  condition  may  be 
difficult  of  recognition. 

Peritonitis. —  The  majority  of  all  attacks  of  so-called  idiopathic  'peritonitis  spring  from 
appeudirnlar  disease,  at  first  and  perhaps  throughout  unrecognized.  A  condition  of 
jwritonitis,  then,  for  which  other  explanation  is  not  found  may  be  considered  as,  in  all 
probability,  due  to  appendicitis  whose  peculiar  features  may  have  been  masked.  It 
is  not  <lifficult  to  recognize  a  condition  of  general  peritonitis.  The  great  difficulty  is 
to  ascribe  its  j^roper  cause.  As  already  and  elsewhere  indicated  these  conditions  merge 
into  expressions  of  acute  obstruction  which  still  further  coni})licate  the  case,  and  it  is 
by  no  means  infrequent  to  have  this  order  of  events:  an  acute  gangrenous  appendicitis 
followed  by  local  peritonitis,  with  adhesions,  which,  becoming  dense,  ra])idly  ])roduce 
obstructive  symptoms,  the  condition  going  even  farther  and  gangrene  spreading  from 
the  apjiendix  proper  to  any  or  all  of  those  intestinal  loops  which  come  in  contact  with 
the  primary  focus,  so  that  when  the  condition  is  thoroughly  revealed  it  is  found  to  be  one 
of  multi])le  gangrene  of  the  bowel  as  well  as  of  fierce  and  septic  peritonitis. 

Gastric  and  intestinal  ulcers  imth  perforation  are  easily  mistaken  for  appendicitis, 
especially  when  the  duodenum  is  involved.  In  at  least  half  of  the  recorded  cases  of  j^er- 
fo rating  duodenal  ulcer  the  condition  has  been  at  least  at  one  time  supposed  to  be  oiu' 
of  acute  appendicitis,  while  after  perforation  has  occurred  and  the  matter  which  has 
escaj)ed  has  worked  its  way  down  toward  the  right  iliac  fossa  the  similarity  of  conditions 
will  be  all  the  more  striking.  If  an  accurate  history  can  be  obtained  there  will  probably 
be  learned  from  it  that  which  will  tend  to  avoid  mistakes.  The  exceedingly  abrupt  and 
acute  onset  of  symptoms  will  also  be  more  pronounced  than  in  most  cases  of  commencing 
a])i)endicitis.  This  is  true  also  of  the  perforations  of  typhoid  ulcer,  especially  of 
"walking  typhoid."  While  acute  ap))endicitis  during  the  course  of  typhoid  is  by  no 
means  unknown,  the  abrupt  onset  of  pain,  rigidity,  and  tenderness  during  the  third 


858  SPECIAL  OR  REGIONAL  SURGERY 

wcrk  or  liiter  would  suggest  porfonition  very  much  more  than  the  possihihty  of  an  appen- 
dical   lesion. 

Acute  oLsirurtion  of  the  bowel  due  to  other  causes  than  appendicitis — e.  g.,  volvulus  or 
intussuscejjtion — might  give  rise  to  symptoms  which  would  be  regarded  as  indicating 
appendicitis.  This  is  true  also  of  .s-tnun/ulated  hernias,  especially  the  internal  forms, 
since  there  will  be  no  excuse  for  failing  to  discover  an  external  strangulation  of  this 
kind.  Lend  eolie  may  simulate  some  of  the  milder  and  more  chronic  forms  of  appen- 
dicitis, from  which  it  should  not  b(>  difficult  to  exclude  it  by  its  history,  the  occupation 
of  the  {)atient,  and  the  a|)j)earance  of  the  gums. 

The  kidtieijs  and  ureters  are  sometimes  so  involved  as  to  occasion  doubt.  A  floatiinj 
kidiieij,  with  its  ])()ssible  crises,  (lis])laced  into  the  right  iliac  fossa,  where  it  might  be 
mistaken  for  an  iiiHammatory  mass,  might  thus  cause  some  hesitation.  So  also  might 
the  acutely  sup])urative  forms,  the  formation  of  a  sudden  phlegmon  about  the  kidney, 
or  the  entanglement  of  a  calculus,  either  at  the  hilum  or  along  the  ureter,  produce  severe 
})ain,  tenderness,  and  fever,  which  would  at  first  easily  perplex.  The  pain  of  renal  colic, 
however,  is  usually  more  agonizing,  begiiuiing  in  the  flanks  and  referred  down  along 
the  ureters  to  the  genitals  and  the  inner  side  of  the  thigh.  It  may  also  be  intense  in  the 
back,  and  may  be  accompanied  by  nausea  and  vomiting.  Renal  colic  is  also  nearly 
always  accomj)anied  by  frequent  urination  and  sometimes  by  the  appearance  of  blood 
in  the  urine.  With  an  impacted  calculus  at  the  lower  end  of  the  ureter  at  the  level 
of  the  ap])endix  diagnosis  may  be  very  difficult.  Here  the  .r*-rays  may  afford  some 
assistance. 

Acute  pancreatitis  begins  with  intense  abdominal  pain  that  may  at  first  suggest  appen- 
dicitis. The  pain,  however,  is  usually  epigastric;  abdominal  distention  comes  on  early; 
vomiting  may  l)e  profuse,  and  the  tenderness  is  most  marked  along  the  left  costal  border. 
There  is,  moreover,  a  more  profound  prostration,  sometimes  accompanied  by  cyanosis. 
An  acute  suppurative  pancreatitis  may  soon  l)e  followed  by  peritonitis,  which  when 
seen  will  so  completely  mask  all  synijitoms  that  diagnosis  as  between  the  two  is  quite 
imjiossible,  but  symptoms  which  can  be  accurately  localized  will  usually  point  to  the 
n|)per  rather  than  to  the  lower  abdomen. 

Mesenteric  thromhosis  and  erulxdism  are  rare  conditions  which  commence  usually  with 
fulminating  symptoms  and  produce  intense  agony,  with  tenderness  and  rigidity  all  over 
the  abdomen.  Their  onset  is  so  profound  that  patients  fall  into  a  condition  of  extreme 
collapse  within  the  first  few  hours,  and  their  tendency  is  so  rapidly  to  the  bad  that  they 
are  not  likely  to  be  mistaken  for  acute  appendicitis. 

The  pelvic  viscera  of  women  also  furnish  acute  inflammations,  such  as  pi/osalpin.r, 
with  or  without  rupture,  that  sometimes  precipitate  very  acute  symptoms  which  may 
point  to  the  abdomen  rather  than  to  the  pelvis.  In  many  of  these  instances  the  a])pendix 
is  more  or  less  adherent  to  the  adnexa  on  the  right  side,  and  infection  in  eitlu>r  one  may 
easily  travel  to  the  other,  so  that  both  become  ultimately  involved.  Ix)cal  examination 
will  reveal  the  existence  of  pelvic  conditions,  in  whose  absence  there  may  be  justifi- 
cation for  inferring  that  the  trouble  has  not  originated  in  that  cavity. 

Ruptured  extra-uterine  pregnnnci/  has  been  in  numerous  cases  mistaken  for  acute 
appendicitis.  It  usually  begins  with  violent  pain  and  pronounced  muscle  spasm,  with 
more  or  less  shock.  I  have  repeatedly  been  called  to  o])erate  for  appendicitis  and  found 
the  other  condition  present.  The  operator  may  be  prepared  to  find  it  if  he  elicit  a  sug- 
gestive history  or  if  a  vaginal  examination  reveals  a  pelvis  more  or  less  filled  with  semi- 
solid material.  Amenorrhea  docs  Tiot  always  signify  ecto])ic  gestation,  yet  when  doubt 
arises  it  would  be  advisable  to  iiupiire  carefully  into  the  menstrual  habit  of  the  patient. 
On  the  other  hand  it  is  known  that  acute  apj^endicitis  may  bring  on  uterine  hemor- 
rhage. When,  however,  the  possibility  of  pregnancy  exists,  along  with  a  history  of 
menstrual  irregularity,  or  of  hemorrhag(\s  unaccounted  for,  and  one  finds  within  the 
pelvis  the  uterus  pushed  forward  or  dis]ilaced,  or  perhaps  an  irregular  tumor,  he  may 
suspect  the  condition  if  not  actually  diagnosticate  it. 

A  peculiarlv  unfortunate  coml)ination  is  that  of  acute  appendicitis  occurring  duriug 
pregnanci/,  or  still  worse,  as  I  have  seen  it,  e.  g.,  in  a  woman  with  a  large  uterine  myoma, 
gone  to  about  the  seventh  month  of  ])regnancy,  and  then  suffering  from  an  acute  peri- 
appendicular abscess,  the  whole  proving  more  than  she  could  withstand. 

With  an  ap])endix  placed  behind  (he  cecum  it  will  usually  rest  upon  the  psoas  muscle, 
where  it  may  be  disturbed  Iw  violent  exercise,  or  where  it  may  lead  to  mistaken  diagnosis 


THE  APPKXDIX   AXI)  ITS  DISEASES  859 

cither  ir.  case  of  acute  iiidaiiiinatioii  ol"  the  iniiscle  itseU"  or  ofaciite  a|)])eii(licitis.  When 
the  ri<j[ht  liiiil)  is  (h-awii  up,  aud  espi'dally  when  all  motions  ot"  the  Huih  i^ive  pain,  we  may 
helieve  at  least  in  the  participation  of  the  nuiscl(>  in  the  inflaininatorv  activity.  On  the 
other  hand,  an  insidious  jmias  «/asvv.v.v  may  ^x'^t'  I'i'^e  to  a  certain  deifree  of  tenderness 
in  the  ri<;ht  iliac  fossa,  with  flexion  of  the  thi^h,  and  (gradual  development  of  tumor,  which 
may  he  mistaken   for  chronic  aj)j)en(licitis. 

Tlu>  possil)ility  of  (ippcudiritis  orriirruifj  diirnu/  tiiphoid  has  heen  mentioned.  Dif- 
ferential diaii^nosis  between  the  two  conditions  will  ordiiuirily  not  l)e  difficult  when  one 
can  obtain  an  accurate  history.  In  classical  appendicitis  pain  is  always  the  first  symp- 
tom, and  temperature  rarely  rises  until  a  number  of  hours  at  least  after  the  first  attack 
of  pain.  Even  the  milder  ty|)hoid  cases  may  show  tenderness  in  the  ri<i;ht  iliac  fossa, 
but  one  should  look  for  the  characteristic  eruption  and  make  a  Widal  lest.  'I'he  |)resence 
of  splenic  enlarijenuMit  would  point  to  ty|)hoid,  as  would  also  the  occurrence  of  bronchitis, 
epistaxis,  or  headaclu^  with  perhaj)s  albuminuria.  The  most  perple.xinif  cases  will  be 
those  of  perforation,  |)crhaps  even  of  typhoid  ulcer  of  the  appendix.  In  these  cases 
acute  pain  will  usually  indicate  perforation. 

Inlrnthoracic  afjrciions  sometimes  befi^in  with  or  are  accompanied  by  severe  pains  which 
are  referred  to  various  parts  of  the  abdomen  and  cause  o;reat  confusion.  Thus  I  have 
repeatedly  seen  ])neum()nia,  even  on  the  left  side,  reo;arded  at  least  at  first  as  ac-ute  appen- 
tiicitis,  because  patients  referred  most  of  their  pain  to  the  abdomen  rather  than  to  the 
chest,  while  the  abdominal  muscles  participated  to  such  an  extent  as  to  produce*  j)ro- 
nouncetl  ri(2;idity.  Here  a  blood  count  would  scarcely  help,  l)ut  careful  jihysical  exami- 
nation of  the  chest  would  reveal  the  difficulty,  t^uch  e.rnminntions  slionld  he  niadr 
when  respirations  become  irregular,  or  ichen  the  breathing  is  evident!  1/  in  any  way 
embarrassed.  Acute  pneumonia  and  acute  pleurisy,  especially  (Hai)hragmatic,  may 
have  then  to  be  differentiated  from  acute  appendicitis. 

Finally,  hysteria  is  an  element  not  to  be  disreo;anled  in  some  of  these  cases ;  not  that 
it  is  likely  often,  if  ever,  to  lead  to  serious  doubt,  but  that  patients  with  the  hysterical 
or  neurotic  temperament  are  constantly  tempted  to  so  seriously  exaggerate  their  com- 
plaints as  to  lead  to  at  least  a  more  serious  view  regarding  thejnselves  than  circumstances 
justify.  Thus  a  mild  ap])entlicular  colic  in  a  neurotic  patient  may  produce  a  dispro- 
portionate complaint,  and  one  mast  be  ready  to  assign  to  hyperesthesia  or  exaggerated 
complaints  their  proper  value. 

The  symptomatology  of  appendicitis  may  then  be  summarized  briefly  as  follows: 
When  pain  comes  on  suddenly  and  is  referred  to  the  lower  part  of  the  abdomen,  or  even 
its  central  region,  becoming  ])erhaps  more  localized  as  the  hours  go  Iw,  is  shortly  followed 
by  nausea  or  vomiting,  and  this  by  general  abdominal  sensitiveness,  with  an  increasing 
degrei'  of  rigidity;  and  when  temperature,  which  at  first  is  not  elevated,  begins  to  rise  in 
from  twelve  to  twenty  hours,  then  it  may  be  held  that  this  is  a  classical  picture  of  an 
attack  of  acute  appendicitis.  So  strongly  does  ]\Iurphy,  for  instance,  hold  to  this  order 
of  events  that  he  even  questions  diagnosis  when  symptoms  are  not  thus  timed,  and 
especially  if  vomiting  precede  pain. 

When  pain  which  has  been  severe  subsides,  and  comes  on  afresh  after  an  interval  of 
])erhaps  thirty-six  hours,  it  is  to  be  regarded  as  due  to  fresh  peri-apjiendicular  involvement, 
and  is  an  unfavorable  feature.  In  fact  the  subsidence  of  pain  and  apparent  improve- 
ment often  noted  do  not  always  mean  actual  improvement,  but  may  be  the  forerunners  of 
a  still  more  dangerous  condition.  Thus  the  "perilous  calm"  of  appendicitis  should 
hasten  operation,  or  at  least  increase  watchfulness,  rather  than  beget  confidence.  Should 
one  rely  too  much  upon  them  and  jirocrastinate  he  will  find  that  his  mortality  rate  will 
rise  accordingly.  The  statement  elsewhere  quoted  in  this  work  that  "the  resources 
of  surgery  are  rarely  successful  when  practised  upon  the  dying,"  will  apply  here. 

There  is  scarcely  any  equally  limited  area  of  the  body  in  w^hich  as  many  varied  and 
widely  different  pathological  conditions  may  be  exemjilified  as  in  the  appendix  and  the 
space  immediately  around  it.  The  mildest  degree  of  hyperemia  or  vascular  engorge- 
ment, the  most  destructive  form  of  inflammation,  with  fulminating  necrosis,  may  here 
be  observed.  Moreover,  conditions  commencing  imder  one  type  may  quickly  change 
and  the  whole  type  of  an  attack  may  within  a  short  time  be  merged  from  the  mildest 
into  the  most  severe. 

In  catarrhal  or  endo-appendicitis  it  is  mainly  the  mucosa  which  suflfers.  This  may 
undergo  merely  a  congestion,  with  increase  of  discharge,  and,  so  long  as  the  outlet  be 


860  SPECIAL  OR  REGIOXAL  SURGERY 

not  completely  obstructed,  may  })c  a  purely  tcm|>()rary  matter  of  but  a  few  hours'  dura- 
tion, or  it  may  extend  over  a  few  days.  The  purulent  or  more  destructive  forms  may 
commence  in  either  of  the  coats  of  the  appendix.  It  is  no  uncommon  thing  to  find  a 
necrotic  mucosa  with  a  still  unbroken  serosa,  or  a  p>erforation  of  the  outer  coats  and  a 
hernial  protrusion  of  the  inner,  perhaps  just  ready  to  give  way.  In  location  and  extent 
the  suppurative  and  desirurtive  process  may  also  vary.  Whereas  ordinarily  the  distal 
portion,  Ijeing  less  supplied  with  blood,  will  suffer  first,  it  is  not  uncommon  to  find  per- 
foration at  the  junction  of  the  appendix  with  the  cecum,  or  even  gangrene  of  a  limited 
area  of  the  cecal  wall  itself.  Again,  at  times,  the  trouble  seems  limited  to  accumulation 
of  pus  within  the  appendix,  i.  e.,  an  empyema  of  the  appendix,  without  great  tendency 
to  involve  the  structures  adjoining,  and  an  appendix  may  be  found  containing  a  few- 
drops  of  pus  or  distended  almost  to  its  Vjursting  point  still  free  or  but  slightly  attached 
by  exudate.  In  the  milder  cases  there  may  be  found  strictures  indicating  the  site  of 
preWous  lesions.  Again,  aside  from  pus,  there  may  be  more  or  less  fluid  or  semisolid 
fecal  matter  or  dense  concretions,  in  addition  to  the  possible  foreign  bodies  whose 
presence  has  been  elsewhere  considered.  In  the  more  subacute  or  chronic  forms 
there  will  be  found  relics  of  previous  rather  than  active  ex-pressions  of  present  trouble, 
such  as  strictures,  thickenings,  contortions,  old  adhesions,  sometimes  quite  dense,  and 
contained  concretions,  or  other  foreign  bodies,  or  one  may  find  appendices  shrivelled  up 
or  more  or  less  obliterated  ^appendicitis  obliterans). 

The  role  of  the  omentum  has  elsewhere  been  mentioned,  but  must  be  alluded  to  again 
at  this  p)oint,  since  it  participates  more  or  less  in  almost  every  case  of  acute  appendicitis. 
The  moment  the  appendix  Ls  acutely  inflamed  the  omentum  tends  to  shift  itself  over 
toward  it  and  finally  around  it,  and  it  is  not  uncommon  to  find  a  gangrenous  appendix 
wTapped  in  a  roll  of  this  kindly  disposed  fatty  apron.  In  fact  this  may  constitute  the 
tumor  which  may  have  been  already  discovered  and  found  to  be  fixed  or  movable. 
The  inner  surface  at  least  of  the  omentum  thus  applied  will  nearly  always  have  sacrificed 
itself  and  one  has  need  asually  to  remove  a  considerable  area  of  gangrenoas  omentum, 
as  well  as  the  ap])endix  itself,  feeling  as  he  does  it  that  he  is  necessarily  sacrificing  the 
best  friend  that  the  incriminated  appendix  has  had. 

Aside  from  what  may  concern  the  appendix  itself  the  two  most  serious  complicating 
local  c-onditions  are  abscess  and  gangrene  icith  perforation.  Abscess  is  not  necessarily 
the  result  of  perforation,  at  least  at  first,  but  may  be  due  to  infection  by  continuity,  the 
sequence  of  events  being  acute  appendicitis,  with  exudation,  fixation,  and  adhesion  of 
surrounding  tissues,  followed  by  pus  formation,  perhaps  first  within  the  appendLx  and 
then  perforating,  or  perhaps  having  its  origin  in  the  infected  exudate  exterior  to  it. 
St>  long  as  this  process  is  localized  by  a  protective  barrier  of  surrounding  lymph,  with 
intestinal  adhesicms  and  the  assistance  of  the  omentum,  there  is  to  be  dealt  with  a  more 
or  less  complicated  peri-appendicular  abscess,  such  as  in  the  past  was  frequently  seen 
and  spoken  of  as  perityphlitic.  Concerning  the  frequency  of  perityphlitic  abscess  in 
days  gone  by  the  literature  of  the  pre\-ious  century  will  afford  ample  illustration,  but  in 
spite  of  the  surgical  acumen  and  adWce  of  Willard  Parker,  who  taught  the  profession 
how  to  deal  with  it,  its  proper  explanation  did  not  come  until  the  researches  of  Fitz, 
alluded  to  at  the  beginning  of  this  chapter.  Even  now  it  is  perhaps  not  quite  correct  to 
say  that  ever}-  t\-phlitic  abscess,  i.  e.,  ever\-  collection  of  piLs  around  the  t_\-phlon  or  head 
of  the  large  intestine,  is  of  appendicular  origin,  for  the  tendency  has  been  to  forget  the 
|>fj.ssibility  of  phlegmonous  cellulitis  about  any  part  of  the  bowel  without  reference  to 
the  appendLx. 

Such  a  peri-appendicular  abscess  may  be  small,  containing  but  a  few  drops  of  pus, 
or  e.xtensive,  even  to  the  degree  of  holding  a  pint  or  more.  The  pus  is  usually  offensive 
and  sometimes  one  will  find  floating  in  it  shreds  of  tissue,  or  even  a  completely  separated 
and  sloughed-off  gangren(ias  appendix.  According  to  the  original  location  of  the 
apf>endix,  and  the  disposition  of  the  adjoining  parts,  such  a  collecti(m  of  pas  may  form 
a  tumor  in  the  iliac  fossa,  which  may  also  fill  the  pehis,  or  may  present  in  the  loin, 
closely  simulating  a  f>erinephritic  abscess. 

It  is  unfonunate  when  the  natural  walling  off  process  has  failed  and  we  have  to  deal 
with  a  spreading,  generalized,  septic  peritonitis.  A  partial  compromise  between  these 
cf)nditions  sometimes  appears  as  a  widespread  yet  practically  localized  peritonitis,  in 
which  several  loops  of  bowel  have  become  affixed,  and,  what  is  worse,  infected  to  such 
an  extent  that  they  are  themselves  breaking  down,  so  that  there  may  be  impending  or 


Tin-:  ArrhXD/x  axd  its  diseases  801 

actual  i;aii<fr(  IK-  of  the  iiitcstinc.  Such  ji  coiHlitioii  bespeaks  the  intensity  of  the  infection 
and  the  destructiveness  of  the  infectious  ])rocess,  and  produces  a  condition  which  may 
ajjpall  the  operator.  The  resuU  is  not  only  acute  obstruction  of  the  howel  hut  such  a 
local  condition  that  one  scarcely  knows  where  to  begin  or  terminate  his  operative  efforts. 
It  was  in  such  a  case  as  this  that  I  removed  eight  feet  and  nine  inches  of  })owel,  the 
last  nine  inches  including  the  colon,  turning  in  both  ends  and  making  a  lateral  anasto- 
mosis, l)ecause  of  multiple  gangrenous  patches,  each  of  which  taken  alone  would  have 
recjuired  a  distinct  and  laborious  intestinal  resection,  it  seeming  better  to  remove  the 
entire  amount  involved.  This  j)atient  recovered  and  was  well  years  after  the  operation. 
Still  other  complications  may  disturb  the  surgeon's  calculations.  Thus  jrcnl  fistula 
may  have  already  occurred,  or  suppiirativr  titrouihoplilchifi.s-  may  have  already  ])roduced 
the  b(>giimings  or  an  hrpafir  ahs-rrs-s,  while  septic  exi)ressions  within  the  lungs,  the  heart, 
or  elsewhere  may  have  also  occurred.  In  addition  to  this  general  peritonitis,  with  all 
of  its  terrors,  may  put  a  hopeless  aspect  upon  the  case. 

Treatment. — Viewed  in  the  above  light  it  will  be  seen  that  appendicitis  is  essentially 
a  sunjirni  disra.sr,  and  that  while  mild  attacks  may  at  times  be  successfully  conducted  to 
resolution,  or  tend  in  that  direction  without  treatment,  the  danger  of  sj)reading  infection 
with  all  its  possible  disasters  is  ever  present,  and  even  a  mild  case  is  at  no  moment 
free  from  the  danger  of  becoming  acute.  Considering  its  widest  relations,  and  believing 
in  the  greatest  good  to  the  greatest  number,  the  surgeon  may  easily  maintain  that,  save 
ivliru  it  is  too  late,  it  is  never  a  mistake  to  operate,  providing  operation  be  properly  per- 
formed. This,  however,  is  sometimes  out  of  the  question,  and  the  laity  occasionally 
assume  responsibility  for  a  decision  against  the  better  judgment  of  the  profession.  We 
have  to  accept,  then,  the  fact  that,  no  matter  what  the  theory  may  be,  we  are  not  always 
allowed  to  o])erate  when  we  desire.  Nevertheless  if  a  universal  rule  could  be  estab- 
lished it  could  be  laid  down  in  terms  such  as  these,  that  more  lives  would  be  saved 
by  operating  upon  every  case  of  appendicitis  as  soon  as  the  diagnosis  has  been  made  or 
even  in  the  presence  of  good  reason  for  saspicion. 

With  conditions  such  as  they  are,  and  the  fact  that  these  cases  are  usually  first  seen 
by  general  practitioners  Avhose  surgical  judgment  has  not  been  cultivated,  and  whose 
prejudices  often  actuate  them,  it  may  be  said  that  every  case  should  be  seen  early  by  a 
surgeon,  no  layman  and  no  ordinary  practitioner  of  small  experience  being  in  position 
to  assume  responsibility  for  delay.  It  then  remains  for  the  judicious  and  competent 
operator  who  may  see  such  a  case  early,  as  thus  advised,  to  study  it  carefully  in  order 
to  convince  himself  whether  there  be  about  it  good  and  sufficient  reasons  for  not 
operating.  The  most  honest  ojierator  does  not  gainsay  the  possibility  of  mild  cases 
recovering  without  operation.  He  does,  however,  cjuestion  by  which  course  they  run 
greater  risk. 

The  following  may  serve  as  a  brief  summary  of  conditions  which  justify  waiting: 

1.  When  symptoms  are  mild  and  not  increasing  in  severity; 

2.  When  pain  and  tenderness  are  not  pronounced  and  gradually  subsifle; 

3.  When  the  pulse  rate  does  not  exceed  100; 

4.  AMien  temperature  is  not  rising  nor  showing  abrupt  changes,  especially  if  during 

the  first  thirty-six  hours  there  have  been  no  rise.  (Murphy  states  that  if 
there  has  been  no  temperature  during  the  first  thirty-six  hours  he  begins  to 
doubt  the  diagnosis.) 

5.  When  the  belly  is  not  distending; 

0.  When  rigidity  is  not  increasing  and  there  is  no  evidence  of  peritonitis; 

7.  When  nausea  is  not  increasing; 

8.  When  neither  in  facial  expression  nor  elsewhere  are  there  evidences  of  septic 

infection ; 

9.  When  there  is  no  perceptible  tumor  in  the  right  iliac  fossa. 

Under  the  above  conditions  the  conservative  surgeon  will  be  justified  in  waiting;  being 
prompt,  however,  to  intervene,  shc^uld  there  be  change  for  the  worse  in  any  one  of  the 
features  specified.  Even  here  it  may  be  said  that  wath  conditions  all  as  favorable  as 
above  represented  pus  may  be  present  (in  small  quantity)  and  the  whole  picture  may 
suddenly  change  into  one  of  local  disaster. 

Finally  it  may  be  summed  up  in  these  words :  When  there  is  no  dmiht  as  to  the  advis- 
ability of  waiting,  then  imit;  hit  in  case  of  doubt  operate,  i.  e.,  give  the  patient  the  benefit 
of  the  doubt,  which  he  in  this  way  the  more  certainly  obtains. 


862  SPECIAL  OR  REGIOSAL  SURGERY 

Non-operative  Treatment. — ^Vhilc  thus  waiting  in  oases  wliicii  justify  it,  what  should 
be  (lonr y  Ahsohuc  rest  in  hvd,  even  to  the  extent  of  using  l)edj)an  instead  of  commode, 
is  the  first  essential.  The  seecjnd  eomj)rises  abstention  from  all  food,  and  practically 
the  tenij)orary  starvation  of  the  patient,  who  may  be  allowed  water  in  abundance  and 
nothing  else.  Altogether  too  nuich  stress  has  been  placed  u])on  the  so-called  starvation 
treatment  as  "saving  patients  from  ojieration."  Active  therai)eutic  treatment  is  limited 
mainly  to  the  use  of  cathartics  and  of  anodynes,  according  to  reason  therefor.  On  one 
hantl  it  is  not  advisable  to  rudely  stir  up  the  large  intestine,  one  part  of  whose  structure  is 
already  involved  in  a  serious  and  (luestionable  inflanunatory  process;  on  the  other  hand  it 
is  not  ior  the  general  welfare  of  the  jjatient  to  permit  liini  to  continue  with  a  condition  of 
coj)rostasis  and  the  ever-increasing  stercoremia  which  it  encourages.  On  the  whole  it 
would  seem  better  to  clean  out  the  lower  bowel  at  the  earliest  possible  moment,  after 
which  if  the  patient  be  properly  starved  there  will  be  less  necessity  for  subsequent  active 
catharsis.  The  question  of  anodynes  is  one  of  equal  im{)ortance.  Those  who  bear 
pain  badly,  or  those  who  suti'er  intensely,  will  demand  anodynes,  which  every  physician 
knows  both  help  to  mask  the  symptoms  and  interfere  with  elimination;  but  suth  cases 
seem  to  be  of  themselves  so  violent  that  the  extreme  expression  of  pain  should  of  itself 
be  regarded  as  an  indication  for  operation.  It  should  be  held,  then,  that  cases  which 
demand  opiates  for  relief  of  pain  demand  operation  even  more  strongly.  In  the  mild 
eases,  expectantly  treated,  the  local  application  of  ice  may  be  of  some  value.  In  ct1'c<t 
these  cases  are  to  be  treated  expectantly,  and,  while  expectant  treatment  is  a  confession 
of  weakness  or  of  ignorance,  it  may  be  unav<jidable  because  early  o])eration  is  flatly  refused 

Indications  for  Operation. —  Sufficient  reasons  for  not  operating  being  aljsent  or  having 
j)assed,  the  following  may  l)e  ccMisidered  among  the  more  urgent  indicatiomi  for  immediate 
surgical  attack: 

1.  Continued  and  especially  increasing  pain  and  tenderness; 

2.  A  rapid  pulse  (110  or  over)  tending  to  increase  in  rapidity; 

3.  Any  rapid  change  in  the  temperature,  either  a  sudden  rise  or  a  drop  to  the  normal 

or  subnormal,  without  corresponding  improvement  in  every  other  particular; 

4.  Increasing  or  widespread  abdominal  rigidity;  when  the  right  side  of  the  abdomen 

of  a  sensible  and  non-neurotic  subject  is  rigid  this  of  itself  should  be  sufficient 
to  justify  operation; 

5.  The  aj^pearance  of  tumor  in  the  right  iliac  fo.ssa; 

6.  Recurring  and  especially  constant  vomiting; 

7.  Any  indication  of  septic  infection,  local  or  general. 

Such  are  the  indications  Ijy  which  the  surgeon  may  say  upon  the  instant  of  their 
recognition  that  a  given  ease  requires  immediate  operation.  iMirtunate  are  both  he  and 
the  ])atient  if  the  case  be  seen  early,  when  these  conditions  have  but  lately  shown  them- 
selves, and  before  it  be  too  late.  It  has  l)een  said  that  almost  every  deatli  front  appendicifis 
iitean.s  the  /o.v.v  of  a  life  that  m  ight  Jiave  been  .v« red  and  for  which  someone  is  responsible,  this 
responsibility  being  divisible  among  the  ])atient,  the  parents  (^r  family,  and  the  general 
practitioner  wIkj  first  saw  the  case  and  was  tardy  in  recognizing  its  essential  features. 
While  j)atients  die  after  late  o|)erations  the  surgeon  himself  is  rarely  censurable,  it  not 
being  his  fault  that  he  was  called  in  too  late,  and  the  patient  dying  of  the  progress  of 
the  disea.se  in  spite  of  an  o])eration  and  not  because  of  it. 

Operation  for  appendicitis  may  be  one  of  the  simplest  and  easiest  of  the  abdominal 
operations,  especially  when  the  acutely  infectious  element  be  not  present,  or  it  may  be 
one  of  the  most  trying  and  difficult  of  all  possible  surgical  procedures,  taxing  alike  the 
judgment  of  the  ex|)erienced  operator  and  the  resources  of  the  clinic.  Mu(  h  will  depend 
upon  the  time  at  which  it  is  ])erformed.  If  within  the  first  forty-eight  hours  the  surgeon 
may  exj^ect  to  find  but  a  small  amount  of  pus;  if  from  the  second  to  the  fifth  day,  he 
may  find  a  well-marked  collection,  while  later  he  may  have  not  only  localizetl  abscess  but 
extensive  c(nnplications.  Again,  he  who  o])erates  between  attacks,  during  the  interval 
or  interim  stage,  will  find  conditions  of  adhesion  and  results  of  old  disease  rather  than 
its  active  products. 

These  operations  should  then  be  considered  under  these  different  headings: 

1.  Early  operations  in  acute  cases,  where  there  is  little  or  no  tumor; 

2.  Operations  in  cases  where  abscess  is  present; 

3.  Operations  in  cases  of  more  or  less  peritoneal  involvement,  with  obstruction; 

4.  Interval  operations. 


Tllh:  APPhWDIX   A.\D  PPS  DlSl'ASES  S()3 

riulcr  till-  ahovi'  lu'a(lin<;-.s  coiulitioiis  vary  so  widely  tliat  tlicy  can  SfaiTcly  be  spoken 
of  or  described  under  (lie  same  name.  The  seat  of  the  disease  shouhl  first  be  approached. 
Hero  there  is  wide  raiioc  for  choice  of  location  of  incision  and  even  the  method  of  its 
])erformance.  Some  prefer  (he  outer  border  of  (he  rec(us,  ()(hcrs  <^o  throuffli  (he  rcc(us 
nuistle  j)roj)er  by  an  incision  i)arallcl  to  i(s  fibers,  wliich  when  exposed  are  separated, 
i(s  shea(h  bo(h  an(criorly  and  j)os(eriorly  beinji;  ifividcd  scpara(ely.  ()(hers  <ijo  (hrough 
(he  abdominal  wail  by  in(  isions  more  or  less  ol)li(|nc,  and  made  in^ar  (he  an(crior  superior 
sj)ine,  where  are  found  (he  diiVerent  layers  of  (he  abdominal  mus(  les  arranj^'cd  in  proper 
order,  (heir  fibers  being  disposc^d  at  ri<fht  an<fles  (o  each  odier.  'I'hat  incision  is  Ix-st  in 
each  case  which  afiords  (he  shor(est  and  easiest  route  to  the  site  of  the  lesion  when  it 
can  be  located.  If  tumor  be  present  it  is  ordinarily  best  to  go  in  directly  over  i(.  In 
(he  absence  of  tumor  the  ])oint  of  greatest  tenderness  is  the  l)est  guide,  '^riie  possibility 
of  subsequent  hernia  a(  (hi'  si(e  which  is  weakened  by  o])era(i()ii  should  be  (akeii  into 
accoimt.  If  it  be  possible  (o  aA'oid  drainage  hernia  may  usually  be  avoided.  When 
tirainage  is  necessary  hernia  is  somedmes  unavoidable.  The  advan(age  of  opera(i()n 
(hrough  (he  rec(us  is  (hat  (he  muscle  fibers  can  be  sej)ara(ed  without  dividing  (hem. 
huision  here  uiay,  however,  carry  (he  o])erat()r  so  far  from  the  site  of  (he  ap|)cndi.\ 
that  he  must  i  ecessarily  distiu'b  the  interior  arrangement  more  than  is  advisable,  and 
thus  increase  (he  danger  of  infec(ion.  The  oblique  exterior  incisions  near  the  ilium . 
always  permit  of  separation  of  the  fibers  of  the  external  oblique.  The  deeper  muscle 
fibers  which  cross  at  nearly  a  right  angle  may  some(imes  be  nicked  and  widely  sej)arated 
by  firm  traction,  as  in  the  so-called  "gridiron  method,"  or  they  may  retjuire  (livision. 
A  short  external  incision  is  desirable  when  it  suffices  for  the  purpose.  Considerations 
of  safety  (/".  r.,  the  be((er  ex])()sure  and  easier  removal  of  the  a])pendix)  may  call  in  some 
instaiu'cs  for  long  incisions,  and  (hey  should  be  made  sufficiently  long  for  his  purj)ose. 

It  will  often  hap})en  that  as  the  surgeon  j)asses  more  deeply  toward  (he  peri(()neum 
he  Avill  find  the  tissues  more  or  less  edematous.  This  is  a  reliable  indication  of  the 
presence  of  pus  beneath,  and  should  make  him  o})en  the  peritoneum  with  care  and  (hen 
use  extreme  caution  in  his  fiu'ther  mani})ulation,  lest  by  se}»irating  recent  adhesions 
he  ])ermit  pus  to  escape.  The  peritoneum  being  opened  sufficiently  the  finger  is  gently 
insinuated,  and  thus  the  first  orientation  concerning  internal  conditions  is  obtained. 
With  the  ex])loring  finger  (here  should  be  ascertained,  first,  the  existence  of  any  adhesions; 
second,  their  location  and  relative  firmness,  and,  third,  in  a  general  way,  the  amount 
of  surrounding  distiu'bance.  With  an  appendix  })laced  anteriorly  we  may  thus  come 
directly  upon  it,  while  when  placed  deeply  and  posteriorly  we  may  have  much  to  do 
before  reaching  it.  After  the  first  general  exploration  the  next  procedure  should  be  to 
j)rotect  and  wall  oft"  the  region  involved  from  the  rest  of  the  abdominal  cavity  by  stri|)S 
of  gauze.  These  should  be  long  and  so  secured  that  none  may  be  lost  hy  being  left 
within  the  abdomen.  The  introduction  of  gauze  for  this  pur]K:)se  will  sometimes 
increase  depression  and  decrease  blood  pressure,  but  it  is  a  necessary  procedure 
in  nearl}'  every  instance.  Moreover,  several  strips  may  l)e  needed,  and  the  incision 
may  have  to  be  extended  (o  a  limit  of  two  or  three  inches,  according  as  further  exj)lora- 
tion  reveals  a  more  complicated  situation.  The  fluid  pus  which  may  escape  should 
be  gently  removed  with  dry  gauze,  or,  if  present  in  considerable  amount,  be  carefully 
conducted  toward  the  surface.  Loops  of  bow^el  or  tissue  bound  together  by  lymph 
should  be  gently  separated,  as  they  may  easily  tear,  or  since  imprisoned  between  them 
there  may  l)e  found  small  collections  of  pus.  If  found  gangrenous  the  si(ua(ion  is 
therel)y  seriously  complicated,  and  it  is  advisable  not  to  restore  such  a  looj)  to  the 
abdominal  cavity. 

The  omentum,  as  already  indicated,  may  serve  as  a  valual)le  guide  to  the  location  of 
the  a]>pendix,  which  may  be  found  wrapped  within  it.  It  should  be  handled  with  great 
caution,  while,  at  the  same  time,  it  is  made  to  reveal  the  desired  information.  When 
the  omentum  is  infiltrated,  contorted,  and  adherent  we  may  be  sure  of  finding  pus  con- 
ce^ded  within  the  cavity  which  it  helps  to  wall  off.  That  which  is  already  gangrenous 
should  be  removed,  with  use  of  sutures  in  such  a  way  that  there  shall  be  no  subsequent 
bli^eding.  It  may  be  found  easily,  or  not  until  many  other  details  have  been  mastered. 
The  involved  appendix,  w^hen  found,  may  be  in  one  of  the  conditions  described  above, 
all  of  which  demand  its  removal  save  those  where  this  has  been  already  accomplished 
by  violence  of  the  disease,  in  which  case  the  opening  in  the  cecum  may  have  to  l^e  closed, 
or  one  may  employ  it  for  the  purpose  of  an  artificial  anus.     The  appendix  is  often  so 


S(34  SPECIAL  OR  REGIONAL  SURdERY 

hard  to  find  that  any  reUahle  guide  will  be  welcomed.  Such  a  guide  may  be  found, 
first,  in  the  location  and  relation  of  the  omentum,  and,  secondly,  in  the  cecum  if  this  can 
be  exposed,  or  in  either  one  of  its  firm,  longitudinal,  white  tissue  bands,  which,  leading 
down  on  either  side  of  the  colon,  meet  and  l)lend  at  the  point  of  origin  of  the  appendix. 
Either  of  these  followed  in  the  right  direction  leads  to  this  spot.  Conditions  may 
be  such,  however,  as  to  obscure  both  of  these  guides,  and  then  the  colon  should  be 
followed  downward  toward  the  ilecKccal  valve,  or  the  small  intestine  up  toward  it, 
in  the  belief  that  in  this  vicinity,  and  probably  in  the  centre  of  the  tumor,  the  appendix 
will  be  found.  What  the  siirgeon  shall  next  do  depends  on  the  details  of  each  case.  He 
has  not  onlv  to  remove  the  diseased  appendix,  but  to  ligate  and  separate  from  it  its  mesen- 
terv;  furthermore  to  separate  either  or  both  of  these  from  surrounding  tissties  or  organs, 
e.  f/.,  the  wall  of  the  pelvis,  the  ovary,  the  bladder,  the  retroperitoneal  tissue  above  the 
sacrum,  or  from  the  lateral  or  anterior  abdominal  wall.  This  separation  may  be  easy, 
or  in  its  jjerformance  the  tube  may  rupture  and  both  pus  and  fecal  matter  escape;  or 
j)erfo ration  may  have  already  occurred  and  the  o|)erator  will  be  conducted  into  a  cavity 
containing  matter,  pus  and  fecal  mixed,  in  which  perhaps  fecal  concretions  of  con- 
siderable size  will  be  found  loose.  He  is  fortunate  who,  finding  a  condition  of  this  kind, 
finds  at  the  same  time  that  he  is  still  within  a  circumscribed  cavity.  This  he  should 
respect,  and,  while  endeavoring  to  clean  it  thoroughly  and  drain  it,  he  will  avoid  doing 
further  harm  by  breaking  down  its  walls. 

Another  condition  which  may  arise  after  the  peritoneum  is  opened  is  that  of  escape 
of  a  quantity  of  sero])urulent  fluid  or  of  almost  clear  pus  which  is  free  within  the  abdomi- 
nal cavitv.  There  may  be  little  or  much  of  this.  When  present  it  should  be  removed 
l)v  gentle  s])onging  before  the  gauze  packing  is  introduced.  Some  o])erators  are  inclined 
to  irrigate  freely  and  endeavor  to  wash  out  all  this  contained  fluid.  Others  are  opposed 
to  this  method  and  believe  that  gentle  dry  sponging  is  preferable.  When  the  appendix 
is  found  free  and  movable,  and  when  the  tissues  in  previous  contact  with  it  are  free  from 
evidences  of  destructive  infection  (as,  for  instance,  when  peritoneal  surfaces  have  not 
lost  all  their  glimmer  or  sheen),  one  should  carefully  remove  it,  cauterizing  its  stump, 
burying  it  beneath  the  surrounding  peritoneum,  and  close  the  abdomen  without  drain- 
age. In  spite,  however,  of  the  assertions  and  actions  of  some  operators,  I  believe  it  to 
be  the  wisest  rule  to  lay  down  for  general  application  that  it  is  safer  to  drain  in 
every  case  where  free  pus  or  breaking  down  exudate  is  discovered. 

The  question  of  drainage  thus  raised  is  as  important  as  any  connected  with  this  sub- 
ject. When  and  how  shall  one  drain  is  a  question  upon  which  hundreds  of  pages  have 
been  written  by  various  operators,  and  one  which,  while  settled  for  individuals,  can  hardly 
be  settled  for  the  jjrofession  at  large  by  any  brief  statement.  Inefficient  drainage  is 
almost  as  bad  as  none.  Efficient  drainage  may  call  for  the  insertion  of  a  tube  into  the 
depths  of  the  pelvis,  even  for  counteropening  in  the  cul-de-sac,  or  for  additional 
opening  in  the  loin,  or  for  the  employment  of  two  or  three  tubes  and  drains  of  various 
kinds.  A  large  tube  loosely  packed  with  gauze,  perhaps  split  through  its  length  and 
abundantly  provided  with  openings,  is  probably  the  most  effectual  drain  for  most  pur- 
jjoses.  The  cigarette  drain,  of  gauze  wrapped  in  oiled  silk,  or  a  few  folds  of  oiled 
silk  loosely  tied  together,  along  which  fluid  may  percolate,  may  be  sufficient  for  cases  of 
le^sser  extent.  Large  foul  cavities  are  better  left  more  widely  open,  and  abundantly 
drained  with  gauze  packing,  in  spite  of  the  humorous  stigma  which  has  been  cast  upon 
some  of  these  methods  by  Morris  with  his  expression  "committing  taxidermy  upon 
patients."  The  depressing  reflex  influence  of  such  packing  being  readily  conceded  it 
may  be  regarded  as  the  lesser  of  two  evils. 

Another  almost  equally  im]X)rtant  question  is  that  of  treatment  of  the  peritoneal  earity 
when  involved.  Here  methods  and  opinions  have  varied  widely.  A  peritoneal  cavitv 
once  inflamed  cannot  be  made  absolutely  clean  in  any  way,  and  much  reliance  should 
be  placed  on  the  pro])erties  of  the  membrane  itself,  which,  to  a  large  extent,  should  act  as 
its  own  scavenger.  When,  however,  by  removing  the  parts  evidently  diseased  we  have 
taken  away  the  main  source  of  infection  we  may  feel  like  relying  upon  the  natural 
protective  forces  of  the  human  body;  still  even  here  opinions  differ.  Thus  some  would 
flush  the  abdomen  with  hot  saline  solution  and  even  leave  some  portion  of  it  there, 
closing  the  external  wound,  while  others  would  carefully  avoid  the  introduction  of  any- 
thing by  which  infectious  material  may  be  sjiread ;  and  while  each  method  has  much  to 
justify  it  one  is  scarcely  found  preferable  to  the  other.     I  believe,  however,  in  thoroughly 


THE  APPENDIX  AXD  ITS  DISEASES  865 

tk';iiiiii<j  out  any  (iistiiu-t  ahsccss  cavity,  and  if  tlic  pelvis  l)f  .sucli  tluMi  I  would  irriijate  it. 
1  would  also  tliorouii;hly  drain  it. 

The  attention  of  the  reader  is  here  directed  to  the  i;eneral  considerations  found  earlier 
in  this  work  concerning  the  general  technicjue  of  abdominal  of)erations,  and  the  matters 
of  drainage  and  after-care,  it  being  scarcely  necessary  to  reiterate  what  ha.s  been  there 
said  regarding  the  general  iLse  of  saline  solution  locally  and  by  the  rectum,  the  advantage 
of  the  Fowler  jiosition,  or  of  iMurj)hy's  method  of  slow  and  gentle  introduction  of  saline 
solution  into  the  rectum,  providing  for  its  continuous  absorj)tion,  etc. 

The  po.ssibility  of  appendicitis  leading  to  general  peritonitis,  this  to  acute  olxstruction 
of  the  l)owel,  and  this  j)ossibly  even  to  multij)le  gangrene,  has  l)een  mentioned.  What 
should  best  be  done  under  these  circumstances  must  depend  upon  the  patient  and  upon 
the  .surroundings.  With  a  j^atient  too  much  reduced  to  justify  any  prolonged  operation 
the  surgeon  would  probably  content  himself  with  evacuation  of  pus  which  may  be 
readily  reached,  and  then  perhaps  by  the  formation  of  an  artificial  anus.  Cases 
which  will  justify  such  extensive  operation  as  that  above  re{)orted  by  myself  in  this 
coiuiection,  where  it  was  possible  to  successfully  remove  nearly  nine  feet  of  intestine, 
will  be  exceedingly  rare,  as  well  as  impracticable  in  the  ordinary  private  house. 

A  condition  perha])S  a  little  less  serious  but  always  perplexing  is  that  of  rjanrjrenc 
of  a  limited  area  of  cecum  around  a  gangrencjus  apjjendix.  To  remove  the  appendix 
alone  in  this  condition  is  to  accomplish  nothing,  while  to  meet  the  indication  may 
require  the  exsection  of  a  small  area  of  cecal  wall  or  the  resection  of  the  entire  cecum, 
or  perhaps  in  cases  of  limited  extent  the  enfolding  of  the  gangrenous  area  and  the 
suture  of  its  edges  in  such  a  manner  that  Avhen  it  sloughs  it  may  slough  into  the  bowel 
cavity. 

When  the  surgeon  sees  a  case  of  peri-appendicular  (the  old  peritv'jDhlitic)  abscess 
late,  and  after  it  is  easily  recognized,  he  should  operate  according  to  the  local  indication, 
making  incision  perhajis  short  and  placing  it  at  a  point  where  pus  will  apparently  be 
most  easily  reached  and  best  drained.  ISIost  of  these  instances  present  rather  on  the 
side  or  even  in  the  loin  behind  the  colon,  and  here  a  posterior  incision  might  be  suffi- 
cient. This  may  here  be  more  liberal,  since  there  is  little  danger  of  postoperative 
hernia,  while  through  it  one  may  possibly  expose  the  cecum  freely  and  often  reach 
even  the  appendix  itself.  In  making  this  opening  it  is  well,  if  possible,  to  separate 
the  fibers  of  the  trans versalis  by  blunt  dissection.  Here,  as  in  all  of  the  other  incisions 
made  toward  the  outer  side  of  the  body,  the  opening  should  be  made,  if  possible,  obliquely 
and  parallel  to  the  branches  of  the  iliohypogastric  nerves,  which  are  thereby  avoided 
and  loss  of  sensation  thus  prevented.  In  fact  this  posterior  method  is  sometimes  even 
more  rapid,  and  preferable  in  exceedingly  fat  patients,  while  it  will  always  cause  less  shock 
and  abdominal  distress  than  does  an  anterior  section;  moreover,  drainage  takes  place 
in  the  most  desirable  direction. 

Fecal  fistula  is  sometimes  the  immediate  and  unavoidable,  sometimes  a  more  or  le^s 
delayed  and  apparently  inevitable,  result  or  complication  of  some  of  these  operations. 
In  the  former  instance  it  will  be  because  of  more  or  less  gangrene  or  the  necessity  for 
an  immediate  enterostomy.  In  the  latter  case  it  results  from  conditions  which  are 
concealed,  but  may  be  imagined,  comprising  the  giving  way  of  tissues  already  com- 
promised or  else  being  a  continuation  of  the  ulcerative  or  gangrenous  process.  These 
complications  are  always  unpleasant  and  untoward,  though  they  rarely  reflect  upon 
the  method  or  judgment  of  the  operator,  being  essentially  inevitable.  If  only  the  fecal 
outflow  escape  externally  the  condition  may  be  regarded  as  inconvenient  and  tem- 
{jorary.  Only  in  those  instances  in  which  the  peritoneal  cavity  is  contaminated  does 
septic  peritonitis  ensue.  The  majority  of  these  fecal  fistulas  close  spontaneously  by 
granulation  tissue.  Sometimes  closure  is  rapid,  sometimes  delayed,  in  which  latter  case 
it  may  be  stimulated  by  the  use  of  silver  nitrate,  as  already  indicated  above.  In  a  few 
instances  the  condition  is  so  extensive  or  so  permanent  as  to  justify  or  rec^uire  further 
operation,  which  may  be  in  the  nature  of  a  curettement  of  the  fistulous  tract,  a  slight 
plastic  procedure,  including  a  buttonhole  suture  about  the  opening,  or  possibly  a  complete 
intestinal  resection.  I  have  seen  small,  fistulous  tracts  discharge  occasionally,  even 
for  years,  and  then  finally  close  spontaneously,  and  have  far  oftener  seen  some  form  of 
spontaneous  closure  than  necessity  for  operative  intervention.  The  danger  of  infection 
around  any  such  fistulous  tract  is  ever  present,  and  when  it  has  occurred  the  fact  will 
be  made  known  by  increase  of  edematous  granulations,  with  swelling  and  tendency  to 
55 


8GG 


SPECIAL  OR  REGIONAL  SURGERY 


breaking  down.     In  every  such  case  active  cauterization,  or,  better  still,  the  use  of  the 
curette,  will  be  recjuired. 

A  tuberculous  form  of  chronic  appendicitis,  as   well   as   tuberculous   infection  of  a 
subacute  exudate,  is  possible,  the  case  being  converted  into  one  of  greater  chronicity, 


Via.  583 


Omentum  being  gently  lifted  in  (irder  to  uncover  the 
appendix  enclosed  with  its  fohl       (Lejars  ) 


Appentiix  delivered  from  t)ie  abdominal  cavity 
and  biouglit  to  view.      (Lejars  ) 


Fig.  585 


with  more  or  less  mild  but  constant  septic  features  (hectic).     In  any  event,  so  soon  as 

the  tul)erculous  clement  can  be  recognized  radical  measures  should  be  instituted. 

Operation  for  Chronic  or  Recurring  Appendicitis;  Internal  Operations. —  Other  things  being 

equal  the  most  favoral)le  time  at  which  to  remove  the  aj)pendix  is  that  when  pathological 

processes  are  least  active.  If,  therefore,  there 
be  a  choice  the  interval  of  quiescence  rather 
than  the  stage  of  active  infection  would  be  chosen. 
Interval  operations,  so  called,  are  usually  com- 
paratively simj)le,  both  in  principle  and  tech- 
nique. There  are  times,  however,  when  it  is 
difficult  to  find  a  partially  obliterated  appendix 
which  has  been  covered  uj)  in  thickened  perito- 
neum or  partially  organizctl  exudate.  In  such 
a  case  considerable  blunt  dissection  or  separation 
may  have  to  be  done  before  it  can  be  removed.  In 
those  instances  is  this  particularly  true  where  it 
had  originally  a  retroperitoneal  location,  and  at 
no  time  a  free  or  movable  ])osition.  When  diffi- 
cult of  recognition  we  may  be  unerringly  led  to  it 
if  we  but  follow  the  bands  of  white  fibrous  tissue 
on  either  side  of  the  cecum  to  their  junction. 

The  opening  l)y  which  the  appendix  should, 
under  these  circumstances,  l)e  reached  may  again 
be  made  at  the  point  of  election,  and  should  best 
he  located  over  the  area  of  greatest  tenderness. 
Whatever  incision  is  selected  we  should  endeavor 
to  separate  muscle  bundles  as  much  and  incise  as 

Separation  of  the  meso-appendix.     (Cosset.)    little  as  possible.     The  appendix  being  delivered 


TIIK  APPhWDIX   AM)   PI'S  DISK  ASKS 


867 


tliroii^li  tlic  Avound,  i-illicr  hcforc"  or  jil'ltT  litj:;i(i(»n  of  its  iiiesenterv,  and  l)ein<f  tlius 
completely  isolated,  is  removed  close  to  the  laru;e  intestine,  its  base  hciiij;  tied  and  its 
structure  heinjj;  seized  within  the  blades  of  a  force|)s  in  such  a  way  that  none  of  its  con- 
tents may  esca])e.  The  scissors  with  which  it  is  divided  are  eontaininuted  by  its 
contents   and   siiould  not  be  used  ajijain  until  cleansed.     The  stump   on   the  proximal 


I'lc.  586 


The  base  of  the  appendix  is  tied  with  silk.     Ttie  meso-appendix  is  being  tied  in  sections  with  the  Cleveland 

needle.      (Itichardson.) 

side  may  be  touched  with  the  actual  cautery,  or  scraped  and  then  cauterized  with 
pure  carbolic  acid  or  formalin  solution  in  order  to  thoroughly  disinfect  it.  Subsequent 
treatment  of  this  stump  differs  with  different  operators.  Some  are  satisfied  to  leave 
it  thus  cauterized,  while  others  cover  it  with  the  adjoining  j)critoneum,  which  is 
brought  together  over  the  stump  end  by  either  a  purse-string  or  a  continuous 
suture.     Yet  otliers  have  been  satisfied  to  invert  the  ends  of  the  stump  into  the  cecum 


Fig.  587 


Fig.  588 


Appendix  surrounded  with  ligature  at  its  base, 
after  its  isolation  from  its  mesentery.  Purse- 
string  suture  in  place.     (Cosset.) 


Complete  detachment  of  appendix.     (Cosset.) 


aid  thus  leave  it  with  or  without  further  protection.  It  seems  to  make  really  very 
little  difference  how  the  stumj)  is  treated,  providing  only  it  be  disinfected  and  prevented 
from  leaking.  Nevertheless  it  would  appear  preferable  to  give  it  at  least  a  peritoneal 
covering  to  prevent  adhesions  (Figs.  583  to  588). 

In  the  subsequent  closure  of  the  external  wound  drainage  is  not  made,  there  having 
been  no  pus  to  call  for  it;  while  the  more  perfectly  the  w^ound  layers  be  closed,  each  with 


868  SPECIAL  OR  REGIONAL  SVRGERY 

a  row  of  chromicized  catgut  sutures,  the  peritoneal  incision  being  first  carefully  apjjroxi- 
mated  and  over  it  the  muscle  and  aponeurotic  layers,  each  by  itself,  the  less  the  tendency 
to  subsequent  postoperative  hernia.  On  general  principles,  also,  the  shorter  the  incision 
the  less  the  danger  of  this  undesirable  event.  Nevertheless  other  considerations  should 
not  be  sacrificed  to  shortness  and  beauty  of  the  cutaneous  scar. 

The  essentials  of  after-treatment  of  these  cases  have  been  already  summarized  in  the 
pre\-ious  section,  and  to  these  little  exception  may  be  taken  in  cases  such  as  those  above 
described.  Every  precaution  should  be  taken  to  prevent  vomiting,  as  every  muscular 
effort  involved  in  the  act  tends  to  disturb  a  freshly  sutured  wound.  "While  violent 
muscular  efforts  of  defecation  are  also  to  be  deprecated,  there  is  perhaps  as  much  (jr 
more  to  be  dreaded  from  the  abdominal  distention  which  may  result  from  inattention 
to  free  intestinal  elimination.  Until  the  bowels  have  been  moved  it  is  best  to  restrain 
the  diet  to  the  simplest  fluid  nourishment.  So  soon  as  elimination  becomes  free  more 
liberality  in  diet  may  be  allowed.  There  is  the  same  liability  to  and  danger  from  other 
jx)ssible  complications,  such  as  ]X)stanesthetic  pneumonia,  anuria,  or  lack  of  expulsive 
power  of  the  liladder,  which  recjuires  the  use  of  the  catheter,  in  these  as  in  other  abdominal 
cases.  Principles  of  treatment,  however,  do  not  vary,  and  tlie  reader  is  referred  to  the 
prenous  section  already  indicated. 

Paraiyphhfir  abMcr.t.^es  are  to  be  distinguished  from  perityphlitic  or  peri-appendicular 
abscesses  in  that  they  arise  from  a  phlegmonotis  process  in  the  cellular  tissue  around  the 
colon  not  due  to  intra -appendicular  infection.  In  consequence  of  such  a  cellulitis 
more  or  less  considerable  collections  of  pus  may  form,  which  are  most  likely  to  present 
either  in  the  loin  or  jtist  in  front  of  the  cecum,  which  may  burrow  either  upward  or  down- 
ward, or  appear  elsewhere.  They  are  mentioned  here,  not  because  they  are  to  be  dif- 
ferently treated  or  surgically  regarded,  but  because  it  is  worth  while  to  remember  that 
here  about  the  cecum  and  ascending  colon,  as  on  the  left  side,  such  pericolic  abscesses 
may  form  without  reference  to  the  appendix. 


CHAPTER   L. 

THE  LARGE  INTESTINES  AND  THE  RECTUM. 
ANOMALIES  OF  THE  LARGE  INTESTINE. 

The  more  common  congenital  anomalies  of  the  various  divisions  of  the  colon  have 
to  do  mainly  with  the  j)resence  of  divertirula  and  airr.s-iop,  or  possibly  total  absence, 
due  to  defects  in  development.  Diverticula  are  much  the  more  common.  Some  degree 
of  constriction  is  not  particularly  infrequent,  hut  complete  absence  of  even  a  section 
of  the  colon  is  an  extremely  rare  anomaly. 

The  acquired  anomalies  have  to  do  with  disease  processes  or  results  of  injury.  Dis- 
placements  may  be  the  result  of  old  adhesions  and  distortions;  of  chronic  ccmstipation, 
i.  e.,  fecal  impaction  and  resulting  overloading,  with  sagging,  stretching,  and  comj)lete 
change  in  shape  and  position ;  with  displacement  due  to  enlargement  of  other  organs, 
e.  (/.,  the  liver,  stomach,  spleen,  uterus,  or,  in  milder  degree,  with  the  gradual  but 
inevitable  and  chronic  results  of  tight  lacing.  The  causes  which  produce  a  gradual 
enteroptosis  of  the  transverse  colon  are  not  supposed  to  concern  the  surgeon,  yet 
the  condition  may  precipitate  acute  obstruction  which  will  necessitate  his  urgent 
participation  in  its  final  treatment. 

There  are  no  diseases  peculiar  to  the  large  which  do  not  also  concern  the  small 
intestine,  and  no  surgical  diseases  peculiar  to  it  which  have  not  been  considered  in  the 
foregoing  pages.  It  is  not,  therefore,  necessary  to  make  even  a  brief  summary  of  the 
surgical  diseases  peculiar  to  the  large  intestine.  Of  well-known  lesions,  however,  in 
this  location  there  is  perhaps  a  little  worth  emphasis  in  this  place.  The  most  serioas 
surgical  conditions  of  the  large  bowel,  aside  from  the  acutely  ol)structive,  are  those 
pertaining  to  expressions  of  tuberculosis,  syphilis,  actinomycosis,  dysentery  in  one  or 
other  of  its  tropical  forms,  and  cancer.  There  is  a  condition  also  of  either  acute  or 
chronic  colitiji  or  mucocolitis  which  may  assume  such  extreme  degree  as  to  necessitate  a 
colostomy  made  at  the  cecum  (appendicostomy)  for  the  purpose  of  more  perfect  irri- 
gation and  physiological  rest.  The  amount  of  suffering,  as  well  as  of  toxemia,  which 
may  proceed  from  a  seriously  inflamed  colonic  mucosa,  must  be  at  least  once  seen  in 
order  to  be  fully  appreciated.  Such  a  condition  is  characterized  by  local  and  general 
suffering,  with  septic  and  co})remic  symptoms,  as  well  as  by  tenesmtis  and  the  jiassage 
of  numerous  small  or  larger  and  more  infrequent  amoimts  of  blood-stained  mucus, 
sometimes  of  almost  pure  blood.  As  an  illustration  if  one  recall  what  may  be  seen  in  case 
of  a  \'iolently  inflamed  conjunctiva  or  pharyngeal  mucous  membrane,  and  realize  that 
this  condition  is  duplicated  through  a  large  portion  of  the  colon,  a  more  A'ivid  picture  of 
what  it  actually  represents  can  be  afforded.  When  exposed  to  inspection,  as  it  may  be 
when  the  rectum  and  the  sigmoid  are  involved,  it  will  be  found  to  bleed  at  the  slightest 
touch  and  to  freely  discharge  large  quantities  of  thick  mucus.  While  such  a  colitis  is 
usually  treated  by  non-(^perative  methods  an  anesthetic  is  sometimes  required  for  its 
more  perfect  diagnosis  and  recognition,  as  well  as  for  such  local  applications  as  can 
scarcely  be  made  without  it. 

TUBERCULOUS   AND   SYPHILITIC   ULCERATIONS   OF   THE   COLON. 

Tuberculotis  and  syphilitic  ulcerations  of  the  colon  may  be  locahzed  and  relatiA-ely 
insignificant,  or  numerous,  disseminated,  extensive,  and  serious.  In  extreme  cases  of 
this  kind  the  entire  colonic  mucosa  will  be  involved  and  the  amount  of  distress  thus  occa- 
sioned be  scarcely  controllable.  These  are  the  cases  which,  failing  to  yield  to  ordinary^ 
therapeutic  measures,  justify  colostomy  at  the  cecum,  for  the  purpose  of  temporary- 
exclusion  of  the  large  intestine  and  its  physiological  rest,  as  well  as  its  more  perfect  local 
treatment  by  the  irrigation  and  suitable  local  applications  thus  permitted. 

(869) 


870 


SPECIAL  OR  RECIOXAL  SURGERY 


STRICTURES   OF   THE   LARGE    INTESTINE. 

Strictures  of  the  large  bowel  have  the  same  etiolojjy  as  those  of  the  small  l)owel,  and 
are  to  be  recognized  by  the  same  general  indications,  of  which  increasing  obstipation, 
perhaps  with  alternating  attacks  of  diarrhea  and  increasing  difficulty  in  evacuation,  are 
unmistakable  features.  The  luiture  of  a  stricture  is  not  always  to  be  foretold  Ix'fore 
the  ex])loration  which  it  will  necessitate.  No  stricture  of  the  large  intestine  which 
is  al)ove  easy  reach  from  the  anus  can  be  successfully  treated  by  any  save  operative 
methods,  ?".  c,  by  abdominal  section  and  ])roper  attention  to  whatever  may  be  thereby 
revealed.  Thus  at  one  time  bands  may  be  divided  or  some  external  mass  removed  by 
j)ressing  u])()n  the  bowel  {c.  r/.,  a  uterine  myoma),  or  there  may  be  found  an  associated 
tumor,  malignant  or  benign,  whose  complete  removal  is  both  ])ossible  and  permissil)le, 
or  at  other  times  a  malignant  stricture  so  complicated  that  only  an  eutero-anastomosis, 
for  temporary  relief,  can  be  effected. 

CANCER  OF  THE  LARGE  INTESTINE. 


Cancer  of  the  large  intestine  spares  no  part  of  its  length  or  lumen.  Primary  cancer 
of  the  cecum  may  commence  in  the  region  of  the  ajipendix,  and  has  frecjuently  been 
mistaken  for  a  chronic  appendicitis.     If  the  transverse  l)owel  be  involved  there  may  be 

more  or  less  sagging  or  fixation,  while  at  the  flexures  ob- 
^'"-  SS9  struetion  is  more  easily  protluced.     Such  growths  in  time 

become  sufficiently  prominent  to  be  easily  recogn.ized 
from  without,  but  then  they  have  usually  gone  beyond 
the  time  when  radical  operation  can  hold  out  much 
]>r()niise.  In  the  large,  as  in  the  small,  intestine  radical 
f)perations  are,  however,  often  successful,  and  always  in 
])n)])()rtion  as  they  are  made  early  and  thoroughly.  When 
extir])ati()n  is  impossible  anastouKJsis  will  ofl'er  a  tempor- 
ary sul)stitute  (Fig.  589). 


OBSTRUCTION  OF  THE  LARGE  INTESTINE. 

Ciironic  obstruction  of  the  large  bowel  is  usually  due 
to  one  of  the  causes  above  considered.  Acute  obstruc- 
tion of  the  colon  is  the  result  either  of  precipitation  of 
an  acute  condition  upon  the  base  of  an  old  chronic 
trouble,  of  invagination,  of  volvulus,  or  possibly  of  one 
of  the  other  mechanical  contortions  not  included  in  either 
of  these  expressions. 

Intussxiscepiion  is  most  likely  to  occur  either  at  the 
ileocecal  valve  or  in  the  region  of  the  sigmoid.  Vol- 
riihi.'i  is  more  common  in  the  latter  region.  It  is  here 
dm-  to  relaxation  of  natural  ligamentous  supports,  to 
overloading  and  stretching,  oris  ])ossiljly  permitted  by 
some  congenital  condition.  Volvulus  in  this  section 
having  once  occurred  the  patient  is  liable  to  its  suljse- 
cjuent  recurrence.  So  well  known  now  is  this  fact  that 
surgeons  have  endeavored  to  take  special  precautions 
again^st  it,  which  unfortunately  have  not  been  brilliantly  successful.  It  has  been  sug- 
gested, for  example,  to  anchor  the  sigmoid  to  the  anterior  abdominal  wall,  or  to  resect  a 
portion  of  it,  to  anastomose  it  with  the  cecum,  as  well  as  to  reef  the  mesosigmoid.  Desir- 
able as  such  operative  relief  may  be,  all  of  these  methods  present  inherent  objections,  while 
those  which  include  absolute  fixation  of  the  sigmoid  perha])s  ))redisp()se  it  to  subsequent 
obstruction  from  other  causes.  At  jiresent  it  would  appear  that  a  ftir/moirlope.ri/  is 
prol)ably  the  best  procedure,  in  order  to  prevent  local  recurrence,  in  a  sigmoid  volvulus 


Cancer  of  cecum,  showing  ulcerat- 
ing growth  protruding  interiorly  and 
obstructing.      (Dr.  1-.  A.  Smitli.) 


Till-:  RECTUM  871 

which  has  once  l)een  exposed  hy  operation,  care  IxMiiji;  taken  to  fasten  it  well  up  to  its 
outer  side,  as  well  Jis  posteriorly,  in  order  that  there  may  be  no  vacant  spaces  in  these 
directions. 

TITK  UKrPlIM. 

GENERAL  CONSIDERATIONS. 

The  rectum  was  for  too  jont^  a  time  rclc<;atcd  to  the  care  and  almost  sole  interest  of 
the  itinerant  charlatan,  or  the  sonu-what  ambitions,  thou<;h  scarcely  more  honest,  special- 
ist, who  preyed  alike  u|)on  the  sntl'eriiifj;  and  i<i;norance  of  patients,  until  the  practice  of 
rectal  surti;ery  wjis  almost  a  mark  of  (lis<ijrace.  From  this  unfortunate  condition  it  was 
rescued  by  tlie  organized  effort  of  honest  men,  imtil  now,  in  the  light  of  their  researches, 
the  rectum  has  been  shown  to  be  both  tlu>  site  of  numerous,  easily  discernible,  and 
serious,  alike  mysterious  and  rcHex  lesions,  all  deserving  careful  study.  The  connection 
between  the  sensory  nerves  with  which  its  terminal  inch  and  a  half  are  freely  endowed 
and  the  vasonu)tor  nerves  throughout  the  body  is  easily  shown  by  their  iiiHuence,  for 
instance,  upon  the  respiration  and  tlu^  circulation,  and  in  these  respects  some  important 
lessons  have  been  learned  from  the  charlatans.  We  have  learned,  for  example,  that 
general  vasomotor  spasm,  with  its  evidence  in  coldness  of  the  extremities  and  pallor  of 
the  surface,  may  often  be  overcome  by  so  simple  a  measure  as  stretching  the  sphincter; 
while  to  cure  lesions  which  j)roduce  more  or  less  s])hincteric  s])asm  is  to  fre(|uently  restore 
general  circulatory  tone.  Again,  what  may  be  accomplished  in  stimulating  respiration 
by  dilatation  of  the  sphincter  has  been  shown  to  be  of  the  greatest  value  in  patients  breath- 
ing badly   under  an  anesthetic. 

The  "orificialists,"  then,  while  making  absurd  and  impossible  claims,  have  never- 
theless taught  us  considerable  concerning  the  value  of  recognizing  the  importance  of 
sphincteric  spasm.  Their  claims  concerning  so-called  "pockets"  and  "papilke"  are 
untenable  and  absurd,  and  the  expression  which  they  have  taught  many  of  the  laity 
that  they  are  sufferers  from  "rectal  pathology"  indicates  alike  their  ignorance  of  good 
English  and  good  surgery.  That  papilliie  do  become,  under  certain  circumstances, 
exquisitely  sensitive  and  are  occasionally  in  need  of  the  cautery  or  the  scissors,  as  well 
as  of  the  general  relief  afforded  by  stretching  the  sphincter,  is  imdoubtedly  sometimes 
true. 

The  itinerant  "pile-drivers"  and  charlatans  of  their  class  have  done  more  harm  than 
good,  and  yet  even  from  them  the  honest  practitioner  has  learned  that  "it  pays"  often 
to  give  attention  to  the  rectum.  As  a  source  of  various  disturbing  and  particularly 
distressing  reflexes  there  is  scarcely  any  portion  of  the  body  of  equivalent  area  which 
can  furnish  so  many.  The  relief  to  mental  conditions,  amounting  often  to  pronounced 
melancholia,  which  follows  cure  of  rectal  lesions,  is  often  astonishing,  all  of  which 
shows  that  the  rectum  is  well  worth  the  attention  of  the  scientist,  and  especially  of  investi- 
gation in  every  case  where  the  slightest  complaint  is  made. 

All  of  which  {)roperly  leads  u])  to  the  subject  of  rccial  examination  and  Jtoto  to  make 
it  complete.  Much  can  be  learned  here  by  use  of  the  educatetl  finger,  as  well  as  in  the 
vagina,  and  the  surgeon  should  cultivate  that  tactile  sense  which  will  orient  him  so  soon 
as  the  finger-tip  comes  in  contact  with  a  morbid  or  diseased  surface.  In  this  way  it  is 
possible  to  detect  ulcers  which  are  within  reach  by  the  finger  alone,  without  having  to  use 
the  sjieculum,  at  least  to  make  a  diagnosis  sufficient  to  indicate  what  further  procedure 
is  required.  The  rectum  and  lower  bowel  should  be  thoroughly  em]:)tied.  It  is  safe 
to  assume  that  exquisite  sensibility  and  pronounced  sphincteric  spasm  are  the  result  of 
morbid  conditions.  The  use  of  a  local  anesthetic  will  in  many  instances  be  sufficient 
to  permit  at  least  of  a  ]M-eliminary  digital  examination,  the  suggestive  characteristics 
especially  sought  being  the  general  size  of  the  rectal  tube,  infiltration  or  fixation  of  its 
walls,  and  the  presence  of  stricture,  tumor,  or  other  impediment  to  insertion  of  the 
finger,  including  pronounced  spasm  at  the  anus.  The  presence  of  bloody  mucus  or 
pus  should  also  be  noted.  In  addition  the.  rectal  surroundings  should  be  examined  and 
the  presence  of  any  phlegmon,  fistula,  sinus  or  other  evidence  of  present  or  past  disease, 
including  old  scar,  either  of  ulcer  or  incision,  should  be  noted.  The  degree  of  pain  as 
well  as  of  hy})ersensitiveness  produced  sliould  also  be  noted.  With  tact  and  gentleness 
satisfactory  knowledge  of  the  condition  of  the  parts  within  reach  may  be  obtained. 


872  SPECIAL  OR  REGIONAL  SURdERY 

A  rectiil  bouirif  mav  ho  used  should  suggestions  of  the  ])reseiice  of  stricture  he  present. 
Rectal  bougies  are  usually  made  of  soft  rubber  of  various  sizes,  with  tips  variously 
shaped,  of  which  the  tapering  and  conical  are  the  most  useful.  One  of  these  may  be 
anointed  and  gently  introduced,  the  endeavor  being  to  guide  it  first  in  the  middle  line 
along  the  course  of  the  rectum  and  then  gently  toward  the  left  as  the  rectum  swerves 
in  this  direction  as  it  comes  down  from  above.  With  such  a  bougie  the  ])resence  of 
a  stricture  beyond  reach  of  the  finger  may  be  detected.  When  recognized  its  nature 
is,  however,  still  left  in  doubt,  to  be  decided  by  the  history  or  other  features  of  the  case. 
There  is  never  excuse  for  roughness  in  hanclling  a  rectal  bougie,  since  perforation  or 
serious  injury  might  result. 

The  next  method  of  more  complete  examination  of  the  rectum  is  through  one  of  the 
various  forms  of  s|)ecula,  from  the  so-called  rectal  speculum,  with  its  blades  only  a  couple 
of  inches  long,  to  the  more  formidable  proctosco])c  or  sigmoidoscope,  with  their  possibilities 
or  artificial  illumination,  etc.  According  to  the  nature  of  the  lesion  and  the  sensibility 
of  the  surface  exposed  various  specula  may  be  usetl,  with  or  without  an  anesthetic. 
For  the  majority  of  purposes  local  anesthesia  is  sufficient.  One  will  furthermore  often 
need  the  aid  of  position.  The  ordinary  digital  examination  may  be  made  with  the 
patient  u]X)n  the  side  or  back.  When  an  ordinary  speculum  is  used  a  position  corre- 
sponding to  Sims'  for  gynecological  work  is  far  preferable.  For  more  thorough  work 
when  the  long,  tubular  instruments  are  used,  the  knee-chest  position  is  necessary.  The 
specialists  have  devised  certain  elaborate  chairs,  instruments,  and  methods  by  which 
exceedingly  complete  and  satisfactory  exposures  of  twelve  or  fifteen  inches  of  rectal 
and  colonic  mucosa  can  l)e  made.  What  is  written  here,  however,  is  not  for  their 
purposes,  but  rather  for  those  of  the  general  practitioner,  who  must  work  with  ordinary 
means  and  methods.  The  knee-chest  position,  ff)r  instance,  can  be  assumed  upon  the 
ordinary  table  or  it  may  be  facilitated  by  certain  additions  made  to  a  regular  operating 
tal)le.  With  all  these  facilities  and  the  peculiar  skill  which  specialization  produces  it  is 
possible  to  make  striking  demonstrations  of  the  valvular  arrangement  of  the  rectal 
mucosa,  and  of  the  varying  degrees  of  obstruction  which  mucous  folds  or  cicatrices  may 
produce,  as  well  as  to  successfully  dilate  or  divide  them.  In  the  hands  of  a  limited 
number  of  skilled  surgeons  local  treatment  of  obstipation,  as  well  as  of  various  other 
conditions  of  the  sigmoid  or  upper  rectum,  has  become  extremely  satisfactory.  These 
are,  however,  in  the  writer's  estimation,  methods  and  procedures  which  are  scarcely 
within  the  domain  of  the  general  practitioner  or  even  the  general  surgeon,  as  they 
recjuire  a  degree  of  peculiar  facility  and  an  amount  of  time  which  can  scarcely  be  exj;)ected 
of  him.  Therefore  the  conditions  and  methods  of  treatment  here  considered  will  be 
limited  to  those  intended  for  general  use. 

CONGENITAL  DEFECTS  AND  MALFORMATIONS  OF  THE  RECTUM  AND  ANUS. 

The  lowermost  portions  of  the  intestinal  tube  are  by  far  the  most  common  sites  of 
congenital  anomalies  and  defects.  These  rarely  occur  in  the  direction  of  excess,  rather 
of  atresia  or  entire  deficiency.  The  lower  end  of  the  alimentary  tube  is  differentiated 
from  the  balance  of  the  original  neurenteric  canal,  and  connected  with  the  exterior,  in 
ways  similar  to  those  followed  at  its  upper  extremity.  The  canal  itself  should  early 
become  obliterated  at  a  point  whose  site  is  marked  by  that  small  collection  of  lymphoid 
tissue  known  as  the  coccygeal  or  Luschka's  body,  corresponding  in  this  respect  and 
location  to  the  pituitary  body  at  its  other  extremity.  The  rudimentary  rectum  is  then 
connected  with  the  surface  by  the  formation  of  a  depression  and  disappearance  of  tissue 
in  just  the  same  way  that  the  mouth  is  formed,  and  as  about  the  mouth  we  find  atresia 
or  incomplete  communication,  so  we  may  find  the  same  condition  in  various  expressions 
about  the  termination  of  the  rectum.  ]\Ioreover,  there  may  occur  also  more  or  less 
arrest  or  abnormal  development  of  the  tissues  which  eventually  shut  off  the  rectum 
from  the  genito-urinary  tract.  In  consequence,  we  have  various  degrees  of  rectal 
atresia,  and,  finally,  actual  imperf oration.  Beyond  this  we  may  more  rarely  meet 
with  complete  absence  of  the  rectum,  and  even  of  some  portion  or  of  nearly  all  of  the 
entire  large  intestine.  In  one  case  under  my  observation  this  entire  tract  was  represented 
by  little  more  than  a  mere  cord. 

The  mildest  degree  of  such  malformation  refers  to  partial  occlusion  of  some  portion 


PLATE  LIT 


*j-. 

'''^' 

-»^ 


Cancerous  Stricture  of  Rectum.      Bowel  Laid  Open  for  Inspection. 


CO.\(;h'.\lTAJ.   DEFI'ICTS  AS  I)  M  ALFOliM  ATIOSH  OF  RECTUM   ASD  ASUS     S73 


()(■  (lie  rcctiini,  or  oxtiniu*  sniallncss  of  its  natural  ()|K'niii^,  citlicr  of  wliicli  constitutes 
essentially  a  stricture  of  coui^eiiital  ori<riii,  which  may  We  suflicieiitly  tij^ht  to  harely  allow 
passap'  of  luecoiiivini.  Such  strictun's  may  escai)e  notice  for  a  considiTahle  length  of 
time  and  will  alwavs'tend  to  produce  dilatation  and  conse(|uent  displacement  of  howel 
above. 

Ordinary  linpvrjomtc  anas  is  produced  by  its  closure  by  a  more  or  less  thick,  mem- 
branous diaphragm,  which  may  act,  in  some  cases,  like  a  thin  but  imperforate  hymen, 
or,  in   others,  be  so  dense  and  mas- 
sive as  to  act  more  like  a  j)lug  than  ^'"-  ^^^ 
a  ))artition.     The    thinner  the    dia- 
phragm   and   the   more    ))erfect    its 
structure   as    such    the  simpler   the 
ease,  for  it  simj)ly  needs  perforation, 
with    sufficiently     frequent    subse- 
quent  dilatation    to    maintain    the 
proper  size  of  the  aperture. 

Complete  ah.srnce  of  the  anus  and 
the  loirer  end  of  the  rectal  pone h  may 
be  so  marked  that  scarcely  a  dimple 
in'dicates  the  j)()int  where  the  anus 
should  be  found.  In  these  cases 
the  external  s])hineter  may  or  may 
not  be  present,  while  the  rectal  pouch 
may  present  loosely  in  the  pelvis,  or 
be  defective,  or  attached  to  some 
portion  of  the  abdominal  wall,  the 
intervening  space  being  filled 
with  indifferent  tissue.  The  fact 
that  there  appears  to  be  a  slight 
anal  depression  is  to  be  taken  for 
nothing  more  than  an  indication  of 
what  should  be  found,  and  signifies 
nothing  regarding  the  deeper  con- 
dition. 

A  somewhat  mitigated  expression 
of  this  last  defect  is  seen  when  the 
anus  is  normal,  with  a  more  or  less 
complete  sphincter,  but  where  a 
distinct  partition  separates  this 
pouch  from  the  rectum  above. 
This,  again,  may  vary  considerably 
in  thickness.  If,  then,  fluctuation 
be  detected  the  condition  may 
prove  less  unfavorable  for  the 
little  patient,  since  at  this  point 
communication  may  be  easily  es- 
tablished. Too  often,  however, 
this  diaphragm  is  dense  and  tough. 
When  successfully  perforated,  like 
the  hymen,  it  may  allow  a  slow 
dril)bling  of  material,  and  will  re- 
quire constant  attention  and  dilatation.  Figs.  590  and  591  portray  these  conditions  in 
some  of  their  expressions. 

The  anus  itself  is  by  no  means  a  fixed  anatomical  opening,  and  its  position  may  vary 
considerably.  It  may  be  found  anywhere  along  the  middle  line  of  the  perineum  or  even 
in  the  sacral  region. 

Another  variety  of  complication  is,  with  the  conditions  represented  as  above,  a  prac- 
tically imperforate  anus  or  rectum  which  nevertheless  opens  into  one  of  the 
other  pelvic  cavities — the  vagina,  the  bladder,  or  the  urethra.     In    female  infants  an 


Rectum  ending  in  a  blind  pouch.     (Kelsey.) 


Fig.  591 


Rectum  ending  in  pouch;  anus  normal.      (Kelsey.) 


874  SPECIAL  OR  REGIONAL  SURGERY 

opening  into  the  vagina  may  be  of  a  size  sufficient  to  serve  its  purjiose,  even  throughout 
hfe.  This  condition  has  occurred  in  ignorant  women  Avho  became  wives  and  mothers, 
and  were  never  conscious  of  anything  abnormal.  When  the  rectum  communicates 
with  the  urinary  passages  meconium  will  escape  with  the  urine.  When  the  opening  is 
in  the  urethra  it  is  not  so  serious,  and  patients  live  to  adult  life,  whereas  when  the  bladder 
is  thus  involved  the  ureters  will  become  infected  and  the  patient  eventually  dies  of  a 
terminal   infection   of  the   kidney. 

There  is  a  somewhat  reversed  condition  similar  to  this  where  the  urinary  passages 
connect  with  the  rectum  or  with  the  colon. 

INIost  of  the  anomalies  above  catalogued  produce  conditions  of  acute  intestinal 
obstruction  within  the  first  two  or  three  days  of  the  newborn  infant's  life.  The  condition 
is  |)crhaps  first  made  known  by  the  nurse's  failing  to  note  the  presence  of  meconium  upon 
the  diapers.  A  suspicion  of  such  a  condition  should  ])rompt  immediate  investigation, 
which  should  be  made  with  the  little  finger  or  with  a  soft  catheter  projjerly  anointed; 
the  finger  making  the  l)est  probe  for  jjurpose.s  of  orientation.  The  first  thing  is  to  deter- 
mine the  patnlency  of  the  anus.  This  established,  the  next  pnx  edure  is  a  determina- 
tion of  the  rectal  condhion  and  of  possible  communication  with  other  passages.  In 
this  the  presence  of  a  small  sound  or  metal  catheter  in  the  urethra  and  bladder  may 
be  of  assistance.  If  a  fluctuating  sac  presenting  downward  can  be  discovered  in  the 
location  of  the  rectum  its  character  may  be  assumed,  and,  after  exploring  with  an  ordi- 
nary aspirating  needle,  one  may,  if  meconium  be  discovered,  leave  the  needle  ///  sifu  for  a 
o-uide  and  with  sharp  scissors  or  pointed  knife  passed  along  it  carefully  cut  into  the 
sac,  and  then  gradually  enlarge  the  opening  until  it  be  given  a  sufficient  size.  The 
surgeon  is  fortunate  iii  this  respect  who  has  a  case  of  im})erf()rate  rectum  so  simple 
as  to  permit  of  doing  this  and  finding  it  sufficient. 

Everv  completely  obstructed  case  becomes  instantly  a  surgical  one,  whose  outcome 
deiientls  not  on  the  operator  alone,  but  on  the  actual  anatomical  condition.  There  is 
justification,  therefore,  in  going  to  almost  any  extreme  in  the  endeavor  to  open  up  a 
passage-way,  for  no  danger  can  be  greater  than  that  of  failing  to  establish  it.  After  a 
careful  search  of  the  pelvis,  aided  by  anesthesia  and  a  metal  instrument  in  the  bladder, 
if  no  trace  of  large  l)owel  can  l)e  found  or  if  tissues  be  so  dense  as  to  completely  mask 
the  anatomical  details,  then  as  a  last  resort  an  artificial  anus  may  be  made  in  the  left 
inmiinal  region,  if  there  be  no  reason  for  not  violating  the  usual  rule  and  opening  the 
lar<'-e  bowel  in  the  right  groin.  Colosinmij  in  an  infant,  under  these  circumstances, 
is  alwavs  a  hazardous  and  serious  matter,  but  it  offers  the  only  resource.  It  is  made 
in  exactlv  the  same  way  as  enterostomy  described  previously,  and  the  operation  requires 
no  special  description  here.  Very  young  infants  thus  affected  make  bad  subjects,  and 
o])eration  should  be  performed  as  expeditiously  as  possible.  Considering  the  danger 
of  leakao-e  it  would  be  well  if  practical)le  to  wait  a  few  hours  after  attaching  the  intestine 
to  the  abdominal  surface  before  opening  it,  in  order  that  the  peritoneal  cavity  may  be 
more  perfectly  protected. 

Even  those  cases  where  the  rectum  communicates  with  the  urethra  or  bladder  should 
have  a  natural  anal  opening.  In  cases  where  communication  is  into  the  vagina  it  may 
be  proper  to  wait  until  youtli  or  adult  age  is  reached,  when  more  may  be  accomplished. 

INJURIES  AND  FOREIGN  BODIES  IN  THE  RECTUM. 

The  rectum  may  l)e  the  site  of  injuries  of  various  kinds  from  both  extrinsic  and 
intrinsic  causes.  When  weakened  by  disease  it  may  be  burst  by  accumulation  and 
straining,  or  it  may  be  the  site  of  perforation  of  ulcer,  just  as  may  any  other  part  of  the 
intestine.  Although  well  protected  from  most  directions  it  may  suffer  from  penetrating 
wounds,  such  as  stab  or  gunshot.  It  is  occasionally  injured  in  fractures  of  the  pelvis, 
and  possilnlities  of  such  injuries  should  be  excluded  in  such  cases.  It  may  also  l)e  lacer- 
ated during  parturition.  The  sphincter  and  even  the  muscular  tube  itself  sometimes 
suffer.  It  has  been  indifferently  wounded  or  punctured  in  operations,  especially  for 
stone  in  the  bladder  and  in  prostatectomy. 

In  the  absence  of  disease  a  laceration  occurring  in  any  of  these  ways  may  be  repaired 
by  prompt  suture,  although  to  make  a  suitable  exposure  may  require  an  extensive 
removal  of  sacrum,  or  the  performance  of  a  laparotomy  with  the  patient  in  the  Trendelen- 


PROCTITIS  875 

burg  position.  Tlic  rccliiiii  is  also  I'lXHiuciitly  injured  l)y  uccidcntal  or  intentional 
introduction  of  j'onif/H  bodies'  from  imtliouf.  Museums,  especially  the  foreign,  are  full 
of  collections  of  foreign  bodies  wliicli  have  been  removed  from  the  rectum,  most  of 
^vhich  have  been  placed  ther(>  with  intent,  malicious  or  otherwise.  They  include  objects 
of  all  imaginable  character,  shape,  and  size,  some  which  are  easily  introduced  and  are 
also  easily  removed;  others  which  hav(>  been  passed  inward  under  no  small  diflicuhies  are 
removed  only  with  a  more  or  less  formidable  operation,  or  have  even  determined  the 
death  of  the  individual.  The  ignorant  have  jjcculiar  suj)erstitions,  and  the  criminal 
most  vicious  tendencies,  toward  the  insertion  of  such  foreign  bodies,  and  the  com- 
plications that  may  be  brought  about  are  too  numerous  to  be  rehearsed  here. 

On  the  other  hand,  by  actual  accident  serious  injuries  may  be  produced;  as  in  one  case 
under  my  obs(>rvation  where  a  boy  of  twelve  fell,  in  the  s(|uatting  position,  over  an 
iron  j)icket  nearly  one  inch  in  diameter  in  such  a  way  as  to  permit  it  to  pass  into  the 
anus,  scarcely  bruising  the  nnicous  membrane,  yet  entering  the  jx-lvis  for  nearly  six 
inches,  penetrating  the  anterior  wall  of  the  rectum,  the  jiosterior  wall  of  the  bladder,  and 
bruising  its  anterior  wjdl  without  perforating  it.  One  feature  of  the  accident  was  the 
carrying  into  the  bladder  of  a  piece  of  his  trousers.  In  this  case  I  opened  the  abdomen 
in  order  to  be  sure  that  there  was  no  abdominal  complication,  closed  the  major  part  of 
the  wound,  and  drew  a  good-sized  drainage  tul)e  through  from  just  above  the  j)ubes 
out  through  th(>  anus,  after  removing  the  piece  of  cloth  above  mentioned.  The  boy 
made  a  ]«M"fect  rec()V(>rv. 

The  danger  in  all  these  cases  is  of  infection,  either  of  the  bladder  or  of  the  j)elvic 
cellular  tissue.  In  the  female  similar  perforating  injuries  may  involve  the  vagina  or 
the  other  female  organs. 

Some  of  these  accidents  or  conditions  above  recounted  take  place  during  intoxication. 
The  recurrence  of  tenesmus,  pronounced  rectal  pain,  the  appearance  of  blood  either 
at  the  anus  or  in  the  urine,  should  in  every  instance  prompt  a  thorough  investigation 
of  the  rectum,  if  necessarv  under  an  anesthetic. 


PROCTITIS. 

Under  the  term  ])roctitis  are  comjirised  acute  inflammations  of  the  rectal  mucosa, 
which  are  characterized  by  discharge  of  mucus,  mucopus,  and  perhaps  blood,  and 
accompanied  by  more  or  less  tenesmus,  pain,  and  sphincteric  spasm.  The  conditions 
which  produce  proctitis  are  those  which  lead  to  ulceration.  It  may  be  the  result  oi  a 
downward  extension  of  trouble  from  above,  as  in  mucocolitis,  dysenteric,  tubercidous 
or  other  forms  of  colitis,  or  it  may  be  the  result  of  infection  from  below  (c.  g.,  gonorrheal). 
An  inflamed  rectum  may  be  more  or  less  easily  ex])osetl  for  study  through  some  form 
of  speculum  (see  above),  and  a  more  perfect  picture  of  the  actual  condition  thus  pre- 
sented to  the  eye  than  can  be  seen  elsewhere,  save  in  the  mouth  and  pharynx,  of  the 
effects  which  serious  and  even  ulcerative  inflammation  may  produce  in  the  way  of  con- 
gestion, swelling,  bleeding,  and  actual  breaking  down. 

Gonorrheal  froctitis  is  not  common,  yet  it  may  occur  either  by  extension  or  by  direct 
infection,  and  will  be  of  an  acute  type.  The  other  forms  may  vary  in  severity  according 
to   their  cause  and  duration. 

Symptoms. — The  symj^toms  differ  only  in  degree,  and  include  the  features  already 
mentioned.  There  are  soreness,  tenderness,  and  often  j)ain,  especially  when  the  lower 
part  of  the  rectum,  with  its  numerous  sensory  nerves,  is  involved,  while  reflex  jiains  are 
referred  to  the  sacrum  and  the  lower  part  of  the  back.  Sensation  of  local  heat  and 
of  soreness  is  generally  noted,  while  the  patient  is  more  or  less  tortured  by  frequent 
desire  to  evacuate  the  bow^el,  but  passes  ])erha))s  a  little  bloody  mucus  with  the  accom- 
paniment of  tenesmus  and  straining.  In  acute  cases  the  condition  is  an  exceedingly 
painful  one. 

Treatment. — Treatment  should  be  begun  by  a  search  for  and  removal  of  the  cause. 
Relief  is  att'orded  by  local  anodynes,  of  which  the  hot  sitz  bath  is  one  of  the  most  com- 
forting, and  l)y  hot  rectal  lavements  of  soothing  antiseptic  fluid,  such  as  linseed  tea, 
to  which  a  little  thiol  or  ichthyol  has  been  added.  These  should  be  retained  as  long  as 
possible,  then  ejected.  Local  anodynes  may  be  furnished  through  the  medium  of  sup- 
positories containing  opium,  or  preferably  some  of  the  milder  local  anesthetics,  such  as 


S76  SPECIAL  OR  TiEGIONAL  SURGEJiY 

orthoforiH.  Cases  which  do  not  (juickly  yield  to  this  form  of  treatment  should  he  anes- 
tiu>tized  in  oriler  that  complete  exposure  of  ulcerated  areas  aiul  viororous  local  treatment 
may  be  accom])lished.  A  brushini;  of  the  entire  surface  with  a  2  or  3  per  cent,  solution 
of  silver  nitrate  will  frecjuently  be  followed  by  relief,  which  will  be  further  furnished  by 
sufficient  stretching  of  the  sphincter  to  overcome  its  painful  spasm.  The  diet  should  be 
so  regulated  as  to  leave  a  minimum  of  undigested  residue  that  may  irritate  the  lower 
bowel,  and  laxatives  should  be  so  administered  that  there  shall  be  no  coprostasis  in 
the  colon,  but  that  whatever  enters  it  shall  be  speedily  extruded.  The  specific  forms 
of  proctitis  require  specific  treatment,  for  which  there  is  perhaps  nothing  better  than 
the  silver  preparations,  either  the  mild,  like  argyrol,  or  the  active,  like  solutions  of 
silver  nitrate. 

ULCERATION  OF  THE  RECTUM. 

The  causes  of  the  formation  of  ulcer  in  the  rectum  nowise  differ  from  those  of  ulcer 
elsewhere  about  the  body.  They  may  be  summarized  as  catarrhal,  i.  e.,  more  pro- 
nounced and  local  extensions  of  non-specific  inflammation  of  the  mucosa,  which,  in 
certain  areas,  assume  more  intense  and  later  infective  and  degenerative  form  (in  this 
way  are  formed  the  so-called  catarrhal  ulcers);  specific,  including  primary  chancre, 
which  is  rarely  met  with  high  up  in  the  rectum,  or  the  later  expressions,  varying  from 
mere  mucous  i)atches  which  may  abound  both  within  the  rectum  and  around  the  anus, 
to  the  deejier,  more  destructive,  and  usually  tertiary  ulcerations,  with  destruction  of 
tissue,  extensive  involvement  of  surface  and  most  pronounced  tendency  to  subsequent 
cicatricial  contraction  when  they  begin  to  repair. 

What  has  been  said  regarding  syphilitic  ulcer  is  true  also  of  chancroid,  which  when 
found  in  this  region  involves  most  frecjuently  the  anus,  but  which  may  extend  or  even 
be  seen  as  a  primary  lesion  higher  up. 

Tuberculous  ulcers  are  not  infrequently  primary,  usually  the  accompaniment  of 
advancing  and  ulcerative  infection  t)f  the  intestine  above,  or  secondary,  as  fre(|uently 
occiu's  when  the  more  innocent  forms  suffer  a  secondary  tuberculous  infection,  becoming 
thus  converted  into  lesions  of  pronounced  type. 

Typhoid  ulcers  in  the  rectum  are  rare,  but  those  connected  with  dyseniery  are  common, 
especially  in  localities  where  tropical  or  other  forms  of  the  disease  prevail.  The  inno- 
cent tumors  within  the  rectum,  such  as  polypi  and  adenomas,  etc.,  tend  to  break  down 
because  they  are  kept  continually  macerated  and  exposed  to  contamination.  Even 
innocent  hemorrhoidal  tumors  are  extremely  prone  to  suffer  in  this  way  because  their 
e|)ithelial  covering  is  thin  and  they  are  exposed  to  both  external  and  internal  contamina- 
tion. Finally  every  malignant  tumor  which  grows  into  the  rec-tum  tends  to  break  down, 
and  sooner  or  later  to  present  an  ulcerating  surface.  The  causes  of  rectal  ulceration 
are  then  seen  to  be  various.  Nearly  everyone  of  them  may  be  an  exaggeration  of  a 
condition  first  producing  an  acute  proctitis. 

Ulcers  occupyinrj  the  anal  region  are  usually  compressed  into  a  linear  form  and  present 
rather  as  cracks  or  linear  abrasions.  These  are  known  as  fissures  and  are  spoken  of  as 
fissures  in  ano  or  rectal  fissures,  according  to  their  situation.  These  fissures  occupy 
the  most  sensitive  portion,  i.  e.,  the  lower  inch  and  a  half  of  the  rectum,  and  become  in 
time  irritable,  erethistic  lesions,  whose  sensibility  is  constantly  enhanced  by  the  reflex 
spasm  of  the  sphincter  which  they  produce.  An  essential  part  of  the  treatment  of  every 
such  case  is  dilatation  of  the  sphincter,  as  well  as  the  destruction  of  the  irritable  surface, 
even  the  former  alone  often  sufficing  for  the  milder  cases.  Anal  fissures,  like  c-orneal 
ulcers,  give  rise  to  exquisite  pain  and  annoyance,  and  produce  irritability  and  general 
distress.  Their  treatment  is  so  simple  that  there  is  no  excuse  for  allowing  patients 
thus  to  suffer. 

To  a  peculiar  form  of  combined  infiltration  and  ulceration  involving  the  lower  part 
of  the  rectum,  the  anus,  and,  in  females,  more  or  less  of  the  vulva,  the  French  have 
given  the  name  esthiomene.  It  has  been  considered  due  to  more  or  less  mixed  forms 
of  infection,  including  those  of  chancroid,  syphilis,  tuberculosis,  and  other  undescribed 
types.  It  is  a  mixed  infection,  and  not  necessarily  of  the  same  type  in  all  cases.  It  is 
usually  seen  in  old  syphilitic  subjects  or  in  prostitutes.  It  produces  more  or  less 
deforming  lesions,  and  sometimes  such  active  and  protuberant  granulations  as  to  cause 
it  to  be  mistaken  for  epithelioma  or  condyloma.     It  is  essentially  chronic,  and  its  most 


STRICT  I' RE  OF   THE  RECTUM  877 

strikiii<i-  {•liaractcristic  is  tlu-  coiiihiiiatioii  of  ulirrative  and  hyperplastic  processes  which 
it  presents.  Clinically  it  is  a  chronic  ulcer,  with  thickened  and  deformed  base  and  with 
all  tlie  ])ossiI)le  consecjuenc-es  or  comj)lications  of  ulcer  in  this  re<'ion. 

The  other  forms  of  ulcer  above  mentioned  appear  singly  or  multiply  in  any  and 
every  possible  location,  pronounced  tyi)es  presenting  extreme  pictures  of  an  ulcerated, 
inflamed,  partially  destroyed  tube,  which  needs  only  to  be  seen  before  recognizing  the 
advisal)ility  of  a  colostomy  for  the  purjK)se  of  rest  of  the  inflamed  surfaces. 

Symptoms. — The  symptoms  of  rectal  ulceration  are  essentially  those  of  proctitis, 
mild  or  severe  as  the  case  may  be,  with  local  pain,  and  escaj)e  of  pus  and  l)lood.  Much 
depends  upon  their  location,  i.  c,  whether  within  the  sensitive  area  or  not.  Ulcer 
low  down  in  the  rectum,  no  matter  how  j)roduccd,  will  always  cause  a  dispro|)ortionate 
amount  of  suffering,  because  of  the  reflex  sphincteric  spasm  which  it  produces.  On 
the  contrary,  ulcers  high  up  give  rise  to  little  or  no  sufi'ering,  and  may  be  discovered  only 
after  a  history  of  discharge  of  blood  or  pus  prompts  a  thorough  local  examination. 
Therefore,  without  reference  to  the  feature  of  -pain,  every  statement  that  mucus,  pus, 
or  blood  is  discharged  from  the  rectum  should  lead  to  an  examination,  sufficiently 
thorough  to  detect  and  ex]x)se  the  cause  and  permit  of  proper  treatment.  Should  locsil 
anesthesia  prove  unavailing  for  this  purpose  a  general  anesthetic  must  be  administered. 
Thus  the  non-sj)ecific,  the  syphilitic,  and  the  tuberculous  ulcers  may  be  scraped  and 
cauterized,  care  being  taken  not  to  perforate.  If  ulcerating  tumor  is  found  it  should 
be  operated  upon  at  once.  Sometimes,  however,  by  these  examinations  unsuspected 
conditions  are  revealed  such  as  to  give  the  case  a  serious  aspect.  In  this  event  a  second 
anesthetic,  with  operation,  will  be  necessary.  For  all  ordinary  purposes,  however, 
sufficient  specula,  curettes,  the  actual  cautery,  and  applicator,  by  which  suitable  local 
treatment  can  be  made  to  the  affected  surfaces,  should  be  provided. 

Treatment. — As  indicated  above  in  the  treatment  of  proctitis  there  is  need  also 
for  various  local  anodynes  and  soothing  applications.  Physiological  rest  for  the  inflamed 
bowel  is  imperative.  Finally,  in  extreme  cases,  it  has  been  shown  that  it  is  best  to  open 
the  colon  above  the  seat  of  the  principal  disturbance,  doing  this  even  on  the  right  side 
should  the  whole  large  intestine  be  involved,  and  by  thus  relieving  it  of  its  duties  enable 
more  complete  physiological  rest  and  local  treatment. 


STRICTURE   OF   THE   RECTUM. 

The  inevitable  consequences  of  any  of  the  serious  forms  of  ulceration  above  described 
are,  if  recovery  ensues,  and  usually  even  if  it  does  not,  the  formation  of  cicatricial  con- 
strictions by  which  varying  degress  of  rectal  stricture  are  produced.  Rectal  strictures, 
then,  are  to  be  grouped  as: 

1.  Those  due  to  previous  and  more  or  less  active,  morbid  intrinsic  processes; 

2.  Those  due  to  the  presence  of  organized  exudate,  tumors,  or  other  compressing 

causes  from  without; 

3.  Those  due  to  traumatism. 

The  symptoms  and  signs  of  rectal  stricture  include  those  of  ulceration  and  obstruction, 
or  difficulty  in  defecation.  A  history  of  alternating  constipation  and  diarrhea,  with 
perhaps  tenesmus,  and  with  discharge  of  pus  or  blood,  will  prove  the  presence  of  some 
obstruction.  One  characteristic  feature  met  with  in  some  strictures  is  the  passage  of 
stools  which  when  solid  or  semisolid  have  a  characteristic  tape-  or  cord-like  shape,  as 
though  extruded  through  a  constricted  passage-way.  This  is  not  a  feature  necessarily 
present,  and  may  be  produced  even  in  non-malignant  cases,  as  when  the  rectum  is 
obstructed  by  uterine  myomas. 

With  respect  to  any  suspected  rectal  or  colonic  stricture  it  is  necessary  to  determine: 
(1)  Its  existence;  (2)  its  location;  (.3)  its  character;  (-4)  any  other  circumstances  bearing 
upon  the  case  which  might  affect  the  question  of  treatment.  The  latter  is  particularly 
important  when  the  question  of  syphilis  is  raised. 

The  al)ove  features  are  determined  by  careful  physical  examination  for  which  the 
finger  alone  may  he  sufficient,  or  which  may  require  instruments  and  postures  already 
described. 

Treatment. — Treatment  of  rectal  strictures  is  necessarily  mechanical,  but  will 
dc])end  in  large  measure  upon  their  cause  and  extent.     Thus  a  stricture  produced  by 


878 


SPECIAL  on  RI'AHOXAL  SlUiaKRY 


Fig.  592 
■Qi^eiided  Bon^, 


coiidition.s  extrinsic  to  the  rectum  jjropcr  iiii<>;lit  rc(niirc  Mlxloiiiiiial  section  uiul  removal 
of  a  pelvic  tumor  or  other  similar  o|)eratioii.  Many  a  patient  with  retrofiexed  uterus 
will  complain  of  a  rectal  condition  which  is  essentially  one  of  stricture,  the  overturned 
uterine  fundus  being  forced  against  the  rectum  and  j)ressing  u|)on  it,  demanding  not  a 
rectal  oj)eration  but  one  for  suspension  of  the  uterus.  The  obstipation  Avhich  is  j)ro- 
duced  by  ptosis  of  the  sigmoid,  or  by  hypertr()|)hy  and  abnormal  arrangement  of  the 
folds  and  rectal  valves,  may  necessitate  operation  upon  the  colon  (cohjplication  or  colo- 
pexy)  or  a  careful  division  of  hypertro|)liied  mucosa  through  the  j)roctosco])e,  as  used 
by  (MIC  skilled  in  its  manij>ulation. 

Strictures  of  recent  origin  may  yield  to  a  iVjrcible  dilatation,  which  should,  however, 
be  systematically  repeated  in  order  to  maintain  the  desired  effect.  Old,  dense,  and 
chronic  strictures  will  rec^uire  more  radical  }n-ocedures,  according  to  their  location  and 
extent.  Strictures  practically  impassable  may  indicate  conditions  so  extreme  as  to 
necessitate  colostomy,  while  in  a  small  proportion  of  cases  con- 
ditions will  be  found  so  favorable  as  to  justify  a  resection  of 
the  rectum,  either  from  below  and  from  without,  or  through 
abdominal  section  with  the  j)atient  in  the  "^rrendclenburg  ])osi- 
tion.  Nearly  every  stricture  is  accompanied  by  more  or  less 
ulceration,  sometimes  in  extreme  degree. 

Dilatation  or  expansion  by  some  mechanical  method  is  the 
necessity  in  every  case.  Simj)le  in  theory  its  j)erformance  is 
often  difficult  because  of  density  of  the  structures,  and  its 
danger  often  pronounced  because  of  the  serious  surrounding 
conditions  and  the  ])ossibility  of  ru|)ture  or  perforation  of  the 
Groiith  bowel  at  some  weakened  part,  or  of  infection  and  phlegmon 
folhnving  division  of  the  stricture  and  exj)osure  of  fresh,  raw 
surfaces.  Various  instruments  have  been  devised  for  dilating 
rectal  strictures,  some  of  which  are  ingeniously  arranged  to  be 
used  at  a  considerable  height  above  the  anus.  Danger  at- 
taches to  their  use  in  projjortion  to  the  amount  of  force  em- 
ployed and  its  distance  from  sight  and  touch,  i.e.,  from  intelli- 
gent means  of  control.  The  best  method  is  that  which  permits 
of  exposure  through  the  speculum  and  more  accurate  division 
with  knife,  scissors,  or  actual  cautery,  the  latter  often  being 
preferal)le,  as  hemorrhage  is  less  after  its  use. 
It  should  be  remembered  that  "once  a  stricture  always  a  stricture,"  and  that  the 
tenden(y'  of  cicatricial  tissue  to  contract  is  continuous  and  never  ceasing,  and  that 
wherever  there  has  been  a  stricture  (and  this  is  true  of  any  tubular  ])ortion  of  the  b(Kly) 
there  is  necessity  for  constant  and  more  or  less  frequent  later  attention.  If  possible, 
then,  milder  methods  and  those  more  capable  of  repetition  should  be  adopted.  The 
best  of  these  is  the  use  of  the  finger  for  c-ases  within  reach  of  it,  and  of  the  soft-rubber, 
conical  bougies  for  those  jilaced  higher,  and  for  the  patient's  individual  use.  Dilata- 
ticms  should  be  gradual  and  increased  as  rapidly  as  circumstances  j)crmit,  and  with 
tight  strictiu-es  the  endeavor  should  be  with  each  sitting  to  make  some  gain  until  a  suffi- 
cient size  has  been  attained.  Local  anesthesia  may  be  required,  and  is  justifiable  when 
needed. 


Anal  Orifire 


Stricture  of  rectum. 
(Bryant.) 


PRURITUS  ANI. 

This  condition,  usually  accompanied  with  irritative  or  ulcerative  conditions  of  the 
lower  end  of  the  rectum,  the  vcrgi>  of  the  anus,  and  tlie  surrounding  skin,  is  one  of  intense 
itching,  leading  t(^  an  uncontrollable  desire  to  rub  or  scratch,  by  which  temporary  relief 
may  be  Jifforded,  but  which  tends  to  produce  excoriation  and  ulceration.  The  condition 
is  not  ])rimary,  but  secondary  to  something  else,  although  the  conditions  which  produce 
it  are  widely  variant,  ranging  from  the  neuroses  due  to  anemia  or  other  causes,  to  the 
toxemias  of  uric  acid  origin,  the  local  irritations  produced  by  lesser  degress  of  internal 
disturbance,  or  eczema  or  other  itching  eruptions  on  the  outside.  In  corpulent  persons 
eczema  and  intertrigo  from  friction  are  common,  and  these,  c()m])ined  with  irregular 
tags  of  skin  or  remains  of  old  ])iles,  permit  of  irritation  and  maceration  which  still  further 
complicate.  Annoyance  is  usually  greatest  at  night,  when  the  attention  is  less  distracted 
by  other  things. 


piii.r.cMosors  affectioxs  of  tjif  rectum  S70 

Treatment.  Tlic  Ircalincnt  slimild  coiisist  in  rciiioval  ol'  the  caii.si'  and  local  relief. 
The  t'ornitT  nuiy  hr  (IKHcult  and  rccniiir  prolonged  cll'ort.  Local  relief  iimy  be  afi'orded 
by  frequent  a])|)lieuti()n.s  of  water  as  hot  as  can  be  borne,  with  local  a))|)lieation,  after 
the  parts  are  thoroiifjhly  dried,  of  a  powder  eontaininfj  menthol,  a  solution  containing 
caHi|)h()plieiii(|ue,  with  the  addition  of  a  little  chloroform,  or  by  soothinj^  ointments 
c()ntainiii<;'  carbolic  acid,  menthol,  and  orthoform.  When  there  is  abrasion  of  the  skin 
a|)|)li(ati()ns  of  silver  nitrate,  in  5  per  cent,  .solution,  may  be  made;  but  when  there  is 
mulli|)U'  ulceration,  stretchin>:;  the  s|)hincter  and  thoroughly  cauterizing  or  excKiing  tlie 
ulcerated  surfaces  will  Ix-  more  radical  and  ellective. 


PHLEGMONOUS   AFFECTIONS   OF   THE   RECTUM. 

On  either  side  of  tlu>  rectum,  between  the  dividing  folds  of  the  deep  pelvic  fascia,  is 
situated  the  iscluoircial  fo.sm,  a  ])yramidal-shaped  cavity  filled  with  fat  and  cellular 
ti.ssue.  This  is  not  only  in  close  relation  with  tlu'  outer  rectal  surfa(es,  but  is  peculiarly 
liable  to  infection  and  acute  inflannnatory  disturbance,  '^riuis  it  happens  that  isrhio- 
rccfdl  or  perirectal afmr.ssc.^  are  of  fre(|uent  occurrence,  ofti'u  of  marked  violence,  and  not 
without  their  peculiar  dangers.  Infection  may  travel  from  the  rectum,  or  the  first  excite- 
ment may  occur  in  one  of  the  mucous  or  skin  follicles  at  or  near  the  anus.  The  eonse- 
(juenee  is  what  the  patient  ordinarily  calls  a  boil,  which  to  the  surgeon  is  a  phlegmon, 
first  limited  by  the  w\alls  of  the  cavity  within  which  it  rises.  So  long  as  the  phlegmonous 
j)rocess  \w  confined  within  these  walls  it  is  acutely  painful. 

The  local  s-'upin  of  such  an  abscess  are  redness  and  infiltration  of  the  exterior  surface, 
swelling,  which  becomes  (juite  distinct,  and  pain  and  tenderness,  of  which  the  patient 
may  complain  bitterly.  The  local  soreness  is  so  extreme  that  defecation  becomes 
difficult  or  almost  impossible.  Any  attempt  at  digital  examination  of  the  rectum  w  ill 
give  rise  to  extreme  pain. 

Treatment. — Could  every  perirectal  abscess  be  distinctly  recognized  and  properly 
treated  in  its  comparatively  early  and  localized  stage  there  would  be  few  cases  of  residual 
trouble.  This  treatment  consists  of  early  and  extensive  incision,  made  externally  and 
directed  to  the  centre  of  the  jjlilegmonous  mass,  sufficiently  deeply  also  to  reach  it.  The 
evacuation  of  even  a  small  amount  of  jius,  followed  by  more  or  less  blood,  will  give 
prompt  and  immediate  relief,  and  bleeding  may  be  encouraged  rather  than  checked 
for  purposes  of  local  depletion.  Such  incision  may  be  in  most  instances  made  with 
freezing  spray  or  local  anesthesia.  In  children  and  exceedingly  nervous  jmtients  it 
would  be  better  done  under  general  anesthesia,  in  order  that  it  be  done  thoroughly. 
It  is  in  patients  who  decline  such  early  relief,  or  who,  from  ignorance  or  inattention 
have  not  received  it,  that  ischiorectal  abscesses  sometimes  assume  serious  proportions 
and  become  extensive  |)hlegmons,  breaking  down  anatomical  partitions  in  the  j)e]vis, 
burrowing  extensively  in  various  directions,  since  there  is  considerable  fatty  and  cellular 
ti.ssue  l)oth  inside  and  outside  of  the  pelvis  in  this  regif)n.  Thus  the  surgeon  may  not 
see  such  a  case  until  the  entire  buttock  is  involved,  or  until  the  process  has  gone  perhaps 
even  farther.  Relief  now  must  come  from  radical  apj)lication  of  the  same  princi|>les, 
by  the  aid  of  general  anesthesia,  multiple  incisions  with  counteropenings,  use  of  drain- 
age tubes,  etc.  The  patient  now  is  fortunate  if  perforation  into  the  rectum  has  not 
already  occurred  so  that  no  pus  is  discharged  from  the  bowel.  If  this  has  not  yet  hap- 
pened it  will  jirobably  be  jirevented  by  the  above  measures;  but  when  it  has,  and  a 
fistulous  communication  has  already  been  establishcfl,  it  may  be  sufficient  to  thoroughly 
cleanse  the  infected  cavity  to  see  both  it  and  the  fistula  close  by  granulation  in  the  course 
of  time.  Wide  external  incisions  are  necessary  in  these  cases,  for  complete  access  to 
the  deep  fossje  must  be  made.  In  more  ]>ronounced  cases  the  |)us  evacuated  will  be  ex- 
tremely offensive,  and  there  will  be  found  masses  of  necrotic  tissue,  sloughs  of  fascia,  and 
evidence  of  extensive  local  gangrene.  Such  putrid  cavities  must  be  thoroughly  cleaned 
out,  and  will  then  be  found  to  quickly  resume  a  healthy  aspect  when  treated  by  packing 
with  gauze  saturated  in  brewers'  yeast. 

The  more  chronic  and  slower  expressions  of  this  condition  are  usually  connected  with 
local  tuhercfilnii.s-  disease.  In  fact  everv  phlegmon  which  has  passed  the  acute  stage 
is  favorabli/  situated  for  tuberculous  infection,  and  becomes  in  time  a  tuberculous  lesion, 
which  is  to  be  treated  on  the  general  principles  elsew'here  enunciated.     These  fistulas 


SSO  SPECIAL  OR  REGIONAL  SURGERY 

arc  often  seen  in  consunij)tive  patients,  and  apprehension  has  widely  prevailed  that 
the  pulmonary  disease  might  be  aggravated  by  radical  attention  to  the  fistula.  This 
was  only  when  such  attention  was  made  incomplete.  To  divide  the  fistulous  passage 
and  leave  its  raw  surfaces  unprotected  and  in  contact  with  tuberculous  tissue  is  to  invite 
the  spread  of  infection.  To  do  the  proper  thing,  on  the  other  hand,  i.  e.,  to  radically  dis- 
pose of  all  tuberculous  tissue  and  so  treat  both  fresh  and  old  surfaces  that  a  new  infection 
is  not  invited,  is  not  tp  make  a  patient  worse  in  any  respect,  l)ut  to  relieve  him  of  at  least 
one  focus  of  disease.  There  is,  therefore,  no  reason  why  rectal  fistulas  should  not  be 
radically  treated  even  when  they  occur  in  consumptive  patients. 

RECTAL   FISTULAS. 

Rectal  fistulas  are  always  the  consequence  of  ischiorectal  abscesses  left  to  open 
s])ontaneously  in  either  or  both  directions.  They  may  occur  also  without  the  pre- 
existence  of  a  distinct  phlegmon,  as,  for  instance,  when  a  small  ulcer  in  the  rectum  gives 
way  and  permits  the  gradual  extension  into  the  perirectal  tissues  of  a  mildly  ulcerative 
or  suppurative  process. 

Rectal  or  anal  fistulas  are  classified  as  blind  external,  blind  internal,  or  complete, 
according  as  they  open  and  discharge  themselves  or  show  a  complete  passage-way 
from  the  rectum  to  the  exterior.  They  may  be  small  and  single,  or  numerous  and 
extensive.  Old  and  especially  chronic  tuberculous  cases  are  seen  when  the  whole  gluteal 
region  is  honeycombed  and  perforated  by  numerous  fistulas,  some  of  which  probably 
connect  with  the  interior  of  the  bowel.  I  have  seen  such  openings  as  low  as  the  knee 
and  as  high  as  the  dorsal  spines,  as  the  result  of  extremely  insidious  advance  of  tuber- 
culous granulation  and  its  subsequent  breaking  down.  In  such  cases  a  history  of  an 
acute  phlegmon  occurring  years  previously  may  be  obtained. 

A  blind  external  fistula,  simple  or  complicated,  naturally  discharges  its  pus  upon  the 
exterior.  It  may  be  accompanied  by  little  or  no  local  tenderness  or  pain.  A  blind 
internal  fistula  makes  itself  known  by  a  certain  amount  of  rectal  tenderness  and  by  the 
discharge  of  pus  with  the  stool,  or  at  other  times  of  pus  which  may  possibly  be  blood- 
stained. Here  there  may  be  a  history  of  eld  trouble,  with  external  evidences  of  it, 
which  suggests  that  exterior  communication  has  been  shut  off  while  that  with  the  bowel 
remains.  In  complete  fistulas  there  is  discharge  not  only  of  purulent  material,  but  of 
more  or  less  of  that  which  is  distinctly  fecal,  while  gas  sometimes  escapes  through  them. 
Such  a  statement  made  by  a  patient  is  of  itself  significant.  A  fistulous  passage  may  be 
surrounded  by  more  or  less  infiltrated  and  inflamed  tissue,  or  it  may  appear  much  like 
a  duct.  While  always  causing  mire  or  less  annoyance,  it  may  produce  symptoms 
which  seriously  disturb.     (See  Plate  LIII.) 

Treatment. — The  treatment  of  rectal  fistula  in  any  of  its  forms  is  distinctly  surgical 
and  should  always  be  radical.  A  blind  internal  fistula  can  be  discovered  only  with  the 
speculum. 

Every  such  fistulous  passage  should  be  split  up  and  its  tubular  portion  thoroughly 
excised  or  destroyed  with  a  sharp  spoon  or  caustic.  Furthermore  it  should  be  followed 
to  its  ultimate  ramifications.  For  this  purpose  it  is  of  great  assistance  to  first  inject  it 
with  methyl-blue  solution,  or  something  else  which  shall  stain  it  and  make  it  recognizable 
wherever  it  may  extend.  To  incise  a  superficial  and  external  fistula  is  a  simple  matter, 
for  which  local  anesthesia  alone  may  suffice;  but  to  deal  radically  with  an  extensive 
fistulous  tract  requires  dilatation  of  the  anal  sphincter  and  such  thorough  investigation, 
with  complete  relaxation  of  the  patient,  that  general  anesthesia  is  needed.  Now  with 
a  probe  identifying  the  tract,  and  the  knife  and  spoon  made  to  follow  it,  or  by  identifi- 
cation of  the  stained  tissues  colored  as  above  mentioned,  the  surgeon  should  proceed 
to  the  extreme  of  every  morbid  passage-way,  dilating,  cutting,  trimming,  scraping,  as 
may  be  needed;  while  after  the  work  is  done  every  particle  of  disturbed  raw  surface 
should  be  cauterized  with  some  reliable  caustic  (such  as  })ure  carbolic  followed  by  alcohol) 
so  as  to  sear  the  surface  and  prevent  the  possibility  of  reinfection. 

To  do  this  operation  thoroughly  necessitates  sometimes  multiple  and  extensive  inci- 
sions, with  a  fierceness  of  action  which  may  cause  surprise.  It  is,  however,  the  only 
effective  way  in  which  to  proceed. 

One  source  of  doubt  and  disappointment  is  met  occasionally  in  the  radical  treatment 


PLATE   LI  II 


^  "  b 


Illustrating  Various  Forms  of   Rectal  and  Anal  Fistulas,  and  the  Conventional  Methods 
of  Dealing  with  Them.      (Bernard  and  Huette.) 


rnoLM'si-:,  I'uocinr.sTiA,  .\.\i)  i.wAaix at/on  of  rifh'  rectum    ,s81 

whicli  rc(niirc.s  division  of  (lie  spliiiictcr,  lor  to  coiiiplclcly  divide  this  iiiusclc  is  to  j)rac- 
tirjdly  paralyze  it  and  leave  the  j)atient  thereafter  with  feeal  ineontinenee  more  or  less 
marked.  Sueh  accidents  leave  more  or  less  disahling  consequences.  Usually  they  are 
avoidable,  for  it  is  rarely  necessary  to  cut  completely  throuj^h  a  s[)hincter  muscle,  it 
heirifi;  possible  to  avoid  the  necessity  by  partial  division,  with  |)erhaps  more  complete 
e.\i)osure  above  and  below.  Even  in  those  instances  where  it  seems  unavoidable  if 
the  nniscle  be  first  vifforously  stretched,  and  thus  temporarily  j)aralyzed,  it  may  then  be 
safely  divided,  provided  it  be  neatly  and  completely  sutured  (U  once,  and  the  j)arts  kej)t 
at  rest  for  a  few  days,  the  intent  in  stretchin<i;  the  muscle  beinji^  partly  to  so  weaken  it 
that  it  shall  be  temporarily  disabled.  It  was  suggested  years  a^o  by  .Jenks,  of  Detroit, 
and  later  by  Kelly  and  others,  to  make  a  complete  excision  of  the  entire  fistulous  tract 
and  then  to  treat  this  as  any  other  fresh  wound,  closing  it  completely  with  sutures. 
The  method  is  good  in  theory  and  occasionally  applicable,  and  should  not  be  neglected 
when  circumstances  favor  its  practice. 

Every  fistulous  tract,  simple  or  complicated,  not  promptly  and  neatly  closed,  should 
be  dressed  with  gauze,  with  or  without  yeast,  balsam,  or  some  one  of  the  other  local 
aj)plications  recommended  elsewhere  in  this  work. 


PROLAPSE,  PROCIDENTIA,  AND  INVAGINATION  OF  THE  RECTUM. 

Prolapse  of  the  rectum  is  observed  in  two  degrees,  either  as  a  mere  evcrsion  of  its- 
mucosa,  which,  however,  may  be  profuse  and  extreme,  or  as  an  actual  f'.srapc  hij  process 
of  invagination  through  the  anus  of  some  portion  of  the  rectal  tube,  with  all  its  coats, 
including  in  well-marked  cases  even  its  peritoneal  covering.  The  former  is  more  com- 
mon in  children  as  the  result  of  diarrhea,  colitis,  the  presence  of  pin-worms,  or  other 
parasites,  or  any  other  cause  which  produces  tenesmus  and  frequent  straining,  with 
consequent  relaxation  of  the  anal  sphincter.  It  is  amenable  to  treatment  and  is  usually 
of  insignificant  proportion.  It  is  also  frequently  seen  in  adults  in  connection  with 
internal  hemorrhoids,  which  are  extruded  with  every  stool,  carrying  with  them  more  or 
less  mucosa,  and  which  are  usually  returned  within  the  rectum  by  the  patient  at  the 
conclusion  of  the  act  of  defecation. 

The  more  complete  form  of  prolapse  by  true  invaginatiori  is  rarely  seen,  save  in 
adults,  and  in  consequence  of  some  serious  preexistent  condition,  such  perhaj^s  as 
complete  laceration  of  the  perineum  in  the  female,  paralysis  of  the  sphincter  from  pre- 
vious accident,  or  from  the  existence  of  spinal-cord  disease.  Here  and  in  extreme 
cases  several  inches  of  bowel  may  be  extruded  from  the  anus,  and  to  an  extent  scarcely 
permitting  spontaneous  or  even  individual  restoration.  So  complete  a  form  is  permitted 
only  by  some  previous  lesion  of  the  pelvic  floor,  while  the  mesorectum  and  even  the  meso- 
sigmoid  become  gradually  stretched  and  useless.  The  lower  portion  of  the  rectum 
is  by  far  the  more  muscular,  and  such  a  condition  requires  that  its  intrinsic  muscles  yield 
also  with  those  around  them. 

Prolapse  is  a  condition  of  general  and  usually  slow  development  rather  than  of  abrupt 
onset.  It  is  made  known  by  the  presentation  at  the  anus  of  the  bright-red  mucosa  of 
the  rectum,  where  it  pouts  and  protrudes,  forming  a  tumor  of  varying  size,  with  more 
or  less  tender  surface,  which,  with  gentle  coaxing  pressure,  is  easily  made  to  return  within 
the  rectum.  It  can  usually  be  made  to  appear  by  straining  effort  on  the  part  of  the 
patient.  Boys  with  phimosis,  who  are  in  consequence  made  to  strain  every  time  they 
urinate,  will  frequently  present  minor  degrees  of  the  condition,  perhaps  oftener  than 
when  the  rectum  itself  is  at  fault,  as  the  act  is  so  frequently  repeated.  The  oftener 
suc-h  protrusion  occurs  the  more  relaxed  becomes  the  anus  and  the  more  irritated  the 
presenting  surface,  until  ulceration  and  even  keratosis  may  result.  Chronic  consti- 
pation of  children  or  adults  will  also  produce  the  same  eflFect.  The  presence  of 
hemorrhoidal  tumors  or  of  polypi,  or  even  of  parasites,  causes  the  same  result. 

The  most  pronounced  and  complete  types  of  invagination  produce  a  condition  m 
which  reduction  is  perhaps  not  possible  and  procidentia  is  constant.  There  may  form 
here  a  pouch  around  the  rectum,  containing  loops  of  bowel,  bladder,  or  ovary,  or 
there  may  even  occur  a  perirectal  hernia. 

While  patients  nearly  always  become  more  or  less  accustomed  to  the  condition  it 
nevertheless  is  distressing  in  proportion  to  its  size  and  the  inclividual's  temperament, 
56 


882  .SPECIAL  OR  REGIONAL  SURGERY 

Treatment. — TrcatiiK'nt  (Icixuds  entirely  ii|)()ii  tin*  nature  and  extent  f)f  the  con- 
dition. Mild  forms  oceurrin<j;  in  younff  children  may  he  easily  ohviatcd  hy  attention  to 
their  stools,  hy  circumcision  il'  needed,  or  hy  the  use  of  a  five-ii;rain  capsuk;  of  ergotin 
inscrteti  as  a  suppository,  it  having  the  effect  of  invigorating  the  involuntary  muscle  and 
stimulating  the  sphincter.  Cases  not  amenable  to  the  milder  methods  become  surgical 
and  the  treatment  is  then  apportioned  to  the  extent  of  the  lesion.  If  connected  with 
hemorrhoids  or  other  tumors  it  becomes  a  part  of  their  treatment  and  is  to  be  dealt 
with  at  the  same  time.  Occurring  a|)parently  in(lej)endently  the  milder  forms  will 
often  yield  to  the  proper  use  of  caustics.  The  actual  cautery  being  preferable,  it  is 
appliecl  in  streaks  up  and  around  the  rectum,  in  such  a  way  that,  when  the  ulcers  thus 
formed  cicatrize,  the  rectum  shall  be  shortened  by  cicatricial  contraction  as  by  a  series 
of  loops  drawn  up  to  shorten  it.  When  permitted  by  rupture  of  the  ])erineum  and 
more  or  less  combined  perhaps  with  cystocele,  repair  of  the  ])erineum,  rather  than  atten- 
tion to  the  rectal  condition  itself,  will  be  demanded,  while  the  latter  may  be  combined 
with  an  operation  for  rectocele  by  excision  of  an  elliptical  portion  of  the  vaginal  mucosa 
and  the  a|)])roximation  of  its  edges  into  a  line  of  sutures.  This  will  reduce  the  capacity 
of  both  the  vagina  and  the  rectum  and  a  double  indication  be  thus  met.  Acute  inflam- 
mation sometimes  follows  ex|)osure  of  a  j)r()la])sed  rectum  and  it  may  slough,  thus 
leading  to  s|)ontaneous  recovery,  the  process  not  being  without  its  dangers  of  thrombosis 
and  septic  infection.  This  procedure  may  be  imitated  by  a  surgical  excision  of  the  entire 
|)r()lapsed  portion,  always  with  great  caution  so  that  if  peritoneal  surfaces  be  ex]K)sed 
they  be  protectcHl  from  infection.  It  has  been  possible  in  many  instances  to  completely 
excise  the  protruding  ])()rtion,  and  then  to  apply  a  double  row  of  sutures  similar  to  those 
used  in  intestinal  resection,  only  with  attention  first  to  the  peritoneal  rather  than  the 
mucous  surface,  in  such  a  way  as  to  excise  several  inches  of  the  prolapsed  bowel  and 
thus  meet  the  indication.     Nevertheless  cases  where  this  can  be  done  are  exceptional. 

Pratt  has  suggested  a  trmporari/  purse-string  suture  of  the  anus,  effected  by  a  curved 
needle,  completely  circumscribing  the  anal  oj)ening,  but  kept  between  the  skin  and  the 
nnicous  membrane,  to  be  brought  out  through  the  same  ])uncture  at  which  it  was 
inserted.  The  finger  of  an  assistant  being  passed  into  the  anus,  the  suture  is  now  tied 
around  it.     This  may  be  used  as  su])plementary  to  linear  cauterization  above  mentioned. 

Numerous  methods  of  prortopr.nj,  or  elevation  and  fixation,  have  been  devised. 
Fowler,  for  instance,  made  an  incision  half-way  between  the  anus  and  the  point  of  the 
coccyx,  and  after  separating  the  rectum  from  the  latter  and  the  sacrum  inserted  two 
fingers  in  the  rectum,  holding  it  up  while  its  posterior  wall  was  forced  into  the  external 
wound  and  there  held  by  heavy  sutures  of  kangaroo  tendon.  By  further  incision  he 
brought  out  the  ends  of  these  sutures  on  each  side  of  the  coccyx  and  tied  them  across 
the  bone,  thus  by  traction  bringing  the  rectum  up  into  position. 

(U)l<>pr.rt/  has  been  practised  as  a  more  radical  measure  for  the  same  piu'pose.  As 
advised  by  Bryant  the  abdomen  is  opened  by  an  incision  parallel  to  Poupart's  ligament 
on  the  left  side  and  one  inch  above  it,  and  the  prolapse  is  reduced  by  firmly  pulling  the 
rectum  upward.  It  is  then  secin-ed  to  the  ])eritoneum  about  it,  and  is  held  by  quilting 
sutures,  which  include  the  entire  muscular  coat  of  the  bowel.  Save  in  exceptionally 
favorable  cases  one  or  the  other  of  these  methods  may  be  considered  preferable  to 
the  complete  amputation  above  described. 


HEMORRHOIDS;  PILES. 

Ilemorrlioids  constitute  perhaps  the  most  common  and,  in  some  respects,  uncomfort- 
able or  distressing  disease  of  the  rectum.  The  term  implies  a  varicose  condition  of  the 
lower  veins,  .sometimes  those  of  one  sc^t  of  hemorrlioidal  veins  being  involved,  at  other 
times  nearly  all  of  them  participating.  They  are  spoken  of  as  external  or  internal. 
In  the  former  case  it  is  the  external  hemorrhoidal  veins  alone  which  are  involved,  and 
usually  only  two  or  three  of  them,  although  occasionally  one  sees  outside  the  anus,  as 
within,  a  general  involvement  of  the  entire  venous  distribution.  A  pile,  then,  is  essen- 
tially a  venous  angioma,  or  a  single  varicosity,  and  its  p(>culiar  features  are  due  solely 
to  its  location. 

Any  vein  thus  involved  is  lial)le  to  the  same  dangers  and  accidents  as  veins  in  other 
parts  of  the  body.     Thus  it  may  undergo  dilatation,  thrombosis,  and  suppuration,  while 


lli:M()lUiU()II)S;  I'lLES  gg3 

the  ordiiiury  coiisciniciiccs  of  tlic  hitter  cDiiditioii  iiuiy  follow  here,  as  elsewhere,  with 
this  difi'ereiu-e  tiloiie,  that  when  the  middle  and  upper  hemorrhoidal  plexuses  are 
involved  the  thronihoseptic  process,  should  it  occur,  follows  the  portal  vein.,  and  the  first 
metastatic  ahscess  that  forms  occurs  within  the  liner.  Thence  it  may  spread  to  other 
parts  of  the  body  in  classic  form. 

'VUv  hemorrhoidal  veins,  save  those  at  the  vcr^e  of  the  aiuis,  an;  more  or  less  entangled 
amoii>i-  the  fibers  of  the  levator  ani  and  the  sphincter.  These  muscles  are  thrown  into 
a  condition  of  more  or  less  spasmodic  contraction  when  the  veins  are  so  involved.  In 
consequence  more  i)ressure  is  made  upon  the  veins  themselves,  and  the  conditions  of 
sj)asm  and  venous  engorgement  react  upon  each  other  in  a  vicious  circle,  each  tending 
to  make  the  other  worse.  Hence  the  great  advantage  of  stretching  the  s-phincter  in  any 
operation  save  that  for  a  small  external  ])ile. 

Hemorrhoidal  angiomas  may  appear  as  single  tumors  or  in  multi])le  form  surrounding 
the  lower  part  of  the  rectum.  Tiie  most  common  cause  for  their  occurrence  is  chronic 
cotistipation.  Occasionally  the  first  exciting  agent  is  some  violent  strain  in  defecation, 
or  possibly  the  actual  rupture  of  a  small  vessel,  but  such  constant  overloading  of  the 
rectum  as  obstructs  its  return  circulation  conduces  to  engorgement  and  the  other  con- 
ditions may  easily  follow.  A  small  pile  may  be  brought  into  existence  in  brief  time,  but 
a  general  hemorrhoidal  condition  is  one  of  slow  development.  Chronic  cases  are  always 
accomj)anied  by  further  changes  involving  the  surrounding  connective  tissue  and  the 
overlying  nur;)sa,  both  of  which  become  thickened  and  infiltrated,  while  ulcers  form 
frecjucntly  upon  the  latter,  and  the  occurrence  of  those  linear  ulcers  which  are  ordinarily 
called  /f.s'.s'»/T.s-  is  very  freciuent.  This  gives  an  additionally  distressing  feature  to  these 
cases.  As  the  condition  goes  on  and  the  angiomas  increase  in  size  there  is  an  increasing 
tendency  to  ]>rolapse.  This  may  be  temporary  or  constant,  i.  e.,  it  may  occur  with  the 
straining  effort  at  stool  or  it  may  result  in  a  condition  of  permanent  protrusion  at  the 
anus  of  the  engorged  mucosa;  or,  if  the  sphincter  has  finally  become  prolapsed  a  true 
prolapse  of  the  rectum  may  result.  A  mucous  surface  thus  constantly  exposed  to  irrita- 
tion will  nearly  always  be  more  or  less  ulcerated  and  tender,  while  hemorrhages  in  either 
variety  are  common.  It  is  not  an  infrequent  event,  then,  for  a  patient  to  lose  a  number 
of  ounces  of  blood  with  or  just  after  stool,  and  sometimes  the  blood  loss  is  even  excessive. 
There  is  then  added  to  the  local  condition  a  secondary  feature  of  anemia  and  its  attendant 
consequences  which  are  sometimes  extreme,  and  may  even  make  operation  somewhat 
hazardous.  The  lower  inch  and  a  half  of  the  rectum  is  the  portion  particularly  supplied 
with  sensory  nerves,  and,  under  these  circumstances,  the  irritated  area  becomes  erethistic 
and  painful  and  the  patient's  suffering  may  be  extreme.  This  is  the  so-called  "pi7e- 
heariiKj  area,"  as  it  is  within  it  that  the  hemorrhoidal  condition  is  practically  confined. 
Even  a  small  individual  pile  connected  with  one  of  the  little  external  veins  may  give 
rise  to  a  disproportionate  amount  of  discomfort. 

There  has  been  so  much  (piack  literature  upon  this  general  subject  that  ignorant 
patients  are  very  likely  to  say  that  they  have  piles,  no  matter  what  may  be  the  local 
condition.  A  statement  to  this  effect  should,  first  of  all,  provoke  a  physical  examination 
with  the  finger,  then  with  the  speculum.  The  educated  finger  will  easily  detect  the 
presence  of  the  rugosities  or  tumors  produced  by  internal  piles,  the  external  being  always 
self-evident.  The  coexistence  of  ulceration  will  be  indicated  by  an  extreme  degree  of 
sphinctcric  spasm  and  of  tenderness.  It  should  be  remembered  that,  along  with  hemor- 
rhoids, there  may  coexist  fissure,  ulcer,  ])ainful  spasm,  j)rolapse,  and,  in  long-existent 
cases,  even  cancer.  The  average  patient  with  cancer  of  the  rectum  will  go  to  his  physi- 
cian saying  that  he  thinks  he  has  piles. 

Treatment. — Treatment  needs  to  be  something  more  than  merely  local  in  aggra- 
\atcd  cases,  as  it  should  also  be  more  comprehensive.  Patients  who  have  thus  long 
suffered  have  almost  inevitably  contracted  the  constipated  habit,  postponing  defecation 
whenever  possible  because  of  pain  and  tenderness,  and  perhaps  the  hemorrhage  accom- 
panying it.  The  large  bowel  has,  therefore,  become  weakened,  and  attention  should  be 
given  to  it  as  well  as  to  the  general  digestive  process. 

Localhj  very  mild  degrees  of  purely  temporary  disturbance  may  be  sometimes  accept- 
ably and  temporarily  treated  by  the  use  of  suppositories  containing  some  soothing  and 
anodyne  drug,  as  well  as  ergotin,  the  latter  being  valuable  because  of  its  constringent 
effect  upon  the  bloodvessels.  A  five-grain  gelatin-coated  pill  of  ergotin  makes  a  satis- 
factory suppository  for  the  young,  under  these  conditions. 


884  SPECIAL  OR  REGIOXAL  SURGERY 

A  freshly  formed,  external  hemorrhoid,  which  may  attain  a  size  no  larcrer  than  that 
of  a  pea,  but  which  will  .seem  to  the  patient  as  large  as  a  bird's  egg,  is  best  treated  by 
open  division,  turning  out  the  blood  or  clot  contained  within  the  dilated  vein,  which  will 
quickly  obUterate,  so  that  recovery  will  be  complete  within  two  or  three  days.  This 
may  be  done  under  local  anesthesia  and  with  prompt  relief.  There  have  been  methods 
in  vogue,  especially  among  the  charlatans  and  some  of  the  specialLsLs,  of  treating  external 
and  the  more  localized  internal  conditions  by  injection  of  carbolic  acid,  either  pure  or 
reduced  with  a  little  glycerin.  A  few  drops  are  thrown  into  the  tumor  with  a  h\-podermic 
needle,  the  effect  being  to  promptly  coagulate  the  contained  blood,  the  intent  being  to 
produce  a  final  cure  by  absorj)tion  of  the  clot  and  obliteration  of  the  veins.  This,  in 
fact,  is  the  secret  method  long  employed  by  the  travelling  charlatans  and  often  connected 
with  the  name  of  Brinkerhof.  It  is  uncertain  in  action,  and  the  production  of  a  clot 
under  these  conditions  is  by  no  means  always  free  from  danger,  nor  is  the  relief  prompt. 
What  is  desired  is  to  empty  the  vein  and  turn  out  the  clot  rather  than  to  provoke  its 
production.  The  method  is  rarely  practised  by  judicioas  surgeons,  who  have  too  often 
seen  serious  sloughing  and  even  general  septic  disturbance  follow  it. 

For  the  radical  relief  of  distinctly  hemorrhoidal  conditions  there  is  no  satisfactory 
method  save  the  operative.  So  many  measures  have  been  de\ised  in  time  past  that  it 
is  necessary-  here  to  be  selective  and  only  mention  one  or  two.  On  general  principles 
ever\-  pile  is  a  venous  tumor,  and  there  is  no  reason  why  it  should  not  Ije  treated  like 
anv  other  tumor,  i.  e.,  by  enucleation  or  excision.  The  same  is  true  of  the  area  which 
contains  a  number  of  such  tumors,  i.  e.,  the  .so-called  pile-Vjearing  area.  Hence,  surgeons 
of  the  largest  experience  have  practically  discarded  the  more  Vjungling  methods  and  have 
applied  to  these  conditions  the  same  radical  measures  which  they  recommend  elsewhere. 

One  important  feature  which  should  always  be  practised  is  thorough  dilatation  of 
the  sphincter,  not  only  for  reasons  above  described,  but  because  of  the  facihty  with  which 
the  surgeon  then  exposes  the  diseased  tissues.  Any  distinct  tumor  or  series  of  them 
may,  for  instance,  be  seized,  isolated,  and  dissected  out,  either  by  an  elliptical  incision 
of  the  mucosa  or  by  a  more  blunt  dissection  with  scissors.  The  base,  or  j>edicle, 
if  sufficiently  large  to  justify  it,  may  be  ligated  before  the  incision  is  completed,  after 
which  catgut  sutures  may  be  used  to  close  the  opening  in  the  mucosa.  AVhen  the  tumor 
b  small  the  suture  may  be  made  to  include  the  bleeding  p>oints  so  that  even  a  ligature  is 
not  required.  A  more  radical  method  of  extending  this  same  principle  to  the  entire 
pile-Vjearing  area,  especially  when  prolapsed,  or  to  so  much  of  it  as  is  affected,  is  the 
so-called  Whitehead's  operation  of  excision,  which  practically  consists  in  trimming  off 
a  ring  of  exposed  mucosa,  with  its  clusters  of  enlarged  and  more  or  less  penduloas  veins. 
This  ring  extends  from  the  mucocutaneous  border,  at  the  verge  of  the  anus,  to  a  point 
perhaps  1^  inches  above,  the  intent  being  to  separate  the  mucosa  and  the  tumors  from 
the  fibers  of  the  sphincter,  which  can  Vje  practically  effected  in  such  a  way  that  sphincter 
control  is  not  lost.  Hemorrhage  will  be  free  for  a  few  moments,  but  is  always  within 
control.  Larger  vessels  which  spurt  may  be  twisted  or  tied,  while  oozing  surfaces 
are  included  within  the  row  of  catgut  sutures,  which  is  later  placed  in  such  a  way  as  to 
unite  the  di\'ided  mucous  tube  with  the  skin  border  at  the  anus.  The  operation  is,  in 
effect,  an  annular  excision  of  the  lining  of  the  rectum,  and  as  such  proves  satisfactory. 
There  is  about  it  this  temporarA*  disadvantage  that  the  pile-bearing  area  thas  removed 
is  also  the  .sensitive  area,  and  that  for  a  few  weeks,  at  least  until  nerve  communications 
have  been  reestablished,  there  is  a  lack  of  peculiar  or  normal  sensibility  about  the 
parts  which  is  annoying,  and  may  perhaps  lead  to  .some  incontinence,  but  this  soon  passes 
away.  The  measure  Is  the  most  satisfactory  of  all  for  well-marked  cases  of  hemorrhoids 
associated  with  more  or  less  ulceration  and  prolapse. 

An  occasional  dilatation,  scattered  here  and  there  around  the  lower  end  of  the  rectum, 
perhaps  with  a  mild  degree  of  ulceration,  is  u-sually  very  satisfactorily  treated  by  a 
method  which  it  must  be  confessed  would  be  rarely  used  on  the  exterior  of  the  body, 
and  yet  which  proves  quite  .servicealjle  here,  namely,  the  actual  cautery.  The  conse- 
quences of  its  application  are  obliteration  of  the  vein,  cicatricial  contraction  of  the 
overstretched  tissues  and  eventual  relief. 

Other  methods  of  operation  include  the  use  of  the  clamp  and  cautery  for  removal 
of  con.siderable  masses,  a  method  ordinarily  less  satisfactf>rv  than  excision,  and  the 
use  of  the  ligature,  with  or  without  incision  of  the  muco.sa  at  the  base  of  the  tumor,  it 
Ijeing  thus  cauterized  and  ex|>ected  to  .separate  by  sloughing,  an  uncertain  procedure, 


TUMORS  OF  THE  RECTUM  885 

None  of  tlu'sr  methods,  nor  otiicrs  not  worlli  nu'iitioiiiiiir,  compare  with  the  newer 
methotls  of  extision. 

Miuh  has  been  recently  written  concerning  the  advantage  of  local  anesthesia  in  doing 
these  operations.  This  seems  to  have  been  advocated  largely  for  effect,  although  external 
tumors  can  he  treated  by  cocaini-  ai)plications  or  by  the  ordinary  injections  of  cocaine 
or  one  of  its  substitutes.  It  is  claimed  tiiat  the  infiltration  of  the  surrounding  tissues 
with  normal  salt  solution  affords  an  elfective  local  anesthetic.  Mere  local  anesthesia 
is  not  sufficient  for  thorough  work  upon  parts  not  easily  visible,  and  the  actual  stretching 
of  the  sjjhincter  is  half  the  battle  in  dealing  with  these  conditions.  This  cannot  be 
thoroughly  accomplished  without  general  anesthesia.  Consecjuently  for  any  well- 
marked  hemorrhoidal  condition  chloroform  offers  decidedly  the  ])referable  method, 
not  alone  from  considerations  of  comfort,  but  from  the  standpoint  of  permitting  more 
thorough  and  effective  work  to  be  done. 

After  these  operations  it  is  advisable  to  place  within  the  grasp  of  the  anus  a  stiff 
rubber  tube  wra|)j)ed  with  gauze.  It  permits  the  escape  of  flatus  without  distress  to 
the  j)atient,  and  it  effects  a  better  coaptation  of  surfaces  recently  united  by  suture  than 
would  otherwise  be  secured.  Such  a  tube  may  be  left  in  situ  for  from  six  to  thirty-six 
hours. 


Fig.  593 


TUMORS    OF    THE    RECTUM. 

The  rectum  is  the  frequent  site,  more  especially  in  children,  of  poli/poid  degenerations 
similar  to  those  seen  in  the  nose.  In  consequence  there  are  formed  the  so-called  rectal 
polypi,  which,  in  origin,  consistence,  and  course  correspond  to 
the  common  nasal  polypi.  Such  a  pedunculated  tumor  may 
attain  considerable  size,  especially  when  solitary,  while,  on 
the  other  hand,  the  mucosa  may  be  studded  with  small 
pedunculated  growths,  giving  the  appearance  represented  in 
Fig.  593. 

Pathologically  these  polypi  are  originally  of  myxomatous 
or  adenomatous  type.  They  may  bleed  easily  and  may  be 
passed  with  stool.  In  their  multiple  and  smaller  expressions 
they  give  rise  rather  to  rectal  uneasiness  and  tenesmus  than 
to  more  distinct  symptoms.  On  the  other  hand  an  isolated 
tumor,  so  pedunculated  as  to  become  gradually  stretched  out, 
may  attain  considerable  size  and  give  rise  to  all  the  sensa- 
tions of  a  foreign  body  in  the  rectum,  Avith  constant  tenesmus 
and  desire  to  expel  it,  while  it  may  even  present  at  the  anus 
or  bleed  freely. 

Only  exceptioHally  will  these  tumors  be  recognized  previous 
to  examination,  which,  however,  should  easily  disclose  their 
characteristics.  Isolated  polypi  should  be  removed,  either 
by  being  twisted  off  or  by  excision  and  ligature  of  their  bases. 
General  polypoid  degeneration  may  be  treated  with  the 
curette  or  with  the  actual  cautery.  In  all  these  instances 
surgical  intervention  in  some  form  will  be  required. 

Other  benign  tumors  in  the  rectum  are  mainly  of  the  ade- 
nomatous type.  Owing  to  their  location  it  is  rare  that  they 
are  seen  early  by  one  competent  to  judge  of  them.  In  con- 
sequence the  surgeon  sees  them  usually  as  more  or  less 
ulcerated,  sometimes  extensive  growths,  perhaps  bleeding 
freely,  and  much  changed  by  maceration  and  by  compression 
from  their  original  condition. 

In  such  cases  it  becomes  a  question  of  importance  to  dis- 
tinguish between  the  benign  and  the  cancerous  growths. 
This  is  not  always  easily  done,  especially  when  they  are  high 
up  and  ulcerated.  The  matter  is  usually  decided  by  the 
presence  or  absence  of  actual  infiltration  around  the  base  of 
the  growth,  and  perhaps  the  involvement  of  lymph  nodes.  A  movable  tumor  with  an 
infiltrated  base  is  usually  clinically  benign,  nevertheless  it  should  be  radically  removed, 


Multiple  polypi  of  rectum, 
(Potherat.) 


886 


SPECIAL  OR  REGIOXAL  SURGERY 


It  is  in  manv  of  these  instances  that  one  may  see  exj)ressions  of  transforraation  of  adenoma 
into  carcinoiiia. 

Cancer  of  the  Rectum. — This  will  be  considered  here  rather  from  its  clinical 
side;  hence  what  is  said  refers  alike  to  sarcoma  and  carcinoma,  the  latter  being  far 
more  common.  Carcinoma  of  the  rectum  may  assume  the  type  either  of  epithelioma,  as 
when  it  begins  low  and  spreads  ujjward,  or  of  adenocarcinoma,  when  it  arises  from 
that  ]X)rtion  f)f  the  tulje  not  lined  with  squamous  epithelium. 

It  usually  begins  insidiousJif,  and  for  a  considerable  length  of  time  furnishes  scarcely 
anv  recognizaljle  svmptom.  The  first  indications  noticed  by  the  patient  are  usually 
more  or  less  frequency  of  stool,  with  tenesmus,  and  the  passage  of  mucus,  })crha]xs  stained 
with  l)lo()d,  rather  than  of  fecal  matter.  By  the  time  those  conditions  are  noticed  there 
will  usually  be  more  or  less  mechanical  difficulty  of  defecation,  due  to  the  j)resence  of 
the  tumor  and  obstruction  of  the  rectal  tube.  Pain  may  be  a  long-deferred  feature,  and 
local  soreness  may  be  absent  until  late  m  the  case  or  until  its  terminal  stage,  when 
the  growth  is  above  the  peculiarly  sensitive  part  of  the  rectum,  i.  e.,  when  it  does  not 
approach  to  within  U  inches  of  tlie  sphincter.     As  time  goes  on  there  is  more  and  more 


Epithelioma  of  anus  and  rectum.     (Grant.)  * 

suffering  in  the  rectum,  with  l)ackache,  referred  pain,  while  the  t^esmus  and  other 
local  conditions  cause  increasing  distress.  It  often  happens  that  it  is  not  until  this 
period  is  reached  that  the  patient  consults  a  physician,  and  then  he  usually  goes  with 
the  statement  that  he  is  suffering  from  piles. 

So  frequently  is  this  the  case,  and  so  prone  are  many  practitioners  to  accept  such  a  state- 
ment, that  the  proper  examination  which  should  permit  the  recognition  of  the  condition 
is  perhaps  not  made  until  the  patient  is  really  in  a  ])itiable  condition.  I  do  not  recall 
ever  having  seen  a  case  of  cancer  of  the  rectum  which  had  not  been  regarded  In/  some 
physician  as  piles,  and  in  most  cases  locally  treated  hy  him,  usually  without  any  adequate 
local  examination,  and  usually  also  until  the  time  had  passed  when  a  radical  operation 
could  be  practised  with  any  degree  of  hope.  The  first  examination  at  least  will  be 
digital,  and  if  the  malignant  growth  l>e  within  reach  of  the  finger  it  should  be  possible 
to  appreciate  it,  to  estimate  its  size,  degree  of  attachment,  and  the  amount  of  infiltration, 
as  well  as  the  extent  to  which  it  is  breaking  df)wn.  A  soft,  ra])idly  growing  cancer  will 
give  a  fungous  sensation  to  the  finger,  while  the  more  dense,  scirrhous  forms  produc-e 
hard  masses,  groAnng  in  irregular  .shapes,  .sometimes  involving  one  side  of  the  bowel, 
sometimes  appearing  in  annular  form,  and  tending  sooner  or  later  to  produce  malignant 


TUMORS  OF  THE  RECTUM  887 

(.Instruction.  Tlic  only  diflicultv  would  he  in  cases  seen  exceptionally  early  or  in  those 
beyond  reach.  The  circumstances  above  detailed  should  lead  to  a  careful  prorfo.'icopic 
examination  with  suitable  instruments,  perhaps  in  the  knee-chest  jjosition,  when  the 
growth  is  not  easily  appreciated  from  below.  Any  complaint  of  tenesmus,  with  dis- 
rlian/f  of  hlood  and  in  urns,  iritli  more  or  less  pain  and  tenderness,  local  or  referred,  demands 
an  examination  .siiffirienllij  carefnt  to  reveal  the  nature  and  extent  of  the  lesion  and  indicate 
the  treatmenf.  If  such  an  exaniinalion  call  for  an  anesthetic,  it  should  be  administered. 
Practically  every  rectal  cancer  is  a  malignant  ulcer  by  the  time  it  is  recognized,  uiccralion 
being  fa\ored  by  warmth  and   moisture. 

Treatment.  There  are  few  malignant  lesions  anywhere  about  the  body  which  recpiire 
more  good  judgment  in  treatment  than  ca.ses  of  cancer  of  the  rectum.  So  much  depends 
upon  their  location,  their  extent,  the  degree  of  infiltration,  the  age  and  general  condition 
of  the  patient,  that  it  is  almost  impossil)lc  to  lay  down  succinct  rules.  The  question  of 
treatment  hinges,  first,  u|)on  the  location  and  extent  of  the  lesion;  is  it  operable  or  is 
it  not?  When  the  lymph  nodes  of  the  ])elvis  or  the  groin  are  noticeably  inyolyed  it  is 
jmicticallv  too  late,  under  any  circumstances,  to  hold  out  pros])ect  of  radical  cure.  When 
the  disease  has  extended  far  above  reach  of  the  finger  it  is  again  late  to  expect  nnich 
even  from  radical  measures.  When  the  prostate,  the  floor  of  the  bladder,  the  vagina, 
or  any  of  the  pelvic  viscera  are  involved  it  is  again  too  late  to  justify  tliem.  There  are 
wide  differences  of  opinion  between  surgeons  as  to  the  propriety  of  extensive  operations 
in  serious  cases.  Mild  cases  are  certainly  much  benefited  and  even  actually  cured  by 
early  and  thorough  removal,  l)ut  this  occurs  too  infrequently,  because  such  cases  are 
rarely  seen  sufficiently  early. 

The  class  of  cases  universally  acknowledged  to  be  inoperable,  so  far  as  radical  measures 
are  concerned,  ar(>  nevertheless  much  benefited  and  tlu-ir  lives  prolonged  by  a  colosfomij, 
the  eftect  being  to  ])rovi(le  an  easy  and  manageable  outlet  for  fecal  discharge,  and  to 
avoid  the  irritation  and  attendant  difficulties  associated  with  an  obstructed  and  malig- 
nantly ulcerated  rectal  outlet.  The  surgeon  has  to  select  between  some  method  of 
excision  and  colostomy.  My  own  opinion  is  growing  in  favor  of  the  latter,  save  when  the 
prospect  of  complete  excision  is  good.  The  opening  is  more  manageable,  the  progress 
of  the  disease  seems  much  checked,  patients  have  Ijetter  fecal  control  and  live  in  far 
greater  comfort,  while  their  lives  are  placed  in  less  jeojiardy,  and,  in  general,  are  actually 
prolonged.  Thus  a  colostomy  performed  in  a  well-marked  case  of  inoperable  cancer 
of  the  rectum  may  ]i(>rmit  of  j)rolongation  of  life  for  two  or  three  years,  something  not 
often  attained  by  any  other  method  of  treatment. 

Of  the  various  radical  operations  some  are  made  from  below,  i.  e.,  by  the  perineal 
route,  some  by  the  so-called  sacral  route,  and  some  from  above.  Of  the  latter  it  may  be 
said  that  occasionally  an  annular  cancer  of  the  rectum  is  seen  so  favorably  located  that 
by  opening  the  abdomen  with  the  patient  in  the  Trendelenburg  position  it  is  possible 
to  make  a  complete  excision  of  the  growth,  to  remove  enlarged  lymph  nodes,  and  to 
make  an  end-to-end  reunion  with  success.  In  a  case  in  my  own  practice  nearly  six 
years  have  elapsed  since  this  operation  was  done,  and  the  patient,  a  young  woman,  is 
still  absolutely  free  from  the  disease. 

Through  the  perineum  the  lower  portion  of  the  rectum  may  be  attacked  either  by 
splitting  the  sphincter  and  dividing  it  posteriorly,  completely  dissecting  out  the  gut 
from  its  surroundings,  removing  all  infiltrated  tissue,  and  then,  by  dividing  the  bowel 
above  the  growth,  amputating  the  lower  part.  It  may  be  possible  to  bring  down  the  upper 
end  and  attach  it  to  the  mucocutaneous  Ijorder  of  the  anus,  reuniting  the  divided  sphincter, 
and  aiming  for  a  restoration  to  something  like  the  original  condition,  which  under  quite 
favorable  conditions  is  attainable.  At  other  times  it  will  be  impracticable  to  thus  attach 
the  lower  end  of  the  tube  because  it  has  been  too  much  shortened,  and  in  these  cases  it 
should  be  l)rought  out  through  a  posterior  incision  just  below  the  tip  of  the  coccyx,  or 
higher  up  if  the  bone  has  been  removed.  Here  the  rectal  outlet  is  placed  posteriorly, 
but  is  devoid  of  a  sphincter.  Something  like  sphincteric  action  can  be  provided  by 
giving  it  a  third  or  half  of  a  revolution  on  its  axis  before  fastening  it  to  the  external 
wound.     After  this  ex]>edient  more  or  less  control  of  solid  fecal  matter  is  afforded. 

The  more  complete  and  radical  operations,  associated  with  the  names  of  Kraske  and 
other  operators,  include  removal  of  the  coccyx,  and  of  the  lower  portion  of  the  sacrum, 
which  are  usually  comj)letely  excised,  although  certain  "trap-door"  operations  have 
been  devised.     If  the  sacrum  be  not  cut  away  al)ove  the  third  sacral  foramen  there  is 


ggg  SPECIAL  OR  RKCIOXAL  SURGERY 

not  much  daina(j;c  doiR'  to  the  iutvcs,  while  .sufficient  room  is  afforded  for  any  removal 
that  is  iustifiable.  Some  operators  ojien  tlie  ])eritoneum,  others  attempt  to  avoid  it.  If 
the  growth  be  attached  to  that  meml)rane  it  becomes  necessary.  If  peritoneal  inva- 
sion can  be  avoided  it  is  desirable.  It  is  possible  to  completely  exjMxse  the  contents 
of  the  pelvis  through  such  an  opening,  while  from  this  direction,  the  gut  being  with- 
drawn after  the  peritoneum  is  divided,  the  jx)uch  of  Douglas  may  be  opened  and  further 
removal  of  diseased  tissue  be  effected.  In  all  these  operations  the  endeavor  should 
be  to  disturb  the  mesosigmoid  and  the  mesorectum  as  little  as  possible,  in  order  to 
not  interfere  with  blood  supply,  for  reasons  already  mentioned  when  discussing  the 
mesentery. 

In  all  these  operations  contamination  of  the  wound  should  be  avoided,  especially 
of  the  peritoneiun,  by  clamping  or  ligating  the  bowel,  or  by  amply  packing  and  by  every 
]x)ssible  additional  precaution.  Bowel  should  be  divided  between  two  clamjis  and  the 
divided  edges  at  once  thoroughly  cleansed  with  compresses  and  with  hydrogen  peroxide. 

One  may  read  in  the  works  on  operative  surgery  descriptions  of  most  extensive  and 
elaborate  operations  of  this  general  character,  and  of  extensive  and  even  daring  feats  of 
removal,  where  portions  of  the  bladder,  of  the  tubes,  of  the  ovaries,  even  the  uterus, 
have  been  removed.  It  has  seemed  to  me  that  the  surgeon  should  avoid  operative 
gvmnastics,  especially  in  this  region,  so  far  as  possible,  and  confine  himself  to  measures 
which  if  successful  would  improve  conditions  rather  than  complicate  them.  My  own 
judgment  then  is  that  in  any  case  where  so  formidable  an  o]:)eration  would  be  attempted 
by  some,  the  best  interests  of  the  patient  will  be  served  rather  by  sim})le  colostomy. 

Early  operations  up3n  cancer  of  the  rectum  afford  comforting  prospects.  It  is  not 
so  much  to  the  discredit  of  surgery  as  to  the  discredit  of  the  patient's  judgment,  and  of 
the  carelessness  of  the  practitioners  who  first  see  these  cases,  that  cancer  of  the  rectum  has 
become  such  a  brie  noir  and  is  justly  regarded  as  so  serious  and  unpromising  a  measure.^ 

Colostomy. — Colostomy  ff)r  relief  of  rectal  cancer  is  not  a  radical  oj^eration,  but  in 
manv  cases  is  far  more  humane  and  satisfactory  than  are  those  alluded  to  above. 
The  intent  is  to  make  an  opening  in  the  left  side  of  the  groin  at  a  point  where  it  is 
easily  made.  There  are  two  methods  of  performmg  colostomy  here.  One  is  to  make  an 
opening  through  the  abdominal  wall,  attach  to  it  the  presenting  surface  of  the  sigmoid 
or  colon,  and  either  open  it  at  once  or  some  hours  later,  when  adhesions  have  cemented 
the  desired  union.  Such  an  opening  may  be  made  for  emergency  purposes  under  local 
anesthesia,  but  when  the  colon  is  movable,  and  when  the  disease  has  not  yet  involved  the 
area  thus  exposed,  or  any  portion  above  it,  a  more  desirable  method  is  a  deliberate 
one.  An  opening  is  made  such  as  is  usually  made  on  the  right  side  when  operating  upon 
the  apjiendix.  The  bowel  thus  being  accessible  is  divided  between  two  clamps,  while 
the  end  of  the  lower  segment  is  inverted  and  closed  with  chromic  or  silk  sutures,  after 
which  it  is  dropped  back.  This  leaves  the  ujiper  portion  with  its  open  end  corresponding 
to  the  al)dominal  opening,  into  which  it  is  fastened  by  a  series  of  sutures,  being  attached 
to  the  peritoneum  and  to  the  deep  musculature  rather  than  to  the  skin,  for  if  it  be  brought 
out  too  freely  and  attached  externally  there  is  greater  tendency  to  prolapse  and  subse- 
quent discomfort.  Into  the  opening  thus  afforded  a  large-sized  rubber  or  bent  glass 
tube  is  inserted  for  a  few  inches,  around  which  gauze  is  packed,  and  ever}'  effort  is 
made  to  conduct  fecal  matter  to  the  exterior,  as  well  to  protect,  at  least  for  a  few  hours, 

I  It  becomes  a  question  of  importance  just  when  and  where  we  should  cease  to  attempt  operation  on  the  colon 
from  above  or  on  thesigmoid  from  below;  in  other  words,  the  exact  location  of  the  tumor  should  decide  the  measure 
when  it  can  be  accurately  determined.  Moreover,  a  \\-ide  margin  of  bowel  on  either  sideof  any  new-growth  which 
is  about  to  be  resected  should  be  excised.  The  question  of  blood  supply  to  the  margins  of  the  wound  thus 
made  is  also  of  importance,  as  the  most  ideal  operation  in  appearance  may  be  marred  by  gangrene  due  to  lack 
of  sufficient  blood  supply.  When  there  is  sufficient  uninvolved  gut  below  the  tumor  to  permit  of  complete  opera- 
tion within  the  abdomen  it  is  not  advisable  to  do  anything  from  below;  but  there  are  some  cases  in  which  anything 
like  complete  removal  can  only  be  effected  by  a  combination  of  abdominal  and  sacral  routes.  A  thorough 
extirpation  should  be  made  above  the  growth  as  well  as  of  the  involved  tissue  below.  Those  vessels  which  require 
ligation  should  be  tied  accurately  at  the  level  of  their  di\ision.  and  no  ligation  of  trunks  or  larger  vessels  should 
be  attempted  at  any  distance  from  the  line  of  divi.sion.  If  this  be  carefully  carried  out  and  the  divided  mesentery, 
with  its  ends,  and  all  the  fat  between  the  rectum  and  the  sacrum  be  carefully  dissected  out,  there  will  rarely  be 
difficulty  in  making  an  end-to-end  reunion  of  the  divided  bowel. 

It  is  rarely  necessary  to  include  a  colostomy  -wnth  this  procedure:  in  fact,  when  a  permanent  opening  has  become 
necessary  there  is  little  possibility  of  removing  the  main  growth.  Colostomy  is  a  procedure  for  the  hopeless  cases; 
resection  is  rarely  to  be  thought  of  as  an  alternative.  It  should  be  an  early  not  a  late  measure,  the  reverse  being 
true  of  colostomy,  though  even  this  should  not  be  too  late. 


TUMORS  OF  nil':  ri-a'ti'm 


889 


tlio  woiiiul  itself  from  fc'iil  (oiilamiiialion.  Iinprovciiiciils  in  this  technique  have  been 
su"-"este(l,  siieli  as  tyiii<,'  into  the  bowel  u  curved  ulass  tul)e,.thus  coiukicting  its  contents 
int'cTa  rubber  bag  or  receptacle  placed  outside  the  dressing.  Another  method  which 
has  been  sugocstrd  by  Stewart  is  to  connect  the  interior  of  the  colon  by  a  Murphy 
button  with  T rubber  bag  or  rubber  dam  ujjon  the  outside  of  the  abdomen,  by  which 
protection  for  this  purpose  can  be  afforded. 

This  oiieration  makes  a  comj^lete  and  final  division  of  the  colon,  and  ]jermaiieiitly 
excludes  ihe  rectum  with  its  cancerous  involvement.  It  is  not,  therefore,  in  this  respect, 
a  radical  measure      The  result,  however,  is  that  if  the  rectum  be  washed  from  below 


Fic.  mi 


(Jleason's  pouch  and  supporter. 
Fir..  596 


Colostomy  pad  and  bag,  worn  as  is  a  truss.      (Kelsey.) 


each  day  it  is  kept  far  cleaner  and  freer  from  contact  with  irritative  foreign  material  than 
it  otherwise  would  be.  Furthermore,  being  disused  it  tends  to  undergo  to  some  degree 
a  species  of  physiological  atro])hy,  and,  in  consequence,  the  cancer  grows  more  slowly, 
if  there  do  not  occur  an  apparent  temporary  cessation  of  malignant  activity. 

By  suitable  management  of  the  artificial  anus,  including  the  deliberate  emptying  of 
the  bowel  every  morning  and  the  use  of  protective  pads  for  receptacles,  it  can  be  made 
far  less  disagreeable  than  patients  ordinarily  fear  (Figs.  595  and  596). 

The  colostomy  opening  in  the  abdominal  wall  should  be  made  as  small  as  practicable 
lest  there  occur  not  only  more  or  less  ventral  hernia  through  the  weakened  outlet,  but 
even,  as  I  have  seen  in  one  case,  a  most  extensive  prolapse  of  the  colon,  in  which  two  o:f 
three  years  after  performance  of  the  operation  the  colon  could  be  made  to  prolapse 
to  an  extent  of  twelve  or  fifteen  inches. 


CIIAPTEK    LI. 

HERNIA. 

The  term  hernia  of  itself  implies  protrusion  or  escape  of  a  contained  orjjan  or  part 
throucrli  its  containincr  walls,  yet  covered  In-  some  of  them.  Thus  we  may  have  hernia 
of  the  iris,  of  the  brain,  and  the  like;  Ijut  when  no  particular  part  of  the  body  is  sjxcified, 
by  common  consent  the  term  is  understood  as  implying  hernia  either  of  the  iiUrstine 
or  ihe  omentum,  or  of  both.  Such  hernia  may  l>e  either  of  congenital  or  acquired  character, 
the  former  condition  being  permitted  by  some  defect  or  abnormality  in  the  abdominal 
parietes,  the  latter  being  the  immediate  or  remote  result  of  accident  or  of  operation; 
and  in  the  latter  case  they  are  referred  to  as  traumatic  or  as  postrjperative.  Of  these 
the  former  is  usually  of  rapid  and  the  latter  of  slow  development.  Increased 
abdominal  pressure  doubtless  has  much  to  do  with  the  occurrence  even  of  a  truly  con- 
genital hernia,  as  this  would  hardly  develop  were  it  not  for  the  former.  Such  pressure 
may  l:>e  the  result  of  occupation,  of  pregnancy,  or  of  certain  morl)id  conditions — for 
example,  those  which  cause  constant  coughing  or  straining  at  stool,  or  straining  during 
urination — as  from  prostatic  hypertrophy  or  phimosis,  or  such  intra-abdominal  con- 
ditions as  tumors,  which  distort  the  abdominal  walls,  or  accumulations  of  fluid  which 
weaken  them.  Accident  produces  hernia  mainly  by  causing  the  effects  of  pressure  to 
be  manifested  in  a  brief  space  of  time.  Thus  pressure  or  strain  on  abdominal  muscles 
may  part  them  in  such  a  way  as  to  permit  the  immediate  appearance  of  a  hernia,  f)r  its 
more  slow  development.  Tlie  postoperative  hernias  are  usually  of  the  so-<alled  ventral 
type,  and  occur  most  often  after  wounds  which  could  not  be  immediately  closed  r)ecaiLse 
of  necessity  for  drainage,  or  in  those  which  were  closed  in  such  a  way  as  to  permit  of 
gradual  warping  or  stretching  of  the  resulting  scar. 

The  surgical  anatomy  of  hernia  is  described  in  works  on  anatomy.  It  is  necessary, 
therefore,  here  only  to  remind  the  reader  that  the  conditions  existent  in  an  old  hernia 
may  l^e  different  from  those  so  described,  for  the  original  anatomical  outlines  may  perhaps 
have  long  l>een  lost  and  the  original  coverings  more  or  less  blended  together  so  as  to 
become  indistinguishable.  Particularly  is  it  true  of  strangulated  hernia  that  the  more 
minute  details  are  lost,  and  that  in  such  cases  there  is  great  difficulty  in  the  effort  to  recog- 
nize distinct  anatomical  layers  and  coverings.  In  old  cases  the  sac — namely,  the 
original  peritoneum — may  be  greatly  thickened,  while  in  strangulated  cases  it  will  l)e 
discolored,  ]>erhaps  even  gangrenous,  and  will  bear  but  slight  resemblance  to  the 
original  condition.  Tlie  same  is  true  of  its  contents,  which  may  be  adherent,  strangu- 
lated, or  gangrenous,  according  to  circumstances. 

The  opening  through  which  the  hernia  appears  is  usually  referred  to  as  the  ring, 
to  which,  however,  it  may  bear  very  little  resemblance.  Thus  it  may  be  an  elongated 
buttonhole-like,  or  a  warped,  irregularly  rounded  sac  opening,  whose  margins  are 
thick  or  thin  and  easily  distinguished  or  othen\"ise. 

By  all  writers  hernias  are  classified  according  to  their  anatomical  characteristics  as 
follows:  Inguinal,  indirect  and  direct;  femoral,  umbilical,  ventral,  diaphragmatic, 
gluteal  or  ischiatic,  obturator,  perineal,  lumbar,  saerorectal,  retroperitoneal  (including 
the  recently  described  paraduodenal  or  Treitz  variety),  and   proprritonenl. 

Of  these  the  most  common  are  the  inguinal  and  the  femoral,  the  umbilical  ranking 
next,  while  the  other  forms  are  rare. 

Causes. — Regarding  the  cause  and  nature  of  the  common  forms — namely,  the 
inguinal  and  femoral — I  propose  here  to  introduce  the  \-iews  enunciated  by  Russell,  of 
Mellx)iUTje,  which  seem  to  me  to  furnish  the  actual  ex-planation  for  nearly  all  instances. 
Tliis  explanation  refers  to  the  ccmgenital  origin  of  the  cojidition,  even  though  it  do  not 
appear  until  the  middle  years  of  life.  In  the  case  of  inguinal  hernia  it  refers  also  to  the 
persistence  of  the  canal  of  Xuck,  or  of  at  least  incomplete  obliteration  of  the  original 
vaginal  process  or  prolongation  of  the  p>eritoneum.  which  comes  down  with  the  migrating 
(890) 


HERNIA 


891 


tcslii  Ic  and  whose  lower  portion  t'liniislies  the  ejivity  of  the  turiicii  Vii<'inali.s.  It  is 
more  rational  to  e\|)lain  the  occurrence  of  hernia  in  connection  with  this  jjreformed 
sue  tlian  l>y  the  view  that  there  are  so  many  instances  of  congenital  weakness  of  theahdonii- 
nal  wall.  That  such  weakness  exists  in  many  cases  of  hernia  is  undeniable,  hut  this  is 
to  he  reifarded  as  the  elfect  rather  than  the  actual  condition.  From  this  last  statement 
it  follows  al.so  that  there  is  (jreat  advantai^e  in  early  operation,  and  in  complete  removal 
of  the  .sac,  which  when  performed  early  will  not  only  cure  the  hernia  hut  |)revent  the 
weakening;  of  the  ahdoniinal  wall  itself.  It  follows,  further,  fliat  the  use  of  a  tru.ss 
save  po.ssihly  in  the  case  of  youii",'  infants,  is  an  improj)er  method  of  treatment.  In 
other  words,  upon  it  is  hased  the  crux  of  the  whole  matter  of  successful  treatment,  i.  e. 
op(>rative  removal  of  the  sac. 

It  will  he  .seen,  then,  that  the  cause  of  in<^uinai  hernia  is  clo.sely  related  with  the 
cause  of  so-called  contijenital  hydrocele  of  the  cord  (q.  v.),  the  latter  condition  heinjjone 
of  sacculation  of  the  canal,  with  accumulation  of  fluid;  and  it  is  intercstin*^  to  recall  that 
such  sacculations  are  occasionally  foiuid  in  the  ordinary  .so-called  conirenital  hernias, 
when  they  are  .seen  early,  and  Ix-fore  all  anatomical  surromidiiifrs  have  heeii  nicr>;e(l 
tojfcther.  The  r.ristrnrr  of  a  hernia  implies  ihe  presence  of  a  sac,  and  a  c(>n(jenit(tl  deject 
famishes  this  latter,  ndiiJe  the  variations  in  tlie  type  of  hernia  arc  due  mainlij  to  the  varia- 
tions in  the  sac  itself,  i.  e.,  in  its  location. 

Russell  lias  traced  out  the  relations  hetwecn  the  peritoneal  pouches  of  the  lower 
abdomen  and  the  ])rincipal  bloodvessels,  and  has  show^n  how^  the  former  arrange  them- 
selves about  the  latter  ajid  are  carrietl  with  them  as  they  develoj),  assuming  in  conse- 
quence the  ty])e  either  of  inguinal  or  femoral  hernia,  according  as  they  are  placed  to 


Fici.  597 


Fig.  598 


Fi<;.  599 


Congenital  hernia. 


Infantile  hernia. 


Adhesions  in  hernial  sac. 
(Lejars.) 


Scarpa. 


the  inner  or  outer  and  lower  side  of  the  same.  He  has 
insisted,  and  I  think  properly,  that  the  variations  ob- 
served in  the  clinical  manifestations  of  a  hernia  are 
mainly  determined  by  the  size  and  the  position  of  the 
sac,  and  that  these  depend  upon  its  relations  to  the 
femoral  and  epigastric  vessels,  the  associated  sac  and 
vessel  being  subject  io  the  same  vicissitudes  in  develop- 
ment. In  this  way  the  occurrence  at  one  time  of  a 
concjenital  and  at  another  of  a  so-called  infantile  type 
of  inguinal  hernia  may  be  easily  explained,  as  well  as 
the  differences  between  the  so-called  funicular  and  the 

partial  form,  and  al.so  the  occurrence  of  the  retroperitoneal  or  propcritoneal  forms,  which, 
as  variations  are  rare,  and  as  clinical  manifestations  perplexing,  but  which  nevertheless 
are  easily  explained  when  view^ed  in  this  light  (Figs.  597  and  598). 

Thus  viewed,  then,  what  are  the  relations  of  traumatism  to  congenital  defect?  When 
thus  explained  they  seem  to  be  as  follows:  By  no  means  every  individual  who  sustains 
an  injury  to  the  abdomen  suffers  from  hernia,  but  when  the  parts  are  already  weakened 
or  prepared  by  the  preexistence  of  these  congenital  defects,  then  a  small  amount  of  strain 
or  injury  may  serve  to  open  them  up  and  to  produce  a  condition  apparently  due  to 
accident  which  otherwise  could  not  have  occurred.  The  more  I  have  studied  the  entire 
question  the  more  I  have  come  to  the  conclusion  that  hernias  of  the  ordinary  type,  save 


892  SPECIAL  OR  REGIONAL  SURGERY 

in  case  of  extreme  \"iolence,  would  not  orcur  were  it  not  for  such  a  congenital  pre- 
arrancjement  and  tissue  jxTmission,  as  it  were;  no  that  we  are  justified  in  assuming 
that  incruinal  and  femoral  like  umbilical  hernias  are  really  of  congenital  origin. 

The  Si^S  of  Hernia. — The  signs  of  hernia  include  the  existence  of  a  tumor, 
usually  at  one  oi  the  common  outlets,  which  may  be  variable  in  size,  and  fixed, 
changeable,  or  otherwise,  according  to  whether  it  consist  of  intestine  or  omentum.  To 
a  hernial  protrusion  consisting  of  intestine  alone  may  still  ]ye  given  the  old  term  entero- 
cele.  One  consisting  of  omentum  is  known  as  epiplocele.  Hernial  protrusions  may 
attain  tremendous  dimensions,  especially  those  apjx'aring  at  the  umbilicus,  and  some 
of  these  sac-s  contain  perhaps  the  larger  propc^rtion  of  the  intestine  or  even  of  the  entire 
abdc^minal  contents.  Scrotal  tumors,  again,  may  attain  large  size,  e.  rj.,  that  of  the 
indi\"iduars  head  or  even  much  larger.  According  to  the  nature  of  the  contents  such  a 
tumor  will  be  more  or  less  resonant  on  percussion,  and  more  or  less  compressible  as 
well  as  reducible.  Reducihility — namely,  the  ability  to  be  returned  to  the  abdominal 
caNnty — is  the  most  characteristic  feature  of  a  hernia  and  one  possessed  by  nearly  every 
such  tumor,  at  least  at  its  inception.     It  may,  however,  be  lost. 

Lf)ss  of  reducihility,  when  occurring  gradually.  Is  replaced  by  what  is  known  as  incar- 
ceration, i.  €.,  more  or  less  complete  fixation,  at  the  same  time  without  such  pressure  on 
bloodvessels  as  to  produce  necrosis.  Incarceration  may  be  the  result  of  reduction  in 
caliber  of  the  hernial  outlet,  or  of  the  formation  of  adhesions  between  the  walls  of 
the  sac  and  its  contents,  such  adhesions  being  common  alike  to  omentum  and  large  or 
small  Ixjwel.  (See  Fig.  599.)  Strangulation  is  an  acute  process  which  may  terminate 
either  a  reducible  or  an  incarcerated  hernia.  It  implies  some  sudden  change,  such  as 
overcrowding  of  the  bowel  within  the  sac,  or  some  peculiar  kinking,  by  which  intestinal 
caliber  is  shut  off,  as  well  as  blood  supply  affected  because  of  pressure,  by  which  the  ^•itality 
of  the  gut  and  of  the  sac  is  compromised  or  perhaps  quickly  lost.  Strangulation,  then, 
includes  at  least  the  possibilities  and  usually  the  simultaneous  occurrence  of  acute 
obstruction  of  the  bowel  with  more  or  less  gangrene  of  the  sac  itself,  as  well  as  of  the 
compromised  gut. 

Reducihiliti)  as  an  ordirutry  tVature  of  liernia  is  rjne  with  which  the  patient  himself 
is  quite  familiar,  most  patients  with  reduciljle  hernias  being  able  to  effect  reduction  in 
the  horizontal  fxjsition,  accompanied  by  some  manipulation  or  maneuver.  When  in 
such  cases  reduction  cannot  be  accomplished  incarceration  or  perhaps  strangulation 
has  begun  and  the  case  immediately  assumes  serious  proportions.  Reduction  Ls  usually 
accompanied  by  a  peculiar  gurgle,  as  well  as  disappearance  of  the  tumor  itself,  while 
the  opening  through  which  it  has  disappeared  can  usually  be  identifed  with  the  finger, 
by  invagination  of  the  scrotum,  or  by  pressure  over  the  femoral  region.  Such  a  tumor 
usually  reappears  when  the  patient  stands,  or  particularly  when  he  coughs  or  makes  any 
straining  effort,  and  the  occurrence  and  recurrence  of  these  phenomena  clearly  establish 
the  diagnosis  of  hernia. 

Irreducible  or  incarcerated  hernias  usually  give  some  impulse  upon  the  patient's 
coughing,  as  do  the  reducible  forms,  yet  in  some  cases  they  lead  to  more  difficulty  of 
diagnosis.  Ordinarily  in  the  male  the  question  Ls  mainly  as  l>etween  inguinal  (or  scrotal) 
hernia  and  hyrlrocele.  In  the  latter  there  is  a  pear-shaped  tumor  whose  apex  should  be 
found  below  the  level  of  the  inguinal  outlet;  a  tumor  which  will  fluctuate,  whose  shape 
does  not  change,  which  gives  no  impulse  when  the  patient  coughs,  which  Ls  not  influenced 
by  pressure,  even  with  the  patient  in  the  horizontal  pr^sition.  It  is  only  in  incarcerated 
or  in  peculiar  t\-pes  of  congenital  hernias,  or  in  those  combined,  as  they  may  be,  with 
hydrocele,  in  which  doubt  should  not  be  easily  dissipated.  While  incarceration  predis- 
poses to  acute  obstruction  it  is  not  always  followed  by  it,  but  may  produce  a  more  chronic 
t\-pe  of  constipation,  with  tendency  to  fecal  impaction,  because  of  the  mechanical  impedi- 
ment to  freedom  of  bowel  motility.     This  condition  is  more  frequentlv  met  in  the  aged. 

Inpimmation  of  the  hernial  .mc,  as  well  as  of  its  coverings,  leads  to  a  condition  described 
as  inflamed  hernia.  It  is  essentially  one  of  circumscribed  cellulitis.  It  mav  be  due  to 
the  irritation  of  a  badly  fitting  truss  or  to  other  external  causes.  The  inflammation  may 
extend  so  as  to  involve  the  sac  wall  itself,  and  thus  produce  adhesions  and  later  incarcera- 
tion, or  it  may  set  up  actual  peritonitis,  which  may  extend  to  the  general  abdominal 
ca\-ity  and  terminate  fatally.  The  more  superficial  and  less  acute  forms  are  scarcely 
distincruishable  from  a  local  erysipelas  which  may  terminate  by  abscess.  Such  a 
condition  might  be  mistaken  for  one  of  suppurating  bubo.     Nevertheless  the  existence 


IIERSIA 


893 


Gangrenous  strangulated  hernia; 
artificial  anus;  prolapse  of  bowel  re- 
quiring intestinal  resection;  eventual 
recovery.      (Preindlsberger.) 


of  the  hernia  itself  should  ^uanl  one  aj:;uinst  this  error  and  make  him  extremely 
eautious  in  usin<j  the  knife,  even  thouijh  it  be  neeessarv  for  the  evaeuation  of  pus. 

Slmngidatcd  Itcrnia  has  already  been  considered  as  the  most  common  cause  of  acute 
ob.finidion  of  the  boivcl.  Its  possibility  shoukl  l)e  excluded  in  every  case  of  this  serious 
condition.  While  such  are  its  o;eneral  features,  locally  there  is  added  to  the  jjeneral 
bo\v(>l  obstructive  condition  that  of  more  or  less  local  destruction,  which  may  vary  from 
the  presence  of  exudate,  fluid  or  solid,  with  infiltration 
of  ailjoining  tissues,  to  the  most  prompt  and  disastrous 
consequences  of  venous  stasis,  namely,  extensive  gcin- 
grcur,  which,  involving  first  the  bowel  itself  or  the  omen- 
tum, will  later  spread  to  the  sac  wall  and  its  surround- 
ini:;s.  In  this  instance  around  the  loop  or  loops  of  fjut 
involved  will  be  seen  a  titjht  constriction  or  sulcus,  aliove 
which  the  bowel  will  be  more  or  less  discolored  and  dis- 
tended, while  below  it  will  be  com})letcly  necrotic  and 
perhaps  actually  sloughinn;.  Minor  dejTrees  of  strano;u- 
lation  may  produce  conditions  which  would  lead  up 
to  this,  but  have  not  yet  actually  reached  the  stage 
of  gangrene.  Around  such  bowel  will  be  found  more 
or  less  fluid,  the  result  of  transudation,  which  will  be 
swarming  with  bacteria  and  often  offensive.  The  sac  wall 
closely  corresponds  in  appearance  to  that  of  the  bowel, 
and  everything  al)out  the  sac  and  its  contents  will  be  in- 
fected and  contaminated  with  bacteria,  often  of  most 
virulent  activity.  The  gangrene  may  involve  an  area 
of  exceedingly  small  size,  or  the  entire  contents  of  the 
hernial   sac.     In  the  former  instance  the  condition   is 

comparatively  simple  as  compared  with  the  latter,  which  may  require  resection  of 
several  feet  of  necrotic  bowel.  The  proper  treatment  of  these  conditions  will  be  more 
fully  dealt  with  below  (Fig.  600). 

Symptoms. — The  symptoms  of  strangulation  are  those  of  acute  obstruction,  plus 
the  local  evidences  of  a  hernia,  usually  with  added  pain  and  tenderness,  sometimes 
acute.  These  symptoms  may  come  on  as  the  result  of  strain  or  accident  or  without  any 
known  cause.  Their  intensity  will  depend  in  some  measure  upon  the  comjileteness  of 
the  blood  stasis  and  the  rapidity  of  the  consequent  gangrenous  process.  The  latter  may 
vaiw  in  degree.  Thus  the  death  of  the  compromised  bowel  may  be  practically  determined 
within  a  few  hours  or  within  two  or  three  days.  Tlie  hernial  tumor,  within  which  strangu- 
lation has  occurred,  becomes  more  tense  and  incompressible,  and,  at  the  same  time, 
more  tender.  Sometimes  there  is  marked  augmentation  in  volume;  at  other  times  this 
changes  but  little.  So  soon  as  a  loop  of  bowel  has  lost  its  blood  supply  and  l)ecome 
actually  necrotic  it  will  have  also  lost,  when  exposed,  all  of  its  luster  or  "sheen,"  and 
will  appear  not  only  black  and  lusterless,  but  will  be  more  or  less  offensive  in  odor, 
and  of  extremely  septic  character.  The  surrounding  fluid  will  be  found  swarming  with 
bacteria,  and  will  seriously  and  perhaps  fatally  infect  anyone  inoculated  with  it. 

Concerning  the  color  of  the  exposed  bowel  and  its  appearance,  it  is  a  fairly  safe  rule 
to  follow  that  gut  which  has  not  lost  its  luster,  even  though  darkly  discolored,  is  still 
viable,  and  may  with  safety  be  returned  to  the  abdomen,  which  is  probably  the  safest 
place  for  it;  but  when  its  sheen  is  actually  lost  the  case  becomes  one  either  for  resection 
or  for  artificial  anus.  It  is  possible  that  such  a  case  may  be  seen  only  after  absolute 
necrosis  and  fecal  escape  have  occurred.  When  actual  sloughing  is  thus  met  it  is  a 
question  for  resection  or  some  other  expedient. 

Varieties  of  Hernia.  Inguinal  Hernia. — The  inguinal  form  of  hernia  comprises 
nearly  ftnu'-fifths  of  cases  in  males,  a  much  smaller  proportion  in  females.  The 
hernial  protrusion  is  always  through  the  external  abdominal  ring,  either  by  way  of  the 
inguinal  canal,  which  it  enters  through  the  internal  ring,  or  directly  through  the  abdom- 
inal wall.  The  former  is  called  indireci,  the  latter  direct.  Such  a  hernia  is  considered 
complete  or  incomplete  according  as  it  descends  below  the  lower  margin  of  the  inguinal 
canal.     An  incomplete  and  direct  hernia  is  often  referred  to  as  hidmnocele.     (Fig.  601.) 

Holding  the  views  above  enunciated,  regarding  the  congenital  origin  of  practically 
every  inguinal  hernia,  it  is  necessary  to  pay  less  attention  to  the  distinctions  insisted 


804 


SPECIAL  on  REGIOSAL  SURGERY 


u\)tn\  hy  the  earlier  authors  cfjiiccrriinfj  the  conjjenital,  the  infantile,  or  the  eneysted  t'orins 
of  hernia,  which  def)end  ujxjn  the  extent  and  decree  of  closure  of  the  vaginal  process 
or  the  canal  of  Xuck,  which  is  carried  down  with  the  testis  during  its  migration  from  the 
lower  margin  of  the  Wolffian  body,  and  which  is  normally  obliterated  at  birth.  Never- 
theless these  conditions,  however  explained,  are  actually  met  during  life  and  are  repre- 
sented by  the  diagrams  seen  in  Fi^s.  ()02.  ()()3  and  604. 

Fig.  601 


Fig.  602 


Indirect  inguinal  hernia  ^bubonocele.         Ki'  j.ardson.j 
Fig.  e03 


Fig.  604 


Congenital  -.i.c^. 


Infantile  or  encysted  hernia. 


Hernia  of  the  funicular  process 


In  the  female  the  canal  of  Xuck  is  a  matter  of  minor  importance,  containing  only 
the  round  ligament.  Nevertheless  along  it  may  proceed  an  indirect  inguinal  hernia 
corresponding  to  that  in  the  male. 

The  so-called  acquired  indirect  hernia,  according  to  the  above  views,  xmuld  not  occur 
xcere  it  not  for  the  opportunity — as  it  xcere,  the  temptation — already  afforded  by  some 
deviation  of  the  peritoneal  arrangement  in  this  locality.     In  these  cases,  however,  the 


I/hh'MA 


895 


sac  aj)|)oar.s  to  he  new  and  is  piislicd  aloiijj;  the  iiinuinal  (anal  nn(cri(irl\'  to  its  normal 
coiitiMits.  Tliis  may  Ir'  the  result  of  violent  strain,  or  of  one  wliicli  is  apparently 
(lis])ro|)orti()nately  small,  hut  fre(|uently  repeated. 

Direct  UKjuimil  licrnia  is  <(eiKTully  an  oeeurreuee  of  adult  life,  takes  j)laee  commonly 
as  the  result  of  accident,  is  a  direct  protrusion  through  the  uhdominal  wall  at  the  tri- 
angular weak  spot,  whose  outer  limit  is  the 
deep  epigastric  artery,  with  the  obliterated 
hypogastric  artery  to  the  iinicr  side  and 
Poupart's  ligament  helow,  /.  e.,  the  so-called 
triangle  of  llessclhach.  This  hernia  appears 
always  at  the  external  ring,  from  which  it 
may  descend  and  become  scrotal 

With  coin|)lcte  or  scrotal  hernia  there  is 
usually  little  dilliciilty  of  diagnosis  (Fig.  ()()5). 
An  incomplete  hernia,  protruding  at  the  exter- 
nal ring,  covered  with  considerable  fat,  and 
perha|)s  shifted  a  little  in  jjosition,  is  sometimes 
hard  to  distinguish  from  a  hernia  through  the 
femoral  o|)ening.  The  inguinal  form  escapes 
above  Poupart's  ligament,  the  femoral  always 
below  it,  and  Pouj)art's  ligament  is  to  be 
located  by  a  line  drawn  from  the  anterior 
sujK'Hor  spine  to  the  spine  of  the  pubis. 
The  inguinal  forms  are  usually  nearer  the 
middle  line.  If  the  epigastric  artery  can  be 
identified,  either  before  or  during  oj)eration, 
the  character  of  the  hernia  will  Ije  ])romptly 
demonstrated  by  its  relations  to  the  neck  of 
the  sac. 

Hernial  protrusions  give  a  familiar  impulse 
on  cough ing  unless  the  incarceration   of  an   epiplocele  may  mask  this  feature.     By  it 
they  are  to  be  distinguished  from  hydrocele,  varicocele,  aneurysm,  undescended  testicle, 
and  the  like. 

Fig.  60r> 


Scrotal  liernia.     (Richardson.) 


I 


Hernia  of  liver  through  congenital  opening  in  the  umbilicus.     (Kichardson.) 

Femoral  Hernia. — Femoral  hernia  is  much  more  common  in  women  than  in  men, 
and  constitutes  about  one-tenth  of  all  cases.  This  form  is  also  nearly  always  congenital 
in  the  above  sense,  and  is  particularly  liable  to  strangulation.  It  escapes  through  the 
femoral  ring  into  the  femoral  canal,  to  the  inner  side  of  the  femoral  vein,  and  then, 
passing  forward  through  the  femoral  opening,  finds  its  direction  of  least  resistance  up- 
ward. In  consecjuence  a  loop  of  bowel  thus  esca])ing  from  the  abdomen  may  first  pass 
downward,  then  forward,  and  then  upward,  which  will  illustrate  the  futility  of  the  ordinary 
methods  of  taxis  in  the  effort  to  reduce  it  by  manipulation.  These  hernias  are  usually 
small,  hence  their  greater  danger.     These  cases  have  especially  to  be  differentiated  from 


S9() 


SPECIAL  OR  REGIOXAL  SURGERY 


Fig.  607 


psoas   abscess,    from    inc.niinal    lymphatic   enlargements,   and   tumors.     If   the   sac   be 
entirely  filled  with  omentum  diagnosis  is  often  difficult. 

Umbilical  Hernia.— Umbilical  hernia  is  primarily  permitted  by  failure  in  obliteration 
of  the  oitenint:  at  the  navel  for  the  omphalomesenteric  duct  and  for  the  urachus. 
Oritrinally  small,  it  may  yet  assume  enormous  dimensions.  Though  actually  of  con- 
genital origin,  as  just  sated,  it  may  not  be  discovered  until  the  later  years  of  life.     It 

occurs  much  more  commonly  in  females  than 
males,  and  usually  in  connection  with  a  large 
deposit  of  fat  in  the  abdomen,  by  which  its  ex- 
istence, or,  at  least,  its  limits  and  dimensions  are 
masked.  Through  the  umbilical  opening,  which 
in  the  majority  of  cases  is  small,  may  escape 
other  of  the  abdominal  viscera,  as  is  shown  in 
Fig.  606,  illustrating  hernia  of  the  liver.  Fig. 
()()7  illustrates  the  pendulous  form  which  many 
of  these  cases  assume. 

An  infantile  form  (umbilical)  is  known,  in 
which  the  actual  protrusion  does  not  occur  until 
the  infant  is  several  months  old,  and  which 
appears  to  be  due  to  frequent  strain,  on  a  weak 
or  incompletely  closed  fenestrum,  by  coughing, 
crying,  efforts  to  expel  urine  through  a  strictured 
prepuce,  and  the  Uke.  These  tumors  at  first 
are  small  and  always  intestinal.  It  is  often 
possible  to  .so  adjust  a  small  pad  over  these 
openings  as  to  secure  subsequent  closure  by 
natural  processes.  On  the  other  hand,  the 
forms  which  come  on  in  later  life,  acquired 
durint'  pregnancy,  ascites,  or  in  connection  with  excessive  obesity,  assume  sometimes 
relativelv  enormous  size.  Here  the  hernial  contents  may  be  solely  omental,  but  are 
usuallv  at  least  partially  intestinal.  Strangulation  occurs  in  a  large  proportion  of  these 
instances  and  incarceration  is  nearly  always  observed.  Naturally,  in  consequence,  the 
patient  comjilains  of  gastric  disturbances,  as  well  as  of  chronic  constipation,  with  frequent 
colicky  attacks.' 

Ventral  Hernia. — Ventral  hernia  is  of  two  types — the  spontaneous,  usually  epigastric, 
which  is  an  omental  escape  in  the  middle  line  above  the  umbilicus,  occurring  most  often 
in  fat  women,  in  whom  it  is  likely  to  be  mistaken  for  a  hernia  of  ordinary  umbilical 
t\T)e.  Bv  fixation  of  its  contained  intestine  and  omentum  there  is  more  or  less  dragging 
upon  the  upper  abdominal  viscera,  with  con.sequent  disturbance  of  function. 

Postoperative  Hernia. — Postoperative  hernia  often  also  spoken  of  as  ventral,  occurs 
through  the  cicatrix  of  the  wound  which  has  permitted  it,  whether  this  be  in  the  middle 
line  or  elsewhere.  It  is  an  unfortunately  frequent  sequel  of  laparotomy  wounds  which 
have  required  drainage,  but  occasionally  occurs  in  perfectly  clean  wounds  which  have 
closed  satisfactorily  in  the  first  place,  but  which  have  subsequently  parted  because  of 
unsati.sfactory  methods  of  bringing  together  their  deeper  portions.  (See  p.  778.)  Conse- 
quently it  should  be  sufficient  here  to  remind  the  reader  that  the  more  accurate 
the  method  of  approximating  the  margins,  layer  by  layer,  and  effecting  a  complete  anfl 
perfect  union  between  them  individually  the  less  the  tendency  to  this  unpleasant  sequel. 
Postoperative  hernia  may  be  so  small  as  to  be  kept  under  subjection  with  some 


Umbilical  hernia  of  pendulous  form.     (Park.; 


•  A  rare  form  of  hernia  into  the  umbilical  cord  ha.<  been  described  by  Moran.  It  has  been  known  as  hernia 
funiculi  umbiiic/ilis,  and  has  been  held  to  be  due  to  abnormal  persistence  of  the  \Ttelline  duct,  which  holds  the 
loop  of  intestine  to  wliich  it  was  attached  inside  the  abdominal  wall,  the  intestine  continuing  to  grow,  the  umbilical 
ring  remaining  open  and  the  hernia  thus  enlarging.  Occurring  in  this  way  it  liappens  about  the  tenth  week  of 
fetal  life.  Such  a  hernia  has  no  covering  except  the  peritoneum  and  the  amnion — i.  e..  is  without  mu.«cle  or  skin 
covering.  It  would  be  probably  first  noted  when  the  cord  is  about  to  be  tied,  when  at  its  loop,  as  a  translucent 
tumor,  var>Tngin  size  from  that  of  a  small  cherr>'  to  a  lemon,  the  cord  being  distended  and  assuming  its  own  natural 
size  only  after  it  has  left  the  hernial  tumor.  The  bloodvessels  will  run  on  one  side  of  the  amniotic  sac.  Such  sacs 
rupture  easily,  perhaps  during  cr>Tng  efforts  or  even  during  parturition.  The  condition  is  serious,  and  when 
present  no  traction  should  be  made  on  the  cord.  If  easily  reduced  by  taxis  an  antiseptic  compress  should  be 
fastened  over  the  opening.  Should  anjThins  like  strangulation  occur  operation  is  imperative  and  should  be  done 
immediately. 


iii:iisi.\ 


S07 


form  (»r  iilxloiiiiiial  siippoit,  or  it  iiuiy  rull  tor  o|nTutioiis  tor  radical  cure,  as  do  otlicr 
c-a.st>s.     'riu-y  arc  siil)jc(l  to  tlie  sainc  (luii<!;er.s  of  .strangulation  of  their  contents. 

Diaphragmatic  Hernia.  l)iai)lira<:;inatie  lieniia  may  l)e  roinjcnital,  as  when  oeeurrinn; 
(hn)ii;;li  a  delect  in  this  partition,  or  (injiiiird,  as  when  under  stress  or  strain  .some  of 
the  aixlominal  contents  are  forced  into  the  thorax,  either  tlu'oujfh  natural  o|)eninf;s 
or  throuiih  a  rcMit  or  tear.  Such  escape  may  inchide  hut  a  small  j)ortion  of  bowel; 
in  coiiiicnital  cases  one-half  the  ahdominal  contents  have  been  found  within  the  thorax. 
The  left  side  seems  more  often  involved  than  the  ri<2;ht.  Serious  wounds  of  the  dia- 
phra<jm  may  he  followed  by  this  condition.  Under  these  circumstances  the  thoracic 
viscera  are  more  or  less  displaced,  and  the  heart  may  be  pushed  considerably  out  of 
place.  In  cases  with  a  history  of  violent  accident  the  surgeon  may  more  readily  suspect 
and  recot;ni/,e  the  condition  than  in  con<fenital  cases,  where  anatomical  relations  have 
lon<i;  been  disturbed,  but  aj)i)ar(Mitly  more  or  less  adjusted  or  compensated. 

Pelvic  Hernia. —  In  the  lower  part  of  the  jxdvis,  under  rare  circumstances,  hernial  jiro- 
trusions  occur  (Mther  throuy-h  the  sacrosciatic  foramina,  in  which  <'asc  tluy  are  known  as 
'/luteal  or  iscldniic  {V\\i.  (iOS),  or  through  the  obturator  foramen,  when  they  are  known  as 


Fig.  (JOS 


Flo.  609 


Ischiatic  hernia.     (Richardson.) 


Hernia  into  foramen  of  Winslow. 


obturator  hernias,  the  latter  occurring  more  often  in  stout  women.  Unless  these  consti- 
tute some  form  of  recognizable  tumor,  or  produce  acute  obstruction  by  strangulation, 
they  will  f)ass  quite  unrecognized.  A  perineal  form'  of  hernia  is  also  known,  which 
occurs  in  Douglas'  cid-de-sac,  behind  the  bladder  or  uterus,  the  levator  ani  muscle  being 
more  or  less  disturbed,  and  the  protrusion  occurring  somewhere  between  the  labium 
and  the  anus.  In  such  hernial  sacs  the  ovary  has  been  found,  as  well  as  intestinal 
loops,  and  the  so-called  orarian  hernia  includes  sonje  anatomical  anomaly  of  this  kind. 

Lumbar  Hernia. — In  so-called  lumbar  hernia,  which  is  very  rare,  the  hernia  escapes 
along  the  outer  border  of  the  quadratus  lumborum  muscle  into  the  triangle  of  Petit. 
Such  a  tumor,  usually  small,  may  be  easily  mistaken  for  lipoma  or  for  cold  abscesses. 

Other  anomalous  types  of  hernia  may  occur  in  connection  with  congenital  defects 
of  the  bones  or  the  less  dense  structures  of  the  pelvis  proper. 

Retroperitoneal  and  Properitoneal  Hernia. — Retroperitoneal  and  properitoneal  hernia 
are  types  which  seem  to  corroborate  the  views  already  enunciated  concerning  the  essen- 
tially congenital  origin  of  the  ordinary  forms.  The  former  implies  a  protrusion  into 
an  internal  peritoneal  pouch,  and  is  usually  found  in  the  upper  abdominal  cavity  in  the 
duodenojejunal  fossa,  although  it  may  also  occur  lower  down  on  either  side.     It  will 


898 


SPECIAL  OR  REGIONAL  SURGERY 


not  be  recognized  save  by  its  effects,  which  will  usually  be  those  of  acute  intestinal 
obstruction,  and  even  then  will  only  be  diagnosticated  after  the  operation  which  the 
condition  will  necessitate.  Hernia  through  the  foramen  of  Winslow  has  already  been 
mentioned  in  the  chapter  on  the  Small  Intestines.     (See  Fig.  609.) 

Properiioneal  liernia  implies  usually  the  existence  of  a  double  sac,  with  a  common 
opening,  its  inner  portion  lying  between  the  peritoneum  and  the  abdominal  musculature, 
while  its  outer  ])ortion  takes  the  usual  jiosition  of  the  hernial  sac,  either  the  inguinal, 
the  femoral,  or  the  umbilical  form.  It  may  be  suspected  when  reduction  which  has 
been  apparently  successful  has  later  evidently  failed.  It  occurs  most  often  in  the 
inguinal  region,  where  it  is  usually  referred  to  as  inguinoproperitoneal  hernia,  and  where 
it  was  first  recognized  by  Parise,  and  later  fully  described  by  Kronlein.  It  may  be 
with  equal  propriety  called  inter.ttitial  hernia,  and  is  often  associated  with  imperfect 
descent  of  the  testicle,  which  perhaps  has  served  to  deflect  the  descending  hernia  in  an 
unusual  direction.     The  properitoneal  sac  is  most  often  found  between  the  internal 

ring  and  the  anterior  spine,  although  it 
Fig.  610  may  be  directed  downward  and   inward 

toward  the  bladder,  or  backward  toward 
the  iliac  fossa.  In  size  it  is  usually  small 
as  compared  with  the  external  portions. 
Its  existence  may  be  suspected  when  a 
patient  w^ith  a  hernia  previously  easily  re- 
ducible suddenly  develops  strangulation, 
which  is  apparently  relieved  by  taxis,  only 
to  recur  a  little  later.  So  far  as  its  radical 
treatment  is  concerned  all  that  is  necessary 
is  the  extirpation  of  the  extra  sac,  with  per- 
haps separate  treatment  of  its  neck,  when 
dealing  with  the  greater  and  more  com- 
pletely filled  pouch  in  front  (Fig.  610). 

Littre's  or  Richter's  Hernia.  —  These 
terms  have  reference  to  strangulation  of 
intestine  in  which,  nevertheless,  the  entire 
lumen  of  the  bowel  is  not  completely  in- 
volved, rather  only  a  small  area,  which 
soon  becomes  sacculated,  or  perhaps  by 
a  diverticulum  becoming  involved  in  the 
occlusive  and  later  gangrenous  process. 
These  forms  are  most  frequently  seen  in 
women  and  at  the  femoral  ring.  They 
are  peculiarly  dangerous  in  that  they  produce  symptoms  which  do  not  include  those  of 
total  and  acute  bowel  obstruction,  and  hence  are  often  allowed  to  go  unoperated  until 
gangrene  has  already  occurred.  These  forms,  then,  will  produce  signs  and  symptoms 
of  partial  strangulation,  with  incarceration,  followed  after  hours  or  perhaps  days  by 
those  of  local  cellulitis,  with  perhaps  necrosis;  conditions  which  when  opened  may 
ex])ose  gangrenous  bowel  and  promptly  become  fecal  fistulas. 

Treatment  of  Hernia. — Hernia  is  treated  for  three  different  purposes:  for  the 
relief  of  Strang ulat ion,  i.  e.,  as  an  emergency,  for  palliation,  or  for  radical  cure,  according 
to  the  nature  of  the  case  and  the  wishes  of  the  patient. 

The  relief  of  strangulated  hernia  becomes  a  measure  of  instant  importance  so  soon 
as  the  condition  is  recognized,  mortality  being  due  to  delay,  practically  every  case  being 
curable  coukl  it  be  recognized  and  operated  promptly.  The  symptoms  of  strangulation, 
as  repeatedly  indicated,  are  those  of  acute  obstruction  of  the  bowel,  including  fecal 
vomiting  with  meteorism,  and  the  local  indications  which  may  be  trifling,  as  in  very 
small  hernial  protrusions,  or  unmistakable,  as  in  large  hernial  masses.  The  indication 
in  every  instance  is  to  restore  the  occluded  bowel  to  the  abdominal  cavity.  Occasion- 
ally this  may  be  effected  by  the  method  of  manipulation  or  by  taxis,  which  should  never 
be  thought  of  save  at  the  very  outset,  and  which  may  be  aided  by  the  local  use  of  cold, 
or  especially  by  the  Trendelenburg  position,  which  may  be  exaggerated.  Under  these 
circumstances,  as  Richardson  has  said,  minutes  are  precious  and  delay  adds  materially 
to  the  danger,  so  that  usually  all  non-operative  methods  are  to  be  condemned. 


Properitoneal  hernia.     This  illustrates  also  incomplete 
reduction  of  hernia.     (Richardson.) 


PLATE   LIV 


Strangulated  Right  Inguinal  Hernia.      (Richardson.) 

The  sac  has  been  opened  and  its  edges  are  drawn  apart  by  means  of  forceps, 
canal  and  spermatic  cord  have  been  dissected. 


The  inguinal 


HERNIA  899 

Taxis. — Tlic  ])riii(i|)al  (langrr  in  connection  with  taxis  is  that  of  (loin<r  harm  to  the 
occluded  howel  hy  roii^h  inani|)uhition.  Tlie  method  includes  a  coaxiui!;  ])ressure  in 
the  i^roper  direction,  witii  more  or  less  compression  of  the  external  mass,  the  effort  heing 
to  gently  persuade  it  back  into  the  ahdominal  cavity.  In  this  effort  the  temj)tation, 
especially  among  the  inexperienced,  is  to  use  too  much  force,  by  whic-h  extravasation 
is  j)roduced,  exudate  increased,  and  tlu^  local  condition  in  every  way  made  worse.  That 
which  is  ])ossil)le  during  the  first  hour  after  strangulation  has  occurred  may  be  impos- 
sible a  little  later,  when  edema  and  exudate  have  distorted  the  parts  or  cemented  them 
together.  The  effort  should  not  be  prolonged,  but  rather  very  brief,  and  if  after  a  very 
few  moments  no  gain  be  made  it  should  be  discontitmed. 

lirdiirfion  "en  bloc'  is  an  unusual  but  cver-j)resent  danger.  It  implies  forcing  back 
the  j)eritoneal  sac  as  well  as  its  contained  intestine  unreduced,  so  that  while  the 
external  tumor  is  dissij)atetl  the  actual  condition  of  strangulation  is  not  influenced. 
Its  effect  would  be  in  no  way  to  diminish  the  danger  of  the  condition,  but  rather  to  more 
seriously  menace  the  patient,  under  the  supj)osition  that  reduction  had  been  accom- 
plished satisfactorily. 

Two  or  thnu^  axioms  in  the  treatment  of  strangulated  hernia  are  imperative: 

Very  Utile  time,  if  antj,  .should  be  wasted  in  mani'pnJation  or  taxis. 

Taxis  faili)tg  or  there  remaining  any  susjyicion  of  reduction  en  bloc,  open  operation 
is  imperative. 

TJie  time  to  operate  is  just  after  the  diagnosis  has  been  made  and  the  condition  recog- 
nized.    Every  hour  of  delay  increases  dayiger  of  obstruction  and  of  gangrene. 

Operations  for  strangulated  hernia  should  thus  always  be  done  early  and  before 
much  exudate  or  local  disturbance  has  occurred,  as  when  thus  performed  they  may  be 
combined  with  measures  for  radical  cure,  which  are  hardly  to  be  thought  of  when 
infection  has  occurred.     (See  Plate  LIV.) 

Strangulated  ht^nia,  then,  being  always  a  dire  emergency,  is  in  nearly  every  instance 
best  treated  by  herniotomy,  whose  principles  are  the  same,  no  matter  whether  applied 
to  inguinal,  femoral,  or  umbilical  hernia.  By  a  suitably  planned  incision  the  sac  is  ex- 
posed. In  the  inguinal  region  this  follows  the  general  direction  of  the  cord  and  inguinal 
canal.  In  the  femoral  region  it  is  best  to  raise  a  flap,  while  in  umbilical  hernia,  although 
the  first  incision  may  be  in  the  middle  line,  it  will  usually  be  found  necessary  to  make  an 
elliptical  excision  of  the  overlying  skin,  in  order  that  both  it  and  the  sac  may  be  removed. 
Under  conditions  of  long  existent  hernia,  plus  strangulation,  the  original  anatomical 
conditions  are  much  altered,  and  it  is  not  necessary  to  waste  time  in  the  endeavor  to 
recognize  the  various  coverings  of  the  sac.  One  cuts  directly  down  upon  it  with  such 
care  that  he  may  recognize  it  as  he  comes  upon  it,  usually  by  its  color  and  by  the  sen- 
sation of  proximity  to  its  strangulated  contents.  This  is  ordinarily  not  a  difficult  matter; 
all  bleeding  vessels  should  be  secured  before  the  sac  is  finally  opened.  Final  and 
complete  identification  may  be  made  l>y  finding  that  the  sac  itself  may  be  pinched  up 
between  the  fingers  or  forceps,  while  the  underlying  contents  slip  away.  Only  when 
parts  are  bound  together  in  exudate  will  there  be  difficulty  in  this  regard.  The  surgeon 
should  still  proceed  with  caution,  although  the  sac  will  usually  contain  sufficient  fluid  of 
transudation  to  protect  against  injury  to  the  enclosed  bowel.  Nevertheless  the  greatest 
care  should  be  observed  not  to  wound  the  intestine,  which  sometimes  lies  very  closely 
under  the  skin,  especially  in  the  middle  line  of  an  umbilical  hernia,  although  there  may  be 
masses  of  fat  on  either  side  of  it.  Sometimes  the  sac  distended  with  discolored  fluid  is 
itself  mistaken  for  the  bowel.  Error  can  usually  be  avoided  by  following  it  upward 
and  identifying  its  continuity  with  the  surrounding  tissues. 

When  o])ened  its  contained  fluid  may  be  found  quite  clear,  blood-stained,  purulent, 
extremely  ofi^ensive,  or  even  fecal,  according  to  the  relative  age  of  the  condition  and  the 
degree  and  results  of  strangulation.  Under  all  circumstances  it  is  advisable  to  disinfect 
the  sac  and  its  contents  before  endeavoring  to  release  them.  This  may  be  done  with 
dilute  ])croxide  of  hydrogen  or  with  any  ordinary  irrigating  fluid. 

Within  the  sac,  when  thus  identified  and  opened,  may  be  imprisoned  omentum  or 
bowel,  or  both,  in  any  degree  of  preservation  from  that  which  is  almost  normal,  and  with 
circulation  but  slightly  disturbed,  to  that  which  is  absolutely  gangrenous.  Congested 
bowel  will  nearly  always  be  more  or  less  discolored.  So  long  as  it  is  dusky  or  even 
almost  l)lack,  but  has  not  lost  its  luster,  it  may  probably  be  safely  returned  to  the 
abdominal   cavity;   but  if  green  or  if  luster  be  gone,  or  if  the  contained    fluid  be 


<  II II I  .SPECIAL  OR  RKdlOSAL  SURGERY 

distinctly  putrefactive,  then  serious  doul)t  as  to  its  vial^ility  will  arise.  In  case  of 
actual  perforation,  crancjrene,  or  fecal  abscess  there  will  he  no  doubt  as  to  the  danger 
of  returninij  sucii  lx)wel,  and  other  measures  should  Ix-  adopted. 

The  viahUitij  of  the  bowel  having  been  tleterniined  and  the  sac  disinfected  the  loca- 
tion and  detjree  of  tightness  of  the  con.stricting  ring  should  now  be  determined.  In 
inguinal  hernia  the  constriction  may  occur  either  at  the  external  or  internal  ring;  in 
feuKjral  iiernia  it  is  usually  at  the  femoral  ring;  in  umbilical  hernia,  at  .some  ]X)rtion  of 
the  umbilical  ojx-ning;  while  in  all  three  fornxs  constriction  may  occur  within  the  sac 
it.self  and  with  little  reference  to  the  ordinary  hernial  outlets;  all  of  which  needs  to  be 
clearly  kept  in  mind.  This  identification  is  usually  done  with  the  tip  of  the  little  finger, 
gently  insinuated  and  used  as  a  probe.  The  ojx-rator  who  is  sure  of  his  methods  does 
not  necessarily  need  to  expose  the  constricting  ring  in  order  to  nick  it  or  divide  it,  but 
he  who  is  not  as  j)roficient  should  extend  and  dee]>en  his  incision  until  the  parts  are 
clearly  exposed,  so  that  he  may  be  sure  of  not  doing  more  harm  than  good. 

Ordinarily  it  is  necessary  only  to  nick  at  one  or  two  [xjints  the  margin  of  the  ring, 
which  will  feel  much  like  a  wire  loop,  anfl  then  to  use  the  finger  as  a  dilator,  stretching 
and  fX'rha]>s  tearing,  i.  e.,  making  the  knife  do  as  little  and  the  finger  as  much  work  as 
|K)ssible,  in  order  to  so  loo.sen  up  the  constricted  canal  that  by  gentle  taxis  or  manipula- 
tion reduction  can  now  be  accom])lished.  The  text-books  on  anatomy  give  minute 
descriptions  of  the  relations  of  these  hernial  outlets  to  imjx)rtant  Ijloodvessels,  with  whicii 
even  the  student  should  be  jierfectly  familar.  Nevertheless  by  following  the  subjoined 
rule,  and  never  departing  from  the  principle  thereby  indicated,  the  operator  may  safely 
prrxeed  in  practically  every  instance.  This  is  to  cut  in  the  direction  of  the  patient's 
none.  The  knife  used  for  this  purpose  is  ordinarily  the  herniotome,  i.  e.,  a  blunt, 
slightly  curved  bistoury,  with  but  a  small  exposed  cutting  blade,  whose  dull  [X)int 
is  passed  along  the  finger  until  the  constriction  is  reached,  and  then,  by  the  sense  of 
touch,  beneath  and  beyond  it,  until  the  wire  edge  of  the  ring  rests  upon  the  cutting  part. 
The  handle  is  then  turned  until  this  edge  jxjints  upward  and  is  moved  with  a  gentle 
sawing  action  always  in  the  above-six'cified  direction,  until  the  ]XHuliar  resistance  is 
felt  to  have  yielded.  It  may  then  he  turned  a  little  and  another  nick  be  similarly  made. 
These  nicks  should  not  be  more  than  one-quarter  of  an  inch  deep,  after  which  the  knife 
is  withdrawn  and  the  finger  now  made  to  dilate  and  tear.  With  these  precautions  there 
is  very  little  danger  of  diNiding  an  anomalously  jjlaced  vessel. 

Dilatation  of  the  ring  being  now  sufficient  it  is  well  to  pull  the  hernial  mass  a  little 
downward,  in  order  that  the  condition  of  the  lx>wel  at  the  point  of  constriction  may  be 
exactly  noted.  It  should  therefore  be  gently  coaxed  into  the  wound,  once  more  subjected 
to  insix'ction,  and  then  to  disinfection.  The  surgeon  should  now  determine  what  to  do 
both  AAith  the  Ixjwel  and  the  omentum.  Omentum  which  is  covered  with  exudate  or 
darkly  discolored,  or  surrounded  by  offensive  material,  should  be  first  liberated,  then 
ligated,  above  the  original  point  of  constriction,  and  the  undesirable  part  removed, 
the  stump  l>eing  returned  to  the  abdominal  ca\ity.  The  bowel,  if  decided  by  alx>ve 
indications  to  be  viable,  may  then  be  gently  coaxed  back  if  handled  with  care. 

But  gut  which  has  j>erforated,  or  is  so  compromised  as  to  be  threatening  gangrene, 
should  not  be  returned  into  the  abdominal  cavity,  but  treated  by  resection,  or  by  fixation 
and  the  formation  of  an  artificial  anas,  decision  depending  both  upon  the  condition  of 
the  patient  and  of  the  bowel.  Some  of  these  cases  are  too  nearly  moribund  when  o|)er- 
ated  to  justify  such  procedures  as  resection,  and  are  suffering  too  profoundly  from  the 
ctjnsequences  f)f  obstruction  to  make  it  advisable  to  do  more  than  open  the  bowel  for  its 
immediate  relief.  Artificial  anus  is,  therefore,  the  inevitable  necessity  in  some  forms 
of  strangulation.  A\  hen  the  lx)wel  is  gangrenous  it  is  not  necessary  even  to  endeavor 
to  draw  it  farther  drjwn  into  the  sac-,  but  it  may  be  simply  ojxned  m  -fitu. 

Intestinal  resection  and  suture  instituted  under  these  circumstances  are  essentially  the 
same  as  those  already  described  in  the  chapter  on  the  Small  Intestines.  With  the  forma- 
tion of  an  artificial  anus  there  results  the  ine\-itable  fecal  fistula  which  will  require 
subsequent  operation,  probably  secondary  resection. 

In  non-septic  and  favorable  cases,  the  reduction  having  been  accomplished,  the 
operator  then  may  proceed  to  extirpation  of  the  sac  and  the  closure  of  the  hernial  outlet, 
I.  e.,  operate  for  radical  cure,  this  being  a  modern  extension  and  addition  to  the  old 
operation  for  relief. 

If  obstructive  symptoms  should  persist  after  operation  the  possiblity  of  twisting  of 


HERNIA 


901 


the  intestine,  or  a  possible  reduction  rn  hlor,  may  be  feared,  whic-li  is  not  likely  to  occur 
it'  the  o])eu  j)art  of  the  o|)eratin<i;  have  l)een  done  thoronirhly. 

Clean  cases  of  strant>;ulation  may  be  closed  without  drainaj^e.  In  case  of  doubt, 
h()wev(M-,  it  is  advisable  to  provide  at  least  a  capillary  drain,  while  every  case  known  to 
have   been   containinaled  should  be  perfectly  drained. 

Radical  Cure  of  Hernia. — From  the  earliest  times  rude  and  crudf  methods  of 
emleavorinjf  to  ett"ec-t  a  radical  cure  of  hernia  have  been  in  vojfue.  While  sonietimes 
elfective  thev  have  alwavs  been  dano;erous  and  always  (;lumsy.     Not  until  the  antiseptic 


I'lc:.  C.U 


BassiniV  ..pciatiiiu.  Ligation  <if  the  sac  by  means  of  a  innM— .tiiiiK  suture  l)a■^M■(i  through  the  internal 
surface  of  its  neck.  The  cord  is  <hawn  to  one  side.  The  aponeurosis  of  the  external  obUque  is  drawn  apart  with 
forceps.     (Richardson.) 


Bassini's  operation.     Suture  of  the  conjoined  tendon  to  tlie  internal  surface  of  Poupart's  ligament.  Fortification 
of  the  posterior  surface  of  the  canal.     (Richardson.) 

method  was  introduced  could  they  be  regarded  as  in  any  way  safe  or  reliable.  With 
the  introduction  of  Listerism  it  became  practicable  to  do  this  work,  upon  principles 
simple  in  character  and  ordinarily  easy  of  performance,  which  may  be  summed  up  in 
the  formula:  Isolation  and  obliteration  of  the  hernial  sac,  wiih  permanent  closure  of 
the  hernial  outlet.  Easy  as  such  description  may  sound  it  has  been  found  more  or  less 
difficult  in  practice,  and  numerous  methods,  apparently  both  simple  and  ingenious, 
have  jiroved  defective  and  have  called  for  the  most  pronounced  modification.  Con- 
siderable space  could  be  devoted  to  operations  for  radical  cure,  but  the  intent  here  shall 


902 


SPECIAL  OR  RKOrOXAL  SURaPJRY 


bo  to  siinplil'v  the  siihjcct  as  woll  as  tlir  method,  and  coiiscciucntly  hut  two  or  three  will 
be  deserihed.  Suffice  it  to  say  that  while  ail  are  l)ase<l  on  the  same  j)riiiei|)l(^  they  vary 
somewhat  in  detail,  and  that  some  of  tiiese  details  have  to  he  adapted  to  the  special 
requirements   ot"   individual   cases. 

With  increase  in  experience  has  come  enlari;'ed  confidence  in  the  o])eration,  and  it  is 
now  reo;arded  as  justifiable  in  nearly  every  instance  amouff  individuals  otherwise  in  ojood 
condition.  It  has  a  double  purpose — namely,  the  avoidance  of  the  danger  of  sudden 
strangulation  and  the  riddance  of  necessity  for  wearing  trusses,  or  suffering  the  dis- 
comforts of  luM-nia  without  any  mechanical  control.  Some  modern  methods  include 
the  utilization  of  som(>  portion  or  all  of  the  sac,  while  in  others  it  is  entirely  cut  awnv. 

I'ici.  (313 


Park's  nieth 


-liciwiiiK  its  isolation  ami  one  way  of  eniplojuifnt  in  inalving  t  lie  suture 
further  represented  in  Fig.  614. 


Consequently  some  ojierators  have  endeavored  to  utilize  such  portion  of  the  sac  as  could 
be  made  available  for  either  ])iirpose,  either  as  plug  or  suture  material. 

The  method  of  Bassuii  for  relief  of  inguinal  hernia,  more  or  less  modified  to  meet 
individual  demands,  seems  to  have  become  of  late  years  the  most  ])opular  and  widely 
adopted.  The  incision  is  made  over  the  most  ])rominent  jiart  of  the  tumor,  extending 
as  far  downward  u])on  the  scrotum  as  necessary,  and  upward  to  near  the  anterior  superior 
spine.  Through  it  the  external  ring,  with  its  ])illars,  is  ex])osed,  and  then  the  sac,  by 
a  dissection  long  and  sufficiently  wide  to  fully  reveal  it.  The  exposure  is  made  more 
complete  by  dissection  of  the  aponeurosis  of  the  external  oblique  from  the  level  of 
the  external  ring  upward  and  outward  for  an  inch  or  so  above  the  external  ring.  By 
seizing  the  edges  of  the  aponeurosis  on  each  side  with  forceps  and  retracting  there  is 
now  afforded  an  excellent  view  of  the  hernia  proper.     (See  Fig.  611.) 


ITERXIA 


903 


\]y  careful  dissi-ctioii  the  sac  and  cord  arc  identified  and  isolated,  wliile  the  sac  is 
(.ncned  and  its  ed^n-s  lield  apart  l)y  i"()ree|)S,  after  wliieli  it  is  carefully  separated  from  the 
otiier  structures  of  the  cord.  After  thus  isolating;  the  sac,  and  witli  the  least  |)ossil)le 
disturhance  of  the  cord  and  of  the  testicle,  it  is  li^^ated  as  W\<r\\  as  the  internal  rinf;,  or, 
if  possible,  hi«,duM- y(>t.  This  leaves  the  cord  uninjured;  its  size  shoidd  next  he  reduced 
1)V  cuttino;'  a\uiv  ail  superfluous  tissue.  Some  oju-rators  remove  all  the  veins,  but  this 
seems   unproniisin<;-   and   dangerous. 

By  all  this  dissection  and  reduction  the  inguinal  canal  has  been  tcni|)oranly  cleared, 
amfthe  sac  havinj;  been  elevated,  li<iated,  and  cut  away  it  becomes  now  a  (|Uestion  of 
what  to  do  with  tlu"  cord.  The  lower  surfmvs  of  the  external  oblitiue  and  of  Toupart's 
lijrament   arc  next   U-rvi],   the  cd<;c  of  the  internal  oblicpie,  of  the  transversalis  with  its 

Fid.  ()14 


Park's  oijeration.      Continuous  suture  made  with  a  long  thin  sac. 

fascia,  the  outer  border  of  the  rectus  and  the  conjoined  tendon  being  all  exi)osed  to  view 
bv  whatever  dissection  may  be  required,  all  fat  and  areolar  tissue  being  removed.  The 
cord  is  finallv  disposed  of  by  holding  it  out  of  the  way,  usually  by  a  loop  of  gauze,  while 
the  deep  layer  of  the  external  oblique  and  the  external  portion  of  Poupart's  ligament  are 
sewed  to  the  muscle  edges  of  the  internal  oblique  and  transversalis,  as  appears  m  Fig. 
()12,  by  a  line  of  sutures  which  include  the  conjoined  tendon,  at  the  lower  angle  of 
the  wound,  which  should  be  affixed  to  the  outer  border  of  the  rectus.  In  the  deeper 
])ortion  of  every  such  wound  there  is  danger  of  injury  to  the  external  iliac  vessels  as  well 
as  to  the  epigastric.  For  the  escape  of  the  cord,  and  to  avoid  its  undue  constriction,  an 
opening  should  be  left  for  it,  i.  e.,  a  new  interned  ring,  adapted  for  the  purpose  and  not 
too  small.  This  is  made  by  not  suturing  the  upper  part  of  the  wound.  The  cord  being 
afforded  this  exit  is  now  dropped,  and  the  edges  of  the  external  oblique  are  brought 


904 


SPECIAL  OR  RECJnXAL  SVRGERY 


together  over  it,  the  sutures  extending  well  downward,  but  being  omitted  at  the  lower 
portion,  where  a  new  cxiernal  ring  is  thus  left,  only  not  of  its  original  size,  but  sufficiently 
large  to  accommodate  the  corfl. 

Such  are  the  essentials  of  the  Bassini  method,  which  has  been  modified  by  Ilalsted  in 
such  a  way  that  the  corfl,  reduced  as  much  as  possible,  usually  by  removal  of  most  of 
its  veins,  is  now  not  left  within  the  inguinal  canal,  but  transplanted  entirely  outside  of 
the  external  oblique,  escaping  at  the  upper  part  of  the  incision  and  requiring  no  further 
accommodation  in  its  course  toward  the  testicle.  In  children,  or  even  in  arlrdts  with  very 
small  veins,  he  floes  not  so  reduce  the  cord.  After  isolation,  opening  anfl  transfixion 
of  the  upper  end  of  the  sac,  anfl  its  secure  ligation,  he  drf»ps  the  stumj)  back  into  the 
abflfmicn.  The  muscular  anfl  tendinous  layers  of  the  ring  anfl  abflomen  are  unitcfl  alsf). 
by  layers,  with  quilted  sutures. 

Fig.  615 


L 


Park's  me- 


In  these  as  in  many  other  methofls,  much,  practically  everything,  flepends  upon  the 
certainty  and  durability  of  the  sutures  used  for  disposal  of  the  inguinal  canal.  For 
some  years  surgeons  usetl  silver  wire,  which  has  now  been  abanflonefl.  The  choice 
now  seems  to  depend  on  sill:,  thoroughly  and  freshly  boilefl,  or  animal  sutures,  such  as 
kangarfio  or  reindeer  tendon.  McArthur  suggested  to  fli.s.sect  off  a  strip  from  the  margin 
of  the  opening  in  the  external  oVjlique,  or  from  the  aponeuro.sis,  anti  to  u.se  this  strip  of 
the  patient's  own  ti.ssue  for  suture  material.  I  have  moflifiefl  this  methofl,  as  will  be 
flescribcfl  later.  Kfjcher  flevisefl  a  methofl  of  isolation  of  the  sac,  withfiut  such  complete 
emjitying  f)f  the  inguinal  canal,  the  .sac  being  flrawn  up  through  the  canal,  then  thrf)Ugh 
the  internal  ring,  anfl  finally  through  an  opcninir  in  the  external  i)blif|ue,  over  the  internal 
ring,  where  it  was  twisted  and  fastened,  after  wliich  the  external  pf)rtif)n  was  removed. 


HERNIA 


oo: 


My  own  pn'rcrciicc  in  ()|)<'r;itioiis  Tor  r;i(li(;il  cure  lias  hccii,  until  rcronlly,  jin  ox])().siirc 
similar  to  that  ot"  Uassiiii's,  witli  (•()iii|)l('t('  iscdation  of  the  sac,  which  is  separated  u|)  to 
the  level  of  the  internal  rin<^  or  even  higher.  At  this  point  it  is  drawn  out  throu<;h 
an  incision  made  in  the  external  aponeurosis,  twisted  and  fastened.  The  in<ruinal 
eanal  is  then  closed,  its  deeper  layers  by  a  shoelace  suture  of  tendon,  threaded  in-to  two 
stout  curv(>d  needles,  hy  which  the  dee|)er  mari^ins  of  the  canal  are  brought  accurately 
tooc'ther.  Somelimes  I  have  transj)lanted  the  cord  and  a<jain  have  dro|)|)ed  it  hack, 
till'  layer  of  shoelace  sutuns  closinji;  the  external  aponeurosis  over  it.  It  has  not  seemed 
to  me  to  make  any  ditference  which  mclhotl  was  adoptc(l,  and  I  have  practically  never 
seen  any  atrophy  or  permanent  disturhance  of  the  testicle. 

Fig.  61G 


Park's  method.     A  short  sac  is  so  divided  as  to  be  elongated  sufficiently  for  use  as  a  suture. 

]\Iore  recently  it  has  occurred  to  mc  to  utilize  the  sac  it.self  for  suture  material,  and 
this  is  the  method  which  I  now  adoj^t  in  those  cases  that  permit  of  it. 

Fi<is.  ()13  to  616  show  the  method  of  thus  utilizincj  the  sac.  A  lono;  thin  sac  may 
be  twisted  into  a  cord  and  used  as  an  over-and-over  suture,  by  which  the  margins  of 
the  canal  are  brought  together.  If  found  thick  and  unwieldy  it  may  be  trimmid 
down  into  a  single  suture,  or  it  may  be  splii,  with  more  or  less  trimming,  into  two 
portions,  by  which  the  canal  is  then  braided  together  or  closed  with  a  shoelace  suture, 
the  ends  being  tied  or  fastened  at  the  lower  portion.  Fig.  616  shows  how  a  short  sac 
not  otherwise  available  can  be  lengthened  and  made  sufficient  for  the  purpose. 

This  again  is  utilization  of  the  patient's  own  tissue,  he  himself  furnishing  his  own 
animal  ligature,  which,  l)eing  fresh  anrl  sterile,  may  be  regarded  as  reliable.  The 
method,  furthermore,  has  this  advantage,  that  there  is  rea.son  to  believe  that  tissue  so 
utilized  becomes  organized,  in  time,  and  that  the  union  becomes  more  reliable  rather  than 


906 


SPECIAL  OR  HIXilONAL  SVUGKRV 
Fig.  617 


Radical  cure  of  femoral  hernia.      J)is.se 


liwii  of  tlie  saidienous  o|jeiiint;.       I' 
(Richardson.) 


Fig.  618 


sac  of  the  hernia  has  been  lied. 


Radical  cure  of  femoral  hernia,  showing  method  of  application  of  purse-string  ligature  to  close  sai>henous 

opening.     (Richardson.) 


Iff'RXfA 


907 


„tlu«nvis,>.      At  all  (•v.-i.ts  in  :.  <-..nsi.lcr.-.l.lc  iniiul.cr  ..I'  <-asr.s  it  lias  yicldc.l  sati.si'actory 
ivsults,  and  in  no  case  has  it  caiiscil  any  (lisa|)|.()inlnicnl . 


Kadicul  cure  -f  femoral  hernia.      Suture.s  applied  ...  per.ineal  fascia,  fascia  lata,  and  P.mpart's  ligament. 

(Richardson.) 


Fig.  620 


Obi 


iteration  of  the  femoral  opening  l..v  purse-string  suture.      (Coley.) 


Recurrence  after  these  operation.s  occurs  less  and  less  frequently  as  operators  gain  in 
experience  and  technique  is  improved.     At  all  events  the  procedure  has  now  become 


90.S 


SPECIAL  07?  REGIOXAL  SURCERY 


standard  and  disappointments  aiv  relatively  rare.  It  is  useless  to  qiiote  statistics  of 
individuals,  for  they  necessarily  differ.  In  fjeneral,  however,  it  is  probable  that  from 
90  to  90  per  cent,  of  cases  properly  oj)e rated  suffer  no  recurrence. 

In  the  female  incjuinal  hernia  is  treated  in  j)ractically  the  .same  way,  conditions  being 
siinj>lified  by  the  absence  of  necessity  for  making  any  provision  for  the  blood  supply  of 
the  testicle  or  cord.  The  canal  and  rings  may,  therefore,  in  the  female  be  absolutely 
closed. 

Femoral  hrrnia  is  radically  treated  on  the  same  general  princij)les,  but  with  greater 
difficulty,  as  anatomical  conditions  are  less  favorable.  A  flap  is  raised  below  Pouj)art's 
ligament,  with  its  centre  over  the  tumor,  and  the  sac  exposed  and  completely  flissccted, 
then  opened,  as  in  inguinal  hernia.  Its  contents  being  reduced  fibliteration  of  the  .sac 
and  its  utilization,  if  possible,  are  in  order.  It  is  rarely  difficult  to  .separate  it  from  its 
surroundings  well  up  in  the  femoral  canal.  It  may  be  twi.sted  and  its  neck  ligated,  or 
it  may  be  possible  in  .some  cases  to  either  infold  or  reduce  a  sufficient  portion  of  it  to 
thus  form  a  plug,  which,  being  pushed  upwarrl,  .serves  as  a  means  of  closing  the  femoral 
o|)ening  from  above.  Whatever  use  may  be  made  of  it  it  should  be  obliteraterl  as  a 
pouch,  and  its  descent  prevented  by  closure  of  the  canal  around  it.  This  is  difficult 
becau.se  of  the  j)roximity  of  the  femoral  vi  in  aiul  the  somewhat  unyielding  character  of 


Fig.  621 


Fig.  622 


Grai^er's  method  of  dealing;  with  umbilical  hernia. 


the  falciform  and  crural  fasci.-r.  By  some  form  of  purse-string  suture,  or  by  a  little 
di.s.section  and  sliding  of  aponeurotic  flaps,  it  is  usually  j)ossible  to  l>ring  the  surrounding 
structures  snugly  together.  Even  here  I  have  been  able  to  apply  my  principle  enunciated 
above,  and,  by  cutting  away  a  .strip  of  the  sac,  utilize  it  for  the  purpo.se  of  closing  the 
femoral  canal;  but  it  is  not  often  that  a  femoral  pouch  will  be  .sufficiently  large  to  afford 
ti.s.sues  for  this  purpo.se.  Figs.  017.  Hi's.  019  and  020  will  save  the  necessity  for  further 
description. 

In  many  inguinal  and  umbilical  an<l  in  a  few  femoral  hernias  the  operator  will  be 
hampered  by  adhe<<ion.'<  between  the  omentum  or  between  the  bowel  and  the  sac  wall. 
The.se  may  be  infrequent  and  slight  or  extensive  and  dense.  They  are  relatively  unim- 
portant .so  long  as  they  involve  only  the  omentum,  which  may  at  any  time  be  cut 
away,  the  stump  being  dropped  back  into  the  abdomen,  after  being  suitably  .secured; 
Init  when  bowel,  especially  large  intestine,  is  thus  adherent,  great  care  .should  be  exercised, 
avoifling  all  po.ssibility  of  shutting  off  the  blood  .supply  while  .securing  every  divided 
vessel. 

Particularlv  is  this  true  in  treatment  of  umbilical  hernias,  either  radical  or  under 
conflitions  of  .strangulation.  In  stout  individuals,  usually  women,  umbilical  sacs  .some- 
times contain  several  feet  of  bowel,  anfl  adhesions  may  be  met  at  many  points,  rlifficulties 
arisinor  not  only  in  their  .separation,  but  in  the  final  disposition  and  accommodation  of 


iii:r.\i.\ 


909 


all  this  l)()ucl  witliiii  tlic  alxinmiii.il  cavity,  riuin  wliicli  it  lias  Incii  so  Ion;;  ahsciit. 
Uadical  ciiix'  w  ill  in  tlu'so  cases  Iravc  intra-alxloininal  \  isccra  in  a  rather  overcrowded 
eondition. 

The  essential  details  of  radical  trfalmrnf  of  iniihi/ical  henna  are  the  same,  modified 
by  the  extent  of  sae  which  has  to  he  removed,  and  hy  the  wis<lom  in  many  instances  of  a 
lar^e  elliptical  excision  of  the  overlying  skin  and  removal  of  much  superfluous  tissue. 
After  freeing  the  contents  and  reducing  them,  tiic  sac  wall  beinj;  completely  sej)arated, 
there  is  the  choice  of  two  or  three  methods  of  dosinij  the  umbilical  opening,  either  by 
overlappiiitj  of  Haps,  whicii  may  be  cut  from  the  thickest  |)ortion  of  the  sac,  which  will 
be  close  to  the  outlet,  or  by  <lissectin^  tliiMu  from  tin-  a|)oneurosis,  as  su^^'csted  by  Mayo, 
and  turniui,'  the  np|)er  down  over  the  lower,  or  by  any  other  ex})edient  which  individual 


Tiu.  023 


Ik;,  (il'l 


Method  by  transverse  closure  of  botli  deep  and  extcrnai  iiui^ion-;. 

peculiarities  may  suor<rest  (Fio;s.  621  to  624).  I  have  been  able  to  employ,  to  apparent 
advantaije,  my  method  of  securin^r  suture  material  for  this  deep  closure  from  tlie  sac 
wall  itself,  this  not  preventing  the  employment  of  any  other  method  or  improvement. 
Ventral  and  postoprrative  hernias  are  operated  on  in  essentially  the  same  manner  as 
the  forms  above  described.  Adhesions  may  be  found  in  these  cases,  and  plastic  methods 
should  be  devised  for  bringing  together  irregularly  shaped  openings  and  holding  them 
in  the  firmest  possible  manner.  In  any  extensive  abdominal  hernia,  umbilical  or  ventral, 
it  is  advisable  to  use  buried  sutures,  closing  the  abdominal  walls,  layer  by  layer,  and  finally 
to  insert  at  some  distance  a  sufficient  number  of  through-and-through  retention  sutures, 
guarded  by  plates  or  snudl  rolls  of  gauze,  these  taking  ofi"  tension  from  the  wound  and 
affording  protection  against  any  special  strain,  such  as  vomiting. 


CHAPTER   LIL 


THE  LIVER. 


CONGENITAL  DISPLACEMENTS  OF  THE  LIVER. 


Fig.  62.5 


The  congenital  defects  and  disjjlaeements  of  the  liver  which  interest  the  surgeon  are 
few.     More  or  less  transposition,  sometimes  complete  situs  transrersus,  is  encountered. 

The  same  is  true  of  more  or  less  hernial  protrusion 
into  the  chest,  through  a  defect  in  the  diaphragm,  or 
such  dis]jlacement  as  may  he  permitted  by  some  defect 
of  the  abdominal  walls  or  other  viscera.  Hammond 
lias  recently  shown  that  the  left  lobe  of  the  liver  is  some- 
times congenitalhj  enlarged  to  an  extent  sufficient  to  cause 
symptoms,  a  condition  alluded  to  by  very  few  writers. 
In  this  way  the  liver  may  cover  the  stomach  and  even 
extend  over  the  spleen.  Similarly  the  right  lobe  may 
Ije  affected,  but  giving  a  different  train  of  symptoms. 
Under  these  conditions  mistakes  may  arise.  Thus  the 
left  lobe  might  be  mistaken  for  a  large  spleen,  from 
which,  nevertheless,  it  should  be  separated  and  differ- 
entiated by  its  free  movement  during  respiration. 
Hammond  even  reports  one  case  of  this  kind  where, 
instead  of  removing  the  elongated  portion  of  the  liver, 
it  was  held  up  against  the  abdominal  wall  by  sutures. 
For  a  similar  condition  Langenbuch  has  successfully 
resected  a  portion  of  this  viscus.  What  is  said  here 
pertains  to  a  true  congenital  variety,  and  not  to  acquired 
displacements  or  enlargements.  In  Fig.  62.5  is  repre- 
sented the  case  of  xiphopagous  twins  united  by  a  band  of  liver  tissue  and  operated 
(by  division  of  the  band)  by  Baudouin. 


Xiphopagous  twins,  separated  by 
division  of  a  band  of  common  liver 
tissue.  Case  of  M.  Baudouin.  (Pan- 
taloni.) 


WANDERING   OR   FLOATING  LIVER. 


The  relations  between  congenital  laxity  of  the  natural  suj)ports  of  the  Hver  and  certain 
morbid  conditions,  especially  those  produced  by  marked  enhirgcniciit  followed  by  great 
reduction  in  size,  to  the  so-called  wandering  or  floating  liver  are  very  indefinite.  The 
term  "wandering"  implies  a  mobility  far  beyond  the  normal,  with  more  or  less  yielding 
of  ligaments,  especially  the  su.spen.sorv,  which  permits  undue  displacement.  We  often 
fail  to  realize  that  the  liver,  which  is  the  heavie.st  of  the  viscera,  is  nevertheless,  in 
man,  placed  at  their  top,  and  hence  that  it  has,  in  at  least  some  respects,  very  meagre 
support.  This  is  one  of  the  fli.sadvantages  of  the  upright  position,  and  it  does  not  pre- 
vail in  animals.  In  addition  to  this  may  be  mentioned  the  peculiar  enlargement  of  the 
right  lobe,  very  rarely  of  the  left,  so  often  seen  in  connection  with  biliary  ob.struction, 
and  often  .spoken  of  as  Rieclel's  lobe.  Floating  liver  is  more  common  in  women  than  in 
men  by  four  to  one,  and  is  often  ascribal)le  to  the  ill  effects  of  tight  lacing.  Repeated 
pregnancies,  with  the  con.sequent  relaxed  and  pendulous  abdominal  walls  which  often 
follow  them,  al.so  conduce  to  the  condition  by  weakening,  in  fact  almost  removing,  its 
lower  supports. 

Symptoms. — The  symptoms  produced  are  those  of  indigestion,  dyspnea,  perhaps 
with  cyanosis,   nau.sea,  vomiting,   and  occasionally  biliary  ob.struction  and  jaundice. 
In  addition  to  the.se  the  patient  will  show  the  ordinary  physical  signs  of  a  displaced  or 
displaceable  liver,  noticeable  in  the  upright  ot  in  the  knee-elbow  position, 
(910) 


ABSCESS  OF    Till-:   I.IVF.R;  JI hi' A  TIC  MiSCFSS  911 

Treatment. TIic  tri-atiiu-iU  of  milder  cases  will  consist  of  support  from  below 
by  suitably  a(la|)te(l  and  well-fittini,'  abdominal  binders  or  supports.  Serious  cases 
may  necessitate  suri^ical  relict'.  This  consists  of  lirjxUopc.ri/,  i.  c,  fixation  of  the  liver 
to  some  of  its  up|)er  surroun<lin<is.  The  operation  is  jjcrformcd  thnniirli  an  incision 
such  as  that  used  for  exposure  of  the  <;all-bladdcr.  The  lower  surface  of  the  diaphragm 
and  the  upper  .surface  of  the  liver  are  scarified  until  they  ooze  perceptibly.  The  anterior 
edge  of  the  liver  is  then  fastened  to  the  abdominal  walls,  as  also  the  o^all-bladder,  if 
it  can  be  utilized  for  the  purpose.  The  jxitient  is  then  placed  in  bed  with  a>s  much 
comj)ression  of  the  abdomen  l)(>low  tlie  liver  as  can  be  tolerated,  in  order  that  the  scarified 
surfaces  may  be  kept  in  contact  until  adhesions  result. 


INJURIES  OF  THE  LIVER. 

By  its  size  and  construction  the  liver  is  made  peculiarly  liable  to  certain  injuries,  while 
from  others  it  is  made  more  or  less  exempt  by  its  protected  situation,  esj)ecially  by  the 
ribs,  which  nearly  enclose  it.  From  contusions  it  may  underijo  different  degrees  of 
laceration,  sometimes  even  to  the  degree  of  fragmentation  and  j)ulpifaction.  Again 
it  is  frequently  involved  in  punctured  wounds  (stal>,  gunshot,  etc.),  which  may  be 
inflicted  from  any  possible  direction,  perforation  sometimes  taking  place  from  above 
and  throuMi  the  chest,  and  involving  the  tissues  beneath. 

General  indications  of  injury  to  the  liver  will  be  furnished  by  its  nature  and  location, 
the  degree  of  collapse,  and  the  consequent  abdominal  rigidity,  with  the  common  signs 
of  internal  or  intra-abdominal  hemorrhage.  There  is  no  doubt  but  that  minor  injuries 
of  the  liver  are  nearly  always  repaired,  and  that  they  occur  much  oftener  than  is  generally 
appreciated ;  l)ut  a  severe  tear  of  the  liver  is  a  source  of  great  danger  because  of  hemor- 
rhage. In  general,  of  these  injuries  it  may  be  said  that  any  traimiatism  wliich  produces 
profound  or  increasing  symptoms  should  be  regarded  as  indicating  a  careful  exploration, 
done  with  every  j^recaution  at  hand  for  carrying  out  any  possible  indication.  What 
the  liver  may  safely  bear  in  the  way  of  ligatures,  sutures,  and  operative  disturbance 
will  be  indicated  later.  INIany  fatal  cases  show  a  period  of  a  few  hours  of  temporary 
amelioration  of  symptoms  which  may  have  lulled  to  a  sense  of  false  security,  and  during 
which  internal  mischief  is  still  increasing.  Moreover,  any  blow  sufficiently  severe  to 
rupture  the  liver  may  do  other  harm.  In  such  instances,  then,  it  becomes  a  simple 
question  of  whether  there  can  still  be  sufficiently  early  intervention  to  save  life.  To 
what  extent  this  intervention  may  be  required  in  stab  and  gunshot  wounds  it  is  difficult 
to  state.  If  hemorrhage  and  puncture  of  any  hollow  viscus  can  be  excluded  and  if 
no  other  serious  symptoms  be  present,  it  may  be  advisable  to  wait;  otherwise  the  possible 
harm  of  a  judicious  early  exploration  is  so  small,  while  the  prospective  benefits  are  so 
great,  that  it  is  far  the  wiser  course.  Here,  again,  the  general  rule  may  be  applied.  When 
in  doubt  operate.     Further  details  of  operative  procedures  will  be  given  below. 


ABSCESS  OF  THE  LIVER;  HEPATIC  ABSCESS. 

While  abscess  of  the  liver  is,  like  all  other  abscesses,  due  to  germ  activity,  it  may  yet 
definitely  follow  injury  or  be  the  result  of  a  primary  disease,  or  an  extension  from  some 
one  of  the  adjacent  tissues  or  organs;  as  from  above  (empyema,  pyopericardium,  sub- 
diaphragmatic, spinal),  from  belotv  (gall-bladder  and  ducts,  pancreas,  stomach),  from 
the  portal  circulation  (superficial  or  ulcerating  piles,  typhoid  and  other  intestinal  ulcers, 
peculiar  or  tropical  parasites  like  amebas),  from  the  appendix,  from  the  general  circu- 
lation (pyemic,  metastatic),  through  the  li/mphafics  (mesenteric  nodes),  from  the  intes- 
tinal tube  (ordinary  round-worms  and  various  parasites),  from  cancer  breaking  down, 
as  well  as  from  dcfjenerating  gumma  or  granuloma  and  from  hydatid  cyst. 

Hepatic  abscess  may  be  acute  or  chronic,  small  or  large,  solitary  or  multiple.  The 
tendency  is  to  enlarge  and  finally  to  kill.  This  they  do  usually  by  rupture,  e.  g.,  either 
into  the  pleural  cavity  or  the  lungs,  after  adhesions  have  been  contracted,  the  peri- 
cardium, the  mediastinum,  the  peritoneum,  any  part  of  the  upper  alimentary  canal, 
or  the  biliary  passages.  Finally  they  may  open  externally  and  perhaps  be  followed  by 
spontaneous  recovery. 


912  SPECIAL  OR  REGIONAL  SURGERY 

A  certain  convenience  of  (le.scri|)tio!i  is  afforded  by  dividing;  tlie.se  cases  into  the 
so-called  solitury  abscesses  and  the;  vudtiple  forms,  the  latter  being  more  commonly 
associated  with  tropical  diseases  of  the  amebic  type  or  with  pyemic  processes.  In  most 
solitari/  cases  the  abscess  is  located  in  the  right  lobe,  its  extent  varying  within  wide  limits, 
esjK'cially  when  the  subphrenic  s|)ace  has  been  involved.  Its  contents  may  be  of  almost 
any  color  and  the  pus  is  often  thick  and  foul  in  odor.     (See  Subplirenic  Abscess.) 

Symptoms. — Symjjtoms  of  the  solitary  type  may  be  at  tiie  onset  acute,  with  or 
without  history  (jf  ])revious  sickness,  the  patient  being  suddenly  seized  with  severe  e|)i- 
gastric  or  hyj)ochondriac  jjain,  which  is  followed  by  prostration,  with  fever,  chills,  and 
sometimes  cough.  Characteristic  rigidity  and  tenderness  follow  and  the  liver  increases 
in  size,  the  whole  type  of  illness  being  one  of  acute  abdominal  infection.  The  slower 
f<jrms  appear  to  come  on  without  early  liver  symptoms,  patients  complaining  of  cough 
and  discomfort  in  the  chest,  with  loss  of  f^esh  and  appetite.  Gradually  the  indications 
j)oint  to  the  hepatic  region,  while  chills  or  intermittent  fever  occur,  the  liver  gradually 
increasing  in  size  and  becoming  tender.  Again,  in  some  cases,  the  trouble  begins  with 
irregular  fever,  patients  ruiming  down  rapidly,  yet  showing  few  local  signs  until  the 
abscess  invades  the  subphrenic  region.  In  such  instances  examination  of  the  chest 
gives  negative  evidence,  save  that  there  maybe  found  elevation  of  the  diaphragm  due  to 
aecunudation  below  it.  In  nearly  all  instances  there  arise,  sooner  or  later,  severe  chest 
pains,  with  enlargement  of  the  liver,  tenderness,  and  often  indications  of  fluid  in  the  right 
pleural  cavity,  which  on  asj>iration  may  be  found  clear  or  purulent.  Tenderness  along 
the  liver  border  will  be  most  marked  among  characteristic  features.  Sometimes  there 
is  intercostal  tenderness.  Any  indication  of  local  peritonitis  should  be  taken  as  evidence 
of  approach  of  pus  toward  the  surface.  Jaundice  is  an  occasional  accomjnmiment. 
Previous  malaria  should  be  excluded  if  possible  and  a  careful  case  history  is  a  jrreat 
help.  _  .  - 

Diagnosis  is  usually  to  be  made  between  hepatic  and  subphrenic  abscess  and  between 
the  single  and  multiple  forms  of  the  former.  The  possibility  of  empyema  or  of  one  or 
two  subphrenic  abscesses  should  be  carefully  determined."  In  fact,  first  of  all,  the 
surgeon  has  to  determine  whether  the  lesion  is  above  or  below  the  diaphragm.  Some 
of  the  subphrenic  abscesses  contain  gas,  and,  should  indications  of  its  presence  be  found 
below  the  level  of  dulness  due  to  the  presence  of  fluid,  interj)retation  of  the  facts  is  easy. 
Localized  edema  of  the  chest  wall,  or  of  the  region  of  the  liver,  is  of  imjjortance  when 
present.  It  is  necessary,  also,  to  exclude  phlegmons  of  the  alxlominal  wall.  These 
are  cases  where  it  is  justifiable  to  use  an  exploring  needle  rei)eatedly,  if  necessary,  in 
order  to  determine  the  presence  and  location  of  pus.  After  anesthesia  the  needle "mav 
be  used  even  more  freely,  its  use  being  not  only  of  assistance  in  diagnosis,  l)ut  it  aj)pearing 
to  be  an  agent  of  great  value  in  the  relief  of  pain.  I  have  known  paijiful  affections  of 
the  liver  to  be  much  relieved  by  such  exploration. 

The  accompaniment  of  dysentery  of  amebic  type,  and  the  discovery  of  amebas  in  the 
.stools,  would  quite  settle  the  question  of  the  origin  and  nature  of  such  abscess.  Hydatids 
are  of  slow  growth  and  are  almost  symptomless  until  they  produce  pressure  disturbances 
or  those  due  to  the  presence  of  pus.  The  fluid  withdrawn  from  them  is  clear  and  may 
contain  booklets.  Cancer  eventually  produces  jaundice  and  the  resulting  enlargements 
are  nodular,  while  the  lower  l)order  is  irregular,  and  the  liver  itself  less  tender  and  more 
movable,  and  there  is  usually  more  or  less  ascitic  fluid  present.  Syphilitic  gumma 
may  cause  enormous  enlargement  of  the  liver,  with  difficulty  in  diagnosis,  especially 
in  the  absence  of  a  significant  history.  Under  vigorous  mercurial  treatment  it  will 
steadily  improve;  without  it  such  gummatous  tumors  may  suppurate.  It  v/ill  often  be 
advisal)le,  in  case  of  doubt,  to  make  this  therapeutic  test.  Actinomycosis  produces 
granulomas  which  tend  to  increase,  infiltrate,  produce  adhesions,  and  gradually  work 
toward  the  surface,  as  well  as  eventually  to  break  down,  the  defjris  thus  produced  con- 
taining not  only  pus,  but  the  })eculiar  calcareous  particles  characteristic  of  this  disease. 

Treatment. — Multiple  foci  in  the  liver  scarcely  admit  of  successful  operative  treat- 
ment and  are  nearly  inevital)ly  fatal.  The  solitary  liver  abscess,  even  though  large, 
is,  on  the  other  hancl,  usually  satisfactorily  treated  by  the  general  method  of  free  incision 
and  drainage,  although,  in  exceptional  cases,  aspiration  alone  has  seemed  to  suffice. 
Any  collection  of  pus,  no  matter  what  the  internal  condition,  so  long  as  it  be  not  distinctly 
cancerous,  which  tends  to  present  externally,  no  matter  at  what  point,  should  be  thus 
treated.     Incision  may  be  made  over  any  protruding  or  edematous  area  where  pus  seems 


HYDATIDS  OF    Till-:  JJ\  h'R 


913 


to  l)c'  iioiirintf  the  surfiicc.     With  a  considerable  collection  oi"  this  fluid  in  the  ri<rht  lobe, 

especially  nearer  its  diaphra^nn-covered  j)ortion,  it  is  usually  safe  to  assume  that  the 

upper  surface  of  the  livc-r  has  become  adherent  to  the 

(liaphra<j;matic  dome  above  it,  and  that  there  one  may 

follow    the  costal    border   or    may   enter   between    the 

lowermost  ribs,  or  may  even  resect  one  or  more  ribs  if 

necessary,  and  drain  posteriorly  or  by  countcropening, 

as  may  be  indicated.     When  approached  from  beneath, 

the  lower  surfac-e  of  liver  thus  affected  will  usually  be 

found  more  or  less  matted  to  the  colon,  omentum,  or 

pyloric  rci,non,  as  the  case  may  be,  so  that  by  carefully 

openinif  the  abdominal  cavity,  and  wallin<i^  it  off  with 

gauze,  pus  may  be  evacuated  from  below  and  cavities 

satisfactorily  drained.     In  this  work  it  is  of  advantaoe  to 

use  an  e.\j)lorin<i;  needle,  the  operator  guiding  his  further 

procedures   largely   by   what   it   may   reveal.      Vessels 

which  may  be  divided  and  spurt  should  be  ligated  or 

secured  en  ma.s'.sr,  while  oozing  is   overcome  by  gauze 

pressure.     Drainage  of  a  cavity  already   protected  is    Abscess  of  liver,  opened  by  transperito- 

sinijjle;  otherwise    it  may   require   a  very  careful  com-         neal  hepatostomy.    (PantaUmi.) 

bination  of  large  fenestrated  tube,  if  j)ossil)le  sewed  in 

place,  with  the  margins   of   the   opening   carefully   puckered   and   secured   around  it 

and  [)roteeted  with  gauze.     Counteropening  may  be  made,  as  well  as  drainage  of  any 

neighboring  purulent  focus. 


HYDATIDS  OF   THE  LIVER. 

Echinococcus  disease  is  almost  a  surgical  curiosity  in  the  central  portions  of  the  North 
American  continent,  whereas  in  some  j^arts  of  the  world  it  is  extremely  common.  Thus 
while  very  rare  in  the  United  States,  in  Winnipeg  it  is  an  exceedingly  common  disease, 
being  brought  there  by  immigrants  from  a  locality  where  it  is  still  more  prevalent, 
namely,  Iceland,  where  it  is  saki  that  nearly  half  the  inhabitants  die  of  some  form  of 
hydatid  disease.  In  New  Zealand,  also,  as  elsewhere,  this  form  of  parasitic  invasion 
is  very  common.  With  most  American  practitioners,  however,  it  is  so  seldom  seen  that 
its  mere  possibility  may  be  overlooked.  In  the  liver  it  produces  cystic  disease  whose 
symj)toms  are  rarely  significant  until  the  cysts  have  attained  considerable  size  and  have 
begun  to  suppurate.  That  the  liver  is  so  frequently  affected  is  easily  understood,  as 
the  parasites  make  their  first  invasion  along  the  duct  from  the  intestinal  tract.  The 
history  of  these  cases  is  always  slow%  as  four  years  is  a  short  time  and  twenty-five  years 
not  an  exceedingly  long  one  in  which  hydatid  cysts  run  their  course.  Small  cysts  may 
even  undergo  spontaneous  retrogression  and  calcify.  These  cysts  when  large  may 
rupture,  just  as  do  hepatic  abscesses,  and  in  various  directions.  (See  above.)  Ordi- 
narily it  is  only  when  suppuration  occurs  that  the  general  health  suffers,  and  not  until 
that  time  are  they,  at  least  intentionally,  seen  by  the  surgeon. 

Hydatid  cyst  of  the  liver  appears  as  a  tumor,  evidently  cystic  or  fluctuating,  growing 
painlessly  and  attaining  considerable  size.  It  may  usually  be  excluded  from  abscess, 
cancer,  dilated  gall-bladder,  aneurysm,  gumma,  hydronephrosis,  renal  cysts,  or  tumors 
of  unknown  origin.  A  tumor  peculiar  to  the  liver  will  move  with  that  organ.  The 
aspirating  needle  will  probably  need  to  be  used  before  diagnosis  is  complete,  the  fluid 
withdrawn  being  clear  unless  suppuration  has  begun. 

Treatment. — Hydatid  cysts  require  radical  treatment.  Aspiration  does  not  remove 
the  mother-cyst  nor  any  of  its  semisolid  contents.  Even  the  injection  of  iodine  and  resort 
to  electrolysis  hitherto  in  vogue  have  been  abandoned.  Open  incision,  first,  of  the 
abdomen,  and  then,  after  careful  protection  of  the  abdominal  cavity,  of  the  cyst  itself, 
with  scrupulous  attention  to  prevention  of  escape  of  its  contents  save  externally,  is  the 
only  radical  and  promising  procedure.  These  precautions  should  be  taken  because  of 
the  possibility  of  implantation  of  some  living  fragment  of  the  parent  organism,  or  its 
offs])ring,  elsewhere  in  the  abdomen  and  the  growth  of  the  same  in  this  new  location. 
After  free  evacuation  of  such  a  cyst  it  should  be  explored  and  thoroughly  cleaned  out, 
after  which  its  edges  are  to  be  affixed  to  those  of  the  parietal  peritoneum  if  practicable, 
58 


914  SPECIAL  OR  REGIONAL  SURGERY 

a  large  tube  inserted  and  suitably  connrctcd  up  Un-  drainatrc,  uliilr  the  openino;  around 
it  is  closed  with  sutures  or  j)acked  witli  gauze.  This  connection  of  an  interior  cavity 
with  the  exterior  of  tlie  body  is  called  vmrsii pialization. 

SYPHILIS  OF  THE  LIVER. 

The  operating  surgeon  as  such  is  only  concerned  with  gummatous  tumors,  not  witli 
diffuse  expressions  of  syphilis  which  produce  interstitial  hepatitis  or  cirrhosis.  The  latter 
are  often  met  in  cases  of  general  syphilis,  and  yield  to  suitably  directed  treatment. 
Either  the  difjns-e  or  the  gummatous  form  may  produce  enormous  enlargement  of  the  liver, 
with  suspicion  at  least  of  an  abscess.  In  one  case  of  this  kind,  known  to  the  writer,  the 
lower  border  of  the  liver  extended  below  the  crest  of  the  ilium,  and  yet  within  a  short 
time,  under  vigorous  treatment,  the  liver  resumed  its  normal  size.  Gummas  have, 
then,  an  interest  for  the  surgeon,  as  no  other  similar  enlargement  ever  reduces  its  volume 
so  speedily  under  any  other  circumstances.  ^Moreover  gummas  may  occasionally 
break  down  and  produce  al)scesses  requiring  incision  and  drainage.  If  syphilis  can  be 
recognized  as  the  etiological  factor  prognosis  is  satisfactory  in  nearly  every  instance. 


ACTINOMYCOSIS  OF  THE  LIVER. 

The  specific  fungi  of  this  disease  may  be  easily  carried  fnnn  the  alimentary  canal  to 
the  liver  through  the  ])ortal  circulation,  and  its  peculiar  granulomas,  appearing  first 
here,  may  spread  to  the  diaphragm,  to  the  abdominal  wall,  or  in  any  other  direction. 
Unless  aided  by  the  presence  of  other  distinctive  lesions  diagnosis  is  rarely  made  until 
the  presence  of  a  granulating  tumor  and  its  ulceration,  with  the  escape  of  the  distinctive 
calcareous  particles,  makes  it  recognizable  to  touch  as  well  as  to  sight.  This  often 
might  be  secured  by  an  exploratory  operation,  which  circumstances  might  justify. 
(See  chapter  on  Actinomycosis.) 


TUMORS  OF  THE  LIVER. 

Benign  tumors  in  the  liver  are  rare.  So-called  adenomas  of  somewhat  indistinct  type, 
and  jihromas,  have  been  described  as  occurring  here.  I'he  former  are  of  uncertain 
origin  and  probably  do  not  deserve  the  name  given  here.  Xevertheless  they  have  a 
structure  more  or  less  simulating  true  gland  tissue.  Fibromas  may  sjiring  from  any 
of  the  fibrous  structures.  Other  benign  tumors  occur  here  so  rarely  as  to  scarcely  warrant 
mention.  Aneurysms  and  large  venous  dilataiions  also  occur  occasionally  in  the  liver. 
Any  of  these  lesions  may  justify  exploration,  and  those  favorably  situated  may  be  enu- 
cleated or  excised,  with  subsequent  suture  of  the  liver  and  drainage  of  any  remaining 
cavity. 

Of  the  malignant  tumors  the  sarromns  and  rndotheliomas  may  arise  in  almost  any 
part  of  the  organ.  Primarij  carcinomas  have  their  origin  only  about  the  gall-bladder 
and  its  ducts,  from  whose  e])ithelial  lining  they  may  spring;  otherwise  they  are  jjroducts 
of  extension  or  metastasis.  By  far  the  larger  proportion  of  cancers  arise  from  the  gall- 
bladder, within  which  they  begin  to  grow,  either  as  the  expressions  of  irritation  or  of 
parasitism.  The  presence  of  gallstones  in  the  gall-bladder  is  now  knoicn  to  he  an  extremely 
eommon  provocation  of  cancer,  and  the  relation  obtaining  between  the  two  is  certainly 
more  than  accidental  or  casual.     (See  Cancer  of  the  Gall-bladder.) 

That  an  associated  and  solitary  cancerous  growth  of  this  kind  may  be  successfully 
removed  has  been  ])roved  in  my  own  experience,  by  the  good  health  persisting  at  least 
six  years  after  operation  upon  a  woman  from  whom  I  removed  a  large  cancerous  gall- 
bladder containing  two  large  calculi,  and  with  it  a  consideraljle  amount  of  the  adjoining 
liver  tissue.  It  is,  therefore,  possible  to  successfully  remove  some  benign  tumors,  as 
well  as  occasionally  a  malignant  one,  from  the  liver  when  other  conditions  are  favorable; 
but  this  should  always  be  done  before  it  be  too  late,  as  a  comj^arison  of  cases  will  demon- 
strate. If  the  lymph  nodes  or  any  other  viscus  be  involved  in  malignant  disease,  then  it 
is  too  late.     The  tumor  is  to  be  attacked  from  its  most  accessible  aspect.     A  pedunculated 


THE  GALL-BLADDER  9I5 

ffpowtli,  like  a  distinct  l)cni;i,n  liy|)crtn)|)liy,  may  l)t'  tied  off,  sutures  licin*^  also  used  if 
needed.  Tiie  actual  cautery  furnishes  the  best  means  of  division  of  Hver  tissue,  while 
with  a  sessile  f^rowth  elastic  constriction  may  be  of  assistance.  The  principal  danger 
in  these  operations  is  from  hemorrhage.  jVIethods  of  meeting  it  are  discussed  below, 
as  well  as  other  general  procedures.  A  tumor  stump  may  be  fastened  to  the  abdominal 
wound,  or  it  is  better  treated  by  being  j)acked  aroun(l  with  gauze,  the  latter  being  allowed 
to  remain  for  three  or  foiu'  days.' 

Von  Bruns,  in  1S7(),  was  j)r()bably  tlie  first  to  resect  liver  tissue,  after  injury,  with 
good  results.  Modern  surgery  has  done  much  to  improve  tiie  prognosis  in  these  injuries 
and  to  show  that  it  can  be  attacked  much  more  freely  than  j>reviously  sujjjjosed.  Within 
the  past  fifteen  years  Ponfick  and  many  other  ex|)erimenters  have  shown  the  regenerative 
capacity  of  the  liver  by  removing  as  much  as  three-fourtlis  of  it.  The  fear  oi  cholemia, 
due  to  escape  of  bile,  has  also  passed,  and  it  has  been  found  that  peritoneal  complications 
do  not  residt  from  its  presence,  for  bile,  unless  actually  mixed  with  pus,  is  not  septic, 
although  its  antisej)tic  properties  have  been  much  overrated.  Most  of  the  expedients 
which  have  been  suggested  by  various  oj)erators  for  controlling  hemorrhage  have  l)een 
abandoned  for  the  more  simj)le  methods  of  the  tani])on  and  the  suture,  although 
the  actual  cautery  is  still  generally  used  for  the  operative  attack.  For  suture  catgut 
is  preferable  to  silk.  Even  large  wounds  may  be  successfully  fastened  in  this 
way.  Arterial  bleeding  is  easily  distinguished  from  venous  oozing.  .Spurting 
arteries  may  be  ligated  en  masse,  while  continuous  oozing  usually  subsides  under  pressure. 
In  contusions  of  the  liver,  when  it  is  not  practicable  to  bring  hepatic  surfaces  together, 
loops  of  catgut  may  be  jxissed  with  a  large  needle  through  the  liver  structure  in  such 
a  way  as  to  bind  its  edges  whenever  they  are  bleeding.  The  sutures  or  loops  may  be 
drawn  tightly  to  check  hemorrhage  before  they  cut  through  the  liver  structure.  When 
the  attempt  is  made  to  actually  suture  liver  tissue  it  is  necessary  here  as  elsewhere 
to  avoid  dead  spaces.  If  liver  surfaces  can  be  brought  into  actual  contact  they  will 
heal  kindly.  In  fact  when  there  is  access,  and  the  emergency  is  not  too  pressing,  the 
portion  to  be  removed  may  be  excised  with  ordinary  knife  or  scissors,  and  this  is  better 
when  suture  methods  are  to  be  employed.  There  are  times,  however,  when  the  Paquelin 
cautery  knife  will  perhaps  be  preferable.  It  is  a  mistake  in  these  cases  to  try  to  work 
through  too  small  an  incision.  For  wounds  located  posteriorly  Lannelongue  has 
suggested  resection  of  the  thoracic  wall  along  the  anterior  portion  of  the  eighth  to  the 
eleventh  costal  cartilages,  since  the  pleura  does  not  extend  down  to  that  level.  He 
makes  an  incision  parallel  with  the  costal  border,  2  Cm.  above  the  same,  beginning 
3  Cm.  from  the  border  of  the  sternum,  and  terminating  at  the  tenth  costochondral  junc- 
tion. After  retracting  the  muscles  the  costal  cartilages  are  to  be  resected.  If,  now,  the 
rib  ends  be  firmly  retracted  and  pressed  apart  a  large  portion  of  the  convexity  of  the 
liver  can  be  made  accessible. 

In  order  to  make  better  access  to  the  upper  margin  of  the  liver  it  may  be  well  to  adojjt 
IMarwedel's  suggestion  of  retracting  the  rib  arches  by  a  curved  incision,  parallel  with 
the  costal  margin,  with  complete  division  of  the  rectus  and  the  external  oblicpie,  which 
latter  is  to  be  separated  from  the  internal  and  transverse.  The  cartilage  of  the  seventh 
rib  is  divided  at  its  sternal  junction  and  the  cartilages  of  the  eighth  and  ninth  are  also 
exposed  and  divided  by  })lunt  dissection.  After  thus  loosening  the  lower  ribs  the  lower 
part  of  the  chest  wall  can  be  retracted,  and  much  better  access  made  to  the  region  below 
the  diaphragm.  When  necessary  the  left  side  of  the  abdomen  may  be  treated  in  the  same 
manner. 

From  the  liver  we  pass  to  the  consideration  of  the  surgical  aspects  of  cholelithiasis  and 
other  affections  of  the  biliary  passages. 

THE  GALI^BLADDER. 

The  gall-bladder  is  a  convenient  but  more  or  less  superfluous  receptacle  or  reservoir 
for  bile,  whose  normal  capacity  is  from  50  to  60  Cc,  but  which,  when  distended,  may, 
by  virtue  of  its  elasticity,  contain  at  least  200  Cc.  of  fluid.     Its  normal  position  is  beneath 

'As  a  means  of  preventing  the  ligature  cutting  in  liver  sutures  Gillette  has  suggested  the  use  of  a  piece  of 
rubber  tube  drawn  over  a  No.  10  catheter  and  jjlaced  along  the  proposed  line  of  sutures,  which  are  passed  around 
this,  and  through  the  abdominal  wall,  making  exit  between  the  ribs,  after  the  manner  of  a  staple. 


916  SPECIAL  OR  REGIONAL  SURGERY 

the  ninth  costal  cartilage,  at  a  j)()int  where  it  crosses  the  outer  edge  of  the  rectus.  Only 
its  lower  surface  is  covered  by  peritoneum,  in  average  cases,  hut  when  it  is  distended  or 
hangs  well  down  in  the  abdomen  the  peritoneum  may  enc-lose  the  larger  amount  of  the 
sac.  Its  neck  is  bent  into  an  S-shape,  and  contains  two  folds  of  mucous  membrane, 
which  serve  as  valves.  When  this  neck  is  mechanically  obstructed  the  sac  itself  may  be 
distended  with  glairy,  bile-stained  mucus,  amounting  cv(>n  to  500  Cc,  but  in  patients 
who  have  had  repeated  attacks  of  gallstone  colic  and  have  suffered  for  a  long  period  of 
time,  the  gall-bladder  is  usually  contracted,  shrivelled,  and  sometimes  almost  obliterated. 
Under  these  conditions  there  is  a  strong  resemblance  between  it  and  so-called  appendi- 
citis obliterans,  and  when  so  contracted  and  buried  in  adhesions  it  may  not  be  easily 
found.  In  certain  cases  of  cirrhosis  of  the  liver  the  gall-bladder  is  carried  up  well 
beneath  the  ribs  and  then  descends  with  whatever  motion  depresses  the  liver.  On  the 
other  hand  when  distended  it  nuiy  hang  down  into  the  abdominal  cavity  as  a  pear- 
shaped  mass,  which  may  even  cause  doubt  and  uncertainty  in  diagnosis,  for  it  may  be 
then  found  in  the  cecal  region  or  in  the  pelvis. 

The  common  duct  is  from  G  to  8  Cm.  long.  Its  size  is  about  that  of  a  No.  15  French 
sound.  It  is  both  extensile  and  distensible,  and  may  be  dilated  even  to  the  size  of  the 
small  intestine.  About  one-third  of  it  is  in  intimate  relation  with  the  pancreas,  whether 
wrapped  within  its  head  or  lying  in  a  groove  upon  it.  This  is  of  surgical  import,  for 
in  enlargement  of  the  pancreas  the  duct  may  be  first  pushed  away  and  then  obstructed; 
this  explains  why  biliary  drainage  is  imlicated  in  so  numy  })ancreatic  cases.  The  part 
which  passes  obliquely  through  the  duodenum  is  expanded  into  a  reservoir  beneath  the 
mucosa,  into  which  opens  also  the  pancreatic  duct,  the  latter  lying  lower  and  being 
separated  by  a  fold  of  mucous  membrane.  This  dilatation,  the  ampulla  of  Vater,  is 
6  or  7  Mm.  iong,  and  is  surrounded  by  an  unstriped  muscle  fiber — a  miniature  sphincter. 
Its  opening  constitutes  the  narrowest  portion  of  the  entire  biliary  canal.  Seen  from 
within  it  forms  a  little  caruncle  or  papilla,  distant  8  Cm.  from  the  pylorus.  The  duct 
of  Santorini  opens  normally  about  2  Cm.  above  this  papilla,  and  is  patent  in  about 
on(^-half  of  these  cases,  while  in  about  80  per  cent,  of  cases  it  communicates  with  the  duct 
of  Wirsung.  Many  variations  from  the  normal,  as  above  epitomized,  occur — especially 
in  and  about  the  ampulla.  They  are  both  congenital  and  acquired.  Thus  an  hour- 
glass gall-bladder  is  occasionally  seen,  or  one  so  divided  by  a  partition  that  one  part 
may  contain  mucus  and  the  other  calculi.  It  is  worth  remembering  in  this  connection 
that  along  the  free  border  of  the  lesser  omentum  there  are  three  or  four  lymph  nodes 
which,  when  enlarged,  may  be  easily  mistaken  for  calculi.  The  gall-bladder  lies  in  a 
peritoneal  pouch,  having  the  colon  below  it,  the  spine  and  the  pancreas  to  its  inner  and 
jjosterior  aspects,  the  liver  above  and  the  abdominal  wall  on  its  outer  side.  When  this 
pouch  is  seriously  affected  it  may  be  drained  not  only  from  in  front  but  often  to  great 
advantage  from  behind,  /.  e.,  by  posterior  drainage.  This  pouch  may  hold  a  pint  before 
it  overflows  into  the  pelvis,  or  through  the  foramen  of  Winslow  into  the  greater  peritoneal 
cavity.  The  right  lobe  of  the  liver  is  sometimes  enlarged  so  as  to  form  a  tongue-shaped 
projection  which  may  extend  some  distance  below  the  costal  margin.  This  is  frequently 
called  Rlrders  lobe.     (See  Plate  LV.) 

The  gall-bladder  is  essentially  a  biliary  reservoir,  convenient  but  not  essential,  storing 
bile  between  meals  and  expelling  it  during  digestion.  It  is  absent  in  the  horse  and  in 
many  animals,  and  individuals  from  whom  it  has  been  removed  seem  to  suffer  thereby 
no  inconvenience.  Consecjuently  there  need  be  no  hesitation  in  removing  it  when  neces- 
sary. Bouchard  claims  that  bile  is  nine  times  more  toxic  than  urine,  and  that  the  liver 
of  man  may  produce  sufficient  in  eight  hours  to  kill  him  if  it  cannot  escape.  Conse- 
(iiifiifh/  billari/  obstruction  viaij  become  a  very  serious  matter.  Besides  containing  bile  the 
gall-bladder  has  numerous  minute  glands  of  its  own,  which  secrete  the  ropy  mucus 
with  which  it  is  so  often  found  distended.  A  mixture  of  bile  and  pancreatic  juice 
seems  ideal  for  perfect  emulsification  and  digestion  of  fat.  Hence  the  disadvantage 
of  anything  which  interferes  with  the  escape  of  bile  into  the  duodenum.  Bile  possesses 
by  itself  slight  antiseptic  properties,  yet  tvhen  vyxcontaminaied  is  no^  septic.  It  may  be 
reo-arded  as  mainly  excrementitious,  and  its  function  as  an  intestinal  stimulant  has  been 
much  overrated.  The  average  quantity  secreted  in  twenty-four  hours  is  about  thirty 
ounces.  Its  excretion  is  constantly  going  on,  but  is  more  abundant  by  day,  is  not 
much  influenced  by  diet,  nor  nearly  so  much  by  the  so-called  cholagogues  as  has  been 


PLATE   LV 


venfricu 
( facJes 


pancreas 

mesocolon  ^ra^sversurn 


\r»<'^^ 


Surgical  Anatomy  of  the  Gall-bladder  and  of  the  Omental  Foramen  and  Cavity. 

rSobotta.) 

The  probe  enters  the  omental  epiploic)  foramen.  By  retraction  and  removal  of  its  anterior 
covering  the  cavity  of  the  lesser  omentum  (omental  bursa;  is  exposed,  revealing  especially  the 
pancreas  in  situ. 


ISIfJAh'Y   F I  ST  V  LAS  9I7 

generally  supposed.  All  these  points  iiave  a  practical  interest  for  the  surgeon  who  has 
to  do  with  the  conseciuences  ol"  biliary  obstruction,  or  who  has  to  watch  its  progress  for 
lack  of  a  l)iliary  fistula. 

BILIARY  FISTULAS. 

These  may  be  due  to  accidental  injury  during  operation  or  to  disease  processes. 
They  may  be  direct  or  indirect,  and  internal  or  external.  .\n  e.xam|)lc  of  direct,  cxtcnuil 
traumatic  fistula  is  afforded  by  a  cholecystostoiny  or  a  cholangiostomy ;  of  indirect  internal 
when  th(>  gall-bladder  has  burst  into  an  abscess  and  this  into  a  hollow  viscus.  A  fistula 
might  arise  from  a  local  abscess  outside  the  biliary  pas.sages,  later  communicating  in 
botli  directions,  or  it  may  be  connected  with  the  thoracic  organs,  with  evacuation  into 
the  bronchi  or  esophagus,  and  cases  are  on  record  where  gallstones  have  been  passed 
from  the  mouth.  The  external  or  cutaneous  fistulas  tend  in  most  instances  to  spon- 
taneous healing,  but  the  time  re<|uircd  is  often  long.  They  may  discharge  thin,  biliary 
mucus  or  true  bile. 

Mucous  fistulas  result  from  cholecystostomy  wdiere  the  obstruction  in  the  cy.stic  duct 
has  not  been  overcome,  as  when  it  is  the  seat  of  stricture  or  extrinsic  pressure.  They 
cause  but  little  inconvenience.  Nevertheless  if  allowed  to  close  the  mucus  accumulates 
and  pain  results  from  distention.  In  these  cases  either  a  small  tube  or  drain  should 
be  worn,  or  a  cholecy-'stenterostomy  may  be  made.  Sometimes  after  the  discharge  of 
some  foreign  body,  such  as  a  silk  ligature  or  small  stone,  such  a  fistula  will  close  of  itself, 
or  it  may  be  possible  to  fre(juently  cauterize  its  interior  with  a  bead  of  nitrate  of  silver 
melted  upon  the  end  of  a  probe,  or  perhaps  by  using  a  long  curette  to  so  destroy  its  mucus 
lining  as  to  do  away  with  the  condition  and  its  consequent  discharge.  Ordinarily 
cholecystostomy  will  not  be  followed  by  permanent  or  even  long-continued  fistula  if  the 
common  duct  have  been  thoroughly  cleared,  and  if  the  gall-bladder  be  fastened  to  the 
aponeurosis  and  not  to  the  skin.  Postoperative  biliary  fistulas,  with  discharge  of  large 
amounts  of  bile  (one  to  two  pints  per  day)  and  their  consecjuent  inconvenience,  w'ill 
ordinarily  not  he  long  tolerated  by  the  patient,  who  will  insist  on  some  further  procedure 
for  relief.  If  possible,  in  every  such  case,  the  real  cause  of  the  difficulty  shoukl  be 
removed.  If  the  ducts  be  cleared  and  stimulation  with  caustic  be  not  sufficient,  then  the 
abdomen  shoukl  be  opened,  the  gall-bladder  detached,  and  its  fistulous  opening  freshened 
and  sutured.  If  the  patency  of  the  common  duct  can  be  established  this  will  be  sufficient. 
Otherwise,  after  closing  the  gall-ldadder,  it  should  be  anastomosed  with  the  small  intes- 
tine as  near  the  duodenum  as  possible. 

Spontaneous  or  pathological  fistulas  often  open  at  the  umbilicus,  the  disease  process 
having  followed  the  track  of  the  umbilical  vein  up  to  that  point.  Here,  too,  calculi  are 
thus  spontaneously  extruded,  one  case  on  record  including  the  discharge  in  this  way 
of  a  stone  three  inches  in  diameter.  In  any  such  case  as  this  the  fistula  cannot  be  ex- 
pected to  close  until  the  calculi  are  all  extruded.  In  the  treatment  of  any  such  lesion  the 
margin  of  the  wound  and  the  entire  track  of  the  fistula  should  be  carefully  curetted  and 
disinfected,  as  at  least  a  part  of  the  procedure. 

Biliary  intestinal  fistulas,  due  to  escape  of  calculi  into  adherent  intestine,  are  also 
occasionally  seen.  These  often  form  without  marked  disturbance  until  perhaps  at  the 
last,  when  there  may  be  destructive  symptoms,  both  biliary  and  intestinal,  symptoms 
which  will  suddenly  subside  w^hen  perforation  or  passage  of  a  c-alculus  occurs.  After 
their  occurrence  patients  may  enjoy  some  relief  for  a  considerable  time,  or  until  the 
contraction  of  the  fistula  may  necessitate  a  subsec|uent  operation.  At  other  times  their 
formation  by  ulceration  is  often  accompanied  by  severe  pain  and  fever,  and  possibly  even 
l)y  hemorrhage.  Impaction  of  a  gallstone  in  the  intra-intestinal  portion  of  the  common 
duct  is  perhaps  the  most  frequent  cause  of  this  kind  of  trouble.  Fistulas  into  the  colon 
are  less  common  than  into  the  small  intestine.  Such  fistulas  should  never  be  intention- 
ally made  if  it  be  possible  to  utilize  any  part  of  the  small  intestine.  Although  the 
pyiorus  and  the  gall-bladder  often  become  firmly  united  to  each  other  gastric  biliary 
fistulas  are  rare.  If,  however,  there  be  vomiting  of  gallstones,  such  a  sign  would  make 
it  quite  certain.  JNIayo  Robson  has  reported  one  such  case  where  he  separated  adhesions, 
pared  the  stomach  opening,  closed  it  with  sutures,  and  utilized  the  opening  in  the 
gall-bladder  for  the  removal  of  calculi  and  subsequent  drainage,  the  patient  recovering. 


918  SPECIAL  OR  RKGIOXAL  SURGERY 


INJURIES  TO  THE  BILIARY  PASSAGES. 

These  are  less  common  than  injuries  to  the  liver  proper.  They  may  be  caused  by 
penetration  or  by  severe  blows  and  concussion.  In  those  already  suffering  from  local 
disease  accidents  are  more  likely  to  be  followed  by  ruj)ture.  Injuries  have  also  been 
attril)Uted  to  traction  and  later  adiiesions.  The  fundus  of  the  ijall-bladdcr  is  the  most 
e.\jK)sed  ])ortion;  therefore,  that  part  is  most  often  injured;  while  neitjhborin<>;  organs 
may  suffer  simultaneously — for  exam])le,  the  liver,  stomach,  and  colon. 

Injury  will  eitiier  produce  such  damage  as  to  lead  to  acute  local  peritonitis,  with 
extensive  exudation  for  ])rotective  purposes,  and  with  all  the  possibilities  of  subsequent 
infection,  or  there  will  be  actual  rupture,  with  extravasation  of  bile,  and  perhaps  of 
blood,  and  the  development  of  well-marked  local  as  well  as  general  symptoms.  Fluid 
thus  escaping  will  first  fill  the  abdominal  pouch,  already  described  above,  where  it 
will  then  be  confined  by  the  mesentery  until  it  begins  to  overflow.  A  small  opening 
luay  be  sealed  by  lymj)h,  and  a  small  collection  of  fluid  may  even  be  encapsulated,  so 
that  it  may  be  subsequently  opened  and  drained.  The  symptoms  of  such  injury  will 
include  shock,  pain,  fever,  fulness  in  the  right  side  and  hypochondrium,  abdominal 
rigidity  and  the  development  in  certain  cases,  after  a  few  days,  of  jaundice,  indicating 
absorption  of  bile.  Should  this  bile  have  been  aseptic,  no  great  harm  may  ensue,  but 
if  infected  a  general  and  probably  fatal  peritonitis  will  result. 

In  any  case  where  the  condition  may  be  recognized  or  where  it  is  strongly  suspected, 
abdominal  section  should  be  promptly  made.  According  to  the  conditions  thus  dis- 
closed the  opening  may  be  sutured,  if  possible  or  the  gall-bladder  or  other  cavity  contain- 
ing bile  may  be  drained.  It  has  been  possible  in  some  such  cases  to  successfully  suture 
a  tear  or  wound  in  the  duct,  while  in  a  few  cases  the  duct  has  been  doubly  ligated  and 
the  bile  flow  been  turned  into  the  intestine  by  an  anastomosis. 

ACUTE  CATARRH  OF  THE  BILIARY  PASSAGES. 

The  formation  of  bile  takes  place  under  low  pressure  and  therefore  is  easily 
hindered  by  slight  back  pressure.  In  this  way  jaundice  may  be  easily  produced 
with  no  greater  degree  of  chemosis  of  the  duodenal  mucosa  than  that  produced  by  a 
relatively  small  amount  of  activity  in  the  duodenum.  Inasmuch  as  the  common  duct 
traverses  the  intestinal  wall  oljliquely  its  small  outlet  would  be  the  first  to  suffer.  In 
minor  catarrhal  duodenitis  it  is  of  small  surgical  importance,  but  when  the  condition 
becomes  chronic  the  obstruction  then  becomes  a  matter  to  be  (lealt  with  by  the  surgeon. 
Such  conditions  may  occur  in  connection  with  typhoid  fever,  pneumonia,  influenza, 
ptomain  poisoning,  and  other  diseases,  and  are  often  accompanied  l)y  vomiting  and 
diarrhea,  with  referred  tenderness  and  possibly  enlargement,  while  even  the  spleen  is 
sometimes  enlarged. 

Treatment. — In  the  early  stage  of  such  a  condition  the  treatment  is  medicinal,  but 
when  tile  condition  has  become  chronic  biliary  drainage  may  be  required. 

CHRONIC  CHOLANGITIS. 

This  is  frequently  a  sequel  to  the  above  acute  condition,  and  generally  accompanies 
jaundice,  no  matter  how  produced.  It  is  a  frequent  concomitant  of  cancer  and  often 
the  actual  cause  of  its  accompanying  jaundice.  It  has  been  known  to  lead  up  to  sup- 
purative lymphangitis,  the  lymph  nodes  along  the  border  of  the  lesser  omentum,  already 
described,  being  nearly  always  involved  and  occasionally  sujipurating.  Pi/lrphlrhffis 
may  also  have  this  origin.  Gallstones  nearly  always  provoke  a  certain  degree  of  cho- 
langitis and  cause  the  formation  of  thick,  ropy  mucus  which  causes  pain  when  passing, 
this  pain  being  often  mistaken  for  that  j^roduced  by  calc-uli.  Riedel  believes  that  two- 
fifths  of  the  cases  of  jaundice  occurring  in  connection  with  gallstone  disease  are  really 
produced  by  accumulations  of  mucus  and  thickening  of  the  mucosa,  rather  than  by  the 
stones  themselves.  Moreover,  there  is  a  form  of  membranous  catarrh,  both  oip  the 
ducts  and  gall-bladder,  where  actual  casts  are  shed,  this  condition  corresponding  to 


ACUTE  CHOLh'CYSTlTlS  AM)   CJIOI.A  .\(;ITIS  SI  I'l'C  UMIV  A  QIO 

fil)i-iii(>iis  hroiicliilis  or  enteritis,  'riiudiiliiiiii  Ix'liescs  that  these  custs  ol'leii  form  nuclei 
tor  <i<illst()iies.  'I'he  eoiiditioii  has  Ween  spoken  of  as  (Ic.s-ijikuikiIiiuj  aiKnorlioiili.s,  and 
casts  of  thi-  (hict  or  even  of  the  ^'all-Madder  have  heeii  found  in  the  stools. 

The  snr<fieal  interest  attaching'  to  tliese  conditions  lies  in  the  fact  that  the  syin|)toins 
produced  are  often  identical  with  those  caused  hy  <fallstones,  and  the  desircci  relief  is 
to  be  sou<,dit  in  the  .same  \v«ay — /.  c,  by  operation.  The  o])crator  should  not  feel 
cliafjrincil  if  on  opeiiint;  the  abdoTiicn  he  finds  the  ^all-bladder  coiitainin<^ such  material 
rather  than  ealeidi. 

CHRONIC  CATARRHAL  CHOLECYSTITIS. 

This  is  often  mistaken  for  cliolelitiiiasis,  althou<^h  when  tiie  <i-all-l)ladder  is  opened 
only  thick,  roi)y  mucus  will  be  found.  This,  as  just  remarked,  may  f^ive  rise  to  very 
painful  spasm.  The  trouble  when  ])resent  is  usually  coimected  with  similar  trouble  in 
the  ducts.  Moreover,  around  such  a  {jall-l)ladder  numerous  adhesions  are  forme<l 
which  tfive  rise  to  much  pain,  tenderness,  and  local  distress.  I'lider  these  conditions 
the  jj;all-bla(lder  is  enlar>fe(l  and  thickened. 

Here,  loo,  the  curative  treatment  is  essentially  surgical,  althouifh  |)ain  may  sometimes 
be  teni|)orarily  n-lievcd  by  as|)irin  in  doses  of  from  0.5  to  1  (jin. 

('Iii>h'ci/.stifi.s-  ohlitrmiis  corresponds  closely  to  appendicitis  obliterans,  and  is  a  con- 
dition characterized  by  a  reduction  in  the  size  of  the  oal|-j)laddcr  or  its  almost  complete 
obliteration.  In  order  to  account  for  this  it  is  seldom  necessary  to  assume  a  con<^enital 
defect.  The  morbid  process  which  produces  it  l)e(jins  early,  perhaps  even  duriuf:;  fetal 
life.  The  bile  tluets  are  extremely  small  at  birth  and  further  stenosis  is  easily  produced. 
The  accompanyintr  enlarcjement  of  the  spleen  will  illustrate  the  toxicity  of  the  condition 
which  led  up  to  it,  and  which  may  have  occurred  in  infancy  or  early  childlujod.  In 
a  small  pro])orti()n  of  cases  early  constriction  of  the  ducts  produced  by  local  peritonitis 
and  infection  aloni^  the  track  of  the  umbilical  vessels  may  account  for  the  condition. 

ACUTE  CHOLECYSTITIS  AND  CHOLANGITIS  SUPPURATIVA. 

A  suppurative  condition  within  the  gall-bladder  is  neces.sarily  an  expression  of  an 
infection,  in  nearly  all  instances  proceeding  from  the  intestine.  The  colon  bacilli  and 
those  of  typhoid  are  the  organisms  usually  at  fault.  As  has  already  been  shown  in 
the  earlier  ])art  of  this  work  they  are  facultative  pyogenic  organisms.  Mixed  infection 
with  the  ordinary  pus-producing  germs  may  also  occur  here.  Such  infections  may 
spread  through  the  walls  (jf  the  gall-l)ladder  and  cause  at  least  local  and  sometimes  fatal 
general  peritonitis.  The  condition  is  an  esj)ecially  frequent  complication  of  tyj)hoid  fever, 
occurring  sometimes  relatively  early,  at  other  times  after  apparent  recovery  from  the 
disease.  In  most  of  these  instances  it  is  supposed  that  the  bacteria  reach  the  gall-bladder 
by  migration  along  the  ducts,  although  direct  penetration  or  infection  through  the  blood 
is  not  to  be  denied.  Impacted  gallstones  especially  predispose  to  such  infections.  The 
result  of  all  such  cases  is  the  formation  and  retention  of  pus — ?'.  r.,  rmpijcma  of  the 
fjaU-hlnddcr — save  in  tho.se  rapid  virulent  or  fulminating  infections  when  it  quickly 
becomes  gangrenous,  as  does  the  appendix  when  similarly  infected. 

Symptoms. — In  acute  infections  of  the  bile  passages  patients  suffer  severe  pain, 
ma(le  worse  by  movement,  with  general  malaise,  rapid  loss  of  appetite  and  flesh,  extreme 
tenderness  over  the  gall-bladder  and  often  around  it,  because  of  the  accompanying 
local  peritonitis.  It  is  frequently  po.ssible  to  make  out  enlargement  of  the  gall-bladder, 
whicli  will  move  with  the  liver  during  respiration — this  at  lea.st  until  it  has  become  fixed  by 
local  infiaTumation — after  which  the  patient  will  have  thoracic  rather  than  abdominal 
respiration.  As  such  a  case  progresses  local  indications  of  disea.se  will  be  added,  with 
finally  visible  tumefaction  and  redness  of  the  overlying  skin.  .Jaundice  is  an  uncertain 
feature,  dej^ending  on  the  patulency  of  the  common  duct. 

Pus  ivhrn  formed  maij  escape  and  burrow  in  various  direcfions;  thus  it  may  follow 
the  su.spen.sory  ligament  of  the  liver  and  appear  at  the  lunbilicus,  or  it  may  pass  along 
other  reflections  of  the  peritoneum  and  appear  about  the  cecum  or  above  the  pubes,  or 
it  may  pass  into  the  liver  and  appear  as  an  hepatic  absces.s,  or  around  it  and  thus  give 
rise  to  a  perihepatic  or  subphrenic  abscess.     It  may  even  perforate  the  diaphragm 


920  SP/'X'IAL  OR  R/'X.'IO.XAL  SURG'ERY 

iuul  produce  siicli  collcctioiis  of  j)iis  or  such  plicuouicua  ;is  have  been  described  in  tlie 
previous  chapter,  including  empyema,  pericarditis,  abscess  of  the  hmg,  etc.  Again  it 
may  burst  into  the  hollow  viscera,  stomach  or  intestines,  or  into  the  general  peritoneal 
cavity,  where  it  will  cause  speedily  fatal  peritonitis.  Pulmonary  abscess,  with  dis- 
charge of  i)us  and  bile,  has  been  cured  by  Mayo  Robson  by  removing  a  stone  from  the 
common  duct.  (Jallstones  have  also  been  found  in  the  ])leural  cavity  and  have  even 
been  passed  by  the  mouth.  Finally  pus  collecting  in  the  right  abdominal  ])ouch  may 
also  be  mistaken  for  j)erircnal  abscess. 

Ariifc  ph/rf/nroiioiiff  r/iolrci/.s-fifi.s,  ivith  ganrjrrur,  corresponds  to  the  fulminating  form 
of  gangrenous  appendicitis,  and  only  received  its  first  descrij)tion  in  1S9()  b\  ( "ourvoisier. 
This  is  not  connnon,  but  when  met  with  becomes  a  disastrous  lesion.  It  is  essentially 
a  still  more  virulent  expression  of  infection  and  consecjuent  necrosis  than  the  condition 
described  above.  It  may  be  so  rapid  as  to  destroy  the  gall-bladder  before  it  has  had  time 
to  fill  with  pus.  It  may  occur  with  or  without  a  history  of  |)revious  trouble,  in  the  absence 
of  which  a  diagnosis  will  be  made  more  perplexing.  As  the  condition  declares  itself 
and  j)rogresses  there  will  usually  form  about  its  site  a  protective  barrier  of  lym])h  and 
omentum,  which  may  ])r()ve,  when  j)r('sent,  the  salvation  of  the  jiatient,  especially  if 
the  surgeon  who  makes  the  operation,  and  litis  fihould  hr  rcrrli/,  recognizes  the  value  of 
these  ])r<)tections  and  does  not  break  tiiem  down,  "^riie  condition  occurs  in  connection 
with  gallstone  disease,  but  may  follow  tyj)h()id  fever,  cholera,  ])ucrperal  fever,  or  other 
intense  infection. 

Si/mptonis  of  gangrenous  cholecystitis  are  essentially  those  of  the  less  severe  types  of 
infection,  only  more  yironounced.  They  include  severe  pain  of  sudden  onset,  rapidly 
growing  worse,  spreading  over  a  larger  area,  extreme  tenderness  and  muscle  spasm, 
rapid  thoracic  resjiiration,  (juick  pulse,  intense  depression  and  co]laj)se,  vomiting, 
rapidly  increasing  tympanites,  anxious  facies,  with  every  expression  of  intense  sapremia. 
Jaundice  is  an  inconstant  symptom,  while  fever  is  usually  ])resent,  but  is  of  little  impor- 
tance. The  disease  may  l)e  so  raj)i(l  as  to  (piickly  kill.  At  all  events  local  destruction 
occurs  early,  either  with  al>scess  or  gangrene,  or  both. 

Diagnosis. — The  diagnosis  consists  virtually  in  a  recognition  of  the  cause  of  the 
intense  local  ])eritonitis,  after  which  a  history  of  previous  disease,  if  obtainable,  may 
help.  The  condition  is  to  be  differentiated  especially  from  perforat(>d  ulcer  of  the 
stomach  or  duodenum,  from  acute  pancreatitis,  antl  from  acute  mesenteric  embolism 
or  thrombus  with  gangrene  of  the  intestine.  It  is  also  occasionally  to  be  distinguished 
from  an  acute  ajipendicitis,  and  this  may  be  difficult,  since  the  appendix  is  sometimes 
found  high  up  and  the  pain  widely  referred  or  not  accurately  localized.  In  acute 
cholecystitis  the  |)ain  is  more  likely  to  be  subcostal,  and  the  tenderness  and  muscle  spasm 
are  more  marked  in  the  upper  part  of  the  abdomen,  to  which  the  various  local  expressions 
of  the  disease  are  referred  rather  than  to  the  lower.  In  any  or  all  of  these  troubles 
symptoms  of  acute  peritonitis  are  likely  to  be  present  and  paralytic  ileus  or  bowel 
obstruction  may  complicate  the  case. 

Ransohoff  has  called  attention  to  a  hitherto  unnoted  sign  of  gangrene  of  the  gall- 
bladder— namely,  a  localized  jaundice  ahoiif  the  umhilicm,  apparently  brought  about  by 
staining  of  the  fat  beneath  the  peritoneum,  antl  noted  after  incision,  if  not  previously. 
He  considers  it  the  result  of  imbibition,  and  that  it  appears  at  the  navel  first  because 
here  the  abdominal  wall  is  thinnest,  it  being  also  j)ossil)le  because  of  the  anatomical 
relations  of  the  round  ligament  of  the  liver  to  the  transverse  fissure,  where  there  may 
be  a  retrograde  flow^  of  bile  through  the  lyiuphatics  and  toward  the  navel. 

Forfmiafeli/  nil  of  these  acvie  condUions  as  between  which  doubt  may  arise  are  to  be 
dealt  with  in  only  one  way — namely,  by  prompt  operative  intervention — and  minute  diag- 
nosis is  of  less  importance  than  ability  to  appreciate  necessity  for  immediate  operation 
as  it  may  arise. 

Gangrene  is  the  extreme  flegree  of  disaster  in  these  cases,  and  its  occurrence  may  be 
marked  by  sudden  cessation  of  the  pain,  a  most  important  symjitom,  which  may  be 
deceptive  to  the  uninitiated.  Gangrene  may  be  du(»  to  thrombosis  of  the  vessels  of 
the  gall-bladder,  to  bacterial  invasion,  to  extreme  tension  because  of  obstruction  of  the 
duct,  or  to  all  three. 

Acute  cholangitis  was  first  described  by  Charcot,  who  called  it  intermittent  hepatic 
fever.  It  is  usually  due  to  the  presence  of  one  or  more  gallstones  in  the  common  duct, 
but  any  obstruction  of  the  hepatic  or  common  ducts  may  favor  infection  of  retained  bile 


(^LCi:h'AT/().\S   AM)   ri:  UFO  RAT  loss  OF   TIfF   lilLIAnV    J'ASSAdFS       (|21 

and  iinolvciiiciit  of  tlic  tliicl.  Tliiis  it  has  followed  clironic  |)aiicrcalili.s,  cancer,  liydatiil 
disease,  pancnatii-  ealeuliis,  ty|)li()id  fever,  and  tiie  presence  of  the  parasites.  Mertcns 
hat;  collected  fortv-eij;ht  cases  in  which  n.sraridcs  have  been  foinid  in  the  l)ile-(luct, 
their  entrance  haviiiif  prohahly  been  facilitated  by  the  previons  escape  of  ^fallstones 
and  eiilar^enu-nt  of  tlie  duct  end.  Round  or  lunibricoid  ironns  have  also  been  found  in 
the  duet,  as  they  are  occasionally  met  with  in  the  duodenum,  and  1  once  .saw  a  long 
one  in  the  aj)|)en(lix.  Cancer  in  this  neighborhood  is  al.so  a  not  infrequent  e.xeiting  cau.se 
^1  producing  acute  cholangitis. 

Si/inpfoni.s. — There  is  usually  a  history  of  .spasmodic  pain  covering  a  consrderable 
jx'riod,  and  then  of  such  an  attack  followed  by  chill  and  fever,  with  more  or  less  jaundice, 
which  may  persist  for  some  time.  Such  attacks  as  these  become  more  severe  and  more 
frecpient ;  the  gall-bladder  eidarges  if  it  contain  no  stone,  or  ccnitracts  if  c-alculi  l)e  present. 
This  a.s.sociati()n  was  i-specially  noted  by  Courvoisier,  who  formulated  a  statement  to  thi.s 
effect,  often  absurdly  known  as  his  "law."  LattT  the  entire  liver  or  its  right  lobe  may 
enlarge,  while  jiatients  complain  of  tenderness  over  the  gall-bladder,  as  well  as  of  loss  of 
appetite  and  Hesh,  and  tho.se  vague  .symptoms  included  in  the  term  "(lysj)epsia." 

Such  a  condition  may  possibly  subside  in  time,  but  is  more  likely  to  be  followed  by 
acute  trouble  of  one  of  the  types  already  described.  In  the  matter  of  diagno.sis  it  may 
be  distinguished  from  malaria,  esjH'cially  in  districts  where  malaria  [)revaiis  by  ab.senee 
of  relief  from  quinine,  and  the  results  of  a  carefully  comj)lete(l  examination,  combined 
with  the  fact  that  in  the  former  it  is  usually  tlie  gall-bladder  which  is  enlarged,  and 
in  the  latter  the  spleen.  When  the  condition  has  proceeded  to  its  sujjpurative  form  the 
occurrence  of  still  more  significant  synq)toms  and  signs  should  lead  to  i)romj)t  oi^eration. 

Treatment. — In  the  acute  infections  and  affections,  both  of  the  gall-bladder  and 
of  the  duet,  operative  intervention  is  imperative.  The  more  acute  the  case  the  more 
urgent  the  indication.  Free  evaeuation  and  drainage  are  the  indications  to  he  met,  and 
as  earlij  and  comph'teh)  as  possiJde.  These  cases  call  for  chokK'ystostomy,  often  for 
choledochotomy,  with  drainage  of  both  gall-bladder  and  duct,  and  perhaps  of  the  peri- 
toneal cavity,  while  possibly  even  ])osterior  drainage  may  be  indicated.  So  true  is  this 
that  the  back  should  be  as  carefully  jirepared  for  operation  as  the  abdomen,  in  order 
that  no  time  be  lost  during  the  operation,  should  one  decide  on  the  wisdom  of  a  posterior 
counteropening.  Of  course  much  will  depend  upon  the  patient's  condition  at  the 
moment  and  what  it  may  appear  he  can  endure.  By  free  opening  of  the  gall-bkidder 
evacuation  of  its  septic  contents  and  removal  of  calculi  are  secured,  if  present,  while 
the  ducts  are  permitted  to  empty  themselves  and  free  flow  outward  of  all  septic  material 
is  invited  and  permitted,  pressure  is  relieved,  the  tumor  is  disposed  of,  respiration 
allowed  to  become  normal,  and  no  small  load  removed  from  the  kidneys;  and  the 
chronic  pancreatitis  which  so  often  accompanies  many  of  these  cases  is  allowed  to 
subside  by  virtue  oi  the  other  relief  thus  afforded. 


ULCERATIONS  AND  PERFORATIONS  OF  THE  BILIARY  PASSAGES. 

These  may  occur  anywhere  along  the  biliary  tract,  and  vary  as  between  the  super- 
ficial and  the  perforating,  the  former  being  sometimes  multiple,  the  latter  .solitary. 
Of  these  lesions  cholelithiasis  is  the  most  common  cati.se,  while  typhoid  and  cancer  should 
be  ranked  next.  They  are  all  of  jiathological  import,  because  of  their  possible  sequels, 
i.  e.,  not  merely  perforations  with  fistulas,  Ijut  possible  strictures  or  hemorrhages,  or 
peritonitis  with  sepsis.  When  idceration  is  extensive  a  previous  local  difficulty  may  be 
supposed,  with  more  or  less  adhesions,  but  as  the  trouble  becomes  more  serious  the 
local  excitement  will  extend  to  the  peritoneum,  at  least  that  of  the  area  involved.  In 
fact  most  cases  of  gallstone  disease  are  accompanied  by  more  or  less  peritonitis,  and 
adhesions  which  are  protective,  although  they  may  cause  other  troubles  as  well,  such 
as  dilatation  of  the  stomach  from  displacement  of  the  pylorus.  Hemorrhage  is  not 
a  frequent  event,  for  thrombosis  usually  precedes  erosion.  Some  degree  of  sapremia 
or  septicemia  will  lie  present  in  nearly  all  cases. 

Stricture  of  the  dncts  is  the  most  common  result,  especially  of  the  cystic  duct.  If  this 
occur  and  the  mucous  membrane  be  still  active  the  gall-bladder  will  become  distended 
with  pus  or  mucus,  or  both.  These  are  the  cases  which  perhaps  give  the  best  results 
after  ideal  cholecystectomy. 


922  SPECIAL  OR  REGIONAL  SURGERY 

Perforation  is  a  constant  jM)ssil)ility  wliose  nu-nacc  cannot  he  estimated,  hnt  wliicli  is 
always  actual,  the  great  danger  depending  on  the  virulence  of  the  extruded  material  and 
the  consequences  of  delay  in  operating.  Although  healthy  bile  is  but  slightly  toxic, 
these  cases  do  not  furnish  it,  and  one  may  always  look  for  consequences  of  infection. 
Nevertheless  if  diagnosis  be  made  sufficiently  early  to  bring  about  immediatt*  operation 
prognosis  is  good.  Occasionally  during  such  an  oj)eration  there  will  be  found  a  gallstone 
endeavoring  to  extrude  itself,  but  not  yet  completely  escap(>d.  It  might  be,  in  rare 
instances,  possible  to  utilize  the  o])ening  which  it  has  partially  made  for  subsequent 
drainage  purposes. 

It  is  not  advisable  to  permit  patients  with  distended  gall-bladders  to  go  unoperated, 
even  in  the  absence  of  serious  symptoms,  because  the  risk  of  operation  is  small  and 
that  of  rupture  is  large. 

Acute  intesfinnl  ob.ftrucfion  due  to  gallstones  will  usually,  but  not  invariably,  involve 
the  ui)per  intestinal  tract.  It  may  be  due  to  the  actual  occlusion  of  a  large  stone  which 
has  escaped  from  the  gall-bladder  or  duct,  or  it  may  be  caused  by  volvulus  due  to  intense 
colic  accompanying  peristaltic  effort,  or  it  may  depend  upon  adhesions  after  a  local 
peritonitis  due  to  previous  disease  of  the  gall-bladder  or  to  stricture  following  ulceraticMi; 
or  again  it  may  be  purely  paralytic,  and  in  this  way  result  from  a  local  ])eritonitis.  Im- 
paction of  a  biliary  concr(>tion  may  happen  at  any  point,  but  most  often  at  the  ileocecal 
valve,  where  the  intestinal  tube  is  narrowest.  The  size  of  the  stone  is  not  the  only  con- 
sideration. Obstruction  depends  perha})s  as  much  upon  spasm  above  and  below  as 
upon  any  local  disturbance  that  its  presence  may  have  caused.  Biliary  concretions 
may  enlarge  as  they  pass  downward,  growing  by  accretion  of  calcareous  and  of  fecal 
matter.  The  larger  the  calculus  the  more  likely  it  is  to  obstruct  the  upper  intestine. 
The  majority  of  these  calculi  have  escaped  from  the  gall-bladder  by  a  previous  process 
of  ulceration,  and  usually  into  the  duodenum,  rarely  into  the  colon. 

Symptoms. — Symptoms  of  this  condition,  thus  produced,  will  obviously  be  those 
(jf  acute  obstruction  from  any  cause,  the  most  marked  features  being  severe  pain  and 
early  frequent  vomiting.  Bile  may  be  raised  in  (juantities  because  of  the  biliary  fistula 
so  near  the  stone,  and  from  which  it  is  suppose!  to  have  escaped.  The  higher  the 
exciting  cause  the  more  violent  the  symptoms  and  the  less  the  distention  of  the  abdomen 
by  gas.     A  significant  history  may  help  in  assigning  the  cause  for  the  evident  obstruction. 

Treatment. — Since  more  than  half  of  these  cases  treated  expectantly  die  without 
relief  early  oj)eration  is  to  be  urged.  It  should  always  be  preceded  by  lavage  in  order 
that  the  stomac-h  may  be  thoroughly  emptied.  When  a  stone  has  been  exposed  within 
the  intestine  it  is  advisal)le  to  open  the  bowel  a  little  below  where  it  rests,  so  as  to  make 
the  division  at  a  point  where  the  chances  of  re])air  are  not  com{)romis(>d  by  previous 
excitement.  In  severe  cases  a  temporary  enterostomy  may  be  made,  l)ut  this  should 
of  necessity  be  high.  The  volvulus  may  l)e  relieved  by  untwisting  the  kink  or  by  an 
anastomosis.  Obstruction  due  to  adhesions  will  require  separation  of  these  adhesions, 
with  perhaps  an  anastomosis. 


CHOLELITHIASIS,  GALLSTONE  OR  BILIARY  COLIC,  BILIARY  CALCULI. 

Th(>re  is  so  much  which  may  be  said  about  the  formation  of  gallstones  and  the  troubles 
which  they  may  produce  that  it  is  necessary  here  to  epitomize  as  much  as  possible  and 
to  refer  mainly  to  the  surgical  features  of  this  condition.  CaUstoncs  are  of  all  sizes, 
from  the  most  minute  to  that  of  a  hen's  egg,  are  present  in  numbers  varying  from  a  single 
calculus  to  thousands  of  calculi,  are  found  commonly  in  the  gall-bladder,  in  the  cystic 
duct,  or  in  the  common  duct,  but  occasionally  are  met  with  just  escaping  into  the 
duodenum,  through  the  duodenal  ampulla,  or  in  the  smaller  ducts  of  the  liver  or  the 
main  hepatic  duct  (Fig.  627).  In  at  least  99  per  cent,  of  cases  they  will  be  seen  in  one 
of  the  locations  first  mentioned. 

Pages  might  be  devoted  to  a  discussion  of  the  reasons  for  their  formation.  That 
cholesterin,  their  principal  component,  should  more  readily  deposit  in  such  a  way  as 
to  produce  these  calculi,  and  more  often  in  some  individuals  than  in  others,  is  hard  to 
explain,  but  may  be  held  to  be  largely  due  to  its  formation  in  excess  in  certain  individuals 
and  to  concentration  of  those  fluids  which  hold  it  in  solution.  Increase  of  cholesterin 
seems  to  be  connected  with  catarrh  of  the  membrane  which  proiluces  it,  and  thus 


CHOLELITHIASIS,  (LXLLSTOSE  OR  HILIARY  COLIC,  BILIARY  CALCULI     923 


Fig.  G27 


Gallstone  presenting  at  the  ampulla  of 
Vater,    i.  e.,    endeavoring    to  escape   into 
um.      (Pantaloni.) 


stiii^iialioii  of  l)ilc  mav  |)rc(li.s|Ki.s('.  That  l>act»'ria  have  iiiuili  to  do  witli  hiliary  calculi  is 
now  loiucdcd,  and  a  liistorv  <»t  typhoid  is  ol)taiiial)lc  in  many  cases.  It  lias  hccn  shown 
expcriniciitally  that  asc|)tic  torci^ni  hodics  introduced  into  the  gall-bladder  remain 
indefinitely  without  becoming  covered  with  j)rccipi- 
tate,  while  viruk-nt  organisms  set  up  disturbance, 
and  only  the  attenuated  or  moderately  infectious  or- 
ganisms produce  calculi,  and  usually  then  only  when 
some  trifling  foreign  body  is  introduced  at  the 
same  time.  It  will  thus  be  seen  that  a  nidus  maybe 
all'ordcd  by  a  clumi)  of  cpitiiclial  cells  or  debris. 

It  is  not  at  present  so  much  a  ([iicstion  of  what 
organisms  are  at  fault,  although  tlicv  are  usually  the 
colon  and  typhoid  bacilli  and  the  ordinary  pyogenic 
organism.  It  has  been  shown,  moreover,  that  in 
ty|)hoi(l  fever  the  gall-bladder  is  often  invaded,  and 
that  tlie  tyj)hoid  bacilli  may  live  there  indefinitely, 
and  that  they  tend  to  clumj)  or  agglutinate  them- 
selves in  a  very  suggestive  way  into  trifling  masses 
which  may  serve  as  minute  foreign  bodies.  Thus 
each  predisj)osing  factor  reacts  upon  the  other,  and 
by  a  vicious  circle  cither  an  acute  lesion  may  be 
established  or  calculi  may  be  formed  in  varying 
numbers. 

Gallstones  have  been  found  in  the  newborn,  but 
are  relatively  infrequent  below  the  age  of  twenty- 
five,  and  are  most  common  in  the  later  years  of  life. 
The  condition  is  by  four  to  one  more  frequent  in 
women  than  in  men.  The  only  predisposing  habit  duoden 
seems  to  be  such  lack  of  exercise  as  gives  no  expul- 
sive movement  to  the  gall-bladder  by  action  of  the  abdominal  muscles.  They  are  more 
common  in  the  gouty  and  in  those  predisposed  to  uric-acid  diathesis,  while  abundance 
of  nitrogen  seems  rather  protective.  Biliary  calculi  have  never  been  found  in  the  wild 
carnivora. 

Mc Arthur  has  formulated  the  following  conclusions  of  interest  in  this  connection: 

1.  Not  all  gallstones  originate  within  the  gall-bladder. 

2.  The  origin  of  a  cholesterin  stone  is  probably  the  gall-bladder,  with  subsequent 

accretion,  either  in  passing  through,  or  in  the  duct,  where  it  may  have  lodged. 

3.  Bilirubin  calcium  is  the  principal  constituent  of  the  smaller  intrahepatic  duct 

stones. 

4.  Calculi  in  immense  numbers  may  exist  for  months  in  the  ducts  without  producing 

serious  symptoms. 

5.  Under  these  circumstances  the  surgeon  need  not  reproach  himself  if  there  be 

recurrence  of  symptoms  after  common  duct  drainage. 

Biliari/  calculi  are  .serious  menaces  to  a  patient's  welfare,  not  alone  because  of  the 
obstructive  symptoms  which  they  may  produce,  but  because  of  the  acute  or  chronic 
conditions  to  which  they  indirectly  give  rise.  These  have  been  in  some  degree  already 
mentioned.  Thus  cholecystitis  and  cholangitis  of  all  degrees  of  severity,  from  the 
milder  chronic  forms  to  the  phlegmonous  and  fulminating  varieties,  may  be  at  least 
associated  with  the  presence  of  such  calculi  and  seem  to  be  to  a  greater  or  less  extent  due 
to  their  presence.  Around  such  foci  of  excitement  there  will  always  occur  local  peri- 
tonitis, which  will  result  in  adhesions,  and  the  consequent  tenderness  with  referred  as 
well  as  local  pains  to  which  it  necessarily  gives  origin.  The  viscera  suffer  not  only  in 
this  direct  way,  but  functional  disturbances  are  produced,  and  are  usually  covered 
under  those  vague  terms  "dyspepsia"  and  "indigestion"  with  which  patients  crudely 
describe  their  discomforts,  and  under  which  physicians  too  often  conceal  their  failure 
to  appreciate  the  actual  condition. 

Furthermore  there  is  always  a  possibility  of  cirrhosis  resulting,  because  of  distention 
of  the  hepatic  ducts  and  backing  up  of  the  hepatic  secretion.  Thus  the  liver  becomes 
larger  and  more  dense,  is  colored  green,  its  edges  become  more  rounded,  this  occurring 
especially  in  the  right  lobe,  or  at  least  attracting  more  attention  in  that  location  because 


924  SPECIAL  OR  lifXilOXAL  SURGERY 

more  easily  reco^rnizt'd  from  witlioiit.  A^^aiii  tlic  more  acute  inflammatory  conditions 
sometimes  cause  ])aralytic  ileus,  or  at  least  paralysis  of  the  lower  Ijowel,  and  thus  lead 
to  conditions  almost  identical  with,  and  difficult  to  distinguish  from  acute  intestinal 
obstruction. 

Of  equally  great  and  growing  importance  is  the  fact  that,  according  to  Sehroeder, 
some  14  per  cent,  of  gallstone  sufferers  develop  cancer,  the  presence  of  these  irritating 
foreign  bodies  in  the  biliary  passages  having  much  the  same  relation  to  cancer  of  the 
liver  as  does  the  existence  of  previous  ulcer  to  cancer  of  the  stomach. 

S3niiptoms. — There  is  scarcely  any  morbid  condition  which  is  at  one  time  charac- 
terized by  such  significant  symptoms  and  at  another  by  none  at  all  as  cholelithiasis. 
In  rehearsing  the  list  of  the  ordinary  symptoms  produced  by  the  conditions  excejjtions 
should  be  made,  for  no  matter  how  complete  the  list  something  may  be  omitted  which 
has  been  noted  in  some  particular  case. 

Gallstones  confined  within  the  gall-bladder  proper  may  j;roduce  few  or  no  symptoms, 
this  being  particularly  true  so  long  as  the  ducts  are  free  and  there  are  no  persistent 
consequences  of  previous  acute  trouble.  A  stone  may  grow  in  the  gall-bladder  to  a  large 
size  and  cause  little  or  no  distress  until  it  begins  to  work  its  way  by  the  ulcerative  process. 
Doubtless  small  concretions  pass  with  little  or  no  disturbance,  or  only  that  which  would 
be  considered  a  "temporarv  dyspepsia." 

When,  however,  gallstones  produce  symptoms  these  usually  include  more  or  less 
paroxysmal  j^ain,  occurring  un])rov()ked  and  at  irregular  intervals,  referred  not  alone  to 
the  upper  abdomen,  but  radiating  to  the  rest  of  the  trunk,  as  well  as  in  the  direction  of 
the  right  shoulder-blade.  (The  shoulder  pains  of  biliary  and  renal  lesions  are  due  to 
the  connection  of  the  pneumogastric  nerves  with  the  ordinary  sensory  nerves  above,  and 
below  with  the  sympathetic  ganglia.)  Attacks  of  pain  are  usually  followed  by  nausea 
and  vomiting,  and  if  extremely  severe  by  more  or  less  depression  and  collapse.  At  times 
there  will  be  a  sensation  as  of  distention  in  the  region  of  the  gall-bladder.  Tumor  in 
this  location  may  or  may  not  be  present,  and  jaundice  is  an  uncertain  symptom,  not  occur- 
ring unless  the  ducts  are  occluded.  Tlie  stomach  so  far  sympathizes  that  digestion 
is  at  least  temporarily  disordered.  In  proportion  as  angiocholitis  is  produced  by  the 
passage  of  calculi  we  may  meet  with  more  or  less  septic  features.  The  pain  produced 
is  uncertain  in  severity  and  duration,  and  is  often  relieved  by  the  relaxation  which 
may  accompany  or  follow  vomiting.  After  subsidence  of  severe  pain  there  remains 
a  dull  ache  for  several  days,  lasting  perhaps  until  another  acute  paroxysm.  These 
pains  are  sometimes  referred  to  the  left  side  and  over  the  stomach,  in  which  cases  it 
will  usually  be  found  that  tlie  gall-bladder  is  adherent  to  the  stomach,  while  when 
the  pain  is  felt  in  the  right  side  of  the  thorax  it  is  usually  because  there  are  numerous 
adhesions  between  the  lower  surface  of  the  liver  and  the  viscera  below  it.  Such  pain 
may  even  simulate  angina  pectoris  or  may  involve  the  genitocrural  distribution.  In 
fact  it  may  be  referred  to  almost  any  part  of  the  body. 

Voviiting  which  is  at  first  paroxysmal  and  colicky  may  become  persistent,  continuous, 
and  even  dangerous.  It  is  essentially  an  expression  of  pneumogastric  irritation.  The 
vomited  matter  may  contain  bile  or  even,  by  retrostalsis,  fecal  matter.  The  depression 
which  at  first  occurs  may  merge  into  complete  collapse;  it  may  even  be  fatal.  It  will 
necessarily  be  more  marked  when  the  paroxysms  are  more  frecjuent. 

A  significant  feature  in  nearly  every  case  is  muscle  rigid iti/,  especially  of  the  upper 
abflominal  muscles  on  the  right  side,  but  not  necessarily  confined  to  these.  This 
muscle  spasm  is  a  symptom  common  to  many  serious  conditions  and  is  not  of  itself 
indicative.  It  sim])ly  implies  a  serious  condition  ^cithin.  Tumor  or  enlargement  in 
the  region  of  the  gall-ljladder  may  be  met  with,  but  are  by  no  means  constant.  These 
may  become  more  pronounced  with  each  attack,  being  reduced  between  times  because  of 
the  escape  of  bile  between  paroxysms.  It  is  a  valuable  symptom  when  noted,  but  no 
importance  should  be  attached  to  its  absence. 

The  presence  of  gallstones  in  the  stools  is,  of  course,  indicative,  but  most  valuable 
time  is  often  wasted  when  waiting  for  their  discovery.  Moreover,  a  number  of  hours, 
or  even  days,  may  elapse,  the  time  depending  on  the  activity  of  peristalsis,  between  the 
escape  of  calculi  into  the  duodenum  and  their  appearance  in  the  stools.  A  convenient 
wav  to  search  for  them  is  to  let  the  stool  be  stirred  with  a  1  per  cent,  solution  of  formalin 
and  then  strained  through  a  sieve  which  has  about  sixteen  meshes  to  the  inch.  The 
question  of  the  wisdom  of  operation  can  practically  always  be  decided  without  reference 


CIIOLF.LITIIIASIS,   (.AJ./.STOXh'  Oh'   lill.lAUY    COJJC,    lilLIMiY   CALCULI      925 

t(i  the  ;i|»|)c;iraiic»'  of  calculi.      In  lliis  way  the  siii'^cdii  may  feci  (hat  his  (lia<;-ii().si.s  is 
C()rrt)l)()ratc'(l  hy  il,  hut  in  no  sense  weakenecl  without  it. 

Jattndlrr  is  always  a  sii,MiiHeaut  sin;ii  when  present,  but  is  absent  in  at  least  I'our-fifths 
of  eases  which  nevertheless  should  be  subjected  to  operation.  Its  oceurrenee  is  a  matter 
of  interest  aloui,'  with  the  |)revious  history  of  the  ease.  It  is,  however,  of  <)reiit  value 
if  it  wcr(>  iiotccl  in  connection  with  the  first  pains  or  cramps.  In  chronic  obstruction 
by  stone  in  the  conunon  duct  it  is  imj)ortant  to  (letcrn)ino  the  intennitij  of  the  jaundice, 
since  this  may  indicate  whether  we  deal  with  calculous  disease  or  obstruction  from 
tumor.  In  ritwnir  ohsfraclinn  hi)  .stone  the  color  chan<i;es  are  less  vmrlccd,  and  often 
clear  up  entiri'lv,  while  when  protluced  by  tumor  they  become  (jjradually  more  intensi- 
fied. 

Dctp  (ind  pcr.si.slnit  jaundice  /.v  .sin/gesfire  of  inaiirpia7it  disease.  'J'he  defvree  of  cho- 
lemia  rather  predisposes  these  |)atients  to  hemorrha(;'e  or  j)ersistent  oozinjj;  durino-  opera- 
tion. Jaundice  jfradually  (lee|)eninij;  with  each  attack  of  pain  is  also  very  sugo;estive. 
Such  attacks,  comin<i;on  with  symptoms  like  those  of  malaria,  chill,  sweating,  and  pyrexia, 
are  extremely  suggi\stive  and  alwaijs  call  for  surgical  intervention,  i.  c,  drainage.  In 
brief  it  may  be  said  that  jaundice,  with  enlargement  of  the  gall-bladder,  is  at  least  sug- 
gestive of  cancer,  while  a  history  of  gallstone  colic,  without  much  eidargement  of  the 
gall-bladder,  is  indicative  of  stone  in  the  common  duct.  Although  this  statement  is 
j)robably  true  for  the  majority  of  cases  there  are  occasionally  marked  exceptions  to  it, 
as,  for  instance,  when  a  gall-bladder  is  distended  with  hundreds  or  even  thousands  of 
small  calculi,  or  to  such  an  extent  that  it  may  form  even  a  pear-shaped  tumor  hanging 
down  within  the  abdomen. 

In  addition  to  these  features  thus  rehearsed  there  might  be  made  a  long  list  of  possible 
"extras,"  by  wdiich  the  original  condition  is  complicated  and  made  to  appear  in  unusual 
aspect  or  even  life  endangering.  Such  a  list  wotdd  include  nearly  every  imaginable 
lesion  of  the  upper  abdomen.  Suffice  it  to  say  that  the  liver,  stomach,  and  the  pancreas 
es])ecially  may  sutt'er,  while  other  viscera  and  the  larger  veins,  with  the  surrounding  tissue, 
may  any  or  all  of  them  b(>come  involved. 

Diagnosis. — Diagnosis  has  to  be  made  mainly  from  non-calculous  obstruction ;  from 
the  acute  gastric  conditions,  ulcer,  etc.;  from  renal  colic;  from  the  acute  or  subacute 
pancreatic  affections,  duodenal  ulcers,  renal  lesions,  localized  peritonitis  from  some  other 
cause;  from  cancer,  lead  colic,  angina  pectoris,  pneumonia,  pleurisy,  and  even  hysteria. 
Not  so  rarely  pneumonia  and  pleurisy  begin  with  pains  which  are  referred  to  the  upper 
abdomen  and  are  suggestive  of  gallstone  disease,  while  they  seriously  perplex  the  medical 
attendant.  Much  stress  is  to  be  laid  on  the  first  location  of  the  pain,  esj)ecially  if  this 
be  in  the  direction  of  the  right  shoulder,  and  upon  ccjncomitant  vomiting  and  jaundice, 
if  present,  as  well  as  on  the  location  of  the  greatest  tenderness  and  muscle  rigidity. 
Recurrence  of  more  or  less  similar  attacks  is  also  suggestive.  Diaj^hragmatic  j)leurisy 
may  cause  pain,  referred  especially  along  the  esophagus,  and  intensified  during  the  act 
of  swallowing  or  vomiting.  Affections  of  the  appendix  and  gall-bladder  may  co-c.rist,  as 
well  as  be  easily  mistaken  one  for  the  other.  The  former  is  so  true  that  when  operating 
for  one  condition  it  is  always  advisable  to  explore  in  regard  to  the  other.  When  the 
ap])endix  is  placed  high,  especially  behind  the  colon,  confusion  may  confound.  Biliary 
colic  is  usually  free  from  the  associated  ordinary  symptoms  which  are  so  often  met  with 
in  renal  colic,  while  in  the  latter  the  urine  Avill  contain  no  bile  pigment  and  the  pain  will 
usually  be  referred  to  the  external  genitals.  In  lead  colic  the  characteristic  line  upon 
the  gums  and  the  habitual  constipation  which  always  accompany  it  will  be  suggestive. 
When  the  stomach  is  at  fault  and  the  pylorus  obstructed  this  viscus  will  usually  be  dilated, 
and  the  vomit  is  of  a  different  character,  while,  at  the  same  time,  actual  stomach  move- 
ments may  or  may  not  be  made  visible.  With  gastric  or  duodenal  ulcer  pain  it  is  more 
regular  and  associated  with  food  taking  after  a  definite  interval,  longer  in  the  latter 
case. 

Chronic  pancreatitis  is  so  often  associated  with  cholelithiasis  that  it  is  impossible 
to  disassociate  their  symptoms,  but  the  referred  pain  is  rather  midscapular  or  even  on 
the  left  side.  It  will  be  particularly  suggested  by  rapid  loss  of  flesh.  In  acute  pan- 
creatitis the  symptoms  are  usually  more  excessive,  the  distention  earlier  and  greater. 
Cancer  of  these  various  organs  does  not  commence  with  pain,  but  has  a  more  gradual, 
distinctive  downward  course,  with  cachexia.  These  are  some  of  the  considerations  which 
may  aid  in  differential  diagnosis. 


926  SPECIAL  OR  REGIONAL  SURGERY 

The  detection  of  bile  pifjinent  in  the  urine  and  blood  will  have  corroborative 
value. ^ 

Treatment. — The  general  subject  of  cholelithiasis  and  its  associated  lesions  con- 
stitutes an  important  topic  in  the  so-called  "border-land"  between  medicine  and  surgery, 
where  views  and  advice  regarding  jjrognosis  and  treatment  will  depend  on  the  experience 
and  the  training  of  the  medical  attendant.  Surgeons  now  recognize,  and  physicians 
are  being  gradually  converted  to  their  view,  that  gallstone  disease  is  essentially  a  surgical 
disease,  i.  e.,  one  to  be  combated  by  surgical  intervention.  While  it  is  not  to  be  gainsaid 
that  many  patients  live  and  die  with  gallstones  who  are  never  conscious  of  their  presence, 
and  while  others  who  have  had  serious  attacks  live  to  die  of  some  other  disease,  neverthe- 
less the  general  statement  may  be  boklly  made  and  easily  defended,  that  ivhen  the  disease 
is  ivell  marked  and  when  patients  suffer  more  or  less  constantly  from  it  the  only  successful 
method  of  treatment  is  the  surgical,  and  that,  in  other  words,  operation  offers  the  only 
prosjicct  of  permanent  relief.  Regarding  its  associated  dangers  it  may  be  said  that 
danger  comes  from  delay  rather  than  from  operation,  and  that  here,  as  with  many  other 
conditions,  patients  often  wait  too  long,  partly  from  lack  of  proper  advice,  partly  from 
timidity,  and  that  a  septic  and  moribund  patient,  allowed  to  become  so  for  lack  of  earlier 
aj)plication  of  the  resources  of  surgery,  is  a  reflection  on  the  one  who  waits  rather  than 
on  the  surgeon,  who,  endeavoring  to  save,  still  unfortunately  loses  his  patient. 

This  is  not  the  ])lace  to  discuss  non-operative  measures — /.  e.,  medicinal  and  dietetic 
treatment — valuable  as  they  may  be  in  certain  cases.  ^lost  of  the  drugs  which  are 
supposed  to  be  effective  in  their  power  of  solution  of  gallstones  or  of  facilitating  their 
escape  are  disappointing,  and  at  best  are  vague  and  uncertain  in  their  action.  The 
hytlrotherapeutic  treatment,  such  as  carried  out,  for  instance,  at  Carlsbad,  will  do  good 
in  many  cases,  especially  for  those  who  have  been  indulgent  in  their  appetites  and  careless 
in  their  habits.  Cases  of  any  description  not  too  far  advanced  would  be  benefited  by 
a  careful  regimen  of  this  character,  but  that  Carlsbad  or  any  other  waters  will  certainly 
cure  cholelithiasis  is  now  absolutely  disproved.  As  a  preparation  for  operation  a  sojourn 
at  some  such  place  may  be  advised;  as  a  substitute  for  it,  never.  Large  doses  of  glycerin 
(50  to  150  Cc.)  often  temporarily  relieve  the  pain  of  biliary  colic. 

In  general,  then,  it  may  be  said  that  cases  which  give  a  history  of  recurring  attacks 
of  biliary  colic,  with  or  without  recurrent  jaundice,  and  with  those  varied  concomitant 
symptoms  which  are  usually  grouped  under  the  term  "indigestion,"  in  which  there  is 
definite  tenderness  over  the  region  of  the  gall-bladder,  with  or  without  muscle  spasm, 
and  with  the  other  referred  pains  so  often  present  in  this  condition,  should  be  regarded 
as  legitimately  surgical,  \\here  o])eration  is  more  than  justifiable  and  usually  de- 
cidedly advisable,  even  too  often  imperative.  The  same  is  true  of  those  cases  of  dis- 
tended gall-bladder  with  obstructif)n  of  the  duct  where  perhaps  no  calculi  are  present, 
but  where  the  |)atient  suffers  in  much  the  same  way  as  though  they  were  present.  Biliary 
drainage  is  equally  railed  for,  and  the  presence  or  absence  of  calculi  is  but  a  minor  feature 
upon  which  too  much  stress  should  not  be  laid  nor  too  much  disappointment  expressed 
if  they  be  not  found. 

ISIany  cases  of  chronic  cholelithiasis  have  become  more  or  less  toxemic,  as  well  as 
cholemic.  It  is  a  well-recognized  fact  that  cholemic  patients  are  more  likely  to  cause 
inconvenience  to  the  surgeon  from  free  hemorrhage  or  persistent  oozing,  because  of  the 
slowness  with  which  coagulation  of  their  blood  takes  place.  When  time  is  afforded  for 
preparation  it  is  of  great  value  in  these  cases  to  administer  calcium  chloride,  of  which 
several  doses  may  be  given  each  day,  in  considerable  water,  the  former  varying  in  amount 
from  1  to  2  Gm.  When  time  suffices,  too,  it  is  always  of  value  to  prepare  these  patients 
for  the  operation  by  measures  already  discussed,  improving  their  elimination,  reducing 
the  degree  of  their  toxemia,  and  fortifying  their  circulatory  systems  by  well-known 

'  Hand  has  shown  that  a  small  capillary  tube  filled  with  blood,  sealed  at  both  ends,  may  afford  a  convenient 
corroborative  test.  After  standing  for  a  few  hours  in  a  vertical  position  its  separated  servmi  can  be  examined 
against  the  light.  Normal  serum  is  colorless,  while  even  a  trace  of  bile  pigment  will  give  it  a  distinctive  yellow 
tint. 

Baudouin's  test  for  the  urine  will  be  the  most  satisfactory  in  the  matter  of  precision  and  simplicitj'.  If  two 
or  three  drops  of  a  14  per  cent,  solution  of  fuchsin  be  dropped  into  urine  containing  bile  it  immediately  develops  a 
fine  orange  tint,  in  marked  contrast  with  its  own  red.  No  other  coloring  matter  in  the  urine  gives  this  reaction; 
which  is  very  delicate.  (Mayo  Robson.)  Methyl  blue  and  methyl  violet  each  give  a  reddish  tint;  LoefHer's  blue 
solution  gives  a  green  tint  which  vanishes  on  heating,  to  reappear  on  cooling.  There  are  numerous  other  tests, 
but  these  are  the  .simplest  and  most  satisfactory. 


CHOLELITHIASIS,   (;.\I.LST()\h'  OR   lULIMiV   COLIC,   HIIJARY   CALCULI     927 

measures.  Tlic  value  itt'  sucli  preparation  is  |)erliaps  more  aj)parent  in  such  instances 
tlian  in  most  otiiers.  ( )ii  the  other  hand,  many  cases  callinj^  for  operation  arc  almost 
as  im|)erative  as  tliose  of  acute  a|)|)en(ncitis,  where  every  hour's  delay  is  to  the  dis- 
advanta<i('  of  (he  individual.  The  operations  which  arc  practised  up(jn  tin;  biliary  tract 
will  all  be  discussed  to<fethcr  in  a  section  by  themselves. 


TUMORS  OF  THE  GALL-BLADDER. 

This  e.\|)ressioii  refers  rather  to  actual  iii'oplasms  of  the  <j;all-bladdcr  itself  than  to 
distention  of  the  sac  i)V  '.n  liidi  an  intra-abdominal  tumor  may  be  formed.  The  latter 
subject  may  be  dismissed  with  tlie  men^  statcnu  nt  that  the  ^all-bladder  may  become 
distended  with  bile,  with  mucus,  with  pus,  with  concretions,  or  W'ith  the  products 
of  such  disease  as  echinococcus,  actinomycosis,  etc.  In  this  way  it  may  be  so  much 
cnlarij;ed  as  to  be  easily  felt  throu<!;h  the  abdominal  walls  or  to  be  even  mistaken  for 
other  conditions.  In  the  latter  case  it  may  have  to  l)e  differentiated  between  such  a 
condition  and  a  movable  ri<>;ht  kidney,  a  tumor  of  the  kidney  itself  or  of  its  capsule, 
as  well  as  from  tumors  of  the  stomach,  es])ccially  the  pylorus,  of  the  liver,  or  of  the 
intestine  and  from  the  cnlari^ement  of  the  ritrht  lobe  which  often  accompanies 
cholelithiasis,  or  from  fecal  impaction.  It  would  l)e  best  to  abstain  from  the  use  of 
the  aspiratino-  needle  in  these  cases,  as  more  harm  mi(:;ht  be  done  by  the  escaj)e  into  the 
abdomen  of  deleterious  fluid  than  would  be  atoned  for  by  the  information  which  the 
pn)cedure  would  afford.  Even  when  the  abdomen  is  oj)en  the  gall-bladder  should 
rarely  be  pimctured  in  this  manner,  unless  one  is  prepared  at  the  same  time  to  open  it 
and  drain.  In  other  words,  there  is  less  risk  about  a  small  exploratory  incision  than 
in  puncture. 

Nearly  all  varieties  of  malignatit  and  many  of  benign  tumors  have  been  reported 
as  occurrino;  in  this  location.  It  will  be  sufficient  in  this  j)Iace,  however,  to  say  that 
cancer  of  the  gall-bhuldcr,  which,  of  course,  may  extend  in  various  directions,  is  by  no 
means  an  uncommcju  afi'ccti«jn,  and  is  usually  a  complication  of  gall.stonc.i.  In  fact,  it 
may  be  doubted  whether  primary  cancer  of  the  gall-bladder  ever  occurs  in  the  absence 
of  such  a  source  of  irritation.  These  cancers  vary  in  type  between  the  round-cell  and 
the  squamous,  most  of  them,  however,  being  of  the  former  character.  Although  Musser 
has  put  the  percentage  at  65  and  Zenker  as  high  as  85  of  instances  where  gallstones 
are  found  within  cancerous  gall-bladders,  it  docs  not  follow  that  the  above  statement 
may  not  l)e  true  regarding  their  almost  universal  association  and  causal  relation,  for 
any  gall-l)ladder  found  empty  at  a  given  time  may  at  some  other  time  have  contained 
a  calculus.  This  frequent  association  is  justly  among  the  valid  arguments  which 
surgeons  may  now  use  in  making  a  plea  for  earlier  operation,  and  for  making  it  a  more 
standard  procedure. 

Cancer  may  be  suspected  in  cases  of  progressive  and  unintermittent  jaundice,  especially 
when  there  can  be  felt  in  the  region  of  the  gall-bladder  a  distinct  tumor  or  an  enlarge- 
ment of  the  liver.  Pain  is  a  frequent  but  by  no  means  a  constant  or  reliable  symptom. 
As  the  disease  spreads  the  adjoining  textures  will  become  matted  together,  and  a  low 
grade  of  local  peritonitis  may  still  further  cement  them  into  a  mass  which  will  occupy 
a  considerable  portion  of  the  upper  ])art  of  the  abdomen. 

But  few  cancers  of  the  gall-l)ladder  which  are  so  apparent  as  to  be  recognized  without 
exploration  can  be  considered  as  still  amenable  to  surgery,  which  for  them  can  hold 
out  but  little  prospect  save  perhaps  a  temporary  relief  by  biliary  drainage.  It  is  the  cases 
in  their  earlier  stages,  when  the  condition  is  made  out  by  exploration,  and  by  it  alone, 
w'hich  still  afford  prospects  of  more  or  less  permanent  relief.  The  very  impossibility 
of  detecting  the  condition  in  these  earlier  stages  without  exploration  affords  one  of  the 
strongest  arguments  for  such  a  procedure  in  every  vague  case  of  the  kind.  That  cases 
of  this  character  are  not  necessarily  hopeless  is  instanced  by  an  experience  of  my  own, 
where  on  opening  the  abdomen  of  a  large  and  fleshy  Avoman  I  found  a  distinctly  cancerous 
gall-bladder  containing  two  large  calculi,  and  removed  the  entire  mass,  with  a  consider- 
able p(jrtion  of  the  surrounding  hepatic  tissue,  the  removal  being  effected  with  the  actual 
cautery.  At  present  date  of  writing,  nearly  six  years  after  the  operation,  the  patient 
is  a])parently  perfectly  well  and  doing  her  own  housework. 


928  SPECIAL  OR  REGIONAL  SURGERY 

OPERATIONS  UPON  THE  GALL-BLADDER  AND  BILIARY  PASSAGES. 

The  small  area  included  under  the  above  title  has  been  made  the  field  for  a  variety 
of  operations,  dignified  with  formidable  names,  tlu;  entire  list  of  which  might  be  made 
quite  long.  In  order  to  sim|)lify  their  arrangement  and  illustrate  their  purposes  they 
may  be  referred  to  as  (1)  oj)crations  uj)on  the  fjall-hladder  proper;  (2)  those  upon 
the  duds;  and  (3)  the  more  complicated  operations  upon  one  or  both  of  these  in  con- 
nection with  some  other  part  of  the  intestinal  tract;  or,  to  catalogue  them  somewhat 
definitely,  the  operations  upon  the  gall-bladder  include  rho/ccij.s-fototmj,  cholecystoatomy, 
and  choiorijsiertomij,  according  as  the  surgeon  ojjcns  the  gall-bladtler  and  closes  it,  makes 
a  more  or  less  permanent  opening,  or  completely  removes  it.  Again,  upon  the  ducts 
he  may  make  cliolanfjiotomij  or  rJiolauf/iostoniij,  or,  using  their  j)ractically  equivalent 
synonyms,  cholcdochotom.ij  or  cfwlcdorliostomij,  these  terms  referring  to  operations  u])on 
the  cystic  and  the  common  ducts;  while  when  similar  procedures  are  applied  to  the 
hepatic  duct  they  have  been  spoken  of  as  hepaticoionii/  and  Jiepatlcostomy.  Cholecys- 
fcnfcw.stomy  refers  to  an  anastomosis  between  the  gall-bladder  and  the  upper  bowel, 
w  hile  when  this  is  effected  between  the  common  duct  and  the  bowel  it  is  referred  to  as 
rliolrdocheiitcrostomy.  When  a  stone  lies  partly  in  the  connnon  duct  anrl  partly  within 
the  wall  of  the  duodenum,  and  it  becomes  necessary  to  incise  the  latter,  it  may  be  spoken 
of  as  duodenotomy.  The  operation  of  merely  crushing  biliary  calculi,  hoping  that  the 
fragments  will  be  passed  on  with  the  flow  of  bile,  and  sj)()ken  of  as  cholelithrofrity,  is 
now  almost  abandoned,  and  the  term  has  historical  rather  than  present  value. 

To  even  attempt  to  epitomize  directions  for  these  various  ojjerations  into  space  avail- 
able here  would  be  impossible,  for  large  volumes  have  been  devoted  to  this  subject  alone. 
The  main  thing  for  the  student  and  the  junior  practitioner  is  to  ai)})reciate  the  indications 
for  their  performance,  at  which  he  should  certainly  have  assisted  before  attempting  to 
perform  them  himself.  General  directions,  however,  may  be  given  as  follows,  the  usual 
preparations  having  been  made  both  of  the  patient  and  the  cnvironinent:  A  woman 
who  has  borne  children  and  who  has,  in  consequence,  relaxed  abdominal  walls,  makes 
a  more  favorable  subject  for  o])erati()n  than  a  muscular  man  whose  abdominal  muscles 
cannot  be  relaxed  until  a  profcnmd  degree  of  anesthesia  has  been  obtained.  In  many 
instances  exposure  is  made  better  by  placing  a  sandbag  behind  the  region  of  the  liver, 
especially  on  the  side  to  be  operated,  by  which  the  costal  angle  is  more  outlined  and 
the  parts  pushed  forward. 

A  preliminary  incision  should  b(>  made  of,  say,  three  inches  in  length,  and  is  best  placed 
a  little  to  the  inner  side  of  the  outer  l)ordcr  of  the  rectus,  whose  fibers  are  separated  and 
its  tendinous  intersection  divided.  This  incision  may  be  extended  upward  and  curved 
toward  the  middle  line,  as  recommended  by  Bevan,  or  downward,  as  the  exigencies  of 
the  case  may  require.  The  beginner  especially  should  provide  himself  with  sufficient 
space  for  manipulation.  The  posterior  sheath  of  the  rectus  and  the  [jeritoneum  are 
best  divided  together.  SufKcient  opening  being  thus  ma(le,  a  finger  may  be  inserted 
for  the  purpose  of  exploration.  In  the  presence  of  adhesions,  and  especially  in  acute 
cases  in  which  pus  is  likely  to  be  present,  this  should  be  done  with  great  caution.  When 
no  adhesions  are  present  gauze  pads  may  be  inserted  and  so  disposed  as  to  permit 
exposure  to  view  of  the  lower  surfaces  of  the  liver.  The  operator  should  be  prepared 
for  any  and  all  conditions — one  of  dense  adhesions  or  their  complete  absence,  as  well 
as  for  cobweb-like  adhesions  which  surround  foci  of  infected  exudate  or  of  pus.  The 
more  reason  he  may  have  for  suspecting  the  presence  of  pus  the  more  carefully  should 
the  region  be  walled  off  with  protective  gauze.  Adhesions  are  most  likely  to  form 
between  the  omentum  and  the  colon,  in  front  and  below,  and  with  the  stomach,  duo- 
denum, and  colon  below  and  behind.  Those  who  have  had  ex])erience  with  abdominal 
operations  will  appreciate  whether  these  adhesions  are  recent  and  likely  to  cover  puru- 
lent foci,  or  old,  and  will  proceed  accordingly.  Occasionally  tissues  will  be  so  matted 
that  even  an  experienced  operator  will  scarcely  be  able  to  difi'erentiate  them. 

The  endeavor  should  be,  if  possible,  to  expose  the  gall-bladder  itself,  both  to  touch 
and  sight,  in  order  that  after  orientation  concerning  its  actual  condition  its  duct  maybe 
followed  into  the  common  duct,  and  this  into  the  intestine.  This  is  sometimes  an 
exceedingly  easy  matter,  and  again  impossible.  The  presence  or  absence  of  j)us  will 
of  itself  indicate  what  should  be  done.     When,  for  instance,  the  gall-bladder  is  found 


u/y;am 77o.\ N  rrox  Tin-:  cm^i-  ni.AnDi.h'  .wn  iuliary  passages    929 

l)l;i(k  or  parllv  >,r;iiijrn.|i(.iis  tin-  siir<,'r(>ii  will  contiMit  himself  with  doiiij;  the  least  i)()ssil)lc 
amoiiiit  ol"  s."|);u•:lt^Il^^  ciKJcavoriiifi;  ralhor  to  |)r()vi(lc  the  widest  outlet  for  drainage. 
It  Mii^rlit  lu.  In-tter  to  make  simply  a  small  openiii.?  and  permit  the  eseape  of  fetid  debris, 
and  to  postpone  until  a  later  day  further  attempt  to  remove  the  ealeuhis,  whieli  pre- 
sumai)l.v  has  |)ro(luced  the  didieulty.  Local  indications,  then,  shoul<l  he  considered 
aloiij;-  with  the  ^^eneral  t'oiidition  of  the  patient. 

The  lower  surface  of  the  liver  will  alVord  tiie  ^iiidc  l(»  llic  location  of  tlic  ;;all-ltiad(icr, 
and  when  the  latter  is  nearly  ohiiterated  its  discovery  sometimes  taxes  the  resources  of 
the  sur<reon.  When  not  contracted  it  is  usually  easily  exposed,  and  so  far  fre<'d  that 
it  mav^e  even  drawn  up  into  the  wound.  After  havinj,'  thus  isolated  and  perhaps 
secured  it,  it  nuist  he  decided  hy  further  exj)I()ration  how  it  shall  he  treated.  It  is  of 
^M-eat  importance  to  liherate  the  "ducts  from  surroundin<>;  adhesions. 

CholecystOtomy.  Cholecystotomy,  sometimes  fallaciously  sj)oken  of  as  ideal,  con- 
sists in  simpiv  opcniiifr  the  "(rall-hladdcr,  em|)tyino;  it  of  calculi  or  other  contents 
throu^di  a  small  incision,  and  closin«>;  this  hy  sutures.  The  o|)eration  is  ideal  in  hut  one 
way,  hut  conditions  which  permit  it  rarely  justify  it,  for  any  uall-hladder  so  diseased  as 
to  call  for  operation  needs  either  removal  or  draina<>e. 

CholecystOStomy.— (Miolecystostomy  includes  provision  for  draina<2;e  over  a  con- 
siderahle  leno;th  of  time.  A  diistended  gall-hladder  which  permits  ()f  easy  manij)ulation 
and  isolatioir  may  he  suHiciently  long  and  large  to  justify  uniting  its  surface  to  tlie 
peritoneum  and  tjeep  margins  of"  the  wound,  in  such  a  way  as  to  permit  discharge  of  its 
contents  through  the  latter.  The  old  method  was  to  unite  it  to  the  skin.  This  should 
never  he  done,  as  fistulas  thus  resulting  are  more  likely  to  he  i)ermanent.  If  the  gall- 
bladder he  thus  affixed  to  the  ])arietal  peritoneum  the  better  way  is  to  insert  a  drain, 
its  arrangement  being  left  somewhat  to  the  choice  of  the  operator.  For  my  own  i)art 
I  prefer  a  rubber  tube,  not  too  flexible,  inserted  two  or  three  niches  into  the  gall-bladder, 
through  a  small  opening  closed  around  it,  with  invaginated  edg'es,  by  a  purse-string  suture 
of  chromic  gut,  by  which  it  is  intended  to  prevent  leakage  into  the  abdominal  cavity. 
By  another  suture  of  common  gut  the  tube  may  be  so  fixed  as  to  avoid  danger  of  being 
k)st  in  either  direction.  If  the  gall-bladder  be  sufficiently  long  to  permit  additional  fixa- 
tion to  the  depths  of  the  abdominal  w^ound  the  operation  is  made  still  more  ideal;  hut  in 
the  ease  of  a  short  and  contracted  cavity  the  tube  may  be  left  to  follow  it  into  the  abdomi- 
nal recesses.  Within  forty-eight  hours  the  exudate  which  has  been  thrown  out  around 
it  will  have  become  sufficiently  organized  and  well  ordered  to  form  a  canal  in  which  the 
tube  shall  rest,  and  which  shall  serve  later  as  a  conduit  to  conduct  bile  to  the  surface 
after  removal  of  the  tube  itself.  Into  such  a  tube,  after  the  application  of  the  dressings, 
may  be  conducted  another  more  flexible  tube,  whose  upper  end  shall  connect  with  a 
receptacle  of  some  kind,  which  may  later  be  a  bottle  held  within  the  dressing,  to  receive 
the  discharge,  and  thus  avoid  soiling. 

This  operation  has  been  done  occasionally  in  two  sittings,  the  gall-bladder  being 
brought  into  the  upper  part  of  the  wound  and  fastened  to  the  peritoneum  by  sutures, 
which  should  not  perforate  its  walls,  as  that  leakage  would  occur  which  the  method  is 
intended  to  avoid.  After  waiting  a  day  or  two  for  adhesions  to  form  the  cavity  is  then 
opened  with  a  knife  or  scissors  and  drainage  thus  accomplished.  This  method  has 
been  practically  abandoned,  for  the  reason  that  it  permits  no  digital  exploration  by 
combined  manipulation. 

Cholecystectomy. — (Cholecystectomy  includes  the  removal  of  the  whole  or  the 
greater  part  of  the  gall-bladder.  It  has  already  been  stated  that  this  is  a  reservoir, 
convenient  and  advantageous,  l)ut  not  needed  in  a  way,  and  not  essential  to  life.  It 
figures  as  a  superfluous  organ,  then,  similar  to  the  appendix,  and  there  is  no  reason  why, 
when  diseased  and  troublesome,  it  should  not  he  extirpated.  Its  removal  Avill  sometimes 
be  a  matter  of  choice,  and  at  other  times  a  necessity.  The  former  is  the  case  when 
the  surrounding  conditions  lend  themselves  to  its  dissection  from  the  lo^ye^  surface  of 
the  liver  without  too  much  violence  to  other  tissues;  the  latter  when  it  is  involved  in 
malignant  processes  or  when  its  interior  is  seriously  infected.  An  incomplete  method 
of  treating  the  gall-bladder  under  the  latter  circumstances  might  include  the  scraping 
or  removal  of  its  thickenM  mucosa,  without  removing  the  entire  thickness  of  its  structure. 
In  this  case,  however,  drainage  would  be  required.  That  the  gall-bladder  may  be  com- 
pletely separated  and  thus  isolated,  with  comfort  and  speed,  requires  that  its  wall 
be  sufficiently  strong  to  stand  the  ordinary  manipulation.  This  may  not  be  true  of 
59 


930 


SPECIAL  OR  REGIONAL  SURdERY 


the  perfectly  normal  gall-bladder,  hut  in  such  case  no  one  would  think  of  removinor  it, 
whereas  the  cyst,  which  is  diseased  sufficiently  to  justify  removal,  will  usually  permit  of 
the  necessary  manijndation.  Even  if  somewhat  torn  in  the  process  the  procedure  may  be 
effected  without  much  added  difhculty.  This  procedure  consists  essentially  in  separa- 
tion of  the  overlyini;'  peritoneum  and  enucleation  cjf  the  «;all-l)ladder  from  its  bed  or  the 
(lei)ression  in  the  liver  in  which  it  lies,  which,  as  already  indicated,  may  be  narrow  or 
wide  and  deep.  Actual  separation  from  liver  tissue  will  be  followed  by  oozintj;  and  at 
least  two  or  three  vessels  in  the  surroundin<f  structures  and  at  the  neck  of  the  <!!;all- 
bladder  will  require  to  be  secured.  Removal  should  not  be  attempted  in  cases  which 
do  not  permit  of  it,  but  may  be  practised  in  those  cases  not  too  infected,  when  after 

emptying  the  sac  (full  of  calculi,   for 
Fig.  628  instance)    it    can    still    be   established 

with  the  probe  that  the  common  duct 
is  patulous.  These  are  ideal  cases  for 
such  complete  work.  The  gall-bladder 
having  thus  been  isolated  down  to  its 
cystic  termination,  the  surgeon  pro- 
ceeds much  as  though  it  were  the  aj)- 
pendix,  by  firmly  ligating  the  duct  with 
chromic  gut,  guarding  against  escape  of 
contents  while  it  is  divided  on  the  distal 
side  of  the  ligature  thus  applied.  The 
stump  of  the  duct  is  then  cauterized 
with  pure  carbolic,  after  which  oozing 
is  checked  by  tamponing  for  a  few 
moments.  It  then  is  often  possible  to 
bring  together  the  peritoneum  beneath 
the  torn  liver  surface  and  almost  com- 
pletely cover  it  anew.  The  liver  tissue 
will  bear  a  ligature  or  suture  not  too 
tightly  drawn.  If  the  case  have  been 
one  otherwise  surgically  clean,  and  the 
operation  ])roperly  conducted,  the  ab- 
dominal wound  may  be  closed  without 
drainage.  If,  however,  doubt  be  felt 
a  small  cigarette  or  a  tubular  drain 
may  be  placed,  to  be  left  not  more 
than  thirty-six  hours.  Every  infected 
gall-bladder,  if  not  removed,  should 
be  thoroughly  cleansed,  its  interior 
being  mopped  with  gauze,  preferably  with  the  addition  of  hydrogen  dioxide.  An 
important  step,  next  to  attention  to  the  gall-bladder  proper,  is  to  demonstrate  the 
patency  of  the  ducts.  This  is  done  by  gently  passing  a  probe,  which  should  be  bent 
to  suit'the  case,  along  the  duct  and  into  the  intestine.  This,  of  course,  cannot  be  done 
if  calculi  are  discovered  by  manipulation,  neither  can  it  always  be  done  when  calculi 
are  not  present.  Gallstones  in  the  duc-t  can  usually  be  distinguished  by  the  fingers  with 
which  the  exploration  is  made,  and  failure  to  thus  pass  a  probe  may  be  brought  about 
by  stricture  rather  than  by  calculous  obstruction.  The  importance  of  this  determination 
will  be  seen  in  removing  the  gall-bladder,  as  to  remove  it  in  an  obstructed  case  is  to  leave 
no  outlet  for  bile  except  into  the  abdominal  cavity,  whereas  to  fail  to  drain  such  a  case 
is  to  plainlv  neglect  to  meet  the  indication. 

Cholecystendysis.— The  term  cholecystendysis,  now  almost  obsolete,  implies 
practically  a  cholecystotomy  with  drainage,  the 'gall-bladder  having  been  opened  for 
the  pur]M)se  of  removal  of  one  stone  or  more  and  then  united  to  the  abdominal  wound. 
Of  the  operations  upon  the  ducts  there  is  something  to  be  said  in  addition  to  the 
directions  already  given.  Inasmuch  as  they  lie  more  dee[)ly  they  are  more  difficult  of 
access,  and  variously  shaped  retractors,  Avith  walling  off  the  cavity  with  gauze,  are  more 
often  required,  while  in  proportion  as  deep  adhesions  have  enwrapped  the  structures  they 
are  made  more  difficult  of  exposure.  At  present  surgeons  have  less  hesitation  in  leaving 
duct  incisions  unclosed  than  was  formerly  felt.     It  was  formerly  held  that  every  incision 


General  scheme  of  cholecystectomy;  detachment  of  gall- 
bladder and  duct  from  their  investments;  ligation  of  cystic 
duct  and  arteries.     (After  Kehr.) 


()i'i:u.\Ti(>\s  rrox  the  cali.  uladdhu  .\\i>  inLiMty  passages    931 


into  a  duel  slioiild  Ix-  closed  with  siidircs.  It  lias  ht-cn  later  t'oiiiid  that  satisfactory 
results  ensue  when  the  end  ol"  th(>  draiiia<;'e  tulx-  is  left  restiii<i',  or  even  fastened,  within 
the  duct  o|>enin»f,  the  operation  l)ein<v  thus  made  shorter  and  simpler  and  the  didiculties 
of  deep  suture  thus  obviated.  As  elsewiiere  noted  the  conuuon  duct  may  become 
enormously  dtlatcd,  and  may  he  almost  mistaken  for  the  small  intestine.  The  passage- 
way lu'tween  this  duct  and  the  <,'all-l)la(lder  may  be  so  obstructed  that  double  drainage 
will  be  of  advantage,  or  this  may  be  u  ease  where  j)artial  removal  of  the  gall-bladder 
may  be  effected,  with  drainage  of  the  common  duct.  Such  ca.se.s  should  be  judged 
upon  their  m(>rits.  The  more  infectious  the  existing  condition  the  more  is  free  dfainage 
demanded.  When  a  stone  is  impacted  in  the  ani])ulla  of  Vater  there  should  be  no 
hesitation  in  dividing  the  walls  of  the  duodenum  in  order  to  extract  it.  In  such  a  case 
the  duodenum  is  sutm'cd,  but  the  duct  or  the  gall-bladder  must  be  drained  (Fig.  ()29). 
These  deep  o|)erations  ri'(|uire  fr(>e  incision,  several  inches  in  length,  and  it  will  astonish 
the  begimier  t(»  see  how  the  liver  nuiy  l)e  delivered  from  the  abdominal  cavity  through 
such  an  o|)ening.  Much  assistance  will  here  be  gained  by  a  large  pillow  or  sandbag 
placed  beneath  the  back.  Bleeding  vessels  need  to  be  secured,  at  least  temporarily, 
with  forceps,  and  usually  with  sutures  or  ligatures  en  masse.     The  exposed  or  torn  sur- 

FiG.  629 


Removal  of  gallstone  entangled  at  the  papilla.  Kocher's  method  of  displacing  the  duodenum:  o,  incisioa 
in  the  paraduodenal  peritoneum;  h,  pancreas;  c,  location  of  the  stone;  d,  duodenum;  e,  sutures  used  either  for 
retracting  or  closing  opening  in  the  common  duct;  j,  retroduodenal  venous  plexus.     (Kelir.) 

faces  of  the  liver  will  ooze  freely  at  first,  but  bleeding  usually  ceases  with  the  pressure  of 
a  gauze  tampon.  From  the  uninflamed  gall-bladder  the  peritoneum  is  usually  easily 
separated,  with  but  trifling  hemorrhage.  For  deep  work  traction  on  the  middle  portion 
of  the  duodenum  makes  more  prominent  the  junction  of  this  part  of  the  bowel  with  the 
gastrohepatic  omentum,  at  which  point  the  peritoneum  may  be  incised  and  separated 
along  the  free  border  of  the  duodenum  until  this  portion  is  free  from  external  peritoneal 
covering.  There  will  be  exposed  here  the  second  portion  of  the  common  duct  where 
it  lies  upon  the  pancreas,  it  being  more  or  less  embedded  in  the  latter  further  along. 
When  it  is  necessary  to  cut  away  more  tissue  it  is  better  to  sacrifice  a  ])ortion  of  pancreas 
rather  than  of  duodenum  itself.  Blunt  dissection  alone  should  be  made  here.  When 
it  is  necessary  to  cut  it  will  be  better  to  use  the  thermocautery. 

These  various  cutting  operations  have  superseded  the  previous  methods  of  endeavoring 
to  crush  stones  within  the  duct  and  force  the  fragments  along  by  pressure.  The  Mayos 
have  recommended  the  use  of  two  fine  parallel  sutures,  introduced  longitudinally  into 
the  duct,  between  which  the  incision  should  be  made,  and  w'hich  may  be  used  as  tractors, 
or  subsequently  for  purposes  of  closure. 


932 


SPECIAL  OK  REGIONAL  SURGERY 


Practically  every  gall-duct  case  should  be  drained  with  a  tube  extending  down  to  the 
deepest  portion  of  "the  site  of  the  operation.  This  may  he  done  with  what  has  been  called 
a  "dressed  tube,"  made  by  surrounding  an  ordinary  rubljer  drain  with  a  few  layers 
of  gauze  and  covering  this  "with  oiled  silk.  The  lower  end  of  the  tube  is  then  bevelled 
or  "^trimmed  in  fish-tail  fashion.  This  may  be  passed  into  the  depths,  or  it  may  be 
used  for  gall-bladder  drainage  as  well. 

Of  the  anastomotic  operations  there  is  less  heard  now  than  a  few  years  ago.  There 
are  now  considered  to  be  but  a  few^  conditions  which  are  not  better  dealt  with  by  biliary 
drainage  as  made  above  than  by  any  other  method.  Occasionally,  as,  for  instance,  when 
the  common  duct  is  stricturedor  involved  in  pancreatitis  or  cancerous  deposit,  and  bile 
is  backing  up  into  the  gall-bladder,  it  may  be  of  great  advantage  to  effect  an  anastomosis 
between  the  latter  and  the  bowel.  At  one  time  the  colon  was  ii.sed  for  the  purpose,  but 
this  prevented  the  utilization  of  the  bile  in  the  upper  bowel,  where  it  is  most  needed. 
Consequently  it  should  always  be  made  into  the  upper  portion  of  the  bowel,  the  duo- 
denum, or  one  of  the  upper  "loops  of  the  jejunum.  For  this  purpose  a  small  IMurphy 
button  is  probably  still  the  speediest  and  best  expedient.  This  is  true  also  when  it 
seems  necessary  to  drain  the  common  duct  into  the  bowel,  since  the  field  of  operation 
in  most  cases  lies  too  deeply  to  permit  of  accurate  and  satisfactory  suturing.  A  further 
and  more  difficult  as  well  "as  later  application  of  this  principle  has  been  suggested  for 
certain  cases  of  permanent  obstruction  of  the  common  and  main  hepatic  ducts.     Under 


Fig.  630 


Demonstrating  the  technique  of  anastomosis  between  the  gall-bladder  and  the  jejunum.     (Cordier.) 


these  circumstances  the  operation  last  mentioned  would  be  useless  and  a  cholangiostomy 
would  l)e  objectionable,  as  it  would  constitute  a  permanent  fistula.  As  practised  by 
Kehr  and  others  this  hepato-chohnif/o-rntcrostomy  is  [performed  by  removing  from  the 
lower  surface  of  the  liver  a  strip  of  its  tissue  about  7  Cm.  long  and  2.5  Cm.  wide.  The 
hemorrhage  is  checked  with  the  thermocautery,  and  with  it  an  opening  is  made  into 
the  liver,  of  such  a  depth  that  several  of  the  bile  ducts  are  thus  divided  and  opened. 
The  uppermost  loop  of  bowel  which  then  can  be  utilized  without  tension  is  opened  and 
sutured  to  the  margins  of  liver  wound.  The  method  is  still  on  trial,  and  yet  in  at 
least  one  successful  case  it  was  shown  that  the  liver  tissue  tolerated  this  unavoidable 
contact  with  the  contents  of  the  upper  abdomen  (Fig.  630). 

After-management. — What  to  do  with  these  cases  of  biliary  drainage  after  it  has 
been  effected  is  sometimes  a  serious  prol)lem.  No  hard-and-fast  rules  can  be  laid 
down  regarding  the  length  of  time  during  which  drainage  should  be  maintained.  In 
instances  where  the  gall-bladder  has  been  removed  the  drain  should  be  taken  out  within 
thirty-six  hours,  but  in  those  cases  where  a  tube  has  been  fastened  into  the  gall-bladder 
for  so-called  permanent  drainage  the  term  "permanent"  may  be  regarded  as  elastic, 
and  covering  a  period  of  from  ten  days  to  perhaps  ten  weeks.  In  the  majority  of 
instances  three  weeks  or  so  of  such  drainage  suffice  to  meet  the  original  indication. 
In  cases,  however,  of  chronic  pancreatitis  a  long  period  of  easy  outflow  will  be  demanded, 
while  in  rare  cases  of  cancer  drainage  once  thus  made  cannot  be  abandoned. 


OPERATlOXSi  UPOX  THE  ClALL-BLADDER  AND  BILIARY  PASSAGES      033 

When  (lie  <;-;ill-l)la(l(l('r  has  not  Ix-cii  raslciicd  nor  allowed  lo  adlicn-  to  tlic  skin,  hut 
only  to  the  iK-ritoncuni,  tlii'  (istnlas  thus  niadc  will  usuully  close  and  rarely  need  stiniu- 
lution.  Sliould,  however,  the  <franulation  proeess  by  which  closure  is  elTected  l)e  too 
slu<f<rish  it  may  be  stinuiluted  l)y  the  apijlieution  of  nitrate  of  silver,  either  in  solution 
upon  a  swab,  or  in  solid  form,  as  when  melted  into  a  bead  upon  the  end  of  a  suitable 
probe.     Firm  pressure  will  also  assist  in  final  closure. 

It  is  not  reasonable  to  expect  that  after  so  much  intervention,  within  the  rudely  Iri- 
an<j;ular  ])otential  cavity  occupied  by  the  ffall-bladder  and  the  ducts,  adhesions  will  not 
form  as  a  part  of  the  re])arative  process.  In  fact  it  may  rather  be  expected  that  as  it 
beconu's  obliterated  adhesion  must  necessarily  follow.  In  consecpiencc  there  may  result 
an  a;;-^lutination  around  tlie  ti;all  tract,  and  into  a  common  mass,  of  the  liver,  tlu^  colon, 
and  the  j)yloric  end  of  the  stomach.  In  s})ite  of  these  adhesions  bad  symj)toms  rarely 
ensue,  and  when  discomfort  ])ersists  it  is  usually  in  those  eases  in  which  no  stone  was 
found  or  those  in  which  stones  have  been  overlooked.  Andrews  regards  such  jK)st- 
operative  adhesions  as  unavoidable  and  even  desirable,  and,  having  no  faith  in  any 
measures  to  prevent  their  formation,  differs  from  Morris  in  regard  to  the  technifjue  of 
their  subsecjuent  removal.  It  appearing  from  observation  and  ex])erience  that  the 
stomach  is  the  organ  which  suifers  most  by  extensive  adhesion  to  the  liver,  he  has 
j)roj)ose(l  to  sul)stitute  the  colon  for  the  stomach  in  this  necessary  union  of  surfaces,  and 
would  even  practise  it  in  old  cases  after  separation  of  old  adhesions. 

'^riu>  operation  suggested  by  Andrew^s,  and  which  he  calls  cliolchrpatoprxy,  or  colon 
.fuhsiitution,  is  made  with  an  incision  through  the  middle  line  of  the  right  rectus,  avoiding 
any  old  sear,  long  enough  to  afford  plenty  of  room.  The  stomach  is  then  carefully 
separated  from  the  liver,  tearing  liver  tissue  rather  than  that  of  the  former,  if  some- 
thing must  l)e  torn,  and  checking  bleeding  l)y  hot  sponges.  The  pylorus  having  been 
exposed  the  stomach  is  invaginated  into  it  in  order  to  demonstrate  its  patency.  The 
freshly  separated  viscera  will  now  fall  again  into  inmiediate  contact  imless  the  trans- 
verse colon  be  pulled  uj)  and  held  in  place  betw^een  the  liver  and  the  pylorus,  this  not 
being  so  much  of  a  displacement  as  would  appear,  as  the  bowel  is  not  rotated  and 
does  not  cross  over  the  stomach.  The  colon  is  held  in  its  new  relation  by  attaching 
its  omentum  to  the  gastrohepatic  ligament,  to  the  liver  surface,  or  to  remnants  of  old 
adhesions  in  the  angle  between  the  pylorus  and  the  liver.  The  looser  the  omentum 
and  the  more  easily  it  can  be  interposed  in  this  way  the  better.  Andrews'  conclusions 
are  that  gall-tract  adhesions  are  unavoidable,  both  in  disease  and  after  operation,  that 
they  are  harmless  except  in  a  very  few  cases,  and  often  beneficial,  and  that  in  the  few 
cases  w^here  they  do  harm  this  comes  from  malposition  rather  than  from  adhesions 
per  se.  He  even  believes  that  certain  vague  gastric  adhesions  which  might  have  been 
benefited  by  this  operation  have  been  previously  treated  by  gastro-enterostomy. 


CHAPTER   LIII. 
THE   OMENTUM,  THE  MESENTERY,  THE   SPLEEN,  THE   PANCREAS. 

THE  OMENTUM. 

The  omentum  is  somethin<T  more  than  what  it  generally  appears,  i.  e.,  a  more  or  less 
thick  and  extensive  apron  of  fat,  hanging  down  in  front  of  the  small  intestines,  although 
in  this  resj)eet  alone  it  serves  as  a  sort  of  reservoir  or  storehouse  for  fat,  which  is  always 
drawn  upon  as  the  needs  of  the  system  may  require.  The  omentum  varies  within 
wide  limits  from  being  the  flimsiest  veil  of  peritoneum,  whose  four  original  layers  have 
become  so  blended  as  to  be  lost  to  recognition,  and  which  may  even  be  perforated  in 
places  with  openings  through  which  strangulation  of  the  bowel  is  possible,  to  the  thickest 
and  grossest  mass  of  fat  found  in  the  human  body,  resembling  a  coarse  mat  rather  than 
any  finer  texture,  and  having  a  thickness,  in  obese  individuals,  of  two  to  four  inches. 
Under  these  circiunstances  it  makes  a  formidable  obstacle  to  nearly  all  abdominal 
operations.  The  thickness  of  the  omentum  sustains  usually  a  pretty  constant  propor- 
tion to  the  amount  of  adipose  l)etween  the  skin  and  the  abdominal  muscles.  In  certain 
enormously  fat  individuals  one  has  then  to  go  through  from  four  to  six  inches  of  tissue, 
mostly  adipose,  before  reaching  the  rest  of  the  abdominal  contents.  This  necessitates 
a  longer  incision  and  is  always  a  disadvantage  and  impediment.  To  the  operating 
surgeon,  then,  the  omentum  sometimes  appears  a  nuisance. 

It  does  not  deserve,  however,  to  be  so  regarded,  and  when  properly  viewed  the  omentum 
will  frequently  appear  in  the  role  of  the  surgeon's  as  well  as  the  patient's  best  friend. 
This  is  due  to  its  power  of  shifting  itself,  and,  as  it  were,  enclosing  actively  dangerous 
foci  due  to  any  variety  of  infection,  the  natural  intent  being,  as  it  were,  to  wrap  itself 
around  and  thus  completely  imprison  the  source  of  the  trouble,  a  fact  which  is  often 
actually  accomplished,  and  by  which  life-saving  protection  is  frequently  afforded. 
This  is  true  of  the  omentum  whether  thick  or  thin.  By  virtue  of  the  adhesions  which 
often  annoy  the  surgeon,  and  which  necessitate  separation  and  perhaps  considerable 
work  before  the  actual  troul)le  is  exposed,  a  protective  barrier  is  formed  and  the  greater 
portion  of  the  abdominal  cavity  shut  off  from  danger  of  spreading  infection.  Moreover, 
that  the  omentum  has  a  really  valuable  purpose  appears  from  the  fact  that  its  removal 
from  young  animals  seems  to  cause  retartlation  of  development,  and  from  adult  animals 
a  diminution  of  resistance  to  the  action  of  poisons  introduced  into  the  peritoneum. 
It  is  the  omentum  which,  to  a  large  extent,  absorbs  foreign  corj)uscles,  such  as  those 
from  extravasated  blood.  It  helps,  moreover,  to  dissolve  blood  clots  and  to  facilitate 
their  disappearance,  and  after  the  removal  of  the  spleen  it  would  appear  to  vicariously 
perform  at  least  some  of  its  duties.  Thus  when  the  complete  blood  supply  of  the  spleen 
is  cut  off  the  organ  almost  completely  disappears  as  the  result  of  its  absorption  by  the 
omentum.     (This  at  least  in  experimental  animals.) 

The  omentum  serves  further  useful  ])ur])ose  by  plugging  various  openings  and  wounds 
in  the  abdominal  walls,  and  thus  affording  at  least  a  temporary  ])rotection,  just  as  the 
mucosa  sometimes  acts  in  reference  to  the  stomach.  Moreover,  it  is  so  vascular,  so 
flexible,  and  so  available  that  it  may  be  used  for  ])lastic  purposes  in  covering  weak 
spots,  lines  of  sutures,  and  the  like,  in  the  small  intestine  or  even  elsewhere.  These 
same  physical  qualities  make  it  extremely  ])rone  to  escape  through  the  natural  outlets. 
Hence  the  frequency  of  epiplocele  or  omental  hernia  (7.  v.).  By  a  species  of  such  hernial 
protrusion  it  has  saved  many  a  life  after  bursting  open  or  re-opening  of  recent  abdominal 
wounds.  Sometimes  it  will  escape  after  removal  of  a  gauze  drain  which  has  not  been 
judiciously  placed  and  protected,  this  accident  then  constituting  one  variety  of  post- 
operative  or   traumatic   hernia. 

By  virtue  of  its  adhesions,  which  at  first  are  short  and  flat,  luit  which  later  become 
stretched  into  bands,  oh.sintrtion  oj  fhc  hovv/.s-  may  be  produc  ed,  or  by  atro})hic  or  absorp- 
(  934  ) 


TV  MORS  OF  Till':  OM  h:\TVM  935 

tivo  ])r()cc'.ssr,s  ojK'iiiii^'s  or  windows  may  occur  in  it  willi  the  siuno  result.  When  |)ar- 
tieij)atiii<;-  in  septic  processes  it  heconies  infiUrated,  is  often  covered  to  u  hir<>;e  extent 
with  l)reakin<f-(lown  lyni|)h,  and  may  hecoine  i;anii;rcnoiis.  All  ])ortions  thvis  comjjro- 
niiscd  are  best  tied  oil'  and  removed  when  exj)ose(l  din-infj;  operation.  Nevertheless 
the  omentum  should  he  <i;ently  handled,  because  its  venous  walls  are  thin  and  liable  to 
rupture,  and  its  bleeding  points  should  be  carefully  secured,  especially  after  separation 
of  adhesions. 

INJURIES  TO  THE  OMENTUM. 

By  contusions,  lacerations,  and  ])unctures  various  injuries  to  the  omentum  may  be 
inflicted,  naturally  more  connnonly  when  it  is  the  anterior  abdominal  wall  which  has 
sustained  the  traumatism.  As  result  of  lacerations,  hemorrhao;es  or  stran<»-ulati()ns  may 
occur.  The  immediate  dan(:;er  is,  then,  from  hemorrliaoje.  Indications  of  such  lesions 
of  the  omentum  are  not  sj)ecific,  but  <i;;rave  synij)toms  after  any  alxlominal  injury 
require  exploration,  and  that  minute  punctures  or  lacerations  should  be  repaired, 
while  other  injuries  should  be  treated  according  to  obvious  indications. 


TORSION  OF  THE  GREAT  OMENTUM. 

Torsion  of  the  great  omentum  was  first  described  l)y  Oberst,  in  1882,  as  a  condition 
found  in  the  sac  of  a  large  irreducible  hernia.  As  a  distinct  and  serious  condition  it 
has  been  reported  in  about  sixty  instances.  The  condition  occurs  within  the  abdomen 
as  simple  torsion,  also  within  hernial  sacs,  or  in  both,  where  the  torsion  is  not  limited  to 
the  sac,  but  extends  upward  into  the  abdomen.  It  is  more  frequent  in  males,  and  its 
onset  is  usually  sudden.  Of  all  its  symptoms  pain  is  the  most  constant  and  the  earliest. 
This  is  usually  acute  and  persistent,  and  in  a  large  proportion  of  cases  is  referred  to 
the  right  iliac  fossa.  Vomiting  is  not  constant;  bowel  conditions  are  not  significant. 
Absolute  obstruction  is  usually  rarely  noted.  In  most  of  the  recorded  cases  some  tumor 
can  be  felt  on  examination,  which  is  hard,  tender,  dull  to  light  percussion,  and  irregular 
in  shape.  Meteorism  is  not  common.  Death  has  occurred  in  about  15  per  cent,  of 
known  cases.  Diagnosis  previous  to  exploration  can  be  inferential  only,  but  such 
sj^mptoms  as  above  noted  should  lead  to  exploratory  laparotomy. 


TUMORS  OF  THE  OMENTUM. 

The  most  common  of  the  omental  tumors  are  cysis  of  inflammatory  origin,  such  as 
may,  for  instance,  be  formed  by  inclusion  between  surrounding  adhesions  or  by  previous 
hemorrhage;  lymph  cysts,  often  large  and  multiple,  and  sometimes  of  congenital  but 
often  of  lymphatic  origin,  are  also  occasionally  seen.  The  so-called  omental  dermoids 
are  usually  ovarian  products.  Hydatid  cysts  have  been  found  in  the  omentum,  but  only 
as  secondary  products.  Omental  cysts  are  difficult  or  almost  impossible  of  diagnosis 
previous  to  operation,  which  latter  should  always  be  performed,  and  without  pre^^ous 
aspiration,  as  the  presence  alone  of  any  such  timior  requires  removal.  If  large  they 
are  most  likely  to  be  confused  with  ovarian  cysts.  Those  which  may  prove  not  to  be 
removable  should  be  drained,  after  being  fastened  to  the  abdominal  wall — that  is, 
marsupialized.  Ancjioma  in  the  omentum  is  rare,  but  has  been  recorded  by  Homans 
and  others.  Fatty  or  other  benign  tumors  are  also  rare.  Primary  sarcoma  is  rarely 
seen  here,  but  most  of  the  sarcomas,  and  all  of  the  carcinomas  which  never  arise  here 
primarily,  but  are  often  seen,  are  either  metastases  or  direct  extensions.  In  these 
forms  cancer  of  the  omentum  is  common. 

\Yith  extensive  involvement  of  the  omentum  radical  operations  in  these  cases  are 
seldom  advisable.  A  circumscribed  involvement  may,  however,  be  removed,  w'hile 
such  operations  as  anastomoses,  enterostomies,  and  the  like  are  often  necessitated. 

Omental  tumors  are  difficult  of  diagnosis,  although  they  are  usually  superficial  and 
overlie  the  intestines.     They  are  not  affected  by  respiration.     They  move  laterally  and 


936  SPECIAL  OR  REGIOXAL  SURGERY 

upward,  hut  not  dowinvanl.  It'  confined  to  tlie  onicntuni  ])ro[)cr  they  cause  no  functional 
but  only  mechanical  disturbances.  Obviously  in  the  presence  of  extensive  adhesions 
every  distinctive  feature  may  be  confused. 

OMENTOPEXY;    OMENTOSPLENOPEXY;   TALMA'S  OR   MORRISON'S   OPERATION. 

The  effect  of  stasis  in  tiie  portal  circulation  is  to  produce  outpour  of  varying  amounts 
of  serous  fluid  into  the  pleural  cavity.  This  condition,  loner  known  as  ascites  (dropsy), 
is  the  most  distressing  terminal  feature  of  such  diseases  as  cirrhosis  of  the  liver,  cancer, 
and  the  like.  The  osmotic  direction  of  fluid  seems  to  be  reversed,  and  transudation 
tends  to  go  on  until  intra-abdominal  pressure  equals  that  within  the  vessels.  Absorption 
is  always  impeded  and  finally  prevented.  Reflecting  on  the  biophysics  of  this  condition 
Talma  and  ^lorrison,  independently,  and  at  about  the  same  time,  suggested  an  expedient 
by  which  a  portion  at  least  of  this  fluid  might  be  brought  back  into  the  general  venous 
circulation.  The  plan  was  to  attach  the  epiploon  (the  omentum)  to  the  peritoneuiu 
of  the  anterior  abdominal  wall  in  such  a  way  and  over  such  an  area  that,  by  virtue  of  the 
adhesions  thus  produced  and  the  new  vascular  anastomosis  thus  estal)lish(>d,  a  new  line 
of  vascular  connections  should  be  formed,  so  that  fluid  not  returnable  to  the  vena  cava 
by  the  usual  route  should  be  given  a  new  and  artificial  direction.  To  this  fundamental 
proposition  much  detail  has  been  added. 

Thus  Schiassi  has  shown  that,  so  far  as  the  supply  of  toxins  which  shall  pass  through 
the  liver  is  concerned,  there  are  really  two  portal  veins — the  superior  mesenteric  and 
the  splenic — or  he  would  call  what  we  usually  name  the  portal  system  the  splenoporinl. 
Consequently  he  would  include  the  spleen  in  the  above  mechanical  proccflure,  especially 
in  those  cases  where  it  particij)atcs  in  the  morbid  process — e.  cj.,  in  the  he]>atf)splenic  or 
pre-ascitic  form  of  Banti's  disease,  and  the  splcnomegalic  cirrhosis  described  by  Gilbert. 
In  1904  this  problem  was  studied  from  its  surgical  >ispects  by  Monprofit  (French  Congress 
of  Surgeons),  who  collected  224  operated  cases.  Of  these  84  died,  129  recovered  from 
the  operation,  and  11  could  not  be  traced.  In  25  cases  relapse  occurred,  in  2G  there  was 
improvement,  while  in  70  there  was  claimed  complete  recovery.^  In  other  words  about 
one-third  of  the  cases  thus  reported  have  recovered.  He  insists,  as  would  every  other 
surgeon,  that  with  this  showing  the  results  would  be  far  better  Avere  cases  seen  and 
operated  earlier.  His  statistics  are  not  widely  variant  from  those  of  Zesas,  who  found 
that  out  of  254  cases  whicii  he  collected  67  recovered  and  82  died,  while  42  were  greatly 
improved. 

In  brief,  we  may  hold,  witli  Ilolleston  and  Turner,  that  it  is  no  longer  advisable  to 
treat  ascites  by  repeated  tappings,  when  the  patient  is  otherwise  in  fairly  good  general 
condition,  for  nmnerous  surgeons  have  warned  against  repeated  punctures.  When  liver 
cirrhosis  can  be  diagno.sticated  with  fair  certainty  in  the  pre-ascitic  stage,  and  when  there 
is  e\idence  of  splenic  enlargement  or  hematemesis,  operative  intervention  would 
probably  succeed  far  better  than  in  the  later  stages.  So  far  as  special  intlications 
for  operation  are  concerned  they  may  perhaps  be  listed  as  follows: 

1.  Thrombosis  of  the  portal  vein  or  its  compression  by  inflammatory  products 

or  by  tumor; 

2.  Cirrhosis  of  cardiac  origin,  of  the  ordinary  hypcrtro])hic  or  even  atrophic  tA^JCS, 

as  well  as  that  due  to  syphilis  or  malarial  disease; 

3.  Pseudoliver  cirrhosis  of  pericardial  origin; 

4.  Diabetes  of  hepatic  origin ; 

5.  Splenomegaly  combined  with  hepatic  cirrhosis. 

If  these  indiraiions  he  met  hy  reasonably  early  omental  fixation  there  would  seem  to 
be  a  well-marhed  place  for  the  procedure,  while  they  cannf)t  give  rise  to  any  worse  results 
than  the  repeated  puncture  methods  of  old. 

Among  contra-indications  to  such  operations  may  be  mentioned   the  presence  of 

1  It  is  but  fair  to  add  that,  at  the  same  time.  DelageniiTe  maintained  that  sinc-e,  in  his  opinion,  firrhotic  processes 
in  the  lis-er  are  due  to  intestinal  infection,  the  treatment  shoukl  consist  of  combating  this  and  its  possible 
consequences,  to  which  end  he  would  make  a  temporary  cholecystostomy,  having  found  it  of  benefit  even  in  the 
atrophic,  but  mostly  in  the  hj'pertrojjhic,  forms  of  disease.  Thus  in  two  cases  of  this  procedure,  combined  with 
hepatopexy,  the  patients  3ur%-ived  eight  and  two  years  respectively.  Nevertheless  he  acknowledged  that  the 
best  results  would  probably  be  secured  from  combination  of  cholecystostomy,  hepatopexy,  and  omentopexy. 


THh:  Mi:si:\Ti':ny  937 

imich  Itiliarv  pi^iiicnl  in  the  iiriiic,  ils  uhscricc  t'roiii  the  feces,  jauiidiee,  or  marked 
pif^iiieiitatioii  of  the  skin,  w  liile  distiiiet  renal  insndieiency  would  also  make  any  sur^ieaj 
procedure  hazardous. 

The  oprnitton  itself,  done  according  to  the  sini|)ler  and  earlier  reeoinnienchitions  of 
Alorrisoii  and  Talma,  consists  in  median  ahdominal  section,  withdrawal  of  all  ascitic 
fluid,  and  the  deliberate  ])rovocution  of  adhesions  Ix-tween  the  diaj)hra<rm  and  the  upper 
surfaces  of  the  liver  und  the  spleen.  This  is  j)roduce(l  hy  vi(i;orous  .swabhinf;  to  u  degree 
suflicieiit  to  cause  a  little  oozino;  from  the  surfaces  attacked.  The  margin  of  the  liver 
may  then  he  fastciuMl  to  the  costal  border.  After  this  the  anterior  surface  of  the  omentum 
is  also  scarified  or  swabbed  and  afhxed  to  the  anterior  abdominal  wall,  which  has  been 
similarly  treated  over  as  large  an  area  as  possible,  by  means  of  catgut  sutures  |)laced  to 
the  best  possible  advantage  for  the  j)ur])ose.  Some  o|)crators  have  |)referred  to  clo.se 
the  abdomiMi  without  drainage,  some  to  insert  a  tube  in  the  lower  margin  of  the  wound 
for  a  day  or  two,  and  others  to  drain  the  lower  abdominal  cavity  through  a  small,  distinct 
()|)ening  above  the  j)ul)es.  Theoretically  much  advantage  attaches  to  pennitting  no 
immediate  re-accumulation  of  fluid.  Practically,  however,  danger  al.so  attaches  to  it, 
i.  c,  from  the  difficulty  of  so  managing  the  dressings  as  to  avoid  infection. 

Schiassi  has  modified  the  above  procedure  and  has  made  an  omniiosplnioprxij  of 
it  as  follows:  He  makes  a  right-angled  incision  across  the  median  line  and  then  another 
several  inches  downward  along  the  left  semilunar.  The  tissues  down  to  the  [teritoncum 
are  rcHected  toward  the  umbilicus,  and  a  transverse  deep  opening  is  made  just  below 
the  horizontal  skin  incision.  Through  this  the  omentum  is  drawn  U|>ward  and 
spread  over  the  right  portion  of  the  exposed  j)eritoneum,  where  it  is  sutured  in  ])lace. 
Through  another  vertical  opening  in  the  peritoneum,  near  the  vertical  skin  incision,  the 
spleen  is  then  exposed,  a  piece  of  gauze  is  placed  under  each  pole  of  that  organ,  and, 
while  thus  lifted,  by  means  of  a  long  curved  needle  three  to  six  catgut  sutures  are  passed 
through  it,  including  also  the  peritoneum  and  all  the  superficial  structures  except  the 
skin,  this  being  closed  later  and  separately. 

Finally,  whatever  operative  method  be  .selected  it  is  important  that  it  be  done  early 
rather  than  late,  bearing  in  mind  that  "the  resources  of  surgery  are  rarely  successful  when 
practised  on  the  dying." 

THE  MESENTERY. 

No  one  has  done  more  to  forcibly  place  before  the  surgical  profession  those  anatomical 
features  of  the  mesentery  which  most  concern  them  than  Monks,  who,  for  instance,  has 
demonstrated  the  fact  that  the  mesentery  is  practically  an  enormous  fan,  composed  of  two 
layers  of  peritoneum,  between  which  are  spread  out  the  vascular  structures  and  more 
or  less  fat,  and  who.se  border  contains  the  intestinal  tube.  This  fan  at  its  ba.se  is  but 
a  few  (six)  inches  in  length,  while  along  its  outer  border,  when  completely  unfolded, 
one  may  measure  a  di.stance  of  twenty-one  to  twenty-three  feet.  Not  one  of  the  structures 
contained  between  its  layers  can  be  regarded  as  a  negligible  quantity.  The  arterial 
distribution  in  the  mesentery  is  terminal  in  the  same  sense  that  it  is  in  the  brain.  Con- 
sequently dependence  can  be  placed  only  on  a  sufficient  blood  supjily  for  any  given 
portion  of  the  intestinal  tube  when  its  mesentery  is  intact.  If  necessary  to  sacrifice 
a  portion  of  the  mesentery  it  is  requisite  to  resect  that  j)ortion  of  the  bowel  which  is 
dependent  upon  it  for  bk)od.  This  will  explain  the  reason  why  thrombosis  or  embolism 
of  the  mesenteric  vessels  .so  quickly  determines  the  death  of  that  portion  of  bowel  sup- 
plied by  the  occluded  branches,  this  being  equally  true  of  the  tiny  fragment  known  as 
the  appendix  or  of  the  entire  bowel. 

The  root  of  the  mesentery  is  placed  obliquely  across  the  spinal  column,  arising  from 
the  left  side  above  and  crossing  obliquely  to  the  right  side  below.  ]\Ionks  has  shown 
how  easily  we  may  make  prac-tical  application  of  diis  fact  in  determining  approximately 
to  what  part  of  the  bowel  tube  a  given  loop  may  belong,  since  it  is  necessary  only  to  follow 
it  down  to  the  mesenteric  insertion,  and  from  this  estimate  what  proportion  of  the  entire 
distance  is  represented. 


938  SPECIAL  OR  REGIONAL  SURGERY 

INJURIES  OF  THE  MESENTERY. 

Obviously  the  mesentery  may  be  injured  in  the  same  way  as  any  other  of  the  abdominal 
viscera,  either  by  contusions,  lacerations,  punctures,  or  otherwise.  Here  the  immediate 
danger  is  from  hemorrhage,  while  a  more  remote  but  quite  ])ossible  danger  is  that  of 
thrombosis  of  some  of  the  vessels  and  its  consequences  in  tlic  direction  of  necrosis. 

Erdmann  has  recently  reported  two  cases  of  complete  detachment,  for  several  inches, 
of  the  mesentery  at  the  intestinal  border,  as  well  as  a  case  of  multiple  lacerations  in  the 
peritoneal  coat  of  the  mesentery  with  hematoma.  While  the  latter  might  not  be  so  serious, 
the  former  will  almost  invariably  determine  gangrene  of  bowel  from  lack  of  blood  supply; 
all  of  which  shows  the  difficulty  of  diagnosis,  and  furnishes  a  further  argument  for 
intervention  when,  after  an  abdominal  contusion,  the  patient  has  abdominal  rigidity 
or  pain,  with  or  without  evidences  of  hemorrhage,  either  from  the  stomach,  rectum,  or 
bladder.  These  features  are  sufficient  without  the  addition  of  those  by  which  a  more 
certain  or  minute  diagnosis  can  be  made. 

THROMBOSIS  AND  EMBOLISM  IN  THE  MESENTERIC  VESSELS. 

Mesenteric  occlusion  was  first  described  by  Virchow  in  1859.  Whether  it  involves 
first  the  arterial  or  the  venous  circulation  seems  to  matter  but  little.  Of  course  in  one 
case  it  is  to  be  regarded  as  embolic,  in  the  other  as  thrombotic.  In  this  location  either 
condition  is  harder  to  explain  than  in  many  other  places.  The  mesenteric  veins  have 
no  valves  and  collateral  circulation  is  poor.  Mitral  stenosis  and  arterial  sclerosis  will 
often  account  for  the  former.  For  thrombosis  search  has  to  be  made  for  some  local 
infectious  process,  either  in  the  veins  of  the  pelvis,  the  kidney,  or  the  intestines.  It 
seems  to  occur  least  often  when  it  might  be  most  expected,  i.  e.,  after  typhoid. 

The  blood  supply  may  be  simply  shut  off  from  portions  supplied  by  one  of  the 
mesenteric  vascular  branches,  or,  should  the  main  branches  be  involved,  from  the 
entire  intestinal  tract.  I  have  myself  reported  two  cases  of  practically  complete  rapid 
gangrene  of  the  entire  alimentary  canal,  due  to  lesion  of  this  kind,  explanation  being 
forthcoming  in  neither  case. 

Symptoms  and  Signs. — The  more  complete  the  occlusion  and  the  more  extensive 
the  area  deprived  of  blood  the  more  sudden  and  overwhelming  will  be  the  onset.  This 
is  always  sudden  and  characterized  by  intense  and  often  paroxysmal  pain,  so  agonizing, 
in  fact,  as  scarcely  to  be  quieted  even  by  morphine.  While  this  is  common,  instances 
have  been  known  in  which  the  disease  has  run  an  almost  painless  course.  Diarrhea 
is  frequently  an  early  symptom,  evacuations  being  profuse  and  bloody.  Symptoms  of 
obstruction  are  not  uncommon,  perhaps  followed  later  by  loose  stools.  Vomiting 
occurs  usually  early  and  becomes  fatal  in  a  few  hours.  The  general  physical  signs  are 
intensely  acute,  with  rapid  pulse,  subnormal  temperature,  and  meteorism,  beginning 
early  and  becoming  more  pronounced.  Abdominal  rigidity  also  constitutes  a  distressing 
feature,  which,  while  indicating  the  gravity  of  the  condition,  masks  its  diagnostic  features. 
If  the  patient  live  long  enough  fluid  will  accumulate  in  the  peritoneal  cavity.  The  cases 
terminate  with  complete  collapse  and  delirium.  When  the  inferior  mesenteric  vessels 
are  involved  tenesmus  is  a  more  prominent  characteristic  than  when  the  lesion  is  confined 
to  the  upper,  as  the  colon  and  rectum  are  supplied  from  the  former. 

The  surgeon  may  have  to  distinguish  between  the  condition  just  described  and  the 
following:  Perforating  ulcer  of  the  stomach  or  duodenum  (which  will  have  a  previous 
history),  possibly  so-called  phlegmonous  gastritis;  acute  obstruction  of  the  bowel  (whose 
onset  is  rarely  so  acute);  pancreatitis,  which  would,  at  least  at  first,  produce  almost 
identical  symptoms;  acute  splenic  infarct  (when  the  early  symptoms  would  probably 
be  referred  to  the  region  of  the  spleen);  acute  appendicitis;  acute  cholecystitis,  and  that 
acute  peritonitis  to  which  either  of  these  might  lead;  a  ruptured  ectopic  pregnancy;  and 
possibly  certain  intrathoracic  lesions,  especially  pneumonia  in  the  lower  lobes.  Mesen- 
teric occlusion  is  essentially  a  fatal  condition,  at  least  when  extensive.  There  have  been 
known  cases  where  so  limited  an  extent  of  the  bowel  and  mesentery  were  involved 
that  an  exsection,  made  early,  has  proved  successful,  but  when  anything  like  the  entire 
alimentary  canal  or  its  major  portion  becomes  necrotic  there  is  no  hope  for  the  patient.* 

>  Annals  of  Surgery,  April,  1904. 


CANCER  OF  TIfK  MESENTERY  939 


ABSCESS  OF  THE  MESENTERY. 

Abscess  fonnntion  may  take  place  within  the  mesenteric  structures,  as  an  expression 
of  acute  septic  infection  or  of  a  mixed  infection  of  old  tuberculous  foci  in  the  nodes. 
A  careful  case  history  or  some  peculiarity  of  local  conditions  may  ()ccasi(jiially  furnish 
a  clue  to  the  conditions,  otherwise  it  will  not  be  distinctly  revealed  until  such  ()])eration 
as  may  be  necessitated  by  unmistakable  indications  of  the  j)resence  f)f  pus  or  by  autopsy. 
Inasnuich  as  operation  can  scarcely  exafi^fjerate  the  danger  of  the  coiiditioti  it  would  be 
best  attemj)ted  when  such  abscess  is  suspected.  When  the  meso-appendix  is  involved, 
as  is  often  the  case,  the  trouble  may  be  so  walled  off  that  it  is  almost  a  j)urely  local  affair. 


TUBERCULOSIS  OF  THE  MESENTERY. 

Aside  from  the  common  miliary  exjiressions  of  acute  tuberculosis  which  are  seen  so  fre- 
(|ucnlly  dotted  all  over  the  bowel  surfaces  and  the  exj)anse  of  the  mesenteric  folds,  there 
is  a  jM^culiar  form  of  involvement  of  the  mesenteric  nodes,  i.  e.,  those  which  are  cs])ecially 
clustered  alon<j  its  root.  These  are  always  involved  in  general  tuberculous  peritonitis, 
though  but  slowly  in  the  absence  of  such  generalized  features.  To  the  slow  forms  of 
this  condition  the  early  writers  gave  the  name  tabes  mesejiterica.  The  more  limited 
the  involvement  the  greater  interest  the  lesion  has  for  the  surgeon,  since  it  may  be  so 
limited  to  the  nodes  of  a  single  coil  as  to  justify  extirpation.  In  fact,  if  such  a  focus 
could  be  easily  and  thoroughly  removed  without  too  much  disturbance  of  circulation, 
tabes  might  be  remedied  by  surgery.  Not  very  frecjuently,  however,  do  the  location 
or  the  arrangement  of  a  collection  of  tabetic  nodes  permit  of  their  enucleation.  They  are 
Usually  too  numerous,  too  large,  too  degenerated,  too  adherent,  or  the  patient  otherwise 
too  extensively  infected. 

The  acuter  expressions  of  mesenteric  tuberculosis  may  be  considered  as  already 
sufficiently  discussed  under  the  caption  of  Tuberculous  Peritonitis. 

Occasionally  a  localized,  slightly  mobile  tumor,  especially  in  the  ileocecal  region,  may 
cause  susjiicion,  or  may  be  correctly  diagnosticated,  by  taking  note  of  other  symptoms, 
along  with  a  good  case  history.  Especially  is  this  the  case  in  patients  known  to  be  tuber- 
culous. This  is  particularly  true  of  the  appendix  and  its  mesentery,  where  a  tulierculous 
gumma  may  attain  considerable  size  before  there  is  any  active  breakdown.  The  relation 
between  this  condition  and  tuberculous  ulceration  within  the  bowel  will  also  be  obvious. 
Moreover,  it  is  of  interest  to  recall  that  calcification  of  mesenteric  nodes  is  not  impossible, 
and  that  occasionally  chalky  tumors  in  this  location  may  be  thus  explained. 

There  is  also  a  possibility  of  involvement  of  the  mesenteric  nodes  in  constitutional 
syphilis  and  in  actinomycosis. 

The  treatment  of  mesenteric  tuberculosis  should  consist  of  exploration  and  orienta- 
tion, followed  by  whatever  procedure  the  condition  thus  revealed  may  require — e.  g., 
abdominal  irrigation,  with  or  without  antiseptics,  extirpation,  drainage,  or  even 
resection  of  a  portion  of  the  bowel  (appendix,  cecum,  etc.). 


CANCER  OF  THE  MESENTERY. 

The  other  condition  in  which  the  mesenteric  nodes  are  especially  involved  is  the  can- 
cerous. In  this  location,  as  in  the  omentum,  sarcoma  may  be  primary  and  endothelioma 
may  occur,  but  carcinoma  is  never  primary,  although  it  invariably  occurs  as  an  extension 
from  epithelioma  or  adenocarcinoma  of  the  bowel.  Otherwise  cancer  will  appear  here 
as  an  expression  of  metastasis.  In  all  primary  cancers  of  the  intestine  early  involvement 
of  the  mesenteric  nodes  may  be  looked  for,  while  involvement  of  everything  in  the 
vicinity,  even  the  aorta  or  spine,  will  occur  in  due  time,  often  with  more  or  less  breaking 
down.  There  would  be  little  justification  for  attacking  any  cancerous  portion  of  the 
mesentery  or  any  cancerous  nodes  unless  the  primary  lesion  could  be  radically  removed. 
Generally  speaking,  in  bowel  cancer  invasion  of  the  deep-seated  nodes  imparts  to  the 
case  such  an  unfavorable  aspect  as  to  justify  only  palliative  (anastomotic)  rather 
than  radical  measures. 


940 


SPECIAL  OR  REGIONAL  SURGERY 


CYSTS    OF    THE  MESENTERY. 

Cysts  of  the  mesentery  are,  in  the  main,  similar  to  those  met  with  in  the  omentum 
(Fig.  631).  A  jieculiar  form  of  mesenteric  cyst  is  produced  by  ol).struction  and  con- 
sequent dihitation  of  one  or  more  of  the  lacteals,  and  is  known  a.s  rhylr  cy.si.  It  may 
attain  ((iiisidcrahlc  size  and  occur  in  multiple  form.     The  contained  flui<l  is  naturally 

Fk;.  G3i 


Cyst  of  the  mesentery,  containing  clear  fluid.     The  hour-glass  constriction  passes  through  the  layers  of  the 
mesentery.     (From  a  case  occurring  in  Richardson's  practice.) 

milky  and  corresponds  to  that  seen  in  cliylous  ascites  and  hydrocele.  These  lesions 
are  only  recofjnized  after  exploration.  When  found  they  are  to  he  extirpated,  on  general 
principles,  usually  by  enucleation,  witli  ligature  of  the  connecting  lacteals  and  avoidance 
of  all  unnecessary  disturbance  of  blood  supply. 

THE  SPLEEN. 

The  spleen  is  often  an  object  of  surgical  interest,  not  alone  because  of  the  frequency 
with  which  it  is  enlarged  in  the  course  of  the  acute  surgical  infections,  but  because  it  is 
something  more  than  a  reservoir  for  blood.  Thus  it  seems  to  enlarge  to  accommodate 
blood  forced  in  from  the  exterior  under  conditions  of  extreme  exercise,  etc.,  and  in  the 
higher  vertebrates  it  seems  to  he  a  place  where  ])lood  cor])uscles  are  destroyed,  especially 
those  which  are  already  disintegrating,  rather  than  one  in  which  they  are  manufactiu-ed. 
It  is  claimed  by  Ehrlich  tliat  the  splenic  enlargement  of  the  infectious  cHseases  is  {iroduced 
mainly  by  the  products  of  disintegrating  leukocytes  which  are  allowed  to  accumulate. 


ANOMALIES  OF  THE  SPLEEN, 

Of  the  confjenifnl  anomalies  or  defects  the  surgeon  is  mainly  interested  in  the  fact 
that  supernumerary  spleens  are  common,  being  found  perhaps  in  one  out  of  four  bodies 
varying  in  number  up  to  thirty  or  forty,  located  near  the  hilus  in  the  gastrosplenic 
omentum,  in  the  great  omentum,  or  even  in  the  pancreas.  Doubtless  after  some 
splenectomies  no  pecidiar  .symptoms  are  profluced,  which  is  due  to  the  fact  that  .some 
of  the  supernumerary  organs  have  taken  up  the  splenic  function.  The  .spleen  varies 
in  .shape  to  such  an  extent  that  the  notch  upon  which  so  much  stress  is  often  laid  in 


llYl'i:RTR(>l'llli:S  OF   THE  SPLEEN  041 

(liaj,'n(>.si.s  will  iiol  always  In-  lomid  aloiij^MJic  anterior  Ixtnlcr.  Incases  of  transposititHi 
of  the  vistvra  tlic  s|)li>eii  may  be  found  on  the  v\<i\\i  side.  It  has  been  found  hi  the 
sacs  of  Uir^e  umbilical  hernias  and  in  the  left  thorax  after  defects  of  the  diaphragm. 


INJURIES    TO    THE    SPLEEN. 

The  spleen  mav  be  injured  by  itself  or  aloni,'  with  other  viscera.  The  most  conunon 
injury  is  front  contusion,  wiiieJi  produces  more  or  less  disintejfration  or  rupture  and 
hem(')rrha<,'e.  The  organ  is  so  friable  that  it  may  literally  burst  under  a  comparatively 
slight  force,  other  conditions  being  favorable.  Doubtless  minor  degrees  of  these  injuries 
pass  unnoticed  or  are  followed  by  some  local  peritonitis  and  adhesions.  On  the  other 
hand  the  spleen  may  be  actually  fragmented,  with  necessarily  fatal  consequences  unless 
prom|)tly  operated,  liiiptiin;  is  especially  likely  to  occur  after  those  infectious  diseases 
which  cause  its  enlargement — r.  (/.,  typhoid. 

In  case  of  injury  there  is,  in  addition  to  the  history,  a  |)r()mpt  location  of  |)ain  in  the 
region  of  the  spleen,  with  signs  of  intra-abdominal  hemorrhage,  but  without  blood  in 
the  urine;  j)erha|)S  with  tumor  or  dulness  on  percussi;)n,  and  always  with  abdominal 
rigidity,  all  of  which  point  to  the  serious  nature  of  the  injury  and  demand  exploratory 
section.  Should  this  reveal  a  slight  injury  it  may  be  repaired  with  ligatures  or  sutures. 
INIore  serious  tears  or  perforations  are  treated  by  gauze  packing  through  a  sufficiently 
o])en  wound,  while  the  most  serious  cases  of  j)ulpifaction  call  for  complete  extirpation. 
When  the  blood  supply  of  the  spleen  is  left  in  doubt  its  total  removal  will  befar  the  safer 
course  to  adoi)t.  Obviously  such  an  operation  should  include  examination  of  all  the 
viscera  and  a  careful  toilet  of  the  peritoneum. 

ABSCESS  OF  THE  SPLEEN;  SUPPURATIVE  SPLENITIS. 

Pus  may  form  within  the  spleen  in  consequence  of  septic  infarcts  or  thrombosis,  or 
it  may  be  due  to  tiie  extension  of  trouble  from  adjoining  foci,  or  to  pyemic  metastasis. 
Splenic  abscesses  are  usually  localized,  but  the  pyemic  forms  are  always  multiple,  miliary 
at  first,  but  coalescing  into  larger  collections,  and  practically  destroying  the  organ  if 
the  patient  live  long  enough.  The  infectious  fevers  may  be  folio w^ed  by  su})puration 
of  tlu-  s])Ieen,  which  is  also  known  to  occur  rarely  in  malaria. 

Symptoms. — The  symptoms  of  splenic  abscess  are  indeterminate  until  the  capsule 
is  involvetl  and  a  perisplenitis- — i.  e.,  a  local  peritonitis — results,  after  which  pain  becomes 
severe.  These  collections  occasionally  discharge  spontaneously  into  the  colon  or  even 
into  the  stomach. 

On  general  principles  any  absc-ess  which  can  be  located,  even  soinewhat  vaguely, 
should  be  attacked.  After  the  abdomen  is  opened,  preferably  through  the  left  semi- 
lunar line,  the  exploring  needle  may  be  used,  especially  if  adhesions  be  present. 


GANGRENE    OF    THE    SPLEEN. 

Gangrene  of  the  spleen  is  the  result  of  a  still  more  rapid,  otherwise  similarly  septic 
or  throml)otic  process,  or  of  severe  injury,  by  which  circulation  is  practically  cut  off. 
It  is  a  condition  which  rarely  ])i>rmits  of  any  surgical  help,  though  if  it  could  be  foreseen 
it  might  be  prevented  by  an  early  splenectomy. 


HYPERTROPHIES  OF  THE  SPLEEN. 

Enlargement  of  the  spleen  occurs  during  numerous  acute  and  chronic  infections — 
e.  (].,  typhoid,  malaria— in  connection  with  certain  affections  of  the  liver;  in  consequence 
of  interstitial  or  gummatous  forms  of  sijphilis,  with  or  without  similar  lesions  in  the  liver; 
in  acute  peritoneal  infections;  in  general  septic  and  pijcmic  disturbances;  in  rickets  and 
the  status  hpnphaticus;  in  the  various  forms  of  leiil-emia,  Hodqkins  disease,  and  pseudo- 
leukemia, and  in  that  somewhat  peculiar  type  known  as  Banti's  disease,  or  spleno- 


942  SPECIAL  OR  REGIONAL  SURGERY 

megaly.  In  fact  the  sploon  enlarges  under  so  many  cf»nditions  that  its  hypertrophy 
is  an  expression  of  a  j^eneral  infection  rather  than  of  any  pnuiounced  or  particular 
type  of  the  same.  Minor  degre<'s  of  enlargement  have  often  j^assed  unnoticed  or  given 
little  or  no  trouble.  When  seriously  overgrown  its  [principal  features  are  its  inconvenience, 
weight,  and  size.  The  condition  is  recognized  by  its  characteristic  shape  and  notch 
(See  above.)  By  its  extension  upward  it  can  be  u.sually  di.stingui.shed  from  a  tumor, 
of  the  kidney. 

Ever}'  splenic  enlargement,  especially  chronic,  should  )<  ad  tfj  a  careful  blood  examina- 
tion, by  which,  among  other  things,  malaria  may  be  recfjgnized  or  excluded,  while  the 
degree  and  form  of  leukemia,  if  present,  may  be  estimated.  The  lymph  nodes  through- 
out the  body  should  also  be  carefully  examined.  Splenomyelogenous  leukemia,  for 
example,  is  jjrcjgressive,  severe,  and  marked  by  cachexia  and  anemia  of  peculiar  type. 
In  many  of  these  cases  there  is  a  tendency  to  hemorrhage,  both  from  surfaces  and  into 
the  tissues.  The  hemoglobin  is  much  reduced  and  prognosis  after  any  operation  Is 
unfavorable.       (See  chapters  on  the  Blood  and  the  Lymphatic  System.) 

Banti's  dvsea^se,  or  splenomegabj,  seems  alsfj  a  somewhat  peculiar  type  of  lesion  which 
is  probably  due  to  an  infection  proceeding  from  the  intestinal  canal,  and  involving 
the  liver  in  its  later  course.  In  its  last  stage  there  Is  a  tendency  to  hepatic  cirrhosis,  with 
ascites,  and  hemorrhages  in  any  part  of  the  body  are  frequerjt. 

Removal  of  the  spleen  for  any  of  these  conditions  is  usually  a  precarious  procedure. 
It  has  been  more  successful  when  performed  for  malarial  hypertrophy  than  for  other 
conditions,  the  patient's  chances  being  then  about  three  out  of  four;  but  here,  too,  the 
lesion  is  usually  amenable  to  other  treatment.  If  done  in  the  early  stages  of  Banti's 
disease  it  would  seem  to  be  strongly  indicated,  but  not  in  the  later  stages,  when  the 
liver  is  involved  and  the  abdomen  full  of  fluid.  In  the  leukemias  it  has  succeeded  in  a 
few  instances.     It  is  mostly  indicated   in  those  cases  where  hemorrhages  occur  early. 

The  Rontgen  rays  have  recently  been  shown  to  have  an  excellent  effect  in  many  of 
these  cases  and  are  worthy  of  trial.  Es{>ecia]ly  in  the  leukemic  forms,  in  connection 
with  arsenic  internally,  they  fjf^'er  probably  the  }je-,t  [>rf>sf>ects. 


SPLENIC  DISPLACEMENTS. 

While,  under  ordinary  circumstances,  the  .iupport.->  of  the  .^jjleen  may  seem  equal 
to  ordinary  needs  they  prove  insufficient  in  many  cases  of  marked  enlargement.  Hence 
results  displacement,  or  the  so-called  "wandering  spleen,"  whi^h  may  be  due  to  the 
results  of  injury,  to  tight  lacing,  possibly  to  congenital  relaxation  of  ligaments,  but  mainly 
to  hypertnjphy,  with  increase  in  size  and  weighr.  When  the  spleen  enlarges  it  descends 
toward  the  umbilicus,  but  it  has  even  been  found  in  the  pelvis.  As  it  prolapses  it  brings 
down  with  it  the  stomach  and  the  pancreas,  thus  interfering  with  the  circulation  of  all 
three  organs  and  producing  a  train  of  distressing  secondary  consequences.  A  long- 
drawn-<jut  splenic  ligament  may  be  much  stretched  and  may  even  become  finally  tu-isted, 
thus  causing  gangrene  of  the  spleen  from  torsion  of  its  support.  Moderate  displacement 
and  stretching  produce  discomfort,  pain,  and  disturbance  of  function.  Such  a  displaced 
spleen  is  to  be  recognized  by  its  shape,  size,  and  notch,  and  is  occasionally  to  be 
distinguished  from  a  wandering  kidney.  When  displaced  its  normal  location  will  not 
be  didl  upon  percussion. 

Treatment. — Palliative  treatment,  which  may  be  tried  first,  culls  for  whatever  drugs 
may  be  needed  to  unload  the  bowels,  but  especially  for  rest  in  bed  and  sup[>ort  by  suitable 
abdominal  binder,  with  or  without  a  pad.  If  the  spleen  itself  be  much  enlarged  it 
may  also  be  subjected  with  a  judicious  frequency  to  the  j^-rays. 

Operative  help,  which  is  the  only  measure  when  other  treatment  fail>,  should  come 
either  through  a  splenopexy  or  splenectomy,  preferably  the  former,  save  in  the  presence 
of  serious  disease  which  may  call  for  its  extirpation.  Nevertheless  splenopexy,  which 
seems  so  simple  and  so  promising,  is  often  unsatisfactorv'  because  of  the  friability  of  the 
spleen  itself  and  the  weakness  of  its  capsule.  Here,  as  in  hepatopex}',  the  intent  is  to 
profluce  arlhesions,  In'  scarification  of  the  external  peritoneal  surroundings,  which  is 
made  through  a  suitable  incision,  directed  usually  along  the  left  costal  border;  after  thus 
intentionally  provoking  adhesions,  sutures  may  be  u.sed  if  there  be  any  prospect  of  their 
being  serviceable. 


PLATE   LVl 


Upper  Abdominal  Viscera,  showing  their  Normal  Relations.      (Sobotta.) 


Till':  i\\\('Ri:.\s  943 


NEOPLASMS  OF  THE  SPLEEN. 

Splenic  r//.s7.v  of  the  serous  or  hlotxl  ti//)r  arc  seldom  seen.  Even  hi/datids  here  arc 
uneoiiiiiion.  Sdrroiiid  ot"  the  s|)leen  may  he  primary;  rarcluoina  is  due  to  extension  or 
metastasis.  In  |)roportion  as  splenic  tumors  develop  tlicy  may  l)e  reco<);nized  as  involvinir 
this  particular  origan.  While  a  carel'ul  blood  examination  may  permit  the  exclusion  of 
{•ertain  conditions,  exact  early  dia<rnosis  will  scarcely  he  made  without  exploration, 
which  is  justifial)le  whenever  the  blood  count  would  indicate  it.  After  cxposin<f  the 
lesion  the  surgeon  is  for  the  first  time  in  a  position  to  judge  w'hcther  to  drain  or  extirpate 
a  cyst,  or  remove  part  or  the  whole  of  the  spleen  itself. 


OPERATIONS  UPON  THE  SPLEEN. 

Besides  those  operations  addressed  toward  fixation  of  a  more  or  less  enlarged  or  wand- 
ering sj)Ieen  a  sjdenofoiiii/  can  be  made — /.  e.,  incision  and  drainage  at  any  suitable 
point,  anterior  or  posterior,  which  can  be  satisfactorily  exposed;  and  evacuation  of 
fluid  may  be  followed,  with  or  without  suture  of  the  deep  to  the  external  wound,  by 
gauze  packing  or  tubage,  combined,  if  necessary,  with  counteropening  or  posterior 
drainage. 

Splenectomy. — Total  removal  of  the  spleen  is  performed  through  an  incision  w  hich 
should  be  made  anij)le  for  the  j)urj«)se,  either  along  the  costal  border  or  the  left  semilunar 
line  or  by  combination  of  both.  A  median  incision  may  be  also  utilized  if  it  will  j)ermit 
better  access.  Splenect(^my,  under  ordinary  circumstances,  would  not  be  a  difficult 
operation,  but  with  the  organ  enormously  enlarged  and  the  vessels  dilated,  as  they  may 
be,  it  becomes  usually  a  formidable  procedure.  The  most  serious  difficulty  and  danger 
arise  from  the  numerous  adventitious  vessels  which  may  connect  the  spleen  with  the 
diaphragm  or  with  some  of  its  other  surroundings,  and  whose  location  is  to  be  made 
out  before  an  attempt  is  made  to  remove  it.  Thus,  in  one  instance,  I  have  seen  an 
adventitious  vein,  the  size  of  the  little  finger,  between  the  upper  splenic  surface  and  the 
dia[)hragm.  Through  such  large  vessels  torrents  of  blood  will  pour  unless  they  be 
first  secured.  All  such  connections  then  with  the  stomach  and  the  diaphragm  have 
to  be  ligated  and  separated  with  great  care,  while  gentleness  of  manipulation  is  requisite 
throughout  the  operation.  The  spleen  may  be  reached  and  adhesions  be  located  with 
great  speed  of  manipulation,  but  in  the  depths  of  such  a  wound  valuable  time 
may  be  consumed  and  much  blood  lost,  all  at  a  time  when  the  patient  can  least 
tolerate  them.  Oozing  from  vessels  which  cannot  be  secured  should  be  checked  by 
gauze  packing. 

THE  PANCREAS. 

The  anatomical  fcaturi>s  of  the  pancreas  which  have  most  interest  for  the  surgeon 
are  the  facts  that  its  head  is  in  contact  wdth  the  duodenum,  and  lies  usually  so  closely 
against  the  second  pcn-tion  of  the  former  as  to  surround  from  one-fourth  to  one-third  of 
its  lumen.  Becoming  adherent  at  this  point  it  may  then  produce  obstruction  high  up 
in  the  intestine.  In  rare  instances  it  may  even  completely  surround  the  duodenum, 
and  thus  may,  when  swollen,  cause  tight  constriction  of  the  latter.  Should  this  condition 
be  met  with  a  gastro-enterostomy  would  be  the  proper  measure  for  relief.  These  intimate 
relationships  account  for  the  spread  of  disease  from  the  pancreas  to  the  intestine,  rarely 
in  the  reverse  direction.  The  pancreas  lies  also  in  contact  with  the  stomach  along  its 
anterior  peritoneum-covered  surface,  and  malignant  disease  travels  easily  from  one  to 
the  other.  Ulcers  of  the  stomach,  favorably  situated,  may  also  be  followed  by  adhesif)n 
and  inflammatory  infiltration  of  the  pancreas,  by  w^hich  the  viscera  are  cemented  to- 
gether, the  same  result  following  duodenal  ulcer,  as  well  as  serious  disease  about  the 
biliary  passages.  Thus  under  a  variety  of  circumstances  the  operator  may  find  these 
parts  so  cemented  as  to  be  separated  only  with  the  greatest  difficulty,  or  perhaps  not  at 
all,  without  causing  laceration  or  rupture  of  one  or  more  of  them,  with  escape  of  contents 
which  are  often  septic.  Therefore  when  there  is  reason  to  fear  this  accident  it  will 
usually  be  safer  to  simply  make  a  gastro-enterostomy.     (See  Plate  LVI.) 


944  SPECIAL  OR  REGIONAL  SURGERY 

The  relations  of  the  biliary  ducts  to  the  pancreas  are  most  important,  the  association 
of  the  common  duct  with  tliat  of  Wirsunjf  having  the  greatest  bearing  upon  a  variety 
of  conditions,  which  are  nearly  all  essentially  surgical.  The  former,  tlescending  along 
the  head  of  the  pancreas,  comes  in  contact  with  the  duct  of  the  latter,  and  passes  along- 
side of  it  for  a  short  distance  before  entering  tiie  intestinal  wall.  In  about  two-thirds 
of  individuals  it  is  completely  enclosed  by  the  j)ancreas.  In  the  other  third  it  lies  in  a 
deep  groove  upon  it.  Resting  here,  as  it  were  like  Siamese  twins,  it  will  be  easily  seen 
how  disturbance  in  one  duct  or  its  source  may  be  reflected  to  the  other.  When  the 
common  duct  lies  in  a  groove  it  is  less  likely  to  be  seriously  compressed  by  pancreatic 
engorgement  than  when  actually  embedded  in  pancreatic  tissue.  The  degree  of  resulting 
jaundice  may  thus  be  dependent  upon  anatomical  conditions  not  determinable  before 
exploration.  Such  pressure  doubtless  accounts  for  many  cases  of  so-called  catarrhal 
jaundice.  When  the  condition  becomes  constant,  or  nearly  so,  a  chronic  interstitial 
pancreatitis  may  be  assumed,  which  really  warrants  an  operation — /.  e.,  cholecystostomy 
with  drainage.  When  a  gallstone  is  passing  through  the  common  duct,  especially  when 
lingering  or  impacted,  it  may  have  in  turn  reversed  this  condition,  and,  by  obstructing 
the  pancreatic  duct,  set  up  as  a  consequence  pancreatic  stagnation  and  consequent 
digestive  disturbance,  and  such  other  internal  conditions  as  invite  infection  from  the 
duodenal  cavity,  with  a  more  or  less  lively  pancreatitis,  perhaps  even  of  fulminating 
type,  by  which  life  may  be  jeopardized. 

The  pancreas,  however,  being  usually  j^rovided  with  two  ducts,  the  second  (that  of 
Santorini)  is  often  represented  as  an  additional  safeguard,  since  it  usually  has  a  separate 
opening  into  the  duodenum  below  the  ampulla.  Opie  carefully  studied  100  cadavers 
and  found  that  in  more  than  50  of  them  the  accessory  duct  could  be  of  no  use  or  relief, 
and  that  in  only  10  instances  did  two  independent  ducts  enter  the  intestine,  while  in 
the  other  90  they  were  united,  and  in  21  of  the  latter  the  accessory  duct  had  become 
obliterated.  Moreover,  in  only  6  of  the  100  instances  was  it  larger  than  the  duct  of 
Wirsung.  This  will  show,  then,  how  little  reliance  may  be  placed  upon  the  duct  of 
Santorini.  Moreover,  no  matter  which  duct  is  opened,  or  whether  both  are,  so  long  as 
pancreatic  fluid  can  escape  there  is  an  open  channel  for  infection,  and  when  it  cannot 
escape  it  may  be  seen  that  infection  has  already  occurred  and  is  manifesting  its  pressure 
consequences.  Chemosis  of  mucous  membrane  may  be  the  first  mechanical  result  of 
such  infection,  but  this  is  sure  to  be  followed  by  interstitial  sclerosing  and  com- 
pressing effects. 

The  normal  duct  opening  in  the  duodenum  is  also  a  matter  of  surgical  interest. 
The  ampulla  of  Vater,  within  the  second  portion  of  the  duodenum,  is  usually  described 
as  a  conical  protrusion  or  papilla,  having  an  average  length  of  4  Mm.,  with  an  opening 
2.5  Mm.  in  diameter,  this  being  the  narrowest  ])ortion  of  the  common  duct,  but  from  this 
arrangement  there  are  many  variations.  The  ducts  may  join  at  some  distance  from 
the  intestine,  or  they  may  open  independently  into  a  depression  or  into  a  protrusion,  and 
the  amj)ulla  be  thus  totally  wanting,  all  of  which  has  the  greatest  possible  bearing 
upon  what  may  happen  during  the  passage  of  gallstones,  for  instance,  or  by  infection 
.  and  according  to  its  direction;  and  may  account  for  the  difficulty  met  in  certain  cases, 
as  when,  for  example,  it  becomes  necessary  to  incise  the  duodenum  and  open  the  ampulla 
for  the  removal  of  a  pancreatic  or  biliary  calculus.  It  will  emphasize,  too,  the  necessity 
for  always  exploring  the  common  duct  by  opening  the  biliary  passage  and  thus  making 
sure  of  its  patency. 

ANOMALIES  OF  THE  PANCREAS. 

Congenital  anomalies  include  not  only  those  of  the  ducts  above  mentioned,  but  the 
presence  of  acce.ssorij  masses,  like  the  accessory  thyroids,  which  may  occasionally  lead  to 
confusion  and  perplexity.  Furthermore,  accessory  nodules  of  pancreatic  tissue  may  be 
found  alongside  the  ducts,  or  even  in  the  walls  of  the  stomach  and  intestine,  where  they 
are  probably  present  more  often  than  is  generally  appreciated,  and  are  to  be  explained 
by  the  embryology  of  the  parts,  since  the  pancreas  is  known  to  take  origin  from  a  cluster 
of  cells  in  the  wall  of  the  upper  end  of  the  developing  intestinal  canal.  They  have  been 
seen  also  along  the  line  of  a  jx'rsistent  vitelline  duct.  Such  small  accessories,  when 
present,  usually  empty  by  minute  independent  ducts  into  the  intestine.  On  the  same 
embryonal  grounds  are  to  be  explained  other  anomalies  occasionally  met,  such  as 


/NJURIKS   TO   THE   IWSCUKAS  945 

srpiinitioii  into  (U'taclu'd  portions.  Tlie  cxislcnoc  of  ucccssory  j)iUKT('Jitic  jrliuuls  is  also 
liold  to  account  i'or  tlic  absence  of  glycosuria  in  certain  cases  wliere  tlie  ])rinci])al  portion 
of  the  })ancreas  is  itself  extensively  diseased. 

GLYCOSURIA. 

(ilycosuria  is  so  associated  with  the  ])o|)idiir  conception  of  pancreatic  disease  tliat  it 
seems  imperative  to  state  what  importance  should  be  attached  to  it.  It  is  now  clearly 
established  that  the  so-called  "islands  of  Langerhans"  have  to  do  with  the  elaboration 
of  a  certain  glycolytic  ferment,  and  that  the  failure  in  its  supj)ly  to  the  blood  (it  being 
regarded  as  an  internal  secretion)  is  followed  by  the  a])))earance  of  sugar  in  the  urine, 
'iiiese  islands  are  not  coiuiected  with  the  ducts,  at  least  not  in  the  vertebrates,  and 
usually  csca|)e  pressure  efi'ects  in  chronic  interstitial  j)aiicreatitis  of  the  intcracinous 
as  well  as  of  the  intcrlobidar  form.  This  ex])lains  the  accompaniment  of  diabetes  in 
some  instances  of  |)ancn'atic  disease  and  its  absence  in  others.  Again,  if  only  part  of 
tiie  pancreas  be  affected,  as  in  cancer,  the  rcnuiining  healthy  j)ortion  may  still  afford  a 
sufficient  amount  of  this  ferment  to  sup])ly  the  body  needs. 

The  uncertain  symj)tomatology  of  the  slower  forms  of  pancreatic  diseast;  is  to  be; 
accounted  for  by  the  fact  that,  with  the  exception  of  its  glycogenic  function  just 
mentioned,  all  its  other  functions  may  be  vicariously  assumed  by  other  organs  of  the 
body.     'Wws  as  a  com|)oun<l  racemose  gland  it  furnishes — 

1.  Trypsin,  a  j)r()teolytic  ferment; 

2.  Amylopsin,  a  starch-s])litting  ferment; 

3.  Steapsui,  a  fat-digesting  ferment;  and 

4.  A  milk-curdling  ferment. 

The  first  of  tliese  functions  may  to  some  extent  at  least  be  assumed  by  the  stomach 
and  the  others  by  the  bile  and  intestinal  juices.   (Mayo  Robson.) 


INJURIES    TO    THE    PANCREAS. 

Injuries  to  the  pancreas  may  occur  with  or  without  external  traumatisms.  By  any 
kind  of  injin-y  which  affects  the  gland  it  is  probable  that  its  glandidar  structure  may 
be  so  disru])ted  as  to  set  free  an  autodestructive  secretion,  which,  by  softening  and 
weakening  vascular  walls,  may  lead  to  hemorrhage  and  to  the  accumulation  of  a  collection 
of  inflanmiable  material,  which  is  a  good  culture  medium,  and  which  needs  only  the  spark 
of  infectic^n  to  be  easily  aroused  into  a  conflagration.  That  possibility  of  infection  is 
imminent  is  a]i])arent  from  the  relations  of  the  adjoining  viscera  and  their  ducts,  as 
already  outlined.  However,  the  same  is  true  of  even  a  first  and  spontaneous  hemor- 
rhage, as  of  the  clot,  however  produced.  It  has  been  held  that  the  manipulations  to 
which  the  ])ancreas  has  been  unavoidably  submitted  diu'ing  many  operations  may  lead 
to  its  acute  inflammation  or  destruction.  On  the  other  hand,  there  seems  no  doubt 
but  that  it  is  sometimes  much  relieved  or  benefited  by  a  mild  massage  as  a  part  of  the 
operative  ])rocedure.  Mayo  llobson  has  suggested  that  concretions  may  thus  be  pushed 
along  or  adhesions  removed,  or,  as  it  seems  to  me,  circulatory  equilibrium  restored  and 
autonutrition  imj)roved. 

Aside  from  the  injuries  which  the  pancreas  may  receive  during  operations  it  is  un- 
questionably the  site  of  hemorrhages  produced  by  contusions  of  the  abdomen,  although 
these  are  rare,  and  of  injuries  produced  by  deeply  penetrating  wounds,  especially  those 
caused  by  a  stab  or  gunshot.  The  immediate  result  of  a  serious  wound  might  be 
henKn'rhage,  |)erhaps  even  a  large  escape  of  blood  filling  the  lesser  cavity  of  the  peri- 
toneum. Such  injuries  are  always  to  be  treated  surgically,  as  any  external  contusion 
followed  by  serious  collapse  and  evidences  of  internal  hemorrhage  should  be  promptly 
explored,  and,  even  more  so,  every  case  of  penetrating  wound.  Should  blood  be  found 
to  be  escaping  from  the  pancreas  the  bleeding  vessel  may  be  sought  and  secured,  or,  if 
necessary,  a  portion  of  the  organ  extir])ated,  since  no  danger  can  be  greater  than  that 
of  uncontrolled  bleeding.  It  is  on  record  that  through  an  extensive  gash  in  the  abdomen 
the  ])ancreas  has  not  only  been  exposed,  but  has  partially  escaped,  and  one  case  report, 
apparently  authentic,  details  its  subsequent  sloughing  and  spontaneous  separation, 
60 


946  SPECIAL  OR  REGIOXAL  SURGERY 

Any  wound  of  the  pancrea.s  which  needs  no  further  attention  may  at  lea.st  be  sutured 
if  it  can  be  exposed.  Nearly  all  surc;ical  attacks  upon  this  viscas  will  require  exteasive 
incision  and  more  or  le,ss  emptying  of  the  upper  abdominal  cavity.  It  may  now  be  of 
great  assistance  to  place  the  patient  in  the  semi-uprifrht  {wjsiiion  in  order  that  the  viscera 
may  gra\'itate  toward  the  lower  part  of  the  aljdomen — i.  c,  to  reverse  the  ordinary 
Trendelenburg  position. 

NON-TRAUMATIC  SURGICAL  DISEASES  OF  THE  PANCREAS. 

These  diseases  include  especially  the  acute  infectioas,  the  chronic  lesions,  and  the 
occurrence  of  neopla.snxs  or  calculi. 

Certain  local  and  general  conditions  predispose  to  pancreatic  disease  of  any  ty|>e. 
Among  them  are  to  be  reckoned— 

1.  Injury,  either  bv  accident  in  the  ordinary  course  of  events,  as  by  contusions  or 

penetrating  wounds,  or  bruising  during  the  manipulations  of  operation ; 

2.  Anatomiral  anomalies; 

3.  Hemorrharjes  into  the  substance  of  the  gland,  whether  from  vascular  changes 

or  other  caases ; 

4.  Ohstrufiion  along  either  the  biliary  or  pancrratir  ducts,  whether  due  to  catarrh, 

calculi,  adliesioas  or  stricture,  ])arasites  (worms)  or  cancer; 

5.  General  toxemias:  typhoid  .syphilis,  influenza,  mumps,  and  the  like. 

The  principal  exciting  causes  are  the  various  infections  which  may  proceed  from  the 
blood,  as  in  pyemia  or  s%-phills,  or  from  the  alimentary  canal,  which  is  never  free  from 
bacteria,  either  by  adhesions  and  continuity,  as  from  gastric  ulcer  and  cancer,  or  by 
those  natural  passage-ways,  the  ducts. 

^^^^en  summed  up  the  most  common  of  all  the  causes  of  pancreatic  disease,  acute  or 
chronic,  will  be  found  to  be  cholelithiasi.^,  with  some  of  its  variant  consequences  or  com- 
plications. This  will  help  to  make  clear  the  reason  for  oj^erating  on  the  biliary  passages 
in  most  cases  of  pancreatic  disease,  especially  the  more  chronic  forms.  A  stone  impacted 
in  any  portion  of  the  common  duct,  especially  in  its  terminal  portion,  after  it  has  come 
into  relation  with  the  duct  of  Wirsung,  may  cause  an  amount  of  disturbance  dispro- 
portionate to  its  size.  ^Moreover,  a  stone  impacted  at  the  orifice  of  the  duct  will  permit 
the  entrance  of  bile  into  the  pancreatic  canal,  where  it  does  not  belong,  and  where  of 
itself  it  mav  caase  trouble. 


ACUTE  AFFECTIONS  OF  THE  PANCREAS. 

These  include — 

1.  Hemorrhagie  pancreatitis. 

(a)  Ultra-acute,  where  hemorrhage  precedes  infection,  and  bleeding  occurs 

outside  as  well  as  inside  the  gland. 
(h)  Acute,  where  inflammation  precedes  hemorrhage,  the  latter  being  less 

profase  and  occurring  in  patches. 

2.  Gangrenous  pancreatitis. 

3.  Suppurative  panrreaiitls. 

(a)  Diffuse,  destructive. 

(h)  .Subacute,  localized,  with  abscess  formation. 
Acute  Pancreatitis.— Acute  pancreatitis  is  a  distinct  form  of  disease,  like  appendi- 
citis with  an  etiologv  and  symptomatology  of  its  own,  which  has  been  recognized 
onlv  within  the  past  t^-entv-five  years.  This  statement  will  account  for  the  fact  that 
so  little  reference  to  it  is  made  in  any  but  the  recent  tex-t-books.  In  fact  it  is  to  the 
wTitin<^s  of  Fitz,  of  some  fifteen  vears  ago,  that  the  world  owes  its  first  keen  interest  in 
the  subject.  Bv  no  means  a  frequent  disease,  it  nevertheless  occurs  with  frequency 
sufficient  to  make  it  inexcusable  for  the  practitioner  to  fail  to  take  it  into  consideration, 
although  he  mav  waver  in  diagnosis. 

The  predisposition  to  infection  which  pre\nous  injuries,  especially  minute  hemor- 
rhacres  or  previous  pathological  conditions,  seem  to  afford  has  been  already  mentioned, 
and^a  hlston-  of  previous  injury  or  digestive  disturbances  will  aid  in  diagnosis.     The 


ACUTE  AFFKCTIOXS  OF   THE  PAXCREAS  947 

(•\citiii<f  cause  is,  however,  in  ii(>iiriy  every  case  when  not  distinctly  traumatic,  con- 
nected with  |)revious  ihscasc  in  tiu-  hihary  tract,  either  cholelithiasis  or  chohm^ntis. 
Ret'erence  to  what  has  been  said  above,  and  a  consideration  of  the  anatomical 
relations,  will  show  how  readily  an  infections  |)rocess  can  travel  upward  from  the  duode- 
ninn  into  (lu>  pancreatic  duct,  as  well  as  into  the  common  duct;  or  how,  passin(r  down 
the  latter,  it  may  sju'cdily  find  its  way  uj)  the  former.  The  previous  conditi(jn  of  the 
tissues,  and  the  activity  or  virulence  of  the  infective  or<fanisms,  have  to  do  with  thedcffree 
of  acuteness  of  the  resultinij;  |)ancreatitis.  This  is  sometimes  of  such  overwhelming 
toxicity  that  the  entire  <jland  dies  almost  as  does  the  apj)en(lix,  within  a  few  hours,  the 
result  beiuL!:  an  acute  necrotic  condition  that  of  itself  is  necessarily  fatal. 

Symptoms.  —Acute  ])ancreatitis  t^jives  rise  to  symptoms  which,  in  general,  assume 
the  clinical  form  of  an  nrntc  prrifoni/i.s'  of  f/ir  upper  abdoineu.  It  commences  with  sharp 
pain  in  the  epigastrium,  accompanied  by  faintness,  nausea,  vomiting,  and  colla|)sc, 
while  tenderness  over  the  pancreas  is  an  early  symptom,  and  swelling  or  enlargement 
can  sometimes  be  detected.  Consti|)ation  is  so  frequently  a  feature  that  the  diagnosis 
of  acute  bowel  obstruction  is  sometimes  made,  but  it  will  be  found  that  obstruction  is 
not  comj)lctc,  for  flatus  may  pass  and  enemas  may  be  successful.  The  j)ain  becomes 
paroxysmal,  is  increased  by  movement  and  pressure,  while  the  tenderness  becomes 
more  localized.  Meteorism  may  so  quickly  succeed  the  other  symptoms  as  to  make 
physical  signs  uncertain,  while  rigidity  of  the  abdominal  nuiscles  makes  them  still  more 
vague,  yet  affording  in  itself  a  sign  of  value.  Vomiting  intensifies  the  pain  and  the 
vomitus  changes  from  food  to  bile,  and  then  to  blood,  which  is  dark  and  altered.  Hence 
jaundice  may  be  an  early  feature,  in  which  case  it  becomes  more  marked  as  the  disease 
progresses,  and  may  Ix'come  intense.  This  is  likely  to  be  the  case  if  the  exciting  cause 
prove  to  be  a  stone  impacted  at  the  ampulla.  The  face  indicates  profound  distress 
and  disturbance.  The  temperature  affords  no  certain  indication,  save  that  in  the  most 
serious  cases  it  may  be  subnormal.  On  the  other  hand,  as  the  case  progresses,  the  pulse 
becomes  small  and  rapid.  Every  expression  of  overwhelming  toxemia  is  added, 
and  delirium  usually  precedes  death.  In  fact  death  may  follow  the  first  expression 
of  j>ain,  in  unrelieved  cases,  in  from  two  to  three  days.  Other  less  acute  expressions  of 
the  same  general  character  are  met  with  in  the  so-called  subacute  forms  of  pancreatitis. 

While  the  postmortem  findings  differ  in  various  instances  the  symptoms  above  noted 
do  not  vary  conspicuously.  They  differ  rather  in  intensity  only,  in  accordance  with 
the  gravity  of  the  case. 

The  pathologists  have  described  various  forms  of  j)ancreatitis  as  the  hemorrhagic, 
the  gangrenous,  the  suppurative,  and  those  distinguished  by  fat  necrosis,  as  well  of 
the  omentum  as  of  the  pancreas  itself.  These  distinctions  have  the  greatest  interest 
for  those  engaged  in  minute  research  and  are  not  to  be  regarded  lightly.  They  have 
no  small  interest  for  the  clinician,  since  j)rognosis  is  in  some  measure  dependent  upon 
them.  Nevertheless  the  symptoms  of  the  condition  are  but  slightly  modified,  whether 
the  destructive  process  assume  one  or  the  other  of  these  types,  and  the  therapeutic 
indication  is  the  same  for  all — namely,  the  earliest  possible  operation. 

If  pathologists  were  better  agreed  on  their  pathology  it  might  be  worth  while  to  give 
more  space  here  to  this  aspect  of  the  subject.  It  is,  however,  not  yet  certain,  for  instance, 
whether  in  a  given  case  inflammation  precedes  hemorrhage,  or  whether  hemorrhage 
occurs  first  and  the  outpour  of  blood  is  suddenly  invaded  by  bacteria.  In  fact  it 
is  probable  that  sometimes  one  thing  occurs  and  sometimes  the  other.  Certain  it  is 
that  the  pancreas  is  not  only  loosely  held  together,  and  consequently  disrupts  easily, 
but  that  it  quickly  succumbs  both  to  its  own  digestive  juices  and  the  disintegrating 
effect  of  bacteria,  so  that  putrefaction  quickly  occurs  hours  before  life  is  extinct.  The 
morbid  excitement  quickly  spreads  to  the  adjoining  peritoneum,  and  along  it,  so  that  a 
more  or  less  generalized  peritonitis  soon  complicates  the  case.  Mayo  Robson  inclines 
to  the  view  that  in  the  most  fulminating  cases  the  hemorrhage  is  the  prior  lesion. 

Diagnosis. — The  diagnosis  should  be  made  mainly  from  perforating  gastric  or  duo- 
denal ulcer;  phlegmonous  or  gangrenous  choleci/stitis  or  cholangitis;  ruj)ture  of  the  biliary 
tract,  with  escape  of  contents;  fulminating  appendicitis;  acute  intestinal  obstruction, 
including  internal  hernias,  and  acute  mesenteric  thrombosis  or  embolism.  Fortunately 
in  every  one  of  these  conditions  prompt  operative  intervention  is  alike  demanded,  save 
possibly  in  th(>  last  named;  while  even  in  the  latter  diagnosis  cannot  l)e  made  without  it, 
and  it  may  still  be  possible  to  accomplish  something  if  the  occlusion  be  not  too  wide- 


948  SPECIAL  OR  REGIONAL  SURGERY 

spread.  A  history  of  previous  "dyspepsia"  or  "indigestion"  may  point  to  the  stomach 
or  the  bihary  channels;  repeated  hemorrhages  to  gastric  ulcer,  an(l  rc])eated  attacks  of 
pain  to  gallstone  trouble.  General  tyni])anitis  would  indicate  intestinal  obstruction, 
especially  if  no  fiatus  were  passed,  while  when  limited  to  the  u])per  abdomen  it  would  be 
more  suggestive  of  pancreatic  disease.  This  would  be  corroborated  by  vomiting  of 
blood,  while  fecal  vomiting  wound  indicate  obstruction.  Tenderness  and  tumor  located 
in  the  region  of  the  gall-bladder  would  j)oint  rather  to  it  as  the  source  of  trouble,  while  in 
pancreatitis  something  distinctive  may  l)e  perhaps  made  out  by  palj)ation  and  jiercussion, 
and  the  tenderness  will  be  com])lained  of  alike  on  each  side  of  the  middle  line.  Abdomi- 
nal rigidity,  while  general,  is  usually  most  pronounced  near  the  site  of  the  most  important 
lesion.  Much  imjiortance  is  attached  by  Halsted  to  excessive  jxiin,  and  to  cyanosis  of 
both  the  face  and  the  abdomen.  The  latter  may  be  helpful  as  a  corroborative  indication, 
but  is  certainly  not  always  present,  and,  on  the  other  hand,  is  seen  in  many  cases  of 
general  peritonitis.     Glycosuria  is  rarely  a  feature  of  the  acute  cases. 

Treatment. — This  is  of  necessity  not  only  surgical,  but,  to  be  effective,  should  be 
prompt,  every  added  hour  of  delay  causing  increased  danger.  While  arranging  for  this 
it  is  possibly  justifiable  to  allay  pain  by  giving  mor])hine  hypodermically.  The 
colon  should  be  emptied  by  a  copious  enema.  Collapse  is  to  be  combated  by  the 
usual  means,  including  hypodermoclysis  or  infusion,  perhaps  with  the  addition  of  a 
little  adrenalin  to  the  saline  solution.  The  prejjaration  of  the  patient,  both  before  and 
during  anesthesia,  should  include  the  same  scrubbing  of  and  attention  to  the  skin  of  the 
back  as  that  of  the  abdomen,  as  there  is  much  jjrobability  in  any  such  case  that  posterior 
drainage  will  l)e  neetled. 

The  operation  is  begun  as  an  exploration,  through  a  median  incision  above  the  umbili- 
cus, some  three  inches  in  length,  through  which  the  operator  may  inform  himself  as  to 
the  state  of  affairs  within  the  abdomen.  wShouId  fat  necrosis  be  revealed,  and  first  noticed 
in  the  omentum,  no  doubt  need  be  felt  as  to  diagnosis.  Any  tumefaction  by  which  the 
stomach  or  colon  is  displaced,  or  the  gastrocolic  omentum  placed  upon  the  stretch, 
calls  for  further  and  deeper  exploration.  The  ujjper  alxlomen  should  next  be  walled 
off  with  gauze  and  a  small  rent  made  through  the  gastrocolic  omentum;  or  it  may 
in  rare  instances  prove  wiser  to  push  down  an  already  depressed  stomach,  or  more  likely 
to  lift  uj)  the  greater  omentum  and  enter  the  lesser  peritoneal  cavity  through  the  meso- 
colon. In  the  majority  of  instances  the  condition  can  be  best  appreciated  and  relieved 
by  separating  the  stomach  from  the  colon. 

The  condition  may  be  one  of  extensive  fat  necrosis,  disseminated,  but  with  its  most 
abundant  expressions  in  the  neighborhood  of  the  pancreas,  or  there  may  be  found 
evidence  of  extensive  gangrene,  the  pancreas  itself  sloughing  and  involved  past  any 
possibility  of  repair,  surrounded  by  disintegrating  clot  and  debris;  or  there  may  be 
found  a  more  or  less  localized  abscess,  and  perhaps  evidences  of  putrefaction.  In  at 
least  two  instances  rejiorted  by  Muspratt  and  Porter  the  pancreas  itself  Avas  not  yet 
dead,  but  was  so  darkly  discolored  and  swollen,  as  well  as  so  dense,  that  it  was  freely 
incised,  the  bleeding  vessels  being  tied  and  the  clot  removed.  Both  of  these  cases 
recovered.  Such  incisions,  if  made  in  the  gland,  should  always  run  parallel  with  the 
duct  and  not  across  it.  Whether  pus  be  found  or  not  will  depend  in  large  degree  upon 
ihe  time  that  has  elapsed  since  trouble  began.  It  is  most  desirable  to  expose  the  focus 
before  pus  has  had  time  to  form,  just  as  it  is  in  acute  appendicular  disease. 

The  further  operative  treatment  consists  essentially  in  checking  and  preventing 
hemorrhage,  in  removing  all  sloughing  tissue  w  hich  can  be  safely  taken  away  (and  this 
may  involve  the  greater  part  of  the  entire  gland),  in  disinfection  of  the  cavity  and 
general  toilet  of  the  upper  abdomen,  with  am])le  provision  for  drainage.  This  may 
be  anterior  or  posterior,  and  in  bad  cases  should  be  both,  unless  procedure  is  hastened 
by  collapse.  Posterior  drainage  is  effected  by  having  the, patient  turneil  u])on  the  right 
side,  then  making  an  incision  3  or  4  Cm.  long  at  the  left  costospinal  angle,  where,  if  the 
advice  above  given  have  been  followed,  the  skin  \\\\\  have  already  been  prejiared.  Here 
the  outer  border  of  the  erector  spins'  group  of  muscles  is  quickly  exposed  and  the  blades 
of  a  pair  of  stout  forceps  entered  and  pushed  toward  the  inner  cavity,  Avithin  Avhich 
the  operator's  left  hand  is  acting  as  a  guide.  In  this  Avay  it  is  possible  to  quickly  insin- 
uate the  blades  so  that  the  large  vessels  and  the  upper  end  of  the  kidney  are  preserA^ed 
from  harm.  A  suitably  prepared  drain,  preferably  tubular,  may  then  be  introduced 
deeply  enough  through  the  anterior  wound  to  be  seized  by  the  forceps  and  pulled  through 


ACllTI':  AFFECT  loss  OF   TlIF  PANCREAS  949 

tin-  tiiiiiicl  made  hv  their  iiilrodiictioii.  It  is  lliii.s  drawn  Ijackward  and  ontward  to  such 
an  extent  that  its  "inner  end  sludl  rest  just  wliere  it  is  desired  in  the  cavity  of  the  lesser 
peritoneum,  the  unnecessary  external  part  of  the  drain  l)ein<;'  now  cut  away.  The  whole 
procedure  consumes  but  little  time.  AnU>rior  draina«re  will  also  he  necessary,  and  the 
wound  uuiy  then  be  closed. 

It  has  been  su<?^cst(>d  to  make  tiie  exi)lorati()n  as  well  as  the  drainage  from  the  loin, 
but  this  procedure  cannot  be  here  advised,  since  it  leaves  too  many  features  in  doubt 
and  allords  insudicient  means  whereby  to  appreciate  and  cope  with  many  grave  com- 
j)lications.  Calculi,  either  l)iliary  or  ])ancreatic,  which  are  so  often  an  exciting  cause 
of  these  troubles,  should  be  carefully  sought  for  and  removed  if  |)resent.  They  could 
not  be  revealed  nor  removed  through  any  small  posterior  opening.  Otiier  good  reasons 
are  also  advanced,  since  the  intensity  of  the  symj)toms  is  an  expression  of  an  intra- 
peritoneal rather  than  retroperitoneal  lesion. 

The  readiM-  will  note  that  but  little  has  been  said  as  to  the  distinction  between  the 
hemorrhagic,  gangrenous,  and  other  forms  of  acute  pancreatitis,  as  these  are  for  the 
surgeon,  as  such,  .s-idc  i.sfiurs.  His  parnmoiuit  dviij  is-  to  open  the  abdomen  of  every 
such  rasr,  m  .soon  as  he  ran  po.ssihli/  rfjrrt  arraucjements. 

Subacute  Pancreatitis;  Abscess. — Under  this  term  are  included  disease  processes 
and  lesions  similar  to  or  i(l<>ntical  with  those  described  as  causing  acute  and  even  fulmi- 
nating expressi(.)ns  of  pancreatic  obstruction,  but  less  sever(>  in  their  manifestations,  less 
rapid  in  their  course,  and  more  localized  in  tlu>ir  boundaries.  They  are  often  so 
associated  with  a  ])rotective  and  natural  walling  off  of  the  area  of  excitement  l)y  barriers, 
which  outpour  of  lymph  and  its  consequent  condensation  into  adhesions  afford,  that 
they  ai)pear  more  often  as  abscess  of  the  pancreas  or  hematoma  of  the  lesser  cavity 
of  the  peritoneum. 

So  far  as  ct)ncerns  its  (>tiology  the  causes  are  essentially  the  same  as  in  the  acute  cases, 
only  the  results  an'  brought  about  more  slowly,  weeks  })eing  in  these  cases  as  days  in 
the  otliers.  (Jallstones  are  by  all  means  the  most  common  cause,  and  the  jmncreatic 
disease  is  itself  an  expression  of  an  infection  travelling  uj)  its  duct. 

Symptoms. — The  symptoms  usually  include  pain,  which,  however,  lacks  the  agoniz- 
ing intensity  noted  in  the  more  acute  cases.  Vomiting  is  usually  associated  with  con- 
stipation, but  the  vomitus  is  rarely  or  never  bloody;  jaundice  of  variable  degree  is  a 
common  feature,  and  collapse  is  rare.  Distention  of  the  upper  abdomen  and  tumor 
formation  come  on  more  slowly.  Tenderness  is  less  extreme  and  muscle  rigidity  less 
marked.  While  the  pulse  is  less  affected  the  temperature  is  usually  more  so,  often 
running  high.  Even  early  in  the  case  we  may  note  general  exjiressions  of  septic  intoxi- 
cation, such  as  mild  chills  and  a  characteristic  appearance  of  the  tongue  and  face. 
Constipation  is  followed  by  diarrhea;  at  least  the  stools  which  are  fetid  contain  blood, 
pus,  fat  cells,  and  undigested  meat  fibers.  Pain  is  more  or  less  constant,  but  increased 
in  paroxysms.  Loss  of  appetite  and  rapid  emaciation  are  apparent  from  the  outset. 
Albumin  will  be  found  in  the  urine,  but  rarely  sugar.  The  peculiar  reaction  described 
by  Cammidge  will,  according  to  Mayo  Robson,  give  uniformly  positive  evidence.  As 
abscess  gradually  or  rajiidly  develops  it  will  cause  a  swelling,  which  has  its  origin  behind 
the  stomach  and  may  disj)lace  this  viscus,  as  well  as  the  colon,  upw^ard  or  downward, 
presenting  usually  toward  the  abdominal  wall.  In  rare  instances  the  direction  of  least 
resistance  takes  it  toward  one  loin  or  the  other,  where  it  may  a})pear  as  a  perirenal 
abscess,  or  around  the  cms  of  the  diaphragm  and  above  the  liver,  where  it  would  appear 
as  a  subphrenic  abscess.  It  has  been  known  also  to  burrow  along  the  psoas  muscle 
and  appear  at  the  groin,  or  even  in  the  left  broad  ligament.  Abscess  of  the  pancreas 
may  also  burst  into  the  stomach,  when  pus  will  be  vomited,  or  into  the  bowel,  whence  it 
will  be  evacuated.  A  sudden  relief,  with  disappearance  of  tumor,  follow^ed  by  diarrhea 
and  purulent  stools,  w^ould  inchcate  this  latter  termination.  Under  these  circumstances 
the  abscess  cavity  may  re])eatedly  refill  and  reempty  itself.  Spontaneous  recovery  in 
this  way  is  possible,  but  septicemia  and  hectic  usually  jiersist  until  obviated  by  operation. 

Diagnosis. — The  history,  the  evidently  septic  type  of  the  case,  and  the  distinct  sj^ns 
above  noted  will  make  almost  certain  the  ]:>resence  of  pus,  and  Mayo  Robson  insists 
that  the  pancreatic  reaction  in  the  urine  (Cammidge)  will  make  clear  its  location  and 
origin;  but,  wuth  or  without  the  latter,  the  important  feature  is  that  there  must  be  a 
deep  collection  of  pus  somewhere  in  the  neighborhood  of  the  pancreas. 


950  SPECIAL  OR  REGIONAL  SURGERY 

Treatment. — This  is  necessarily  operative,  and  in  such  cases  as  those  now  considered 
there  will  be  plenty  of  time  afforded  for  all  the  precautions  known  to  careful  surgeons. 
The  asjiirator  should  never  be  used,  at  least  not  until  the  abdomen  has  been  opened, 
then  usually  with  caution,  lest  pus  escape  along  the  needle  track.  The  operation  is 
made  as  described  above  for  the  acute  form  of  this  disease.  The  greatest  care  should 
be  given  to  protecting  the  general  peritoneal  cavity  against  infection.  When  adhesions 
to  the  anterior  abdominal  wall  are  met  they  should  be  separated  as  little  as  possible, 
only  to  such  an  extent  as  will  permit  direct  apjiroach  to  the  collection  below.  Only 
after  the  abscess  cavity  has  been  thoroughly  emjjtied,  disinfected,  and  packed  with  gauze 
should  the  surgeon  proceed  to  clear  away  or  break  down  adhesions  so  as  to  permit 
a  suitable  exploration  of  the  lower  surface  of  the  liver  and  the  biliary  ])assages. 

And  now  perhaps  comes  the  necessity  for  operative  attention  to  these  latter,  as  one 
or  many  stones  may  be  recognized  in  the  gall-bladder  or  the  ducts.  In  this  case  there 
must  be  followed  those  general  directions  elsewhere  given  in  regard  to  the  technique  of 
operations  upon  the  gall-bladder  and  ducts.  Biliarij  drainage  will  in  these  cases  be 
nearly  always  indicated,  for  which  a  separate  small  opening  in  the  usual  position  may  be 
made,  if  desirable,  as  it  probably  will  be,  for  one  wishes  usually  to  continue  such  drainage 
for  several  weeks,  whereas  it  is  desirable  to  have  a  median  incision  heal  as  rapidly 
as  possible.  The  question  of  j^osterior  drainage  will  also  be  raised.  Ordinarily  it 
is  of  advantage,  as  the  time  required  for  anterior  drainage  can  be  materially  shortened, 
the  abdominal  wound  be  encouraged  to  close,  and  because  the  natural  effect  of  gravity 
is  thus  afforded.  Moreover,  by  it  the  whole  period  of  confinement  to  bed  may  be 
materially  reduced.  Therefore,  unless  the  condition  of  the  patient  absolutely  contra- 
indicate,  it  will  usually  be  a  wise  measure.  In  a  few  instances  it  has  been  possible  to 
drain  a  pancreatic  abscess  by  a  tube  in  the  common  duct,  after  removal  of  the  stone 
which  has  been  obstructing  either  it  or  the  duct  of  Wirsung. 


CHRONIC  AFFECTIONS  OF  THE  PANCREAS. 

Chronic  affections  of  the  pancreas  which  interest  the  surgeon  are: 

1.  Interstitial  pancreatitis: 

(a)  Interlobular. 

(b)  Interacinous,  leading  to — 

2.  Cirrfiosis  with   accompanying   tliabetes. 

3.  Neoplasms: 

(a)  Cysts. 

(b)  Solid  tumors. 

4.  Calculi. 

Chronic  Pancreatitis;  Cirrhosis. — The  interlobular  and  interacinous  forms  can 
both  be  considered  under  one  heading  so  far  as  we  are  concerned,  their  symptoms 
being  similar,  save  that  in  the  former  the  compressed  connective  tissue  by  its  presence 
causes  atrophy  of  true  glandular  elements,  and  thus  by  preventing  their  function  inter- 
feres with  digestion;  while  in  the  interacinous  type  the  proliferations  of  this  same  sort 
of  tissue  invade  the  islands  of  Langerhans,  impair  their  glycolytic  secretion  or  suppress 
it,  and  add  a  glycosuria  to  those  features  common  to  both  forms — moreover,  their  treat- 
ment is  essentially  the  same.  In  the  advanced  form  of  either  type  the  pancreas  may 
be  reduced  in  size  and  somewhat  cirrhotic.  This  chronic  affection  may  be  the  result  of 
an  incomplete  recovery  from  one  of  the  more  acute  conditions  previously  described; 
it  may  also  have  its  origin  in  the  chronic  irritation  of  the  poisons  of  syphilis,  typhoid, 
alcoholism,  and  the  like;  but  l)y  far  the  most  common  causes  arc  obstruction  of  the 
pancreatic  duct,  either  by  biliary  or  pancreatic  calculi,  cicatricial  stenosis,  the  presence 
of  tumors  or  the  encroachment  and  erosion  of  gastric  ulcers  and  cancers.  The  morbid 
condition  may  involve  the  whole  gland  or  be  localized,  in  the  latter  case  particularly 
about  its  head. 

Symptoms. — These  should  be  studied  with  particular  attention  to  the  case  history, 
for  a  previous  record  of  pain,  cramps,  chills,  fever,  jaundice,  very  slight  digestive  dis- 
turbances, soreness,  or  local  tenderness  will  be  suggestive  and  valuable  if  obtainable. 
As  symptoms  gradually  arrange  themselves  it  will  be  found  that  tenderness  over  the 
pancreas  becomes  constant,  and  is  accompanied  by  at  least  a  mild  degree  of  muscle 


NEOPLASMS  OF  THE  PANCREAS  951 

spasm,  that  |)aiii  incroascs  and  is  n-l'circd  iiKire  wick^ly,  often  to  the  left  side  or  even  the 
soapuhi,  while  there  may  he  some  fuhiess  in  the  ejHgastrium.  Dyspepsia  and  emacia- 
tion beeome  more  marked.  By  the  time  the  obstruction  of  Wirsuni^'s  duct  has  become 
complete,  perhaps  previous  to  it,  fat  and  undigested  muscle  fibers  will  ])e  found  in  the 
stools,  which  are  light-colored,  bulky,  and  sometimes  contain  blood.  Ah  pressure 
effects  become  more  j)rominent  evidences  of  biliary  obstruction,  if  previously  lacking, 
present  themselves;  tlie  gall-bladder  usually  distends;  the  liver  enlarges  or  may  even 
become  cirrhotic  from  the  irritation  of  pent-up  toxic  bile.  Even  the  spleen  may  become 
enlargeil.  In  the  urine  sugar  will  be  found  in  cases  of  the  interacinous  type,  though 
usually  only  at  a  late  date;  while  bile  pigments  are  usually  present  and  Cammidge's 
test  may  reveal  his  peculiar  pancreatic  reaction. 

Diagnosis. — If  the  peculiar  synijjtoms  above  rehearsed  are  present  diagnosis  is  not 
difficult.  In  many  cases  it  is  not  easy  to  go  beyond  the  point  of  recognizing  that  both 
the  pancreas  and  the  biliary  tract  are  at  fault,  witliout  deciding  as  to  the  exact  degree  of 
culpability  of  each.  The  question  of  possible  cancer  arises  in  almost  every  one  of  these 
instances.  Should  the  ordinary  pancreatic  reaction  in  the  urine  prove  all  that  has  been 
claimed  for  it,  this  grave  problem  can  often  be  settled  previous  to  operation.  If  the 
operator  satisfies  himself  by  any  method  short  of  actual  operation  that  he  has  to  do  with 
cancer  of  the  pancreas,  then  operation  may  be  considered  inadvisable  unless  for  some 
special  reason. 

Treatment. — At  least  a  reasonably  long  trial  will  usually  be  made,  in  these  cases,  of 
medical,  hydrotherapcutic,  and  other  non-operative  treatment,  with  little  or  no  benefit. 
When  after  appreciation  of  the  condition  and  intelligent  treatment  but  slight  relief 
accrues,  the  case  may  be  regarded  (as  it  really  is  upon  its  commencement)  as  surgical. 
Treatment,  then,  consists  of  reinoval  of  the  obstructing  cause  by  drainage  of  the  biliary 
passages.  The  operative  procedure  will  therefore  take  the  form  elsewhere  described 
for  this  purpose.  Should  deep  exploration  reveal  no  calculi  it  will  be  well  to  make 
sure  at  least  of  the  patulency  of  the  ducts,  by  opening  the  gall-bladder  or  common  duct 
and  exploring  with  the  probe,  or  possibly  even  ojicning  the  duodenum  in  order  to  do  the 
same  with  the  pancreatitic  duct.  Whether  calculi  are  discovered  or  otherwise  a  gentle 
stripping  or  massage  of  the  pancreas  may  be  made  to  advantage.  Biliary  drainage 
should  then  be  established,  and  usually  externally. 

It  has  been  difficult  for  the  profession  to  appreciate  why  and  how  these  measures, 
which  seem  to  be  directed  rather  to  the  biliary  passages  than  to  the  pancreas,  have 
given  such  brilliantly  satisfactory  results  as  are  everywhere  reported.  These  are  to  be 
accounted  for  by  the  facts  that  the  primary  cause  most  often  lies  in  the  former  rather  than 
the  latter,  and  is  thus  removed,  and  that  one  source  of  constant  irritation — namely, 
infected  bile — is  thus  done  away  with,  while  tension  is  removed  and  pancreatic  juice 
again  permitted  to  flow  on  as  it  shoidd;  that  a  chronic  toxemia  (cholemia)  is  relieved, 
and  that  physiological  rest  is  afforded  to  the  affected  and  disturbed  organs.  When 
the  operation  is  thus  performed  benefit  may  be  expected;  even  when  done  late  it  may 
be  capable  of  great  good. 

NEOPLASMS  OF  THE  PANCREAS. 

Cysts. — In  addition  to  true  cysts  of  the  pancreas  there  have  been  described  so-called 
"pseudocysts"  in  the  lesser  peritoneal  cavity,  and  more  or  less  surrounding  the  pancreas. 
They  are  rarely  of  congenital  origin,  but  are  probably  due  rather  to  traumatism  than  to 
any  other  cause.  By  many  they  have  been  likened  to  ranulas,  or  the  cysts  which  form 
in  the  salivary  glands  in  consecjuence  of  obstruction  to  ducts  or  their  branches.  Any- 
thing which  obstructs  any  portion  of  the  pancreatic  duct  may  lead  to  the  formation  of 
a  retention  cyst,  the  true  proliferation  cyst — adenomas  being  practically  unknown.  That 
traumatism  figures  so  largely  is  due  to  the  fact  that  injury  is  followed  by  hemorrhagic 
extravasation,  and  this  by  more  or  less  liquefaction  or  degeneration,  both  of  contents 
and  of  surrounding  tissue,  with  the  secondary  formation  of  a  cyst  whose  walls  are  made 
of  new  connective  tissue. 

A  true  pancreatic  cyst  is  a  retroperitoneal  tumor,  while  pseurlocysts  are  intraperitoneal. 
In  front  of  the  former  lie  four  layers  of  peritoneum,  which  may  be  completely  merged 
together,  but  through  which  a  passage  must  be  made  when  opening  into  it  from  the 


952  SPECIAL  OR  REGIONAL  SURGERY 

front.  The  etioloffy  of  old  pancTeatic  cvsts  may  he  completely  concealed  by  the 
changes  which  have  slowly  occurred  since  their  origin.  They  may  be  single  or  multiple, 
occur  in  any  portion  of  the  gland,  and  increase  even  by  coalescence.  Witliin  some  of 
them,  especially  those  of  the  duct  type,  paj^illomatous  excrescences  may  be  found.  The 
more  distinctly  traumatic  cysts  occur  perhaps  oftener  near  the  tail  of  the  pancreas, 
while  into  them  rei)eated  hemorrhages  may  take  place,  and  the  sac  will  become  quite 
thick,  even  exceptionally  calcifying  in  places.  These  have  been  described  as  apoplectic 
cysts. 

Altogether,  up  to  date,  at  least  150  of  these  cysts  have  been  subjected  to  operative 
intervention. 

Pancreatic  cysts  contain  a  fluid  which  may  be  variously  colored  or  sometimes  color- 
less, which  is  usually  alkaline,  and  contains  fat  globides,  cholesterin  crystals,  blood 
crystals,  albumin,  and  various  salts,  most  of  tliese  being  evidences  of  their  hemorrhagic 
origin.  The  fluid  may  also  contain  the  specific  pancreatic  ferments,  of  which  the  dias- 
tatic  is  the  more  common,  tryptic  ferment  being  met  occasionally,  while  the  fluid  may 
also  possess  emulsifying  jiroperties.  In  size  these  cysts  vary  from  minute  sacs  to  enor- 
mous collections  of  fluid. 

As  such  a  cyst  attains  marked  size  it  will  displace  the  adjoining  viscera,  pushing  the 
diaphragm  upward  and  impeding  h(»art  and  lung  action,  obstructing  the  pylorus  and 
duodenum  and  causing  gastric  dilatation,  j^ressing  u])on  the  intestines  and  perhaps  even 
compressing  the  ureters,  thus  producing  hy<lronc])lirosis.  ( )thcr  jX'culiar  pressure  effects 
may  be  met  in  particular  instances.  A  sudden  increase  in  size  indicates  a  fresh  hemor- 
rhage, which  may  lead  to  its  rupture  and  to  death  from  peritonitis.  These  cysts  rarely 
emi)ty  spontaneously  into  the  bowel.  Their  contents  are  liable  to  infection,  and  thus 
a  cyst  may  become  converted  into  a  large  abscess. 

Symptoms. — Symptoms  include  especially  pain,  which  may  have  been  sudden,  but 
becon.es  more  or  less  constant,  accompanied  by  a  sense  of  o])pression,  according  to  the 
size  and  the  pressure  effects  produced  in  each  case.  Digestion  is  always  more  or  less 
distm-bed;  this  may  be  attributed  to  the  stomach  dilatation,  which  is  itself  a  sequel 
of  the  condition.  The  stools  show  little  which  is  significant  save  that  they  are  occa- 
sionally bloody.  Undigested  muscle  fiber  would  indicate  loss  of  pancreatic  function. 
Other  symptoms  will  vary  so  much  with  indi\idual  cases  that  it  is  not  necessary  to 
consider  them  here. 

The  physical  signs,  coupled  with  a  suggestive  history,  especially  one  which  includes 
an  account  of  injury,  are  of  the  greatest  importance  in  diagnosis.  These  physical  signs 
will  include  usually  a  yellowish  tinge  of  the  skin,  marked  emaciation,  dry  skin,  and  the 
presence  of  a  tumor  in  the  upper  abdomen,  which  is  usually  centrally  placed,  l)ut  not 
necessarily  so.  If  the  patient  has  carefully  noted  the  development  of  his  t)wn  sym})toms 
it  will  1)6  found  that  the  enlargement  commenced  above  and  usually  a  little  to  the  left, 
and  develojied  in  other  directions  from  that  location.  Palpation  reveals  a  smooth, 
elastic,  usually  fluctuating  tumor,  sometimes  movable  with  respiration,  rarely  pulsating. 

It  must  be  remembered  that  a  pancreatic  cyst  may  rise  above  the  stomach,  may 
rest  entirely  behind  it,  or  may  protrude  either  below  it  and  above  the  colon  or  else  quite 
below  the  colon.  Distention  of  the  stomach  will  afford  accurate  location,  in  these 
respects,  upon  perc-ussion,  while  percussion  without  distention  may  mislead.  A  tumor 
which  gives  dulness  below  the  stomach  and  above  the  colon  is  extremely  suggestive. 

Diagnosis. — Diagnosis  by  asjiiration  is  inadvisable,  even  dangerous,  for  death  has 
followed  the  introduction  even  of  a  needle  into  such  a  cyst.  Aspiration,  then,  should  be 
reserved  for  tumors  already  exposed  through  an  abtlominal  incision. 

For  the  purpose  of  different iaf ion  it  will  suffice  here  to  remind  that  tumors  of  the 
kidney,  as  well  as  hydronephrotic  cysts,  grow  downward  and  forward  from  the  loin, 
and  can  be  pushed  backward  to  their  proper  place  unless  too  large,  that  they  are  not 
accompanied  by  digestive  disturbances,  while  the  urine  is  usually  more  or  less  indicative. 
A  hydronephrotic  cyst  can  scarcely  be  made  to  occupy  a  position  between  the  stomach 
and  the  colon  and  present  in  the  middle  line  in  front.  Ovarian  cysts  rise  from  the  pelvis 
and  will  rarely  occur  in  the  upper  location,  save  those  provided  with  extremely  long 
pedicles.  Hydatid  cysts  of  the  liver  show  a  continuity  and  fixation  to  that  viscus  which 
are  usually  diagnostic. 

Treatment. — The  only  treatment  for  pancreatic  cysts  is  surgical, _  it  remaining 
with  the  surgeon  to  decide  as   between  drainage  and  extirpation.     While  it  is  indis- 


NEOPLASMS  OF  TlIK  PASCREAS  953 

piitable  that  c.\tir|)atii)ii  is  the  ideal  inclliinl  of  (l('aliii<;  with  all  cysts  and  tumors, 
most  of  these  cases  are  of  such  loii^  (hiratioii  that  the  adhesions  contracted  between  their 
exteriors  and  the  surroniuhni^  viscera  arc  so  dense  and  firm  (hat  much  <i;reater  dantrer 
attaches  to  a  radical  operation  than  to  one  for  simple  incision  and  drainage.  I  liave 
been  ai)li'  in  at  least  one  case  to  comi)lctely  extirpate  such  a  cys),  but  it  was  one  exceed- 
in<;ly  favorably  si(uatc<|  and  surrounded. 

Iiiri.sion  and  drahuKjc  may  be  eiiected  in  one  operation  or  in  two  sittintrs,  and  as 
between  them  it  must  be  decided  according  to  the  merits  of  the  case.  It  is  undesirable 
to  permit  the  escape  of  the  contents  of  tiiese  cysts  into  th(!  abdomen.  In  some  instances, 
therefore,  it  woidtl  be  much  better  to  make  a  small  abdominal  incision  and  through  it 
attach  the  surface  of  the  cyst  to  the  margins  of  the  parietal  perilonemn,  reserving  the 
actual  opening  into  the  tumor  until  a  day  or  two  later,  when  it  may  be  expected  that 
firm  adhesions  will  have  attached  the  sutured  surfaces.  In  this  way  any  leakage  within 
the  abdomen  may  be  avoided,  ('are  must  be  exercised,  even  in  such  cases,  as  a  large 
(yst  too  suddeidy  einptic(|  may  cause  sudden  (lisj)lacemcnt  of  the  heart  or  of  other  viscera, 
which  would  not  l)e  to  the  advantage  of  the  j)atient.  In  this  case  fluid  coidd  be  with- 
drawn in  j)ortions  as  desired,  or,  making  a  small  opening,  one  could  arrange  for  its  gradual 
escape.  On  the  other  hand,  there  are  cases  where  it  would  be  of  great  advantage, 
if  the  cyst  could  not  be  emptied,  to  so  open  it  as  to  permit  posterior  drainage  to  be  made, 
l)y  which  the  period  of  recovery  would  be  much  abbreviated. 

No  case  of  this  kind  can  be  treated  without  drainage,  the  explanation  being  that  the 
cyst  being  emptied  will  collapse,  its  walls  coming  into  more  or  less  close  contact  with 
each  other,  that  the  presence  of  drainage  material  will  provoke  exudate  and  the  formation 
of  gramilation  tissue,  and  that  a  complete  oljlitcration  will  thus  in  time  occur — but 
drainage  in  the  natural  direction  of  gravity  as  the  patient  lies  upon  the  back  will  permit 
of  much  more  speedy  fulfilment  of  one's  hopes;  hence  its  advantage.  Better  still,  per- 
haps, w'ould  be  through-and-through  drainage,  with  such  irrigation  as  might  be  needed, 
practised  daily,  or  oftcner  if  necessary. 

Tumors  of  the  Pancreas.— While  .mrcoma  and  other  forms  of  malignant 
disease,  as  well  as  adenoma  of  the  pancreas,  have  been  described,  they  rec|uire  no  special 
consideration  here,  since  the  surgeon  has  so  rarely  to  do  with  anything  of  this  character 
save  adenocarcinoma  of  the  pancreas.  This  is  a  disease  of  middle  or  advanced  life, 
more  common  in  males  than  in  females,  usually  of  scirrhous  type,  and  localized,  though 
it  may  appear  in  softer  forms  or  be  disseminated.  It  takes  its  origin  from  the  epithelial 
cells  lining  the  acini  and  the  ducts.  Metastasis  is  common  and  direct  extension  b}' 
continuity  most  easy  and  frequent.  It  is  made  known  by  its  pressure  effects  rather  than 
by  any  other  important  signs  or  constant  features.  It  has  been  known  to  lead  to  chylous 
ascites. 

It  is  difficult  in  many  exploratory  operations  to  decide  as  between  a  chronic  induration 
or  cirrhosis  of  the  pancreas  and  that  due  to  cancer,  and,  in  fact,  in  certain  cases  it  may  be 
impossible  to  clear  up  the  difficulty,  leaving  it  to  be  solved  either  by  recovery  or  death 
in  consequence  of  extension  of  malignant  disease.  Thus  when  operating  for  biliary 
obstruction,  where  the  parts  are  surrounded  by  adhesions  and  the  organs  are  only  indis- 
tinctly palpable,  it  may  be  impossible  to  decide  as  to  the  nature  of  a  hard  mass  felt  in  the 
head  end  of  the  pancreas,  especially  when  other  distinct  expressions  of  cancer  are  absent. 

Cancer  of  the  pancreas  is  at  present  a  primarily  hopeless  disease,  and  is  of  interest 
to  the  surgeon  only  in  that  some  of  the  most  distressing  features  which  it  causes  may 
be  temporarily  relieved  l)y  biliary  drainage.  The  symptoms  which  will  bring  such 
a  patient  to  him  will  be  essentially  those  of  biliary  obstruction,  perhaps  with  the  accom- 
paniment of  glycosuria  or  the  discovery  of  fat  in  the  feces.  Neither  of  these,  hoAvever, 
is  an  invariable  symptom.  Diarrhea  is  but  an  occasional  feature,  and  colorless  stools 
may  be  discharged  when  there  is  no  jaundice.  A  perfectly  painless  progressive  (bronz- 
ing) jaundice,  with  distention  of  the  gall-bladder,  would  perhaps  more  than  any  other 
single  feature  indicate  pancreatic  cancer.  When  such  a  growth  has  attained  a  size 
sufficient  to  make  it  discoverable  on  palpation  it  might  be  mistaken  for  a  biliary  cancer, 
from  which  it  would  have  to  be  differentiated  especially  by  the  movability  usually  noted 
in  the  latter. 

The  only  treatment  for  pancreatic  cancer  is  oj:)erative,  and  consists  in  drainage  of 
the  ga/l-hladder,  and  after  a  manner  elsewhere  described  in  the  section  on  Diseases  of 
the  Biliary  Passages. 


954  SPECIAL  OR  REGIONAL  SURGERY 


PANCREATIC  CALCULI. 


From  the  true  pancreatic  secretions  precipitations  of  mineral  salts,  combined  with 
organic  elements,  may  occur,  just  as  from  the  saliva,  the  latter  thus  furnishing  the  salivary 
calculi  elsewhere  described,  the  two  varieties  having  many  points  of  resemblance.  Again, 
calculi,  evidently  of  biliary  origin,  may  be  met  with  in  the  pancreatic  duct.  The  former 
consist  largely  of  calcium  oxalate,  combined  with  calcium  carbonate  and  phosphate. 
They  may  be  single  or  multiple,  and  vary  greatly  in  size  up  to  that  of  a  robin's  ecrg. 
Hypothetical  calculi,  with  consequent  duct  obstruction,  have  been  held  to  be  responsible 
for  many  pancreatic  cysts.  Thus  one  may  explain  cyst  formation,  even  though  no  calculi 
be  found  at  the  time  of  operation. 

Calculi  reposing  within  the  structure  of  the  pancreas  have  much  to  do  with  the  acute 
and  subacute,  as  well  as  the  more  chronic  types  of  pancreatitis,  the  latter  when  they 
act  alone,  the  former  when  to  their  essential  disturbances  are  added  the  possibilities  of 
bacterial  infection. 

When  pancreatic  calculi  produce  symptoms  they  resemble  those  of  cholelithiasis, 
causing  paroxysmal  pain,  with  vomiting,  and  perhaps  transient  jaundice.  Glycosuria 
is  an  occasional  feature. 

The  condition  is  rarely  diagnosticated  previous  to  operation.  Should  a  calculus  be  met 
in  this  location  during  the  progress  of  any  operation  it  should  be  removed  by  an  incision 
made  parallel  to  the  duct,  with  such  closure  of  the  wound  in  the  pancreas  as  can  be  sub- 
sequently effected  and  with  ample  drainage  of  the  deep  wound,  in  order  that  pancreatic 
fluid  may  not  escape  into  the  peritoneal  cavity.  If  encountered  during  operation  for 
pancreatic  cyst  the  same  advice  will  apply. 


CHAPTER    LIV. 

THE  KIDNEYS. 

CONGENITAL  ANOMALIES  AND  DEFECTS  OF  THE  KIDNEYS. 

Recent  embryological  studies  have  established  the  fact,  in  ret^ard  to  the  kidneys, 
and  jfiven  rise  to  the  inference  in  re<fard  to  the  other  viscera,  that  the  jjriniary  cause  of 
coni^jenital  variations  has  much  to  do  with  the  earhest  development  of  the  bloodvessels. 
The  general  inclination  has  been  to  view  the  vessels  as  following  the  organs.  This 
shouhl  be  reversed,  as  we  are  now  learning  that  organs  develop  around  thr  b/oodvesseh, 
and  tliat  so-called  congenital  variations  arise  from  departures  of  vascular  arrangement 
from  tile  ordinary  tyjies.  Without  pursuing  this  subject  further  it  is  sufficient  to  say 
that,  aside  from  defects  of  such  character  that  the  newl)orn  infant  can  live  but  for  a  few 
hours  or  days,  those  which  have  most  surgical  interest  mainly  com])rise  variations  in 
number  and  in  size,  including  every  possible  combination,  from  absence  of  an  entire 
kidney  to  horseshoe  forms,  and  various  anomalies  of  the  ureters  including  defects  and 
redundancies,  double  ureters,  and  the  like.  While  supernumerary  renal  tissue  or  kidneys 
are  extremely  rare,  the  presence  of  supernumerary  adrenal  tissue  in  one  or  both  kidneys 
(even  in  adjoining  organs)  is  not  uncommon.  Here  it  may  lead  to  the  development  of 
a  distinct  form  of  tumor,  hypernephroma,  which  will  be  discussed  later.  The  compli- 
cation of  absence  of  an  entire  kidney  is  sufficient  to  give  it  actual  surgical  importance, 
since  it  has  repeatedly  happened  that  the  remaining  kidney  has  been  removed  for  dis- 
ease, the  inference  being  that  its  work  could  be  carried  on  by  its  fellow,  which  proved 
to  be  lacking.  This  accident  might  be  prevented  by  a  careful  cystoscopic  examination. 
Nevertheless  the  rarity  of  this  condition  permits  it  to  be  almost  excluded  from  ordinary 
consideration.  After  removal  of  one  kidney  the  other  undergoes  compensatory  physio- 
logical enlargement  and  does  double  duty,  if  indeed  this  has  not  already  occurred. 

Acquired  defects  may  be  due  to  intrinsic  or  extrinsic  causes,  e.  g.,  disease  within  the 
renal  structures  or  ureters,  or  lesions  in  adjoining  organs  and  tissues,  producing  mechani- 
cal or  other  disturbances.  Thus  the  functionating  capacity  of  one  or  even  both  kidneys 
may  be  seriously  compromised  by  either  internal  or  external  conditions,  and  it  behooves 
the  surgeon  to  estimate  the  degree  of  renal  disability  or  inadequacy  before  operating 
upon  either  of  these  organs.  On  the  other  hand  if  the  disease  be  confined  to  one  kidney 
he  may  feel  that  it  is  doing  so  little  good  and  so  much  harm  that  the  patient  will  be 
really  relieved  by  its  removal.  Nearly  everything,  then,  depends  upon  a  determination 
of  the  precise  existing  conditions.  They  should  be  ascertained  by  means  of  the  catheter, 
the  cystoscope,  the  microscope,  and  by  the  careful  chemical  study  of  the  urine.  These 
methods  have  been  developed  into  a  specialty  of  considerable  complexity,  but  of  great 
practical  importance.  The  surgeon  should  not  fail  to  employ  them.  If  he  is  not 
familiar  with  the  technique  he  should  seek  special  assistance. 

INJURIES  TO  THE  KIDNEYS. 

Although  the  kidneys  lie  in  a  protected  position  they  are  not  infrequently  injured, 
both  by  contusions  and  by  penetrating  wounds.  From  the  latter  blood  will  escape 
externally.  In  the  former  it  can  only  extravasate  when  the  cortex  and  capsule  are 
torn,  or  escape  through  the  ureter  into  the  bladder,  when  it  will  be  seen  in  the  urine, 
which,  however,  may  have  to  be  drawn  by  the  catheter  on  account  of  retention.  Blood 
in  the  urine  after  a  local  injury  denotes  serious  mischief  inside  the  kidney  or  along 
the  iirinary  tract.  If  continuing  for  several  hours,  but  especially  if  accompanied  by 
local  indications,  swelling  or  other  evidences  of  extravasation,  by  muscle  rigidity  or  by 
severe  pain,  with  general  symptoms,  it  should  be  assumed  that  these  fluids  are  escaping 

(955) 


956 


SPECIAL  OR  R  EG  I  OX  A  L  SURGERY 


into  the  perirenal  tissues,  perhaps  into  tlie  peritoneal  cavity,  and  that  an  immediate 
exploratory  operation  should  he  urjjed.  When  once  this  indication  is  clearly  recognized 
the  condition  brooks  no  delay.  The  same  is  true  of  penetratino;  wounds.  On  general 
principles,  with  a  patient  in  such  a  condition  and  showing  no  im])rovement,  or  esj)ecially 
if  the  reverse,  exploration  offers  the  safer  course  in  by  far  the  greater  number  of  ca.se.s. 
The  surgeon  need  only  convince  himself  that  such  blood  as  the  urine  contains  does  not 
come  from  the  lower  tract,  but  rather  from  the  kidney  or  ureter.  Exploratory  nephrot- 
omy is  by  itself  so  harmless  that  one  need  never  hesitate'  to  urge  it.  A  kidney  found 
slightly  lacerated  may  be  repaired  with  sutures,  while  one  found  seriously  disorganized 

sliould  either  be  sutured  and  drained  or  totally  re- 
^'°-  ®^  moved,    as    the    case    may  require.     There   is   little 

room  for  doubt  that  it  is  better  to  institute  such  a 
measure  early  rather  than  to  permit  the  dangers  and 
even  ravages  of  infiltration  of  blood  and  urine.  In 
fact  it  may  almost  be  laid  down  as  a  precept  that 
every  patient  who  has  received  an  injury  in  the  loin 
or  flank  and  who  repeatedly  passes  blood  in  the  vrine 
should  be  explored. 


PAIN  IN  THE  KIDNEY;  NEPHRALGIA. 

This  is  a  vague  term,  imjjlying  pain  or  neuralgia  in 
the  kidney,  and  can  refer  only  to  symptoms,  not  to 
any  particular  disease.  Yet  it  must  be  confessed  that 
for  certain  cases  of  so-called  nephralgia  no  physical 
cause  is  easily  discovered.  Pain  in  the  kidneys — or, 
as  patients  will  often  say,  in  the  back — may  be  asso- 
ciated with  excess  of  oxalic  and  uric  acids  and  salts 
in  the  urine,  and  is  then  relieved  by  a  steady  course 
of  alkaline  diuretic  treatment,  with  plenty  of  fluid, 
the  severe  pain  being  combated  with  aspirin.  Xej)h- 
ralgia  may  l)e  expected  in  connection  with  many 
renal  disorders,  l)Ut  the  term  should  ordinarily  be  confined  to  cases  of  pain  without 
known  cause. 

When  such  pain  is  uncomrollal)le  and  intolerable  t!ie  iiidieatidii  i>  to  make  an  explora- 
tory operation,  by  which  the  kidney  should  be  at  least  exjjosed,  perliaps  delivered  upon 
the  external  surface  of  the  body,  and  carefully  examined.  Its  capsule  should  be  split 
(capsulotomy),  as  Harrison  and  others  have  suggested,  and  if  on  pal})ation  or  needling 
(using  a  needle  as  a  probe)  there  be  any  goofl  reason  for  opening  it  this  may  be  done, 
so  that  with  the  finger  its  pelvic  cavity  may  be  carefully  explored,  in  order  to  find  any 
previously  unrecognized  calculus  or  other  surgical  lesion.  The  mere  operation  of 
capsulotomy  or  capsule  splitting  has  proved  of  such  great  value  that  I  always  practise 
this  measure  upon  any  kidney  which  for  any  reason  it  may  seem  wise  to  expose. 


Laceration  fragmentation  of  kidney. 
(Giiterbock.) 


INFLAMMATIONS  AND  INFECTIONS  OF  THE  KIDNEYS. 


Under  this  head  it  is  intended  to  consider  (1)  acute  or  subacute  .specific  infections 
of  the  upper  urinary  passages,  due  to  bacteria,  with  the  effects  of  which  we  are  familiar, 
t.  e.,  septic,  gonorrheal,  and  tuberculous  lesions,  and  (2)  chronic  nephrites  of  irregular 
or  uncertain  ty[X',  for  which  operative  treatment  has  been  recently  proposed. 

Septic  Nephritis;  Pyelitis;  Pyelonephritis;  Surgical  Kidney. — Septic  infection 

of  the  kidney  is  usually  the  result  of  a  process  a.scending  from  the  lower  urinary  passages, 
particularly  when  these  are  obstructed  by  calculus,  tumor,  prostatic  enlargement, 
or  ureteral  stricture.  It  may  follow  catheterism  either  once  or  prolonged,  especially 
when  done  without  strict  precaution;  or  the  infection  may  come  from  the  other  direc- 
tion via  the  blood  stream,  as  in  typhoid  anrl  various  other  fevers,  the  exanthems,  and 
diphtheria.  Gonorrhea  is  a  frequent  cause,  acting  insidiously  and  by  a  creeping 
invasion,  with  the  intervention  of  a  rather  more  abrupt  cystitis.     Nevertheless  when 


INFLA.M  \I.\'I7().\S  AND  INFECTIONS  OF   TIN':   KIDNFVS  057 

i^joiioirlicii  is  followed  hy  pyemia  and  iiietastiitic  jil),sccs.s  these  form  early  in  hoth 
kidneys,  anil  disasti-r  (|uiekly  follows.  These  types  of  infection  spreadin<f  n|)\var(l 
alon<;  the  ureters  do  not  span-  thi"  pelvis  of  the  kidney,  but  expend  their  first  violence 
there.  Beyond  this  tlu>y  may  extend  to  the  renal  tissue  [)ro|)er,  where  they  set  up  a 
true  nephritis,  which  may  prove  fatal. 

Sjonptoms. — Clinical  symptoms  do  not  vary  greatly  except  in  detail.  They  include 
fever,  chills,  and  similar  expression.s  of  toxemia,  with  more  or  less  |)ain  in  the  kidney, 
down  the  ureter,  and  even  referred  to  the  ultimate  distribution  of  the  nerves  symj)a- 
thetically  or  anatomically  involved,  r.  (/.,  to  the  testicle  on  the  same  side,  often  with 
n-traction  of  the  scrotum,  and  down  the  thi<fh.  There  is  a  tendency  to  tli(iinuria  (fre- 
(luciu-y  of  urination)  when  the  Madder  is  involved,  as  it  always  is  sooner  or  later.  Pus 
and  mucus  are  recoj;nizal)li'  in  the  urine  by  the  naked  t-yt',  while  a  microscopic  study  of 
this  fluid  will  reveal,  from  the  character  of  the  cells,  the  extent  and  tyj)e  of  the  invasion. 
The  tuberculous  type  will  be  considered  separately.  Suffice  it  to  say  that  in  this  form, 
however  pure  may  have  been  its  oriijinal  tyi)e,  it  becomes  sooner  or  later  converted  into 
a  mixed  septic  infection,  with  which  renal  abscess  is  often  connected.  The  gonorrheal 
type  is  nowise  clinically  distinct,  so  far  as  the  kidneys  are  concerned,  but  is  to  be  recog- 
nized either  by  the  microsco|)e  or  by  other  clinical  evidence. 

Treatment. — Such  cases  as  the  above  may  even  perplex  the  sin-geon,  since  they  com- 
plicate many  other  surgical  conditions.  Yet  if  they  go  no  farther  than  above  described 
they  are  to  be  treate(l  rather  by  internal  methods,  /.  c,  diluents,  with  hot-air  baths, 
and  especially  by  urotro|)in,  the  remedy  of  greatest  value,  while  such  drugs  as  aspirin, 
bcnzosol,  sodium  bcnzoate  and  the  like,  in  moderate  doses  and  at  rather  short  intervals, 
may  be  administered  to  great  advantage. 

Renal   Abscess;   Surgical   Kidney.— The  conditions  above  described  do  not 

necessarily  nor  often  terminate  with  resolution.  Not  infrequently  suppuration  follows, 
with  resultant  abscesses,  which  may  be  solitary  and  |)ossil)ly  large,  but  are  more  likely 
to  ajipear  in  multiple  and  perhaps  punctate  form.  Should  this  condition  occur  in  one 
kidney  alone,  it  determines  probably  its  ultimate  destruction;  if  in  both  kidneys,  the 
])n)gnosis  is  very  grave,  since  later,  if  not  immediately,  such  a  case  will  succumb  to 
renal  failure,  due  to  the  extra  load  put  upon  the  portion  still  capable  of  secreting.  It  is 
to  kidneys  thus  crippled  by  acute  or  subacute  infections,  with  punctate  abscess  and 
similar  lesions,  that  in  the  past  the  term  ^'surgical  kidney'  was  applied,  because  such 
kidneys  were  seen  oftencr  in  surgical  than  in  so-called  medical  cases. 

Brewer  has  recently  calletl  attention  to  a  type  of  acuic  Jicmatogenous  renal  infection, 
to  which  he  has  given  an  identity  of  its  own.  The  possibility  of  renal  infection  through 
the  bk)od  has  been  long  recognized,  but  it  has  been  generally  supj)osed  to  produce 
bilateral  lesions.  Of  late,  however,  it  has  been  shown  that  these  may  be  unilateral,  on 
account  of  the  tliminished  resistance  of  one  kidney  as  the  result  of  {)revious  disease  or 
injury,  among  the  former  being  calculus,  renal  retention,  and  floating  kidney.  While 
the  colon  bacilli  are  most  frefjuently  at  fault  the  infection  is  often  of  the  pyogenic  or 
mixed  type.  It  seems  to  be  more  frequent  in  women  than  in  men.  The  symptoms 
are  those  of  an  acute  infection,  often  ushered  in  by  a  chill,  with  sudden  rise  of  tempera- 
ture, sometimes  followed  by  such  marked  remission  as  possil)ly  to  suggest  malaria, 
■^rhe  pulse  ranges  high.  Alxlominal  pain  is  an  almost  constant  symi)tom,  although  it 
is  usually  vague  and  often  shifting  or  referred.  Sometimes  it  will  cause  such  a  comj)laint 
as  to  lead  to  mistaken  diagnosis  in  favor  of  an  acute  appendicitis.  Occasionally  it 
radiates  along  the  course  of  the  ureter.  Tenderness  in  the  costovertebral  angle  is  nearly 
always  present.  Muscle  rigidity  is  frequent  but  inconstant.  There  is  nearly  always  a 
leukocytosis,  with  a  percentage  of  about  eighty  polynuclears.  Frequency  of  urination 
may  accompany  these  cases,  but  they  will  ordinarily  be  diagnosticated  by  physical  and 
urinary  examination.  The  urine  will  usually  contain  albumin,  perhaps  with  pus,  and 
occasionally  a  few  red  blood  cells.  Urine  obtained  from  the  affected  kidney  by  ureteral 
catheterization  will  contain  more  of  these  evidences  of  abscess  than  that  from  the  other 
side.  Brewer  has  had  far  better  success  in  entirely  removing  the  affected  kidney  than  in 
exposing  and  simply  draining  it.  He  has  thus  done  a  great  service  in  demonstrating  the 
possibility  of  unilateral  acute  and  suppurative  disease  of  the  kidney,  where  diagnosis  is 
most  obscure  and  the  clinical  picture  one  of  acute  general  abscess  rather  than  of  local 
affection,  showing  as  well  that  the  more  acute  cases  tend  rapidly  to  terminate  fatally 
unless  promptly  arrested  by  complete  removal  of  the  affected  organ. 


958  SPECIAL  OR  REGIONAL  SURGERY 

As  we  consider  the  above  infections,  with  others  yet  to  be  mentioned,  it  becomes 
more  necessary  to  appreciate  those  constituents  and  characteristics  of  the  urine  which 
have  for  the  surgeon  the  greatest  significance,  and  those  methods  of  investigation  ^\  hich 
furnish  him  the  promptest  and  most  satisfactory  resuUs. 

The  following  include  methods  in  present  use  for  determining  renal  capacity  and 
function,  i.  c,  the  matters  of  greatest  importance: 

1.  Catheterization  of  the  ureters; 

2.  Cryoscopy  of  the  blood  and  the  urine; 

3.  Phloridzin  test; 

4.  Chromocystoscopy; 

5.  The  toxin  test; 

6.  The  test  for  electroconductivity  (Kakells). 

1.  By  cystoscopy,  with  ureteral  catheterization,  we  determine  whether  urine  is  secreted 
by  both  kidneys  or  but  one,  Avhile  the  secretion  of  each  kidney  may  be  separately  collected 
and  studied.  Even  this  method  leaves  much  to  be  desired.  Though  one  kidney  be 
actively  diseased  it  may  still  contain  sufficient  tissue  to  make  it  partly  competent  for  its 
purpose,  and  undesirable  to  remove;  or  an  organ  with  very  defective  structure  may, 
nevertheless,  yield  a  certain  amount  of  nearly  normal  urine.  These,  then,  are  aids  to 
determine  the  character  of  the  morbid  process,  and  the  information  they  furnish  is  valuable, 
but  not  always  sufficient. 

2.  Cryoscopy,  based  upon  the  physiochemical  law  that  the  freezing  point  of  the  solu- 
tion is  proportionate  to  the  number  of  molecules  it  contains,  /.  e.,  to  its  molecular  concen- 
tration, has  revealed  that  the  blood  of  a  person  with  severe  kidney  lesion  freezes  at  a 
lower  temperature,  while  the  freezing  point  of  his  urine  would  be  much  higher  than  in 
a  normal  individual,  because  those  materials  which  should  have  been  excreted  in  the 
urine  nre,  on  account  of  impairetl  renal  function,  retained  in  the  blood  and  do  not  get 
into  the  urine.  The  freezing  point  of  normal  urine  varies  from — 0.09°  to — 2.3°C.; 
the  freezing  point  of  normal  blood  from  — 0.55°  to  — 0.57°  C.  The  reasoning  employed 
in  the  method  is  sound,  but  the  method  itself  difficult,  requiring  special  apparatus  and 
experience.  Moreover,  the  limits  of  the  possibility  of  error  are  such  that  this  method 
alone  should  never  be  relied  on.  It  is  essentially  a  test  of  the  ability  of  the  kidneys 
to  act  as  filters,  but  does  not  test  their  serviceability  as  secretory  organs. 

3.  The  phloridzin  test  is  one  of  the  most  trustworthy  for  estimating  the  secretory 
function  of  the  kidneys,  as  it  shows  how  much  active  working  epitheliinn  remains  in 
the  organ.  It  consists  in  the  subcutaneous  injection  of  0.005  Cc.  sterilized  phloridzin 
with  an  equal  quantity  of  sodium  benzoate,  to  hold  the  former  in  solution.  The  bladder 
must  be  emptied  just  before  the  injection  is  given.  About  an  hour  after  its  administra- 
tion sugar  should  appear  in  the  urine,  if  the  kidneys  are  acting  normally.  If  they  are  to 
be  studied  separately,  catheterization  of  the  ureters  is  necessary.  The  test  is,  of  course, 
worthless  in  diabetic  subjects.  It  depends  upon  the  amotmt  of  sugar  excreted,  the  time 
of  its  appearance,  and  the  duration  of  its  elimination.  If  no  sugar  be  present  the 
kidneys  are  seriously  affected ;  if  it  be  delayed,  renal  insufficiency  is  present.  The  average 
quantity  of  sugar  eliminated  during  the  first  half-hour,  when  the  kidneys  are  normal, 
is  about  0.5  per  cent.  If  the  kidneys  be  diseased,  this  quantity  is  reduced  by  a  half, 
and  there  is  very  little  more  secreted  in  the  first  than  during  the  second  half-hour.  This 
valuable  method  is  unfortunately  difficult  of  application  and  requires  minutely  careful 
chemical  tests. 

4.  Chromocystoscopy,  introduced  by  Voelcker  and  Joseph,  is  perhaps  the  simplest 
of  all  methods  of  estimating  renal  capacity.  20  Cc.  of  a  0.4  per  cent,  solution  of  indigo- 
carmine  is  injected  into  the  gluteal  muscles.  In  fifteen  or  twenty  minutes,  if  the  kidneys 
be  normal,  the  cystoscope  will  reveal  dark-blue  urine  flowing  fnim  the  ureteral  orifices 
toward  the  median  line,  with  a  peculiar  jet  at  regular  intervals  of  about  twenty-five 
seconds,  and  lasting  for  i^erhaps  five  seconds.  There  is  both  rhythm  and  force  about 
this  ejaculation.  If  the  color  be  pale,  the  jet  weak,  or  the  rhythm  irregular,  the  intervals 
prolonged  or  late,  or  if  no  flow  whatever  occur,  there  must  be  hindrance  in  the  secreting 
and  filtering  structure  of  the  kidney,  or  occlusion  of  the  ureter.  The  results  given  by 
indigo-carmine  in  these  cases  are  superior  to  those  furnished  by  methylene  blue,  since 
it  is  not  so  much  a  solution  as  a  mixture  which  is  formed  and  ejaculated  as  such.  More- 
over, in  passing  through  the  body  the  indigo-carmine  undergoes  no  reduction.  By 
this  method  there  is  no  necessity  for  catheterization  of  the  ureter.     One  needs  only  to 


IXFLAM.^fATIOXS   AM)  IXFECTIOXS  OF   THE  KIDNEYS  959 

use  tlic  cystosfopc  witli  reasonable  dexterity,  and  tliere  is  no  neeessity  for  elieniical 
tests  of  separate  speeiniens.  The  method  is  generally  useful  in  eases  where  ureteral 
catheterization  is  made  impossible  by  growths.  It  affords  an  easy  means  of  differentia- 
tion, for  instanee,  between  ovarian  cyst  and  hydronejjhrosis. 

5.  The  to.vni  text  is  one  only  to  be  carried  out  l)y  the  use  of  aninuils,  since  it  depends 
ujion  the  amount  of  filtered  urine  re(|uired  to  kill  an  animal  after  injection  into  its  veins, 
the  number  of  cubic  centimeters  necessary  to  kill,  divided  by  the  weight  of  the  animal, 
being  called  the  urotoxic  co-cfHcient.     It  has  greater  laboratory  than  clinical  interest. 

().  Klrctroroiidiirtiriti/  of  urine  is  of  value  in  determining  the  capacity  of  the  kidney 
for  eliminating  inorganic  cells.  It  (lei)ends  on  the  resistance  offered  by  the  urine  to  the 
electric  current.  It  is  complicated  in  method,  requires  special  apparatus,  and  its 
results  are  still  of  questionable  value. 

For  ordinari/  purposes  the  most  trustworthy  data  for  the  surgeon  who  is  not  provided 
with  amj)le  laboratory  facilities  are  afforded  by  an  estimate  of  the  amount  passed  in 
twcnti/-four  lioitrs,  its  speeijir  grai'ifi/,  its  color  and  aridili/,  and  by  the  presence  or  absence 
of  albumin.  The  test-tube  and  the  microscope  then  still  afford  satisfactory  means  of 
deciding  those  matters  which  the  surgeon  needs  to  know.  If  applied  to  urine  collected 
separately  from  each  kidney,  they  may  be  regarded  as  trustworthy.  If  catheterization 
be  impossible,  then  it  is  advisable  to  inspect  the  ureteral  orifices  while  elimination  of 
indigo-carmine  is  taking  place. 

Hematuria. — The  significance  of  blood  in  the  urine  is  rather  that  of  a  symptom 
than  of  a  disease,  although  it  should  be  admitted  that  there  are  occasional  patients 
who  lose  blood  in  this  way,  more  or  less  frequently,  even  periodically,  without  seeming  to 
suffer  in  the  least.  Hematuria  may  also  be  present  as  an  expression  of  vicarious  men- 
struation. Again,  blood  may  thus  appear  in  scurvy  and  similar  conditions,  especially 
in  tropical  climates ;  in  certain  of  the  domestic  animals  its  presence  may  be  due  to  infection 
of  the  kidneys  by  macroscopic  parasites  (the  .so-called  "black-water  fever'  of  men  and 
horses).  Such  cases  as  these  are  outside  the  pale  of  surgery.  Nevertheless  general 
experience  has  shown  that  many  cases  of  hematuria,  without  perceptible  changes  in 
the  kidney,  have  been  benefited  or  cured  by  exploratory  nephrotomy.  Among  the 
causes  ascribed  for  these  so-called  "esseyitial  hematurias"  have  been  incipient  tubercu- 
losis, renal  retention  from  prostatic  enlargement,  congestion  from  venous  obstruction 
(due  to  tight  lacing  or  displacement  from  any  cause),  and  even  the  congestion  of  chronic 
nephritis. 

Treatment. — When  known  or  recognizable  causes  are  absent,  and  the  ordinary  thera- 
peutic agents,  the  special  styptics  (cotarnin),  and  such  measures  as  hypodermoclysis 
with  a  2  per  cent,  gelatin  solution  (see  Control  of  Hemorrhage)  have  failed,  an  explora- 
tion may  be  advised.  It  is  of  the  greatest  advantage  to  be  certain  that  but  one  kidney 
is  involved,  or  it  may  be  necessary  later  to  operate  on  the  second  kidney. 

Operative  Treatment  of  Chronic  Nephritis. — The  various  changes  included  under  this 
head  are  usually  bilateral.  The  term  implies  a  non-j)yogenic  infection  of  the  renal 
bloodvessels,  interstitial  tissues,  and  glomeruli  or  tubules,  which  produce  changes,  often 
spoken  of  in  this  country  as  constituting  iyiterstitial  parenchymatous  or  diffuse  forms  of 
nephritis,  and  inducing  gross  changes  which  cause  the  kidney  to  be  spoken  of  as  con- 
tracted, large,  white,  waxy,  etc.  Discussion  of  the  pathology  of  these  conditions  here 
is  out  of  place.  They  have  all  been  grouped,  most  loosely,  in  common  parlance  as 
forms  of  "Brighfs  disease."  Apart  from  the  significance  of  albuminuria  and  the 
many  terms  implying  peculiar  features,  the  apparent  hopelessness  of  many  of  these 
conditions,  and  the  disappointment  following  internal  treatment,  finally  led  surgeons  to 
attempt  to  ascertain  what  they  could  accomplish.  It  was  in  1S86  that  Pean  operated 
on  a  case  of  chronic  nejihritis  with  nephralgia  and  removed  the  kidney.  Ten  years 
later  Harrison  made  three  nephrotomies,  antl,  though  under  a  wrong  diagnosis  in  each 
case,  it  was  noticed  that  the  symptoms  all  cleared  up  and  that  albumin  disappeared 
from  the  urine.  About  the  same  time  Newman  showed  that  albumin  and  casts  have 
often  appeared  in  movable  kidney,  because  of  torsion  of  the  vessels,  and  that  they  dis- 
appeared after  nephropexy.  Then  Pousson,  in  1899,  reported  some  twenty-five  cases  of 
hematuria  and  nephralgic  nephritis,  operated  upon  by  nephrotomy  and  nephropexy, 
with  great  benefit.  In  1S99,  Israel  was,  perhaps,  the  first  to  formulate  rules  for 
nephrotomy  for  these  conditions.  In  1899,  also,  Ferguson  claimed  that  chronic  nephritis 
should  be  treated  as  are  inflammations  elsewhere,  by  relief  of  tension  and  even  drainage. 


960 


SPECIAL  OR  REGIOXAL  SURGERY 


Meantime,  Edebolils  had  been  doino;  partial  decapsulation  and  fixation  in  cases  of  so- 
called  unilateral  nephritis  (the  j)()ssil:)ility  of  which  is  disputed  by  the  best  authorities, 
like  Kiinnnel),  and  later  extended  his  method  to  comi)lete  decapsulation  (rapsulcrtnnuj), 
with  replacement  of  the  kidney  in  its  fatty  bed,  claimin<r  that  by  and  thnni-rh  the  new 
adhesions  thus  produced  new"  and  more  complete  as  well  as  additional  blood  supply 
was  furnished,  and  that  regeneration  of  the  slightly  altered  j)arenchymat()us  tissue,  as 
well  as  absorjjtion  of  exudates,  was  produced,  ((iuiteras.)  The  fact  that  it  seems  now 
well  established  that  these  forms  of  chronic  nephritis  are  always  bilateral  does  not  of 
itself  affect  the  cogency  of  Edebohls'  reasoning,  if  it  be  otherwise  correct. 

Accurate  diagnosis  has  much  to  do  with  this  problem.  Israel  has  shown  that  chronic 
nephritis  is  even  more  difficult  of  recognition  in  the  Hving  than  in  the  dead,  not  only 
after  ordinary  examination  of  the  capsule,  but  also  after  opening  into  the  kidney. 
Age  is  not  a  serious  contra-indication,  and  enlargement  of  the  heart  is  said  frecjuently 
to'^subside  after  these  operations.  If  cardiac  comj^ensation  begood  operation  is  per- 
missible, if  n(jt  otherwise  contra-indicated.  Edebohls'  method  is  to  anchor  the  kidney 
to  the  muscles  of  the  back,  whether  it  was  previously  movable  or  not.  Primary  healing 
is  desirable,  since  "nephritics"  do  not  bear  suppuration  well. 

Indications  for  Operation. — At  present  a  satisfactory  summary  is  impossible.  It 
is  of  the  first  importance  that  operation  should  be  undertaken  earli/,^  since  to  wait 
until  anasarca  or  other  grave  conditions  supervene  is  to   invite  disappointment  as  the 

result  of  a  jirocedure  which  is  by  many 
Fig.  G33  Considered    ca])ital.     The    coincidence 

of  ])r()nounced  disease  of  any  other  type 
would  be  a  contra-indication.  Bac- 
teriuria,  pyuria,  etc.,  would  j)erhaps 
make  it  more  desirable  rather  than 
otherwise.  Cases  of  operative  toxemia 
(postscarlatinal,  typhoid)  aiid  of  cir- 
rhotic type,  without  other  contra-indi- 
cations,  are  the  most  favorable.  When 
a  careful  examination  of  the  patient 
and  the  urine  leads  the  surgeon  to 
think  that  preparatory  treatment  may 
be  of  advantage,  he  should  find  therein 
almost  his  only  excuse  for  delay,  if 
operation  is  to  be  done.  Low  hemo- 
globin percentage  should  also  lead  to 
postponement. 

Operation  may  consist  of  ncphrolysis, 
or  breaking  down  of  adhesions,  by 
which  ])ain  is  frecjuently  relieved,  of 
dcrapsulaiion,  of  ?irpIirotomi/,  and,  fin- 
ally, of  ncphrectmnij,  in  case  serious 
lesions  are  disclosed.  It  is  doubtful  if 
benefit  is  due  so  much  to  formation  of 
new  vessels  as  to  a  freer  circulation  of 
blood  within  the  kidneys,  with  their 
consecjuent  improved  opportunity  for 
repair  and  elimination.  Guiteras,  for 
instance,  does  not  believe  in  total  decapsulation,  but  in  partial  exposure  of  a  sufficient 
area  on  the  posterior  kidney  surface  to  assist  in  its  fixation,  if  movable.  Otherwise  he 
considers  that  simple  division  of  the  caj)sule  over  the  convexity  will  be  sufficient. 
In  cases  oi  unilateral  nephralgia  and  hematuria  he  advises  nephrotomy,  not  so  much 
as  an  approved  theraj^eutic  measure  as  for  exposure,  perhaps  for  revealing  the  possible 
existence  of  deep  lesions. 

The  recent  reports  from  various  surgeons  concerning  the  value  of  renal  decapsulation 
alone  are  by  no  means  unanimously  favorable,  although  a  majority  of  waiters  are  in 
favor  of  exposure  of  the  kidney,  capsulotomy  and  fixation,  either  by  suture  or  tampon. 
Still,  it  does  not  seem  at  present  justifiable  to  maintain  that  decapsulation  can  be  expected 
to  cure  diffuse  or  deep-seated  arteri(jsclerosis  or  degenerative  processes  within  the  kidneys. 


Acute  pyelonephritis  witli  multiiile  miliary  abscess 
formation.     (Israel.) 


INFLAMMATIO.XS   AM)  I.WFl'JCTIONS  OF   TUH   KID.WI'JYS  901 

The  (jiiostioii  of  the  .siiilahlc  aitcsthrtir  i.s  lit-rc  oiu-  (»l"  iiiiportaiicc.  For  iviisoiis  set 
forth  earlk'r  in  this  work,  ctlicr  should  ahviiys  ho  avoiiUMl.  If  the  operation  he  one 
that  can  he  speedily  |)t'rforined,  nitrous  oxid(>  (ijas  alone  nuiy  sufKee.  Otherwise  it 
should  he  done  under  ehloroforni,  preceded  |)erhaps  with  ethyl  chloride,  or  under 
soninoforni. 

Pyonephrosis. — As  a  condition  this  is  to  he  distiiiouisiicd  from  ordinary  ahscess  of 
tlie  kidney,  in  that  it  inij)lies  the  Retention  in  the  renal  cavity  or  pelvis  of  |)us  with 
eventual  destruction  of  kidney  tissue.  In  other  words  it  is  an  rmpijrvia  rather  than  an 
ahscess.  It  results  from  septic  or  tuherculous  invasion,  plus  ureteral  ohstruclion, 
reo-ardlcss  of  the  ohstructini;  cause,  e.  g.,  calculus,  plufjs  of  mucus,  stricture,  kinkin^^ 
of  ureter,  or  extrinsic  tumor  cau.sin<;'  ])ressurc.  Occlusion  may  he  so  complete  that  no 
urine  escapes  from  the  affected  kidney,  while  that  from  the  other  is  clear,  or  the  phe- 
nomenon may  he  intermittent.  There  results  more  or  less  enlargement  and  often  great 
dilatation  of  tiie  diseased  kidney.  Pus  thus  retained  has  heen  known  to  be  discharged 
into  the  intestine  or  even  into  the  lung.  Sj)ontaneous  recovery  is  rare.  Aspiration 
from  tlu"  hack  in  these  cases  is  ])roper  for  diagnostic  purposes. 

Treatment. — ryone])hrosis,  like  any  other  collection  of  pus,  calls  for //k'/.s/o/;  (nephrot- 
omy) and  (Iraiiiac/r,  with  removal  of  any  possible  foreign  body,  such  as  calculus.  If 
the  entire  kidnt\v  be  found  destroyed,  or  so  compromised  as  to  jeopard  its  future,  a 
ncphreriomu  may  be  done  at  once,  while  it  may  be  a  secondary  measure  in  cases  of 
permanent  urinary  fistula  following  drainage.  So,  too,  if  the  kidney  be  found  tuber- 
culous, it  is  better  to  remove  it  than  to  temporize. 

Perinephritis. — To  pus  formed  in  a  perirenal  phlegmon  is  given  the  term  peri- 
rwphritic  abscess;  this  is  sometimes  due  to  external  or  penetrating  injuries;  sometimes  it 
appears  as  a  jirimary  condition  difficult  of  explanation;  but  it  usually  follows  inflam- 
mation of  adjacent  structures,  such  as  the  kidney  itself  (tuberc-ulous  pyelitis),  the  liver, 
the  colon,  and  the  a])pendix.  While  perinephritis  usually  terminates  by  suppuration, 
spontaneous  recovery,  with  more  or  less  absorption  of  exudate,  is  known  to  occur. 
These  perinephritic  collections  sometimes  attain  enormous  size,  and  are  then  sure  to 
migrate,  always  along  lines  of  least  resistance,  which  takes  them  usually  downward, 
either  toward  the  loin  or  the  groin.  I  once  tapped  below^  Poupart's  ligament  a  collectii)n 
which  exceeded  a  gallon.  These  abscesses  may  also,  more  rarely,  burst  into  any  of 
the  adjoining  cavities,  and  discharge  either  by  the  mouth,  bow'el,  or  bladder,  or  even 
externally. 

Sjonptoms. — In  addition  to  the  usual  systemic  indications  of  the  presence  of  pus 
there  may  be  tumor  in  ihe  lumbar  region,  sometimes  with  distinct  fluctuation,  usually 
with  rigidity  of  the  lumbar  and  psoas  muscles,  perhaps  even  contractions  of  the  thigh 
muscles  which  may  simulate  hip  disease.  These  abscesses  have  been  mistaken  for 
peri-appendical  phlegmons.  If  necessary  to  establish  the  presence  of  pus  the  exploring 
syringe  may  be  used,  but  this  is  rarely  necessary. 

Treatment. — While  in  the  early  stages  the  local  application  of  guaiacol  may  be  of 
use,  every  collection  of  pus  thus  formed  here,  as  w^ell  as  elsewhere,  needs  evacuation 
and  drainage.  This  latter  is  to  be  provided  by  opening  through  the  loin,  in  order  that 
gravitation  in  the  dorsal  position  may  be  of  greatest  assistance.  A  more  or  less  free 
incision,  such  as  is  made  for  exploring  or  removing  the  kidney,  will  usually  be  suffi- 
cient, but  may  be  combined  with  a  coimteropening  at  any  point  where  the  latter  would 
be  of  advantage.  Thus  should  pus  present  in  the  grtin  an  opening  should  be  made 
both  nosteriorly  and  at  the  point  where  it  appears  to  be  coming  toward  the  surface. 

Tuberculosis. — At  no  age  are  the  kidneys  exempt  from  tuberculous  lesions, 
although  these  are  more  frequent  in  the  earlier  years  of  life.  Here  as  elsewhere  they 
may  assume  the  disseminated  miliary  type  or  occur  as  a  solitary  focus.  The  infection 
may  ]:)roceed  upward  from  the  bladder,  or  it  may  be  a  local  expression  of  a  widely 
diffuse  process.  In  the  latter  case  it  has  passed  beyond  the  control  of  the  surgeon  as 
such,  and  calls  for  general  therapeutic  measures,  judiciously  selected  and  actively 
maintained.  Not  a  few  cases  of  renal  abscess,  of  pyelonephritis,  and  even  of  peri- 
nephritic abscess,  are  due  to  primary  tuberculous  lesions. 

Symptoms. — About  the  earliest  symptoms  that  a  patient  may  complain  of  are  thamuria 

(frequency  of  urination),  with  blood  or  pus  in  the  urine.     Even  at  this  early  stage  the 

condition  is  essentially  surgical,  so  the  diagnosis  should  be  established.     Cryoscopy  alone 

is  hardly  sufficient,  although  if  the  freezing  point  be  studied  it  should  be  regarded  along 

61 


962  SPECIAL  OR  REGIONAL  SURGERY 

with  the  amount  of  fluid  iiitfcstctl  aiitl  the  (luantity  of  carbohydrates  taken  with  tlie  food. 
Ureteral  catheterization  is  valuable,  althouifji  until  it  came  into  vogue  we  were  content  to 
study  the  cysto.scopic  appearance  and  to  judge  by  the  ureteral  orifices,  assuming  that  if 
one  appear  healtiiy  and  tlie  other  not  so  operation  is  indicated. 

The  question  of  removal  of  a  totally  diseased  kidney  when  the  other  is  more  or 
less  affected  is  one  demanding  greatest  judgment.  Some  of  the  more  recent  operators 
endeavor  to  determine  this  by  the  cryoscopic  test  of  the  urine  from  the  less  affected 
organ.  If  this  stand  the  test  they  do  not  hesitate  to  remove  the  one  which  is  totally 
diseased.  Thus  it  would  a|)j)ear  that  the  ideal  method  is  one  of  careful  study  of  tlie  urine 
from  eac-h  kidney,  although  it  is  acknowledgecl  that  when  the  question  is  still  in  doubt 
the  associate  kitlney  may  be  exj^Iored  before  deciding  to  remove  the  one  most  diseased. 

Diagnosis  of  Renal  Tuberculosis. — The  most  frequent  and  significant  symptoms  of 
renal  tuberculosis  are  pai)i,  local  and  referred;  hematuria,  poli/uria,  and  pi/uria.  In 
young  adults  suffering  from  bladder  irritability,  painless  pijiiria  usually  indicates  tuber- 
culosis of  the  bladder,  secondary  to  that  of  the  kidney,  this  being  particularly  true  when 
the  urine  is  hyperacid.     This  urine,  if  noted,  will  be  found  at  first  faintly  cloudy  or  smoky, 

Fig.  634 


Tuberculosis  of  kidney,  nodular  form.      (Israel.) 

while  later  the  admixture  of  pus  ))ecomes  more  evident.  The  frequency  of  micturition 
(thamuria,  pollakiuria),  which  is  frequently  noted  early,  may  be  due  mainly  tcj  })olyuria; 
the  final  test  is  the  discovery  of  bacilli  in  the  urine.  There  is  another  form  of  thanmria 
wdiich  is  associated  wath  tenesmus,  constituting  the  painful  cystitis  of  Guyon,  which 
depends  on  complications  in  the  bladder  itself.  A  search  for  bacilli  is  often  disap- 
pointing, and  tuberculin  may  be  used  in  the  endeavor  to  make  a  diagnosis,  as  well  as 
animal  inoculation.  Tuberculin  might,  however,  give  rise  to  error  were  there  tuber- 
culous foci  elsewhere  about  the  body. 

Renal  tuberculosis  may  run  a  painless  course,  or  it  may  be  accompanied  by  a  severe 
renal  colic  or  renal  crises,  the  latter  sometimes  due  to  plugging  of  the  ureter  with  cheesy 
debris.  Pyuria  may  be  masked  by  hematuria,  the  latter  trifling,  apparently  sponta- 
neous, and  occurring  even  during  repose. 

More  accurate  diagnosis  can  be  rarely  made  without  resort  to  the  cystoscope  and  cathe- 
terization of  the  ureters.  When  in  the  cystoscopic  image  the  ureteral  orifice  is  enlarged, 
congested,  and  even  hemorrhagic  or  ulcerated,  it  may  be  regarded  as  evidence  of  tuber- 
culous disease  in  the  corresponding  kidney.     Meyer  has  claimed  that  in  the  descending 


IXFLAMMAT/nXS  AND  INFECTIONS  OF   Tiri'J   KIDXFYS 


iXi.'i 


i'onii  of  ttihcrciiiosi.s  tlic  iiioutli  (»!'  (lie  uri-liT  is  ulccralcd,  wliilc  in  tlic  ascciidiii;;'  fonii  it 
is  jippartMitly  licalthy.  VVIicii  both  outlets  arc  a|)|)arciitly  licaltliy,  and  urinalysis  indi- 
cates renal  disease,  the  ease  must  be  one  of  aseendinir  lesion.  Fenwiek  has  described 
wluit  he  calls  a  ">;'olf-hol(>  ureter,"  the  orifice  beint^;  dilated  and  patulous,  and  the 
appearance  being  to   him   j)athof:jn()nionic. 

Ureteral  catheterization  is  perhaps  less  necessary  on  the  susj)ected  side  than  it  is  to 
prove  the  healthfulness  of  the  kidney  on  the  o])|)osi(c  side.  The  disease  is  more  common 
m  the  female,  and  usually  occurs  in  early  adult  life.  It  is  more  often  a  descending 
than  an  asccndiiio-  alfcction. 

Treatment. — Radical  treatment  of  renal  tuberculosis  is  j)ossil)le  only  when  the  lesion 
is  limited  to  one  organ.  What  shall  be  done  with  the  kidney  involved,  when  ex|)osed 
and  the  disease  revealed,  may  dej)end  to  some  extent  upon  the  actual  degree  of  involve- 
ment.    More  and  more  surgeons  are  agreeing  that  anything  like  partial  nephrectomy 

Fig.  635 


Renal  tuberculosis  as  seen  on  section.     Papillary  granulomata  seen  at  T.     (Israel.) 

is  of  questionable  value,  and  that  an  organ  distinctly  tuberculous  should  he  removed. 
In  other  wortls,  |)artial  nephrectomy  is  of  doubtful  merit.  Of  course,  the  kidney  should 
be  opened  before  its  removal,  unless  from  its  exterior  it  is  seen  to  be  hopelessly  involved. 
A  further  question  of  great  importance  is  that  of  involvement  of  the  ureter.  With  a  few 
associated  lesions  in  the  kidney  the  ureter  may  easily  escape,  but  with  a  kidney  thoroughly 
degenerated,  and  with  infected  urine  or  tuberculous  debris  passing  constantly  down 
through  the  ureter  it  cannot  escape  contamination.  It  is  not  a  difficult  procedure,  nor 
does  it  add  to  the  gravity  of  the  operation,  to  extend  the  incision  sufficiently  to  permit 
not  only  the  delivery  of  the  kidney  but  the  exposure  at  least  of  the  upper  portion  of  its 
ureter.  In  this  way  the  renal  yielvis  may  be  opened  and  the  ureter  itself  examined. 
When  thus  involved,  and  especially  if  it  be  determined  to  sacrifice  the  kidney,  as  much 
of  the  ureter  should  be  removed  with  it  as  can  be  reached.  While  theoretical  considera- 
tions would  always  require  these  measures  to  be  combined,  many  mild  tuberculous 


964  SPECIAL  OR  REGIONAL  SURGERY 

lesions  of  the  ureter  undergo  spontaneous  retrocession  after  removal  of  the  diseased 
kidney  from  which  it  has  become  contaminated. 

The  incision  intended  to  expose  the  ureter  should  begin  about  a  half-inch  forward  and 
in  front  of  the  lower  costal  cartilage,  parallel  with  the  last  rib,  and  terminate  on  a  level 
with  the  anterior  superior  spine,  about  one  inch  toward  its  inner  side.  This  incision  will 
then  be  about  four  inches  in  length.  The  use  of  a  pillow  is  of  assistance  in  the  easy 
performance  of  this  operation.  The  body  should  be  rolled  as  far  as  possible  without 
losing  negative  pressure  upon  the  abdomen.  The  more  abdominal  fat  there  is  present 
the  further  over  the  patient  should  be  rolled;  a  stout  patient  should  have  the  hi})s  raised 
from  the  table  by  a  cushion,  in  order  that  the  abdomen  may  be  pendent,  while  the  foot 
of  the  table  is  somewhat  elevated  and  the  operator  is  facing  the  abdomen.  After  exposing 
the  fat  which  is  adherent  to  the  peritoneum,  and  the  knife  is  laid  aside,  the  peritoneum 
is  separated  from  the  abdominal  wall  until  the  kidney  and  the  perinephritic  fascia 
are  recognized.  Then  with  a  short  retractor  the  posterior  edge  of  the  wound  below 
the  ribs  is  elevated,  after  which,  under  the  influence  of  gravity,  the  cavity  opens  widely, 
the  fascia  may  be  torn  through,  and  the  kidney  exposed  and  freed.  The  retractor 
is  then  removed,  the  anterior  edge  of  the  wound  pressed  backward,  and  the  kidney  is 
easily  delivered  from  the  abdominal  cavity;  or  if  its  delivery  be  impracticable,  it  may 
be  at  least  so  drawn  up  that  the  renal  vessels  are  easily  exposed,  tied,  and  divided. 
After  their  division  care  shoidd  be  given  that  the  weight  of  the  kidney  does  not  drag 
injuriously  upon  the  ureter.  The  latter  is  then  cleared  of  peritoneum,  especially  to 
its  outer  side,  by  blimt  dissection,  after  which  a  medium-width  Sims  speculum,  with  a 
long  bill,  may  be  passed  downward  between  the  peritoneum  and  the  abdominal  wall 
and  made  to  draw  the  latter  upward.  Thus  an  extensive  view  of  the  ureter  is  afforded, 
while  its  lower  portion  may  be  still  further  freed  toward  the  base  of  the  broad  ligament. 
By  a  continuation  of  this  process  of  separation  and  exposure  it  is  possible  to  release  the 
ureter  almost  to  its  junction  with  the  bladder,  where  it  is  tied,  its  stump  being  disinfected 
with  pure  carbolic. 

Syphilis  and  Actinomycosis. — These  lesions  may  be  briefly  dismissed  so  far 
as  they  pertain  to  tiie  kidneys.  Gummas  are  rare,  renal  syphilis  being  usually  of  a 
disseminated  t^i^e,  which  should  be  treated  by  internal  therapy,  except  when  abscess 
results  or  when  there  arises  some  peculiar  surgical  complication.  Actinomycosis  is  rare 
in  the  kidneys,  and  is  not  recognized  until  the  peculiar  fungi  are  found  in  the  urine,  or 
until  some  granuloma,  developing  toward  the  surface,  breaks  down  and  discharges  its 
characteristic  products. 

RENAL  COLIC. 

Renal  colic  implies  severe  and  often  agonizing  pain,  which  follows  spasmodic  con- 
traction of  the  renal  pelvis  and  ureter,  in  the  effort  to  expel  an  ol^structing  object  from 
one  or  the  other.  It  may  be  produced  by  calculi,  by  clots  of  blood,  clumps  of  pus  and 
debris,  by  particles  of  sloughing  tissue  (as  in  breaking-down  tuberculous  or  cancerous 
foci),  by  extrinsic  pressure  of  various  morbid  products,  or  finally  by  kinking  or  alternating 
stricture  and  dilatation  of  the  ureter.  Pain  is  the  constant  and  significant  feature, 
marked  by  spasmodic  exacerbation.  It  is  usually  well  localized,  and  referred  along  the 
course  of  the  ureter  and  the  cord  to  the  testicle  in  the  male,  with  retraction  of  the  scrotum, 
to  the  labium  in  the  female,  and  down  the  thigh  in  both  sexes.  With  it  there  usually 
occur  more  or  less  sympathetic  disturbances,  such  as  nausea,  with  most  pronounced 
local  tenderness  and  sometimes  abdominal  rigidity. 

Treatment. — Treatment,  while  palliative  during  the  intensity  of  the  attack,  should 
be  later  made  radical.  For  the  former  hot  applications,  morphine,  and  chloroform 
inhalations  may  be  used.  It  may  happen  that  an  almost  complete  inversion  of  the 
patient  will  be  followed  by  relief.  Large  does  of  glycerin,  and  sometimes  of  aspirin, 
will  also  occasionally  prove  beneficial.  Meantime  the  case  should  be  carefully  studied 
and  a  skiagram  be  taken,  in  order  that  one  may  intelligently  ad^^se  and  carry  out 
whatever  indications  mav  be  revealed. 


RENAL  CALCULUS  965 


RENAL  CALCULUS. 

Re7ial  and  vesical  calculi  are  the  result  of  the  precipitation  of  material  previously  held 
in  solution  by  the  urine  as  it  escapes  from  the  tubules,  their  nuclei  or  nidi  beiuif  usually 
a  clump  of  cells,  particles  of  blood  clot  or  of  tissue.  They  are  comj)osed  mainly  of 
uric  acid,  urates  t)r  oxalates,  less  abundantly  of  plio.s-jjhatc.s,  and  rarely  of  ri/stin  or  .ratithin. 
They  vary  in  size  from  the  smallest  visible  particle  to  those  wei<i;liiu(f  ounces,  and  in 
numbcM"  from  one  to  hundreds.  They  occur  more  often  in  males,  and  usually  late  rather 
than  early  in  life.  They  nuiy  be  found  in  one  or  both  kidneys.  When  the  latter  it 
may  be  assumed  that  some  systemic  defect  underlies  their  formation.  In  shape  they 
vary  greatly,  the  small,  sharp  particles  often  causing  as  much  pain  as  do  large  stones,  or 
even  more.  Diathetic  conditions  produce  them  in  some  de  novo,  while  in  (jthers  they 
result  from  previous  morbid  ])rocesses. 

Small  calculi  esca})ing  into  tlie  bladder  cause  intense  renal  colic  (see  above),  and,  within 
the  latter,  unless  they  escaj)e  through  the  ureter,  as  they  usually  do  when  small  or  are 
not  retained  behind  a  large  ])rostate,  they  increase  in  size,  and  become  then  the  common 
vesical  calculi,  those  with  uric  acid  nuclei.  Calculi  long  present  in  the  kidney  usually 
set  up  what  is  known  as  calculous  nephritis  or  pi/elonephritis.  It  is  (^uite  possible,  how- 
ever, for  such  a  concretion  to  first  form  within  the  tubules  or  at  the  apex  of  one  of  the 
pyramids,  so  that  it  docs  not  fall  free  into  the  renal  cavity.  In  such  locations  it  may 
produce  great  pain,  with  hematuria  and  tenderness,  yet  not  for  a  long  time  escape  into 
the  renal  pelvis.  Such  a  stone  may  be  shown  by  a  good  skiagram.  Calculi  long  retained 
will  cause  other  troubles,  whose  characteristics  will  be  revealed  by  careful  study  of  the 
urine,  especially  of  that  drawn  from  the  affected  kidney,  albuminuria  and  pyuria  often 
figuring.  The  symptoms  include  pain  and  tenderness,  which  may  be  referred;  colic, 
hematuria,  and  pyuria.  Symptoms  of  less  frequency  include  thamuria  (sometimes 
painful),  nausea,  and  vomiting.  The  accompanying  features  include  pyonephrosis, 
tuberculous  or  movable  kidney,  or  possibly  various  neoplasms. 

Symptoms. — Stone  in  the  ureter  may  cause  symptoms  likely  to  be  mistaken  for  appen- 
dicitis, especially  when  lodged  on  the  brim  of  the  pelvis,  or  an  inflamed  appendix  may  hang 
over  into  the  pelvis  and  cause  bladder  and  rectal  symptoms,  while  on  palpation  through 
the  vagina  the  tenderness  and  thickening  may  be  misleading.  In  such  cases  the  urine 
offers  the  surest  guide.  Acute  pancreatitis  should  hardly  be  mistaken  for  renal  trouble, 
as  there  would  be  a  history  of  former  attacks  of  indigestion,  probably  associated  with 
typical  gallstone  colic,  while  the  location  of  pain  and  the  presence  of  pancreatic  enlarge- 
ment would  be  significant.  In  pancreatitis,  moreover,  the  urine  might  show  sugar. 
Renal  or  ureteral  colic  is  sometimes  followed  by  such  reflex  paralysis  of  the  bowel,  with 
meteorism  and  tenesmus,  perhaps  even  with  nausea  and  vomiting,  as  to  suggest  intestinal 
obstruction.  Again,  the  crises  of  Henoch's  purpura,  and  of  angioneurotic  edema, 
sometimes  accompanied  by  hematuria,  may  mislead. 

Inspection  of  the  entire  body  will  probably  reveal  purpuric  spots  or  areas  of  edema. 

Finally,  a'-rays  afford  very  convenient  means  of  diagnosis  under  many  circumstances, 
although  mistakes  have  occurred  from  misinterpretation  of  shadows.  Nevertheless, 
when  a  well-taken  picture  shows  unmistakable  evidence  It  may  be  considered  as  quite 
reliable. 

Diagnosis. — In  the  matter  of  diagnosis  few  diseases,  as  Hunner  has  shown,  present 
such  protean  symptoms.  Between  calculous  nephritis  and  tuberculosis  the  only  positive 
indication  Is  the  discovery  of  bacilli  In  the  urine  or  the  reproduction  of  the  disease  in 
animals  by  inoculation.  Blood  occurs  in  both,  but  Is  more  likely  to  be  Influenced  by 
exercise  in  cases  of  stone.  Pus  occurs  also  in  both,  while  pain  is  unreliable.  Palpation 
shows  nothing,  unless  it  may  reveal  thickening  of  the  ureter  In  the  female  as  felt  through 
the  vagina.  In  pyelitis  the  presence  of  a  stone  may  cause  any  of  these  conditions,  or 
it  may  develop  because  of  them.  If  trouble  have  begun  soon  after  an  acute  Infection, 
or  during  pregnancy,  It  Is  more  likely  to  be  a  case  of  infected  kidney.  When  tumor  is 
suspected,  urinary  examination  is  the  best  guide.  The  sudden  occurrence  of  hemor- 
rhages, with  their  abrupt  cessation,  rather  favor  diagnosis  of  tumor,  as  does  also  the 
absence  of  pus.  Still  the  latter  may  be  absent  when  the  ureter  is  obstructed.  Inter- 
mittent hydronephrosis  is  usually  due  to  kinking  of  the  ureter  connected  with  a  movable 


966  SPECIAL  OR  REGIONAL  SURGERY 

kidney.  Durino;  the  attacks  the  kithiey  will  be  enlarged  and  misj)laced,  while  blood 
may  appear.  With  return  to  place  comes  subsitlcnce  of  enlargement,  while  increase  in 
the  amount  of  urine  is  characteristic.  Idiopathic  hematuria  or  ''renal  cpistaxis"  is 
sometimes  connected  with  the  chronic  interstitial  forms  of  nephritis.  The  urine  shows 
blood,  if  dealing  with  renal  calculus,  and  bile  if  with  biliary  calculus.  In  the  former 
pain  is  more  likely  to  radiate  down  the  ureter,  while  in  the  latter  it  is  upward  and  back- 
ward. In  biliary  trouble  the  gall-bladder  may  be  enlarged  and  movable  or  even  pendu- 
lous. Kelly  has  suggested  a  method  of  differential  diagnosis  by  catheterizing  the  ureter, 
and  forcibly  injecting  into  the  pelvis  of  the  kidney  a  l)land,  sterile  solution.  If  the 
pain  which  it  produces  be  identified  by  the  patient  as  the  same  which  is  usually  suffered 
it  may  be  regarded  as  diagnostic;  if  somewhat  different,  then  the  actual  attacks  are  more 
likely  to  be  biliary.  A  normal  renal  pelvis  should  hold  about  7  to  8  Cc.  before  the 
patient  begins  to  complain. 

Treatment. — In  the  milder  cases,  and  those  where  small  concretions  are  repeatedly 
passed,  medicinal  treatment  may  be  given  a  trial.  While  the  alkalies,  especially  the 
lithium  preparations,  have  repute  in  certain  quarters,  there  is  probably  nothing  sujjerior 
to  piperazin  in  its  power  of  dissolving  small  uric  calculi.  Its  physical  properties  and 
its  expensiveness,  however,  make  it  disadvantageous  to  use.  It  is  so  sparingly  soluble 
that  part  of  the  benefit  obtained  from  it  may  be  due  to  the  volume  of  fluid  ingested  with 
it,  and  to  the  consequent  dissolving  and  washing  down  of  small  particles.  Glycerin  is 
also  an  analgesic  here,  as  in  biliary  calculi,  and  a  half-ounce,  administered  every  two  or 
three  hours,  will  often  give  relief.  Attention  to  the  diet  is  also  necessary,  especially  in 
acute  and  uric  acid  patients. 

When  there  is  reason  to  believe  that  the  kidney  contains  a  calculus  which  cannot  be 
passed,  and  especially  when  an  .r-ray  picture  reveals  such  a  conilition,  then  surgical 
treatment  alone  offers  prospect  of  complete  relief.  This  includes  nephrotomij  and  what 
has  been  named  nephrolithotomy,  i.  e.,  exposure  and  opening  of  the  kidney  and  removal 
of  its  contained  concretions.  When  these  are  easily  felt  the  procedure  is  simple.  How- 
ever when  only  a  small  concretion  has  been  shown  in  the  skiagram,  and  it  is  not  easily 
palpable,  even  with  the  kidney  between  the  fingers,  it  is  sometimes  a  difficult  matter  to 
locate.  One  method  of  doing  this  is  with  a  small  needle,  passed  repeatedly  in  the  direc- 
tion of  the  supposed  calculus — used,  in  other  words,  as  a  probe.  When  such  a  stone  is 
thus  recognized  it  should  be  removed. 

In  cases  of  long-standing,  renal  pelves  are  dilated  into  relatively  large  sacs,  containing 
numerous  concretions,  or  sometimes  a  large  stone  in  branching  form,  resembling  coral. 
If  a  considerable  degree  of  pyonephrosis  or  of  disintegration  accompany  such  a  stone  a 
complete  nephrectomy  should  be  made.  It  remains,  then,  for  the  surgeon's  judgment 
to  decide  as  between  nephrolithotomy  or  nephrectomy,  a  question  which  will  be  settled, 
in  large  measure,  by  what  has  been  ascertained  regarding  the  condition  of  the  other 
organ.  If  considered  fully  competent  little  hesitation  need  be  felt  in  removing  the 
diseased  one;  if  its  condition  be  distrusted,  then  it  were  best  to  not  carry  out  the 
surgical  indication,  but  to  substitute  for  it  good  general  treatment. 


MOVABLE  AND  FLOATING  KIDNEY. 

In  most  of  the  serious  and  in  many  of  the  milder  degrees  of  unnatural  mobility  of  the 
kidney  to  which  the  adjectives  "movable"  and  "wandering"  are  applied,  the  surgeon 
has  to  deal  with  a  somewhat  anomalous  condition,  wliich,  while  it  attains  serious  and 
alarming  symptoms  during  life,  leaves  little  evidence  after  death.  Thus,  Ebstein  found 
it  in  only  5  out  of  36,000,  and  yet  it  is  said  to  occur  in  at  least  20  per  cent,  of  all  women 
examined.  In  women  and  children  the  kidneys  lie  lower  and  deeper  in  the  gutter  on 
either  side  of  the  spine,  beneath  the  seventh  to  the  tenth  cartilage,  the  upper  end  of  the 
left  kidney  belonging  at  the  level  of  the  ensiform  cartilage.  The  kidneys  are  supported 
by  perirenal  fascia,  by  the  renal  vessels,  by  pressure  of  the  surrounding  viscera,  their 
anterior  peritoneal  covering  playing  but  small  part.  Abnormal  mobility  below  the 
twenty-fifth  year  of  age  is  rare;  its  etiology  is  still  obscure,  it  being  found  in  women  at 
least  six  times  as  often  as  in  men;  more  commonly  in  those  who  have  borne  several 
children,  or  who  have  become  suddenly  emaciated  after  long  illness,  while  in  men  it  is  mo.ot 


MOVAHLE  .l.V/)  FLOATIXC!  KIDSKY  0G7 

coinmon  on  the  left  side.  The  kidney  is  jdVordcd  ;i  small,  dislinct  jK-ritoncal  covcrini,', 
the  sd-callcd  luesoncpliroM,  wliicli,  with  its  other  sii|)|)orts,  inay  he  inore  or  less  lux, 
perniittiii^f  (hlli-riiin;  dcjrrces  of  ahiiornial  niol)ility,  tlie  milder  heiri^f  spoken  of  as 
movdhlc  k^dnev,  the  more  serious  us  floaliiKj  kidney.  As  UeKield  luis  sliown,  in  every 
case  ol"  funetionul  disturhunee  of  the  urinury  or<runs  the  possibility  that  u  floutin<r 
ki(hiey  may  he  the  euuse  of  the  trouble  should  be  borne  in  mind. 

Symptoms.— The  symptoms  vary  from  va^ue  discomfort  to  u(ronizin«,f  jmin.  Ordi- 
narily they  include  dru«!;<,nn(2;  sensution  in  the  ubdonien,  with  indefinuble  discomfort,  a 
feelin<;  of  weakness,  sometimes  radiating  down  the  legs  and  across  the  back,  these  symp- 
toms fre(|uently  aeeom|)anied  by  dyspnea,  flatulene(>,  consti|)ation,  and  fre(iuency  of 
urination,  all  of  which  may  be  intensified  by  increased  activity.  In  the  mon;  severe 
forms  we  find  abdominal  tenderness,  severe  pain  and  vomitini-;,  with  collai)se  and  the 
occurrence  of  jjceuliar  crises,  sometimes  of  intense  agony,  which  mav  occur  gradually 
or  suddenly,  ceasing  in  the  same  fashion,  Not  one  of  these  symptoms  is  j)athognoiii()nic 
of  movable  kidney,  nor  can  they  be  with  certainty  attributed  to  it  until  the  sus|)icion  Is 
confirmed  by  physical  examination.  The  severe  crises  are  described  as  coming  on  with 
intense  ))ain,  nausea,  vomiting,  collapse,  chills,  and  sometimes  considerable  temi)erature, 
esj)eeially  in  hysterical  subjects.  Osier  and  Atlee  think  that  too  much  stress  has  been 
laid  ui)o"n  the  condition,  esj)ecially  after  the  patient's  realization  of  it,  the  severer  symj)- 
tonis  often  dating  from  the  first  knowledge  of  the  facts.  Obviously,  temporary  hydro- 
nephrosis may  be  caused  by  teni])orary  obstruction  in  the  ureter,  from  disj)lucement, 
while  temporary  venous  obstruction  may  cause  pain  in  u  diiferent  way.  Actual  alimen- 
tary disturbances  are  very  closely  simulated,  and  sometimes  it  is  difficult  to  distinguish 
between  a  movable  kidney  on  the  right  side  and  a  chronic  appendicitis. 

A  great  deal  of  attention  has  of  late  been  given  to  nephroptosis  and  to  the  effects 
of  enirropfos-is,  and  their  production.  The  peculiar  crises  were  long  ago  describetl  l)y 
Dittel,  and  include  sometimes  a  feeling  of  suffocation,  with  a  desire  to  loosen  and  remove 
clothing,  when,  after  lying  down,  the  kidney  resumes  its  position.  When  after  urination 
relief  quickly  follows,  there  is  much  to  suggest  kinking  of  the  ureter  and  distention  of  the 
renal  pelvis'.  ]\Iuc-h  less  frequent  features  are  jaundice,  from  contraction  of  adjacent 
viscera,  and  persistent  nausea  from  the  same  result,  or  hematuria  from  a  disturbed 
circulation.  The  more  marked  forms  in  women  are  usually  accompanied  by  certain 
neurotic  features,  which  give  them  a  feature  to  which  they  are  not  properly  entitled, 
while  the  entire  digestive  process  and  the  vasomotor  innervation  of  the  viscera  seem 
more  or  less  disturbed,  with  consequent  toxemia. 

The  actual  intlication  of  floating  kidney  is  its  discovery  by  palpafton,  the  degree  of  dis- 
placement being  in  some  cases  quite  noticeable;  thus  it  may  cross  the  middle  line,  or 
may  be  felt  even  in  the  pelvis.  In  the  female  the  kidney  shoukl  lie  above  the  twelfth  rib, 
posteriorly,  and  above  the  costochondral  border  of  the  eighth  rib  anteriorly,  and,  there- 
fore, not  be  easily  palpated  during  respiration.  This  statement  is  somewhat  at  variance 
with  some  of  those  contained  in  the  text-books  on  anatomy,  the  diagrams  being  all  made 
from  male  cadavers.  It  is  of  importance  not  merely  in  locating  the  organs,  but  in  fasten- 
ing them  in  place,  as  all  methods  thus  far  devised  leave  much  to  be  desired  in  complete 
replacement.  A  kidney  prolapsed  only  to  the  waist-line  can  scarcely  be  sutured  to  the 
loin  without  disjilacing  it  even  farther  backward.  On  the  other  hand,  the  kidney  which 
lies  near  the  brim  of  the  pelvis  rarely  causes  acute  symptoms,  because,  supported  from 
below,  it  enjoys  accommodation  of  its  ureter  to  its  abnormal  relations,  so  that  hydro- 
nephrosis rarely  occurs.  The  truth  is  that  in  most  aggravated  cases  of  nephroptosis 
nearly  all  the  viscera  have  been  displaced  downward,  and  Ingall's  suggestion  to  fasten 
in  place  at  one  and  the  same  time  the  kidney,  the  liver,  the  spleen,  the  stomach,  and  the 
transverse  colon  is  well  founded,  although  difficult  to  carry  into  effect. 

Treatment. — Fixation  of  an  abnormally  mobile  kidney  is  indicated  in  every  case 
where  its  displacement  causes  unpleasant  symptoms,  yet  simple  as  it  is  in  theory  it  is 
neither  easy  nor  always  successful  in  practice.  To  completely  restore  the  kidney  to 
place  is  to  fasten  it  higher  than  the  natural  routeseasily  permit,  and  requires  either  resec- 
tion of  a  rib  or  fixation  of  the  kidney  to  one  of  the  lower  ribs,  a  method  which  has  been 
recommended  and  practised  by  some  operators.  Because  of  the  disappointment  so 
often  resulting  from  these  operations  conservative  practitioners  have  felt  that  by  pressure 
from  below,  as  by  an  abdominal  binder  with  a  suitably  placed  pad,  the  kidney  could  be 
so  pushed  upward  and  held  as  to  be  made  comfortable.     This  may  at  least  be  tried  in  the 


968 


SPECIAL  OR  REGIONAL  SURGERY 


milder  cases.  The  supports  should  uever  be  put  iu  place  uutil  the  patient  is  on  her  back 
and  completely  undressed.  This  method  of  external  support  failing  or  })roving  unsatis- 
factory, the  surgeon  may  choose  from  many  different  mctiiods  the  peculiar  plan  for 
nephroppxij  or  kidney  fixation  which  he  will  ado])t. 

Nepnropexy. — These  methods  all  have  in  common  tlu>  intent  to  produce  adhesions 
between  the  kidney  and  its  normal  envin)nment,  by  which  it  shall  be  held  in  or  near  its 
proper  place  and  prevented  from  dropping.  The  kidney  more  than  any  other  organ  is 
held  in  a  cushion  of  fat,  and  it  becomes  a  question  to  what  extent  this  mass  of  surround- 
ing fat  shall  be  removed.  To  take  it  all  away  considerably  complicates  the  procedure; 
to  leave  it  is  to  not  furnish  the  firmest  possible  surroundings  for  the  purpose.  The  patient 
should  be  placed  either  flat  upon  the  abdomen  or  turned  well  over  on  the  side  opposite 
that  to  be  operated,  a  cushion  or  bolster  being  usually  placed  beneath  the  abdomen 
and  loin  in  such  a  way  as  to  push  upward  and  into  prominence  the  side  to  be  attacked. 
The  incision  employed  may  be  parallel  to  the  sj)ine,  about  three  inches  away  from  it, 
and  carried  down  to  the  tissues  outside  the  quadratus  lumborum  and  other  spinal 
muscles.  Most  operators  prefer  an  oblique  incision,  made  between  the  low^er  rib  and  the 
upper  margin  of  the  pelvis,  its  centre  about  four  inches  from  the  spine,  extending  in 
either  direction  two  inches  or  more,  in  order  to  afford  sufficient  access.  It  is  carried 
down  until  the  abdominal  aponeurosis  and  muscles  are  exposed.  These  are  then 
divided  and  the  perirenal  fat,  which  is  sometimes  excessive  in  amount,  is  exposed.     The 

deep    opening    should    now    be 
Fig-  636  Stretched  to  a  size  to  permit  the 

introduction  of  a  hand,  and  ex- 
ploration made  for  the  identifi- 
cation and  retraction  of  the 
kidney.  INIuch  aid  may  be  af- 
forded in  this  effort  by  the  use  of 
the  other  hand  upon  the  outside 
of  the  patient's  abdomen,  which 
should  all  have  been  protected 
and  sterilized  to  permit  such  free 
manipulation.  Sometimes  it  is 
easy  to  find  such  a  kidney,  at 
other  times  and  in  persons  of  cer- 
tain build  it  is  a  difficult  matter. 
It  lies  behind  the  peritoneum, 
and  this  should  never  be  opened 
during  the  effort.  More  or  less 
of  the  perirenal  fat  may  be  cleared  away.  The  more  or  less  elusive  kidney  being  iden- 
tified, it  should  be  seized  with  tenaculum  forceps,  which  should  secure  only  its  capsule 
and  not  injure  its  substance.  With  these  it  is  drawn  up  at  least  to  the  wound,  or 
in  some  methods,  it  is  w^ithdrawn  through  it  and  delivered  upon  the  surface  of  the 
body.  If  sutures  alone  are  to  be  depended  upon  they  may  be  placed  after  any  one  of  a 
number  of  different  methods.  The  older  method  was  to  place  the  kidney  as  nearly  as 
possible  in  its  normal  relations  and  then  unite  the  deep  margins  of  the  wound  to  the 
capsule,  and  perhaps  the  cortex  of  the  kidney,  by  a  series  of  two  or  three  sutures  on  either 
si(le,  either  of  chromic  gut  or  of  silk.  The  theoretical  objections  which  prevail  against 
passing  sutures  through  the  renal  cortex  are  hardly  well  founded,  and  stitches  may 
be  so  placed,  if  desired,  but  they  should  not  be  drawn  too  tightly  (Fig.  636). 

Senn  and  others  have  endeavored  to  induce  the  formation  of  dense  adhesions  by  pack- 
ing around  the  kidney  with  gauze,  left  in  situ  for  several  days,  whose  presence  should 
provoke  the  formation  of  granulation  tissue.  In  theory  this  works  well,  but  in  practise 
the  presence  of  the  gauze  is  painful,  its  removal  especially  so,  and  the  wound  must  be  left 
more  or  less  open  for  the  purpose.  Since  I  have  learned  of  the  harmlessness  and  the 
advantages  of  decortication  I  have  made  a  practise  of  decapsulating  almost  every  kid- 
ney thus  exposed,  and  of  endeavoring  to  utilize  a  portit)n  of  the  capsule  for  the  purpose 
of  support,  as  by  cutting  it  into  strips,  which  are  threaded  into  a  needle,  and  then  passed 
through  the  tissues,  thus  utilizing  the  capsule  for  suture  material,  or  by  fastening  it  with 
sutures  which  are  not  ]:)assed  through  the  kidney  substance.  All  in  all  I  have  had  best 
results  from  a  combination  of  some  such  method  as  this  with  one  of  suspension,  for 


Nephropexy.     Method  by  sutures  passed  through  both  kidney 
and  capsule.     (Hartmann.) 


TUMORS  OF   THE  KIDNEY  969 

which  |)ui|)().si>  t:i[K\s  or  ^mu/a'  are  used  and  passed  l)eiieatli  (he  ki(hiey — one  above  the 
hihnn  and  one  below  it — after  it  has  l)een  delivered  well  into  the  wound,  by  which  it  is, 
first  t>f  all,  lowered  into  the  position  in  whieh  it  is  intended  to  hold  it  and  then  maintained 
there,  the  ends  bein<r  left  han<i;in<;  out  of  the  wound,  where  they  are  tied  over  a  roll  of 
gauze  or  sonie(hin<;  similar.  This  j)rovides  the  smallest  amount  of  gauze,  whose  pres- 
ence may  j)rovoke  granulation  tissue,  at  tiie  same  time  proving  an  efiicient  means  of 
support,  and  leaving  (rilling  strips  to  remove  when  the  time  for  their  removal  has  come. 
1  have  usually  left  (hem  in  place  for  nine  or  ten  days,  by  whieh  time  they  are  comfort- 
ably loosened  by  the  prescnci' of  granulations  around  them,  and  consequent  moisture,  so 
that  they  are  easily  withdrawn,  with  a  minimum  of  discomfort  to  the  patient.  Da  Costa 
has  suggested  an  improvement  on  this  by  sewing  the  ends  of  stri[)s  of  gauze  with  chromic 
gut  ami  letting  these  sewed  ends  be  placed  beneath  the  kidney.  In  the  course  of  time, 
as  the  catgut  softcMis,  the  union  is  separated,  and  the  stri])s  are  easily  withdrawn.  If 
there  be  a  tendency  in  these  taj)es  to  slij)  from  th(>ir  desired  position,  they  may  be  attached 
to  the  ca])sule  by  a  single  suture  of  catgut,  which  will  have  softened  and  disappeared 
before  the  time  for  their  withdrawal  has  arrived.  Again  in  many  of  these  instances  the 
capsule  which  has  been  stripped  off,  or  more  or  less  detached,  may  be  utilized  for  the 
j)urpose  of  fixation  by  suture  with  its  own  tissue. 

Nearly  all  of  these  operations  are  without  mortality,  although  they  are  not  yet  as  satis- 
factory as  could  be  desiretl,  the  trouble  inhering  partly  in  the  fact  that  the  kidney  is  not 
fastened  as  high  up  as  it  should  be,  or  else  not  in  quite  the  same  relative  position,  so  that 
there  is  some  strain  upon  its  vessels  or  upon  its  ureter.  Every  effort  should  be  made  to 
imitate  the  original  position  as  accurately  as  possible.  Methods  theoretically  more 
perfect,  yet  more  complicated  and  but  little  more  advantageous,  include  fixation  of  the 
kidney  to  the  twelfth  rib,  by  suture  passing  through  the  capsule  and  then  around  the 
rib.  No  matter  what  method  be  adopted,  it  is  necessary  to  keep  the  patient  in  bed  for 
several  weeks  after  these  operations,  in  order  that  adhesions  may  not  only  form  but  may 
not  be  stretched  by  too  early  change  of  posture. 


TUMORS  OF  THE  KIDNEY. 

The  kidney  is  the  site  of  an  occasionally  benign  and  frequently  of  a  malignant 
tumor  of  some  of  the  known  varieties.  The  simplest  forms,  like  the  fatty  and  the 
fibrous,  are  uncommon  and  deserve  no  special  consideration  here.  There  is  a  so-called 
adenoTTia  of  the  kidney,  which  does  not  deserve  this  expression  any  more  than  does  the 
so-called  adenoma  of  the  thyroid,  in  that  it  is  not  built  up  of  the  normal  type  of  secreting 
gland,  but  represents  something  more  or  less  similar  to  it,  perhaps  only  undergoing 
multicystic  degeneration,  its  commonest  expressions  being  of  congenital  origin.  The 
consequence  is  the  production  of  the  so-called  congenital  adenoma  or  cyi^tic  or  multi- 
n/Mic  or  polycystic  kidney,  in  which  may  be  seen  a  conversion  of  original  renal  tissue 
into_  a  mass  of  cysts,  surrounded  by  degenerated  kidney  tissue,  all  semblance  to  the 
original  being  lost,  and  the  whole  constituting  a  partial  or  complete  invasion  of  the 
organ,  by  w^hich  sometimes  its  proportions  are  enormously  increased.  The  condition 
is  essentially  of  congenital  origin,  although  its  serious  clinical  expressions  may  not 
occur  for  years.  The  result  is  to  destroy  the  renal  function,  to  produce  a  growing  mass, 
and  to  constitute  an  essentially  surgical  condition  to  be  relieved  only  by  nephrectomy. 
(See  P'ig.  OS?.)  I  recall  one  child  of  tw^enty-three  months  with  a  tumor  of  this  character, 
of  such  size  and  extent  that  it  could  only  stand  erect  when  wearing  from  its  neck  a  sort  of 
suspensory  in  which  the  lower  part  of  the  abdomen  was  contained.  I  removed  this 
kidney  by  abdominal  section,  the  child  recovering,  and  being  at  that  time  the  youngest 
case  that  had  ever  survived  a  nephrectomy.  A  number  of  years  later  a  similar  condi- 
tion developed  in  the  other  kidney,  of  w^hich  the  child  finally  died,  it  having  passed 
during  the  last  thirteen  days  of  its  life  not  more  than  an  ounce  or  two  of  urine. 

Of  the  solid  tumors  of  the  kidney  both  carcinoma  and  sarcoma  occur,  the  former  usu- 
ally as  a  secondary  growth,  the  latter  usually  as  primary,  although  any  form  may  be 
met.  The  sarcomas  are  more  frequent  in  early  life  and  in  general  more  common.  On 
account  of  the  kidney  having  a  well-marked  capsule  metastasis  is  not  so  common,  in  the 
early  stages,  as  from  some  other  organs.     These  malignant  tumors  may  attain  great 


970 


SPECIAL  OR  REOIOXAL  SURGERY 


size;  some  fjrow  regularly  in  sha|)e,  others  eonstitute  most  irregular  masses.     The  entire 
organ  may  he  involved  or  only  a  part. 

There  are  no  indieative   .sipnjjfom.s  of  mini  ranrrr  that  may  not  he  met  in  other  eondi- 
tions;  the  development  of  tumor,  perhaps  its  displaeement,  pain,  and  hematuria,  though 


Fig.  637 


Congenital  cystic  kidney;  exterior  and  internal  appearance;  patient  forty-two  years  ol  age.      (Schmidt.) 

late,  and,  in  proportion  to  the  rapidity  of  growth,  enlargement  of  superficial  veins  and 
general  cachexia.  When  the  tumor  is  large  enough  to  press  uptm  the  vena  cava  or  upon 
one  of  the  common  iliacs  there  will  he  edema  of  one  or  hf)th  lower  extremities.  The 
veins  of  the  external  genitals  are  mf)re  likely  to  sufi'er  early  rather  than  late  (Figs.  638, 
G3<i). 

Fig.  638 


Cancer  oi  kidney,  intraniural,  a.s  seen  after  dividing  the  r)rgan.      (Israel.) 

Hypernephroma. — There  is  one  peculiar  variety  of  solid  tumor  of  the  kidney  which 
deserves  .special  mention,  the  so-called  hypernephroma.  These  tumors  consist  es.sen- 
tially  of  adrenal  tissue,  although  when  they  develop  within  the  kidney  their  occurrence 
there  is  due  to  the  presence  of  aherrant  rests  of  the  original  suprarenal  tissue.  Gravitz, 
in  1883,  was  the  first  to  recognize  their  real  character.  Supernumerary  adrenal  rests 
have  been  met  whh  in  many  parts  of  the  body,  not  alone  in  the  kidney  and  perinephric 


HYDRONEPHROSIS 


971 


tissue,  hnt  in  tlic  ln'o.id  liojinu'iit,  ;il()ii<j  llic  sj)erni;i(ic  vessels,  in  the  sexual  glands  of 
both  sexes,  in  tiie  liver,  tiie  mesentery,  and  even  the  solar  and  renal  plexuses.  Their 
oeeurrenee  in  these  localities  may  be  explained  by  the  (•los(;  relationship  between  the 
mesonephros  and  the  oritjins  of  these  various  organs.  Hypernephroma  has  no  patho<r- 
nomonie  sicjns  or  symptoms.  It  is  usually  a  sin<rle  tumor,  altliou<2;h  bodi  kichuys  have 
been  aHeeted.  When  the  origan  is  not  so  involved  as  to  mask  all  its  oriffinal  features  the 
tumor  will  be  found  beneath  the  eaj)sule,  varyino;  in  size  from  that  of  a  pea  to  that  of  a 
child's  head,  its  ouler  siuface  lobulated  by  (le])r(>ssed  bands  of  ea])sule,  its  color  lijrhter 
than  that  of  the  surrouudin*;-  kidney  texture,  while  ])rojccting  ])ortions  will  be  soft  and 
almost  cystic.  When  met  with  in  other  parts  of  the  body  its  <rross  characteristics  are 
essentially  the  same.  JMetastasis  is  very  common,  the  tumor  often  extending  along  the 
walls  of  the  veins,  or  even  more  often  partially  filling  them  than  th(>  lymphatics.  A  com- 
mon method  of  extension  also  is  by  implantation  within  the  ])entoneaI  cavity;  for  the 
S(>con(lary  implantation  occurs  most  often  along  some  portion  of  the  urinary  tract — e.  fj., 
the  bladder.' 

Fig. 639 


[nfiltrating  fBrm  of  cancer  of  the  kidney.      (Israel.) 

Hematuria  and  renal  colic  are  the  most  conspicuous  features  connected  with  the 
growth  of  these  tumors.  The  former  often  occurs  during  sleep,  and  blood  is  jiassed  in 
almost  pure  form,  perhaps  for  a  considerable  period  of  time,  after  Avhich  spontaneous 
recovery  apparently  takes  place,  the  trouble  recurring  at  intervals. 

There  is  but  one  method  of  treating  hypernephromas,  like  other  solid  tumors,  namely, 
by  complete  extirpation,  ?'.  e.,  nepJirectomy.  Even  this  may  be  too  late,  but  should  be 
undertaken,  except  in  the  most  unpromising  instances.  If  the  existence  of  metastatic 
involvement  can  be  determined  even  nephrectomy  may  be  considered  useless.  (See 
chapter  on  Cysts  and  Tumors.) 

HYDRONEPHROSIS. 


This  term  refers  to  a  more  or  less  permanent  distention  of  the  kidney  cavity  by 
retention  of  urine,  due  to  partial  or  intermittent  obstruction  to  its  escape.  An  inter- 
mittent form  is  common,  which,  however,  at  almost  any  time  may  lead  to  some  degree 

I  It  may  as.sist  in  the  recognition  of  hypernephromatous  tissue,  after  removal,  to  remember  that  adrenal  tissue 
has  the  property  of  decolorizing  starch  which  has  been  turned  blue  by  the  addition  of  iodine.  Crofton  has  shown 
how  there  maybe  put  into  a  test-tube  a  1  per  cent,  starch  solution  colored  with  a  drop  of  weak  tincture  of  iodine. 
If  to  this  solution  hypernephromatous  tissue  be  added  the  blue  color  changes  gradually  to  a  pink  and  then 
fades  out. 


972 


SPECIAL  OR  REGIONAL  SURGERY 


of  (Milaro:ement,  while  when  tlie  obstruction  is  permanent  the  resuhincr  tumor  becomes 
practically  a  thin-walled  cyst,  which  may  contain  an  enormous  amount  (jf  fluid,  more 
or  less  altered    urine,  which  will  contain,"  in  addition  to  the  ordinary  urinary  elements, 


Fig.  640 


Fig.  641 


Hydronephrosis  from  obliteration  of  ureter  by  tuber- 
culous disease.     (Tuffier.) 


Hydronephrosis  in  first  stage  of  development. 
(Rayer.) 


Fig.  642 


cholesterln  crystals  and  other  adventitious  products.  Hyaronephrosis,  then,  may  be 
concjenital  or  acquired  in  origin,  intermitient  or  'permanent  in  character,  and  unilateral 
or  bilateral  in  location.     Among  the  acquired  causes  are  strictures  of  any  portion  of  the 

urinary  tract  below,  either  in  the 
ureter,  the  prostate,or  the  urethra; 
tumors  of  any  kind  making  pres- 
sure; movable  kidney  which  per- 
mits of  kinking;  tuberculous 
diseases  which  lead  to  chemosis 
of  the  mucosa  and  consequent 
obstruction;  renal  calculi  which 
jjlug  the  ureter;  foreign  bodies, 
blood  clot,  and  the  like  (Figs.  640 
and  641). 

Until  the  infectious  or  suppu- 
rative element  be  added  the  urine 
is  in  these  cases  but  little  changed. 
When  infection  is  added  the  case 
becomes  one  of  pijohj/dronephro- 
sis,  and  perhaps   finally  one  of 
distinct  pi/onephrosis.  The  s>Tnp- 
toms   produced   at   first   are   not 
very  pronounced  and  will  vary  with  the  exciting  cause.     If  the  result  of  acute  obstruction, 
renal  colic  is  perhaps  the  most  significant.     When  this  is  accompanied  by  tumor  in  the 
region  of  the  kidney  the  interpretation  of  the  phenomenon  is  easy.     Sudden  decrease  in 


Operative  treatment  of  hj'dronephrosis  or  pyonephrosis. 
(Hartmann.) 


.STHICTUIU'J  ()!<'   THI'J   UltKTICIi  973 

size  of  siuli  Uimor,  with  iiiuisiially  ^rviii  es('u])('  of  iiriiic,  is  also  padiot^Mioinonic  of  intcr- 
Tiiittciit  liydroiu'plirosis.  'V\\v  discovery  uiul  i\\v  history  of  a  ;j;ra(liially  i(icrt'asiii(>;  (uiiior 
ill  wliidi,  when  lari>e,  fluctuation  can  he  detcrniiiicd,  and  in  which  ihjid  is  easily  found 
with  the  aspiratinjf  needle,  will  permit  a  differentiation  of  these  pseudocysts  from  solid 
tumors  of  the  kidney.  'I'hoy  are  to  he  distin<juished  from  ovarian  nj.sts,  from  <reneral 
ascitic  accumulations  within  the  abdomen,  and  from  prrincp/iritic  and  .spinal  ah.sccs.ses. 
Their  location,  which  corresponds  so  closely  with  that  of  the  kidney,  especially  while 
they  are  small,  (heir  <;radual  <j;rowth,  the  displacement  of  the  abdominal  viscera  forward 
and  to  their  inner  side,  {\w\v  enlartrenient  downward  and  their  fluctna(in<r  character 
will  usually  j)rovi(le  features  by  whicli  they  may  be  accurately  recoonized. 

Treatment. — 'V\\v  treatment  of  intermittent  hydronephrosis  in  its  earlier  stage  may 
be  accomj)lished  by  some  measure  less  radical  than  nephrectomy  or  nephrotomy,  par- 
ticularly when  due  simply  to  abnormal  movability  or  to  pressure  of  some  extrinsic 
growth.  Hydronephrosis  d\w.  to  obstruction  by  renal  calculus  may  be  relieved  by  re- 
moval of  the  obstructing  stone,  but  a  hydronej)lirilic  (yst,  which  has  attained  large  size, 
in  which  ])ractically  all  semblance  to  secreting  kidney  structure  has  disa])j)carc(l,  should 
be  extirpated,  unless  this  should  entail  too  f"()rmidal)le  an  oj)eration,  in  wliich  case  it 
should  be  freely  opened  and  drained  until  such  time  as  it  has  contracted  to  a  size 
justifying  enucleation  (Fig.  042). 

THE  URETERS. 

There  are  a  few  morbid  surgical  conditions  of  the  ureters,  so  distinct  from  those  of 
the  bladder  below  or  the  kidneys  above  as  to  require  separate  consideration  here. 
They  are  frequently  involved  in  the  pyogenic  and  tuberculous  infections,  which  spread 
along  them  in  either  direction,  but  the  chief  surgical  diseases  deserving  mention  here  are 
stricture  and  calculus. 

STRICTURE  OF  THE  URETER. 

Stricture  of  the  ureter  may  result  from  intrinsic  or  extrinsic  lesions.  Thus  it  has  been 
injured  in  operations  upon  the  pelvic  viscera,  as  in  parturition,  and  it  is  not  infrequently 
pressed  u|)on  by  neoplasms;  but  the  majority  of  its  contractions  are  cicatricial,  and  are 
consequences  of  ulceration  or  injuries  done  by  calculi.  Stricture  of  the  ureter  is  to  be 
recognized  rather  by  its  consequences — i.  c.,  hydronephrosis — than  by  more  direct 
symptoms.  Its  accurate  location  is  now  possible  by  the  use  of  the  cystoscope  and  the 
ureteral  bougie  or  catheter.  When  by  the  cystoscope  no  urine  is  seen  escaping  from 
the  ureter  one  naturally  infers  its  complete  obstruction — in  fact,  the  degree  of  the  latter 
is  fairly  estimable  with  this  instrinnent.  However,  with  the  passage  of  a  bougie  the 
trouble  may  be  found.  This  is  particularly  of  value  when  the  lesion  is  an  impacted 
calculus,  for  it  indicates  to  the  surgeon  the  level  at  which  he  should  direct  his  operative 
relief,  a  matter  which  may  also  be  decided  by  a  skiagram. 

While  in  the  hands  of  experts  dilatation  of  the  ureters  may  be  accomplished  from 
below,  it  is  usually  beyond  the  ability  of  the  average  surgeon.  He  has  to  decide,  then,  as 
to  whether  the  ureter  should  be  exposed  along  its  course,  from  the  loin,  extraperitoneally 
along  the  groin,  or  by  abdominal  section.  A  ureter  hopelessly  entangled  in  a  mass  of 
cancer  may  be  turned  into  the  other  ureter  or  into  the  bowel.  A  ureter  fixed  in  a  nar- 
row, cicatricial  band  may  be  divided  and  its  upper  end  turned  into  the  tube  below  the 
stricture  by  a  process  of  transplantation  or  anastomosis,  which  is  one  of  the  feats  of  mod- 
ern surgery ;  but  a  ureter  hopelessly  involved  for  a  considerable  jx)rtion,  or  hopelessly 
diseased,  will  recpiire  nephrectomy,  as  the  kidney  above  it  may  be  compromised  and  can 
probably  be  well  spared. 

Calculi  impacted  in  the  ureter  are  most  commonly  arrested  at  those  points  where  its 
caliber  is  normally  smallest,  just  below  its  origin,  at  the  pelvic  brim,  and  just  above  its 
orifice.  The  symptoms  of  impaction  are  those  of  renal  colic,  already  considered.  It 
should  be  sufficient  that  extreme  pain  and  the  escape  of  pus  and  blood  in  the  urine, 
accompanied  by  more  or  less  distention  of  the  kidney  above,  are  noted.  If  there  be  a 
history  of  previous  attacks  of  this  kind,  with  the  passage  of  small  calculi,  the  diagnosis 
may  be  regarded  as  positive.  This  may  or  may  not  be  confirmed  by  the  x-rays,  or  by  the 
catheterization  of  the  ureter  from  below. 


974  SPECIAL  OR  REGIONAL  SURGERY 

Gibbon  has  sufjoje.stcd  intra-ahdomina/  exploration  and  paljKition  of  tlie  ureter  for  the 
discovery  and  location  of  iinj)actcd  calculi,  and  recoinniends  that  when  discovered  they 
may  be  removed  by  extraperitoneal  incision,  which  may  be  lumbar,  iliac,  in<;uinal, 
vaginal,  or  even  sacral  or  rectal;  while  with  the  advantajfc  of  combined  manipulation,  the 
operator  having:;  one  hand  in  the  abdominal  cavity,  the  actual  work  is  more  ra|)id  and 
certain. 

This  procedure  is  not  to  be  advised  in  everv  case  by  any  means,  but  may  |)rove  of 
advantao;e  in  doubtful  cases,  and  especially  in  those  where,  when  the  abdomen  has  been 
already  opened,  a  stone  is  accidentally  found  in  the  ureter,  since  when  the  latter  is  opened 
extraperitoneally  it  is  rarely  necessary  to  suture  it. 

The  uoii-oprrafiir  trraf incut  of  ureteral  calculi  has  been  considered  when  speaking  of 
renal  calculi.  The  operative  treatment,  inversion  of  the  patient  having  failed,  may  con- 
sist of  exjKJSure  of  the  upper  two  inches  of  the  tube,  by  an  incision  jwrallel  to  the  twelfth 
ril),  and  carried  well  forward  and  downward  toward  the  middle  of  Poupart's  ligament. 
Through  such  an  incision  the  wliole  length  of  the  ureter  may  be  reached.  The  open- 
ing is  made  down  to  the  peritoneum,  which  is  then  ])ushed  toward  the  median  line.  On 
its  ])osterior  surface,  adherent  to  it,  will  be  found  the  ureter.  At  the  point  where  the 
stone  is  impacted  the  ureter  is  to  be  divided  and  the  stone  removed.  In  theory  sutures 
should  be  inserted;  in  practice,  they  are  rarely  needed,  as  these  incisions  usually  heal 
kindly  without  them. 

A  stone  impacted  at  the  vesical  orifice  of  the  ureter  may,  in  the  female,  be  removed 
after  such  dilatation  of  the  urethra  as  shall  ])ermit  access,  or  it  may  be  removed  through 
the  vault  of  the  vagina.  In  the  male  only  the  most  ex])ert  manij)ulators  within  the 
bladder  will  attempt  its  removal  in  this  way  without  at  least  a  perineal  section. 


OPERATIONS  UPON  THE  KIDNEYS  AND  URETERS. 

In  addition  to  the  operative  procedures  already  described  the  principal  operation  upon 
tlie  kidney  is  nephrectomy.  While  this  may  be  partial,  under  rare  circumstances,  the 
|)rocedure  is  so  essentially  similar  to  the  complete  operation  that  it  is  only  necessary  to 
say  that  if  a  portion  of  the  kidney  be  removed,  bleeding  from  spurting  vessels  should 
be  arrested  by  ligature,  while  the  oozing,  at  first  pronounced,  will  soon  subside  luidcr 
the  application  of  hot  water,  after  which  absorbable  sutures  may  be  used  in  sufficient 
number  to  approximate  the  parts. 

Fig.  643 

A 


Position  of  patient  and  various  lines  of  incision  for  neplirectomy  and  otlier  operations  upon  the  kidneys.     A,  the 
favorite  method  of  approach  for  most  purposes.      (Hartmann.) 

Total  nephrectomy  is  usually  done  by  the  lumbar  route,  the  kidney  being  exposed  by 
an  obli(|ue  incision  extending  oblicjuely  downward  from  near  the  spine,  parallel  to  the 
lower  ril),  between  it  and  the  crest  of  the  pelvis,  and  as  far  forward  as  may  be  rc(|uired 
for  the  purpose.  For  removal  of  a  large  solid  tumor  a  large  opening  should  be  made, 
and  the  above  incision  may  be  extended  in  any  re(|uired  direction,  or  an  additional  cut 
may  be  made  wherever  required.  In  fact,  in  attacking  some  of  the  very  largest  growths 
it  becomes  necessary  to  apparently  almost  bisect  the  patient  in  order  to  furnish  suffi- 
cient space.  As  the  mass  to  be  attacked  lies  behind  the  peritoneum  it  is  rarely  necessary 
to  open  the  peritoneal  cavity.  This  is  usually  done  only  by  inadvertence  or  because  of 
density  of  adhesions,  and  the  effort  should  then  be  made  to  at  once  close  it  temj)orarily 


OPEHATIDSS   VPOS   THE  KIDXKYS  A.\D   URETERS  975 

or  |)cnii;iiiciul\ .  Ivspccially  should  cvcrv  atlciiipl  he  iiuuk'  to  prevent  coiitainination 
when  (lealitii;  witli  tiihentiloiis  or  .sii|)|)iirative  renal  disease.  Ordinarily  the  ahdoniinal 
o|M'nin<,'  does  not  extend  nearer  to  the  spine  than  the  horder  of  the  s|)inal  nuiseles.  These 
niay,  however,  he  dividi-d  if  necessary.  So  also  may  the  deep  fascia  l)e  divided  in  any 
direction,  and,  in  fact,  the  last  rib  may  be  removed  in  totu  if  required.  The  kidney  or 
the  tumor,  having;  now  been  reached,  should  be  isolated.  If  the  condition  be  cancerous 
as  nuicli  of  the  snrroundin<r  tissue  should  be  removed  as  the  case  will  permit ;  if  otherwise, 
an  enucleation  of  the  kidney  from  its  more  or  less  infiltrated  bed  will  be  sufficient.  It  is 
usually  removed  with  its  capsule,  but  sometimes  the  latter  is  so  adherent  that  it  is  easier 
to  enucleate  the  kidney  itself  from  within  it.  Adventitious  vessels  may  enter  the  kidney, 
more  especially  from  below.  The  sur<,'eon  must  be  ])repared,  then,  at  any  time  to  clamp 
and  secure  them  if  found.  Sometimes  enucleation  of  the  kidney  is  exceedinglv  easy; 
at  other  times  old  adhesions  or  surrounilin<f  infiltration  make  it  a  matter  of  great 
mechanical  difficulty.  The  intent  is  to  not  only  isolate  it,  but  to  make  such  exposure 
of  its  pedicle  that  one  may  be  securely  protected  against  hemorrhage.  Incidentally  the 
ureter  should  be  examined  from  above,  by  passage  of  a  probe,  or  l)y  injecting  a  colored 
solution,  in  order  to  know  later  if  it  passes  freely  into  the  bladder.  It  is  the  accurate 
securement  of  the  renal  vessels  which  is  j)erliaps  the  most  necessary  feature  of  the  opera- 
tion and  upon  which  most  depends.  When  this  is  made  impossible  by  extraordinary 
circumstances  expedients  must  be  adopted,  as,  for  instance,  the  use  of  an  elastic  ligature 
— i.  e.,  a  piece  of  small  rui)ber  tubing,  drawn  tightly  around  the  ba.se  of  the  mass  and 
secured  by  clamp,  ligature,  or  suture,  the  intent  being  to  leave  it  for  at  least  two  or  three 
days  until  it  shall  have  accomplished  its  work,  and  then  either  to  remove  it  or  to  allow  it  to 
loosen  itself  in  time  and  come  away. 

Fig.  644 


Nephrectomy.     Complete  delivery  of  kidney  and  ligation  of  its  vessels  and  ureter.     (Hartmann.) 

Under  some  circumstances  the  surgeon  may  so  complete  the  nephrectomy  that  the 
external  wound  may  be  closed  w'ithout  drainage;  but  when  there  has  been  contamination, 
as  by  escape  of  contents,  either  purulent  or  urinary,  or  when  a  considerable  ma.ss  of 
tissue  has  to  be  left  enclosed  within  an  elastic  ligature  surrounding  the  stump,  then  an 
opening  should  be  left  in  order  that  slough  may  easily  escape  and  ample  drainage  be 
afforded.  A  reliable  ligation  of  the  renal  vessels  should  be  made,  which  is  best  done 
with  at  least  two  ligatures,  taking  the  pedicle  in  parts,  or  else  carefully  isolating  the 
vessels  when  sufficiently  exposed,  and  tying  each  one  of  them  separately,  after  which  the 
whole  group  may  also  be  enclosed  in  a  single  ligature.  A  few  operators  have  reported 
such  accidents  as  tearing  the  renal  vein  from  the  vena  cava,  and  such  a  wound  has  been 
successfully  sutured,  the  patient  recovering;  this  requires,  however,  both  coolness  and 
resourcefulness  in  the  presence  of  serious  difficulty  and  danger.  Certain  dense  tumors 
can  be  removed  by  process  of  morcellation,  i.  e.,  removal  of  a  portion  at  a  time,  the 
separate  pieces  being  cut  away  with  scissors  or  knife,  as  may  be  the  more  convenient, 
and  hemorrhage  being  controlled  by  clamps. 

Tlie  anterior  or  Trendelenburg  route  is  rarely  selected  for  nephrectomy,  but  may  be 
adopted  when  this  procedure  is  mafle  a  part  of  other  abdominal  work,  or  may  be  necessi- 
tated by  the  presence  of  a  large  tumor  in  a  small  abdomen,  as,  for  instance,  in  children. 
The  abdomen  will  be  opened  as  for  any  abdominal  tumor,  either  in  the  middle  or  to  one 
side,  as  may  seem  best.  The  tumor  itself  will  so  far  displace  the  viscera  as  to  perhaps 
present  at  once  beneath  the  knife.  It  may  be  necessary  to  go  through  the  peritoneum 
twice.  After  being  thus  exposed,  and  the  abdominal  cavity  protected,  the  balance  of 
the  operation  is  again  a  process  of  enucleation,  with  securing  access  to  the  pedicle  of  the 


976 


SPECIAL  OR  REGIOXAL  SURGERY 


tumor,  where  its  vessels  and  the  ureters  may  he  found.  These  again  are  hjiated  and  the 
mass  removed  as  though  it  were  from  the  jjeritoneal  ca\"ity.  Posterior  drainage  may  be 
added,  although  rarely  necessary. 

Other  operations  have  been  suggested  to  meet  the  needs  of  indi\idual  cases.  Thus 
pi/electomif,  or  removal  of  a  }X)rtion  of  the  dilated  pelvis  of  the  kidney,  has  been  per- 
formed by  Murphy  and  others,  tlie  process  being  essentially  an  excision  of  a  portion  of 
the  sac  wall  and  its  retrenchment  by  sutures.  Plastic  attachment  of  the  dilated  upper 
end  of  a  ureter  to  the  floor  of  the  renal  jiehis  has  also  been  effected  in  much  the  same 
way,  as  in  a  case  reported  by  iNIurphy,  where,  after  opening  the  sac  of  the  pelvis,  the 
ureter  was  slit  for  a  considerable  distance,  while  at  the  lower  angle  a  V-shaped  piece  of 
the  sac  was  fastened  into  the  ureteral  ojx-ning,  thus  making  a  funnel-like  communication. 

Again,  as  illustrative  of  some  of  the  radical  suggestions  of  recent  years,  Watson  has 
proposed  that  in  instances  of  hopeless  bladder  conditions,  where  the  patient  is  made 
miserable,  there  should  be  a  turning  out  of  both  ureters  on  the  loin,  and  tlie  formation 
of  two  ureteral  fi-'ifula-9,  after  which  the  patient  may  wear  a  drainage  receptacle,  and  in 
this  way  enjoy  a  comfort  otherwise  unattainable.  He  has  reported  the  case  of  such  a 
patient,  who  has  thus  passed  all  the  urine  for  four  years,  and  urine  from  one  side  for 
eleven  years,  who  was  otherwise  in  comfortable  health. 


Fig.  645 


Fig.  646 


Fig.  647 


Longitudinal    suture     of 
ureter.     (Hartmann.) 


Implantation  or  invagination  of  ureter 
with  fixation  and  then  -with  circular  sut- 
ures.    (Hartmann.) 


Longitudioal  Incision  and  trans- 
verse suture  of  ureter  for  stricture, 
similar  to  the  pyloroplastic  method 
of  dealing  with  pyloric  stenosis. 
(Hartmann.) 


Operations  upon  the  Ureters. — The  surgery  of  the  ureters  is  also  quite  modern,  and 
has  been  wijrkeil  out  in  tlie  experimental  laboratorv.  That  ureteral  tissue  will  heal  has 
been  proved  by  Murphy,  who  has  remarked  that  "The  peritoneum  is  the  only  tissue  that 
unites  as  kindly  as  does  the  ureter."  After  accidental  injuries  during  other  operations 
the  ureter  may  be  sutured  almost  as  though  nothing  had  happened.  Tliese  sutures 
should  be  made  with  fine  round  needles,  and  be  placed  closely  together.  They  should 
be  made  of  fine  silk  or  thread. 

Not  only  end-to-end  union  but  lateral  anastomosis  and  even  more  ingenious  methods 
of  transplantation  and  implantation  are  now  in  vogue.  •  Figs.  645,  646  and  647  illustrate 
some  work  in  this  direction,  and  show  what  may  be  done  by  work  quite  similar  to  that 
done  upon  the  small  intestines  or  the  bloodvessels.  More  complete  instances  of  trans- 
plantation have  been  effected  in  connection  with  exstrophy  and  carcinoma  of  the  blad- 
der, where,  for  instance,  the  ureters  indi\-idually,  or  the  base  of  the  bladder  containing 
the  ureteral  orifice,  have  been  dissected  out  and  implanted  in  the  colon  or  the  rectum.* 

'  In  one  case  I  carried  out  the  following  procedure,  necessitated  by  cancer  invohing  the  urethra,  the  base  of  the 
bladder,  the  rectum,  and  the  whole  floor  of  the  pehns,  in  a  female  patient,  the  disease  ha\'ing  attained  a  degee 
making  urination  or  even  catheterizarion  impossible.  I  opened  the  abdomen,  dissected  out  the  right  urHer  from 
the  bladder,  implanted  U  into  the  appendix,  and  then  dissecting  the  left  ureter  in  the  same  way  implanted  it  in  the 
right,  the  intent  being  to  direct  the  whole  urinary  stream  into  the  colon  and  thus  spare  the  bladder.  The  operarion 
was  not  finally  successful.  I  afterward  found  that  this  method  had  been  tried  experimentally  by  Jacobson,  of 
Toledo,  but  without  success. 


CHAPTER    LV. 
THE  BLADDER  AND  PROSTATE. 

Mkthods  of  rc(()i,niiti()ii()f  .siir<,n(al  (list-ases  of  the  l)la(l(l('r  have  hccn  vastly  inij)rove(l, 
as  wi'll  as  ctJiiiplicatc'd,  \\itliin  tlic  ])ast  ffw  years.  Tlie  bladder  lias  now  been  made 
aeeessihle  not  alone  to  touch,  as  through  the  rectum  or  vajjina,  or  by  incisions  above  or 
below  the  pubis,  but  to  siijht,  throujj;h  the  use  of  the  cysUm-ope.  It  is  furthermore  pos- 
sible to  detect  foreign  bodies  within  it  by  the  Ront(,'en  rays.  Palpation  is  chiefly  of  value 
in  thin  ])ersons,  or  when  the  bladder  is  "jreatly  distended;  still,  infiltration  of  the  base  of 
the  bladder  can  be  dctecteil  thr()U<ih  the  vagina  or  through  the  rectum,  as  can  also  cer- 
tain foreign  bodies.  Much  of  value  is  learned  by  both  chemical  and  microscopic 
examination  of  the  urine.  This  may  be  j)assed  by  the  patient  or  withdrawn  by  the 
catheter.  It  has  already  been  indicated  how  much  of  value  can  be  learned  by  separating 
the  urine  drawn  from  each  kidney.  The  difficulties  of  this  procedure  are  greater  in  the 
male  than  in  the  female,  owing  to  the  complications  in  the  requisite  manipulation  of  the 
instruments.  Nevertheless  there  is  no  accurate  method  of  such  estimation  save  by 
ureteral  catheterization.  The  method  of  Harris,  by  the  use  of  tJie  so-called  segregator, 
is  of  occasional  assistance,  but  is  never  accurate  nor  always  satisfactory.  If  the  catheter 
alone  be  used  it  should  be  of  metal,  if  it  be  desired  to  have  it  serve  the  purpose  of  a  probe, 
as  in  the  search  for  a  foreign  body  (calculus  and  the  like)  or  as  a  means  of  estimating  the 
size  and  shape  of  the  bhuider.  For  the  latter  purpose  an  ordinary  sound  will  serve  as 
well,  preferably  one  with  a  short  beak,  ordinarily  known  as  a  stone  searcher.  In  cases 
of  prostatic  enlargement  it  is  of  great  advantage  to  estimate  the  amount  of  residuary 
urine  after  the  patient  has  aj)])arently  emptied  his  bladder.  This  may  be  withdrawn  by 
a  sterile  catheter  under  aseptic  precautions.  The  use  of  the  catheter  is  also  necessary 
for  lavage  of  the  bladder,  a  measure  of  great  value  in  many  cases. 

The  attempt  will  not  be  made  here  to  picture  nor  go  into  a  minute  description  of  the 
various  forms  of  the  cysfosrope.  Their  use,  like  that  of  the  ophthalmosco{)e,  requires 
special  aptitude  and  training.  With  the  latter  they  are  of  great  value;  without  them 
they  confuse  and  complicate.  The  cystoscope  may  be  used  for  ordinary  purposes  of 
inspection,  for  aid  in  introducing  the  ureteral  catheter,  or  even  for  photographic  pur- 
poses, for  it  is  now  possible  with  the  latest  instruments  to  photograph  the  image 
thus  obtained  of  the  bladder  interior.  To  one  not  accustomed  to  viewing  the  field 
seen  in  such  an  instrument  these  revelations  are  of  little  interest.  To  the  expert,  how- 
ever, they  may  be  made  of  the  greatest  value.  Witiiout  further  description,  then, 
allusions  made  below  to  the  use  of  the  instrument  must  presuppose  some  familiarity  with 
it,  and  the  advantages  and  even  necessity  of  securing  special  training  in  its  use. 

CONGENITAL  MALFORMATIONS  OF  THE  BLADDER. 

The  lesser  malformations  of  the  bladder  include  mainly  irregularity  in  shape  or  the 
formation  of  diverticula,  which  are  not  extremely  rare.  These  are  especially  likely  to 
be  met  during  hernia  operations.  I  have  repeatedly  in  operating  for  inguinal,  and 
once  in  operating  for  femoral  hernia,  found  a  diverticulum  of  the  bladder  complicating 
the  situation.  Its  possibility,  then,  should  be  borne  in  mind.  It  may  be  thin  and  lie  in 
such  close  relation  to  the  hernial  sac  as  to  be  mistaken  for  the  latter.  When  opened 
urine  will  escape  and  contaminate  the  wound.  It  would  probably  be  best  to  close  the 
bladder  opening  and  discontinue  the  operation  rather  than  run  the  risk  of  contamination 
of  the  peritoneal  cavity,  postponing  further  work  for  a  few  days.  As  the  result  of  allan- 
toic defects  a  double  bladder  may  be  met,  each  perhaps  having  one  ureter  opening  into  it. 
More  or  less  complete  partitions  in  the  bladder  are  more  frequently  met.  These  condi- 
tions could  not  be  appreciated  previous  to  opening  the  viscus  or  the  use  of  the  cystoscope. 
62  ( 977 ) 


978  SPECIAL  OR  REGIOXAL  SURGERY 

More  complete  forms  of  acquired  vesical  hernia  may  be  found  in  such  conditions  as 
cystocele,  common  in  women  after  perineal  lacerations,  and  frequently  constituting  a 
most  serious  condition. 

Ectopia  or  Exstrophy  of  the  Bladder. — By  far  the  most  serious  and  extensive  of  the 
congenital  malformations  are  tiiose  constituted  by  more  or  less  complete  defects  of  the 
anterior  portions  not  alone  of  the  bladder,  but  of  the  abdominal  wall  which  should  cover  it, 
and  which  are  known  as  ectopia,  exstrophy,  or  extroversion  of  the  bladder.  Of  this  condi- 
tion there  are  different  degrees,  from  a  small  cleft  just  behind  the  symphysis  pubis,  to 
that  which  is  complicated  by  prolapse  of  the  remaining  jx>sterior  wall,  the  umbilicus 
being  situated  just  above  it,  while  the  pubic  arch  itself  is  defective  or  rudimentary. 
Thus  in  the  male  there  is  usually  epispadias  of  a  more  or  less  rvdimentary  penis,  while 
in  the  female  the  clitoris  is  cleft  and  the  xndva  more  or  less  opened,  the  urethra  being 
defective  or  entirely  wanting,  the  vagina  often  small,  and  the  uterus  generally  infantile. 
Extreme  cases  of  this  condition  constitute  one  of  the  most  serious  and  deplorable  con- 
genital defects  which  are  not  inherently  fatal.  Obviously,  with  these  conditions,  there 
is  constant  escape  of  urine,  usually  with  complete  mechanical  impotence,  although  in  the 
female  the  ovaries  are  usually  present,  and  practically  always  the  testicles  in  the  male. 
In  the  latter  the  opening  of  the  seminal  ducts  may  be  frequently  seen  on  the  floor  of  the 
urethra,  more  or  less  concealed  by  folds  of  cystic  mucous  membrane.  The  condition 
is  much  more  frequent  in  males  than  in  females.  Tbe  pro.state  is  usually  at  least 
rudimentary  and  may  be  wholly  wanting.  Occasionally  the  testicles  are  undescended. 
Double  uterus  has  also  been  seen  in  these  conditions. 

Regarding  its  causes  there  is  but  little  known.  Doubtless  these  have  to  do  with  allan- 
toic defects,  bin  the  allantois  is  such  a  tempc^rary  organ  that  there  would  seem  to  be  some 
other  contributing  cause  not  yet  recognized. 

Among  its  most  distressing  features  are  not  only  the  lack  of  control  of  urine,  but  the 
irritation  of  the  exposed  mucous  surfaces  consequent  ujx)n  friction  with  clothing,  or 
decomposition  of  tirine  and  c-onsequent  uncleanliness.  There  is,  therefore,  nearly  always 
ulceration,  with  extreme  irritability  and  more  or  less  constant  suffering.  It  is  not 
strange,  then,  that  for  its  relief  surgeons  have  taxed  their  ingenuity,  or  that  adult 
patients,  finding  the  conditions  unbearable,  are  willing  to  submit  to  even  extreme 
measures. 

Treatment. — So  many  operative  measures  have  been  devised  that  it  is  impossible 
to  inclufle  them  all.  First  of  all  the  proceflure  should  be  adaptefl  to  the  particular  case. 
Much  will  depend,  for  instance,  upon  the  extent  of  the  defect  in  the  abdominal  wall,  or 
in  the  pubic  arch,  and  in  the  male  upon  the  rudimentary  condition  of  the  penis  or  the 
extent  of  the  urinarv  canal. 

Operations  for  this  condition  may  be  di\'ided  into  palliative  and  radical — ?'.  e.,  those 
which  are  intended  to  make  it  more  tolerable  and  those  which  are  really  entitled  to  the 
latter  term.  Thus  if  only  the  expo.sed  mucous  surface  can  be  covered  with  a  skin 
covering,  the  condition  may  be  mitigated  since  a  urinal  or  some  device  may  be  worn  by 
which  its  worst  features  may  be  controlled.  Trendelenburg  has  recently  called  atten- 
tion to  the  fact  that  a  wide  separation  (jf  the  pubic  arch  not  only  weakens  the  pelvis,  but 
constitutes  a  serious  difficulty  in  closing  the  defect.  He  has,  therefore,  combined  direct 
operation  with  separation  of  the  pelvic  bones  at  the  sacro-iliac  joints,  afterward  enclos- 
ing the  pelvis  in  a  comprehensive  bandage,  or  stispending  the  patient  in  an  apparatus  in 
such  fashion  that  the  bony  defect  in  front  shall  be  narrowed,  if  indeed  it  be  not  com- 
pletely obviated.  This,  of  course,  is  a  measure  to  be  carried  out  in  the  early  years  of 
childhood;  in  connection  with  it  the  bones  may  even  be  wired  at  the  symphysis.  In 
fact  immediately  after  the  birth  of  such  an  infant  the  attempt  should  be  made  to  narrow 
the  pelvis,  by  surrounding  that  part  of  the  body  with  a  wide  rubber  band,  which  shall 
influence  growth  without  too  much  interfering  with  nutrition.  Later  subcutaneous 
osteotomy  may  be  done  if  necessary.  At  all  events,  the  growing  pelvis  should  be  sur- 
rounded with  an  enclosure  by  which  a  constant  influence  may  be  maintamed. 

The  various  plastic  operations  for  this  defect  have  the  common  purpose  of  affording  a 
covering,  which  must  unfortunately  be  without  a  sphincter  to  guard  the  outlet  of  the 
canty.  The  best  that  can  be  acc-omplishe(l,  then.  ])y  plastic  methods  is  the  formation 
of  a  more  perfect  ca\'ity  without  affording  sphincteric  control.  A  theoretically  ideal 
method  would  be  one  which  should  permit  raising  of  skin  flaps  around  the  margin  of 
the  defect,  and  so  turning  them  in  that  the  skin  should  vicariate  as  mucous  membrane. 


CONGENITAL  MALFORMATIONS  OF  THE  BLADDER 


979 


These  flaps  when  united,  and  the  anterior  wall  wjicii  thus  formed,  coidd  be  covered  by 
other  Haps  or  by  skin  «,M-at"ts;  but  from  these  flaps  hairs  will  <i;row  into  the  bladder. 
These  will  become  encrusted  with  urinary  salts  and  an  amount  of  irritation  be  produced 
which  may  become  not  only  intolerable  but  locally  destructive. 

In  the  selection  of  any  plastic  method  much  will  dej)cnd  on  the  size  of  the  defect  and  its 
completeness,  the  condition  of  the  surroundinijj  wall,  and  varying;  complications  in  the 
surroundiniij  structures.  The  general  method  above  sujjfjested  will  answer  especially 
for  the  smaller  exstrophies.  Beck  has  suiffjested  an  excellent  device,  namely,  the  dis- 
section from  the  pubes  of  the  recti  muscles,  their  insertions  Ix  ino;  severed,  and  the  ])ar- 
tial  division  of  the  transversalis  fascia  until  the  muscles  arc  so  mobilized  that  they  can 
be  reflected  and  united,  thus  forniinif  an  anterior  bladder  covcrinir.  IJy  a  second  oj)era- 
tion  these  j)artially  formed  flaj)s  may  be  ajjain  dissected  off  from  the  wall  and  a  com- 
plete osteoplastic  covering  afforded.  Practically  no  operation  for  extroversion  can  be 
completed  in  one  sitting.  Frequently  repeated  efforts  have  to  be  made,  a  little  being 
accomplished  at  a  time.  One  of  the  greatest  difficulties  met  with  is  securing  primary 
union  along  surfaces  more  or  less  bathed  or  in  contact  with  escaping  urine.  These  flaps, 
even  if  united,  may  separate  in  a  few  days  as  a  result  of  this  urinary  maceration.  Against 
this  there  is  but  little  possible  provision,  save  perhaps  by  eatheterizing  both  ureters,  and 
emptying  them  into  a  distinct  receptacle. 


Fig.  G48 


Fig.  649 


",.\\0^ 


1         / 


Roux's    autoplastic   method   of    raising   a   perineo- 
scrotal flap  with  which  to  cover  the  defect.      Lines  of 
incision.     (Hartmann.) 


Roux's  autoplastic  method  of  raising  a  perineoscrotal 
flap  and  its  fixation.      (Hartmann.) 


More  complicated  methods  of  furnishing  a  complete  cavity  have  been  devised  by 
Rutkow^ski  and  JSIikulicz,  both  of  whom  have  suggested  to  use  a  small  loop  of  small 
intestine  wherewith  to  complete  the  bladder  cavity.  In  each  of  these  methods  the  abdo- 
men is  opened,  a  loop  of  bowel  brought  down,  a  small  portion  completely  separated  by 
double  division,  end-to-end  anastomosis  of  the  main  part  being  then  made,  while  the 
separated  part  is  in  one  method  closed  at  one  end,  while  the  other  end  is  fitted  over  the 
exposed  bladder  surfaces  as  a  sort  of  cap.  The  method  is  exceedingly  complicated  and 
hazardous,  and  depends  for  local  success  upon  a  sufficient  blood  supply  to  the  intestinal 
loop,  which  should  be  carefully  ensured  by  caring  for  its  vessels  and  mesentery.  It  has, 
nevertheless,  been  successful. 

A  far  simpler  method,  perhaps  the  simplest  of  all,  is  that  of  Sonnenburg,  which  con- 
sists in  extirpation  of  the  bladder  proper,  with  plastic  closure  of  the  opening,  while  the 
ureters  are  carefully  separated  and  sutured  into  the  upper  portion  of  the  urethral  gutter. 
This  removes  all  urinary  cavity  and  provides  only  for  continuous  escape;  but  this  latter 
is  now  provided  in  an  accessible  and  convenient  place,  while  the  wearing  of  a  urinal  per- 
mits the  achievement  of  the  main  purpose  of  the  operation.  Sterson  operates  upon 
young  girls  by  suturing  the  loosened  ureters  to  the  labia  minora,  which  are  then  sew^ed 
together  in  the  median  line,  after  which  a  urinal  can  be  worn.' 


'  Cantwell  has  suggested  the  following  method  for  bladder  exstrophy,  namely,  to  pass  catheters  through  a  perineal 
fistula  up  into  the  ureters,  then  to  dissect  off  the  bladder  wall,  bringing  it  over  a  small  rubber  balloon,  pushing 
the  whole  into  position,  and  uniting  the  abdominal  wall  in  front. 


980 


SPECIAL  OH  REdlOXAL  SlRdiniV 


It  has  occurred  to  many  ()]X'rators  to  more  comj)letely  divert  the  urinary  stream  by  dis- 
])hicino;  the  ureters  and  turnini,'  tliem  into  the  rectum  or  tlie  sigmoid.  Operations  for  this 
purpose  have  been  descril)ed  especially  by  jNIaydl  (Fig.  650),  and  by  ^loynihan,  while 
modifications  have  been  suggested  by  many  others.  In  practically  all  of  these  procedures 
catheters  are  first  ])asse(l  into  the  ureters  for  their  identification  and  control.  vSome  would 
dissect  out  the  trigone  with  both  ureters,  and,  making  a  sufHciently  large  opening  in  the 
rectum,  would  transplant  it  in  its  entirety  within  that  cavity,  closing  the  opening.  Moy- 
nihan  improved  on  this  by  making  a  vertical  incision  and  entirely  dissecting  away  the 
bladder,  separating  it  also  from  the  prostate,  thus  completely  isolating  it.  Then  the 
portion  containing  the  ureters  is  held  upward,  while  at  the  bottom  of  the  wound  the 
rectum  can  either  be  seen  or  made  visible.  The  peritoneal  reflection  is  then  lifted 
upward  from  the  front  of  the  rectum,  which  is  opened  along  its  anterior  surface  by  an 
incision  perhaps  three  inches  in  length.     Into  this  opening  the  bladder  is  placed,  being 

Fig.  650 


Maydl's  operatiou;  diversion  of  ureters  into  rectum.      (Hartmann.) 

SO  reflected  that  its  former  anterior  surface  now  looks  posteriorly.  The  ureters,  instead 
of  passing  forward,  now  pass  backward  and  the  catheters  contained  within  them  are 
passed  into  the  rectum  and  out  of  the  anus.  The  edge  of  the  bladder  and  the  cut  edges 
of  the  rectum  are  carefully  sutured,  after  w^hich  the  abdominal  wound  is  closed.  The 
sphincter  is  then  stretched,  while  the  catheters  remain  in  the  ureters  for  four  or  five  days. 
A  choice  may  be  made,  then,  between  some  such  method  as  that  last  described  or 
that  of  Peters,  who  dissects  out  the  ureters,  retaining  only  a  small  circular  patch  of  blad- 
der wall,  which  is  folded  around  the  orifice  of  each,  the  rest  of  the  bladder  being  extir- 
pated. Each  ureter,  with  its  button  of  bladder  wall,  is  then  drawn  through  a  small  slip 
in  the  rectal  wall,  made  large  enough  to  admit  it,  and  the  end  of  the  ureter  is  then  left 
hanging  for  1  or  2  Cm.  into  the  rectum.  It  would  jirobably  be  better  to  hold  the  ure- 
ters in  place  by  a  stitch  rather  than  run  the  risk  of  their  retraction;  but  care  must  be 
taken  that  these  stitches  make  no  unnecessary  constriction.     Others  have  substituted 


i\./rh'ii:s  TO  rill':  nLADDF.R  OSl 

tlu-  siijinoid  For  iIk-  ivituiii,  tlii'  procedure'  hfiii^'  otiicrw  isi-  tlic  suine,  all  of  these  reetai 
iini)laiitatioii.s  huvin<j  for  their  |)uri)ose  the  utilization  of  the  rectum  as  a  cavity,  which 
may  not  only  contain  urine,  hut  retain  it  reasonably  under  control.  In  many  respects 
they  would  iu-  ideal  were  it  not  for  the  attendant  dangers.  These  are  (1)  those  imme- 
diatelv  connected  with  an  o|)era(ion  which  is  sericnis,  and  (2)  those  connected  with 
secondarv  infection  of  the  kidneys,  which  seems  to  occur  in  almost  all  cases,  no  matter 
iiow  a|)parcntiy  successful  at  first. 

INJURIES  TO  THE  BLADDER. 

Injuries  to  the  bladder  projicr  may  he  accompanied  hy  those  of  the  j)arts  without,  or 
mav  he  isolated.  'I'liey  divide  themselves  mainly  into  ruptures  and  lacerations,  or  pene- 
trations directly  coniiectinjj;  with  the  exterior.  Anions  the  causes  which  predispose  to 
rupture  and  other  injuries  may  he  mentioned  intoxication,  j)artly  because  it  is  often 
accompanied  by  overdistention,  and  partly  because  of  the  jiartial  or  incomplete  insensi- 
bility of  the  patient.  Distention,  no  matter  how  permitted,  is  an  important  predisposing 
cause.  The  injuries  usually  include  blows,  falls,  and  crushes,  and  gunshot  or  other 
perforations. 

The  location  of  the  rent  is  more  commonly  in  the  upper  and  posterior  portion  of  the 
bladder — i.  e.,  in  its  weakest  part.  Such  tears  may  vary  from  one-half  to  four  inches 
in  length.  When  accompanying  fracture  of  the  pelvis  the  peritoneum  is  more  likely  to 
be  injured. 

The  most  significant  symptoms  are  a  desire  to  urinate  and  inability  to  do  more  than 
])erhaps  ex|)el  a  few  drops  of  bloody  fluid.  Of  course  the  passage  of  any  blood  or 
l)loody  urine  will  suggest  the  occurrence  of  such  an  injury.  Patients  are  usually 
unable  to  stand  upright,  and  also  show  a  strong  tendency  to  flexion  of  the  thighs.  The 
introduction  of  a  catheter  and  the  withdrawal  of  bloody  urine  do  not  necessarily  settle  the 
question  as  to  whether  there  has  been  any  possible  laceration.  Some  surgeons  have 
taught  that  normal  urine  is  comparatively  harmless  and  that  it  is  no  more  likely  to  pro- 
duce infection  than  the  catheter  used  for  diagnostic  purposes;  but  this  is  not  safe  teach- 
ing today.  A  clean  metal  instrument  is  of  no  more  danger  than  a  clean  probe  under 
other  circumstances.  Weir  has  suggested  a  valuable  test,  consisting  of  removal  of  all 
the  urine  possible,  after  which  a  measured  quantity  of  sterile  fluid  is  injected.  If  on 
using  a  catheter  again  this  be  all  recovered  it  may  be  assumed  that  the  bladder  is  not 
ruptured,  otherwise  the  contrary.  If  hours  after  the  injury  a  catheter  be  used  and  no 
urine  securefl,  this  fact  will  be  most  suggestiye.  The  cystoscope  is  usually  disappointing, 
since  a  bladder  so  injured  cannot  often  be  satisfactorily  examined. 

Another  class  of  serious  injury  to  the  bladder  includes  the  perforations,  such  as  may  be 
effected  by  gunshot  or  stab  wounds,  or,  as  in  one  case  of  my  own,  where  a  lad  sat  down 
upon  an  iron  spike,  about  three-quarters  of  an  inch  square  and  nearly  six  inches  in 
length.  The  point  of  the  spike  entered  the  anus,  and  the  consequence  of  the  injury 
was  a  perforation  of  the  anterior  wall  of  the  rectum  and  the  posterior  wall  of  the  bladder, 
with  injury  to  its  anterior  wall  without  complete  perforation.  Prompt  operation  saved 
this  case,  as  it  will  most  such  instances,  although  it  was  shown  that  a  piece  of  his  trousers 
had  been  carried  into  and  left  in  the  bladder.  I  opened  the  abdomen  above  the  pubis, 
to  be  sure  that  the  peritoneum  was  not  injured,  and  then  drained  by  a  tube  passed  into 
the  anus  and  out  just  above  the  pubis,  after  removing  the  piece  of  cloth.  Prompt 
recovery  followed. 

The  bladder  may  also  be  injured  by  rude  manipulation  of  instruments,  especially 
the  metal  catheter,  by  one  unaccustomed  to  using  it,  or  when  serious  difficulties  are 
offered  by  jjrostatic  enlargement. 

Treatment. — Diagnosis  or  even  serious  suspicion  of  such  injuries  to  the  bladder  as 
above  described  require  either  perineal  or  abdominal  section,  the  choice  of  the  procedure 
being  based  upon  circumstances.  If  there  be  reason  to  suspect  intraperitoneal  extrava- 
sation, then  the  abdomen  should  be  opened,  carefully  cleaned,  the  bladder  rent  sought 
and  sutured,  the  mucosa  being  first  closed  with  hardened  gut,  while  the  peritoneal 
aspect  may  be  sutured  with  silk  or  thread.  The  bladder  should  be  drained,  at  least  by 
retention  of  a  catheter,  passed  if  necessary  by  perineal  section,  and  the  abdomen  drained. 
In  the  female  drainage  may  be  made  through  the  cul-de-sac.    If  there  be  urinary  extra va- 


982  SPECIAL  OR  REGIONAL  SURGERY 

sation  behind  the  perineum,  then  perineal  section  should  be  made,  and  the  Ijladder, 
thus  freely  opened,  should  be  drained  with  a  sufficiently  large  tube;  while  in  the  female  it 
will  probably  be  sufficient  to  dilate  the  urethra  and  insert  a  tube  of  sufficient  size.  It 
is  not  always  easy  to  discover  an  oj)ening  placed  j)()steriorly  in  the  bladder  wall,  and 
after  a  wide  exposure,  with  emjjtying  and  cleansino;  of  the  pelvis,  it  may  be  of  great 
assistance  to  place  the  patient  in  the  Trendelenburg  j)osition.  Under  rare  circumstances 
the  rent  may  be  so  placed  as  to  justify  a  suprapubic  drainage  of  the  bladder. 


FOREIGN  BODIES  IN  THE  BLADDER. 

Foreign  bodies  other  tlian  calculi  occur  in  the  bladder  in  consequence  of  both  accident 
and  of  design.  The  former  are,  e.  g.,  represented  l)y  pieces  of  broken  catheter,  while 
the  latter  are  materials  introduced  from  without  in  consequence  of  sexual  perversion, 
during  intoxication,  or  from  some  other  vicious  tendency.  The  latter  occur  more  often 
in  girls  and  women,  the  former  more  often  in  men.  In  such  a  collection  of  cases  as  was 
made  by  Poulet  (Foreign  Bodies'  in  Surgery)  almost  every  imaginable  object  that  could 
be  introduced  into  the  bladder  is  mentioned.  Some  of  these  have  slipped  in  accidentally 
after  external  manipulation,  as  in  masturbation,  and  some  have  been  deliberately  intro- 
duced. Perhaps  as  common  an  object  as  any  is  the  ordinary  hairpin.  It  is  the  short 
urethra  of  women  which  is  made  the  much  more  frequent  resort  for  such  practises  than 
the  long  urethra  of  men,  in  which  latter  foreign  bodies  are  often  entangled  or  arrested 
before  they  reach  the  bladder. 

Any  object  allowed  to  remain  in  the  blaflder  will  serve  as  a  nidus  for  the  formation  of 
a  calculus,  which  will  form  in  time,  and  it  may  result  that  not  until  the  removal  of  the 
calculus  and  examination  of  its  interior  structure  will  the  original  foreign  body  be  found. 

All  objects  of  this  kind  should  be  removed  as  early  as  possible  after  their  introduction. 
Such  removal  may  be  easy  and  accomplished  by  dilatation  of  the  female  urethra,  with 
or  without  the  use  of  the  cystoscope;  or  the  bladder  may  require  to  be  opened,  either 
above  the  pul)is,  through  the  perineum,  or  through  the  vagina,  in  order  that  the  object 
in  question  may  be  extracted. 

INCONTINENCE,  RETENTION,  AND  SUPPRESSION  OF  URINE. 

Students  often  confuse  not  only  terms  but  conditions,  and  it  is  necessary  to  be  accurate 
in  teaching  regarding  these  subjects.  Suppression  of  urme  is  purely  a  matter  of  cessa- 
tion of  renal  function,  and  has  nothing  to  do  ivith  the  bladder.  Retention  of  urine,  on 
the  other  hand,  has  nothing  to  do  with  the  kidneys,  but  is  purely  a  bladder  affair. 
It  may  be  due  to  spasm  of  the  bladder  outlet,  or  to  its  obstruction  by  calculi,  other 
foreign  body,  or  by  prostatic  enlargement,  or  it  may  be  a  consequence  of  paralysis  of 
bladder  muscle.  Such  retention  is  the  inevitable  consequence  of  fracture  of  the  spine, 
since  paraplegia  is  to  be  expected  in  such  cases,  and  the  condition  is  to  be  atoned  for  by 
careful  and  regular  catheterization.  Retention,  again,  is  occasionally  seen  in  hysterical 
patients.  It  furnishes  the  distressing  and  sometimes  permanent  or  even  fatal  conse- 
quences of  prostatic  enlargement  in  old  men.  No  matter  how  produced,  it  must  be 
relieved,  for  urine  tends  to  accumulate  and  to  distend  the  bladder,  which  will  finally 
burst  unless  the  difficulty  be  sufficiently  overcome  so  that  urine  may  in  some  way  escape. 
Distention  of  the  bladder  under  these  circumstances  is  recognized  by  the  formation  of 
a  rapidly  increasing  tumor,  which  finally  rises  to  the  level  of  the  umbilicus,  fluctuates, 
and  is  accompanied  or  not  by  pain  according  to  the  nature  of  the  cause  of  retention.  In 
paralytic  cases  there  will  be  little  or  no  pain.     In  obstructive  cases  it  will  be  agonizing. 

By  natural  efforts  final  rupture  of  the  bladder  is  usually  prevented,  as  after  a  certain 
degree  of  distention  has  been  attained  urine  begins  to  escape  drop  by  drop.  This  is 
simply  an  expression  of  an  overflow,  and  is  not  to  be  confused  with  incontinence  in  the 
proper  sense  of  the  term.  It  may  be  spoken  of  as  stillicidium,  due  to  retention.  The 
young  and  indifferent  practitioner  may  mistake  this  escape  of  urine  for  incontinence, 
which  would  be  a  most  serious  errt>r.  Under  any  circum.stances,  when  such  a  condition 
may  possibly  occur,  the  lower  abdomen  should  be  palpated,  when  the  presence  of  a 
distended  bladder  should  be  instantly  recognized.     Tlie  first  indication  is  for  its  prompt 


INCONTINENCE,   RETENTION,   AND  SCPPRESSION  OF   URINE  983 

relief  by  the  use  of  (lie  catlieter,  while  the  neee.ssary  eathcterization  .should  be  done  with 
the  usual  precautious.  When  the  passajije  of  an  ordinary  instrument  is  made  difficult 
or  inij)ossibIe  the  cause  of  the  retention  is  usually  thereby  revealed,  and  may  be  shown 
to  be  so  serious  as  to  necessitate  further  operative  j)r()ce(lures. 

When  the  bladdc^r  is  distended  and  no  cathetcj-  can  be  introduced  it  is  advisable  to 
a.spirafr,  the  asj)irating  needle  being-  introduced  throu<>;h  the  sterilized  skin  just  above 
the  pubis,  its  jjoint  directed  toward  the  centre  of  the  mass  formed  by  the  tlistended 
bladder.  Repeated  asj)iration  may  be  necessary,  and  it  has  been  suggested  to  make 
more  or  less  permanent  use  of  such  a  tube  or  hollow  needle.  At  present  no  surgeon 
would  continue  this  as  a  permanent  measure,  but  simply  as  a  temporary  relief,  even 
if  repetition  be  necessary,  until  more  radical  procedure  can  be  carried  out.  W'hether 
this  be  the  removal  of  a  foreign  body  or  calculus,  or  of  an  enlarged  prostate,  it  is  indicated 
just  the  same,  the  only  exception  to  this  statement  being  those  cases  already  too  seriously 
involved  to  justify  more  than  perineal  section  (cystotomy  for  drainage).  Retention  of 
urine,  then,  is  always  a  preventable  eondition,  and  its  eontinuanee  is  inexcusable. 

Incontinence  implies  a  paralytic  condition,  usually  of  the  expulsive  muscles,  but  some- 
times of  the  sphincter  apparatus  in  either  sex,  by  which  urinary  control  is  lost  and  urine 
escapes  involuntarily.  It  may  be  a  temporary  and  occasional  phenomenon,  occurring 
under  the  influence  of  strong  excitement  or  during  sleep,  especially  in  children,  or  it 
may  be  due  to  spinal  disease  or  traumatisms,  with  jiaralysis  of  the  lower  segments  of  the 
cord  and  nerves  given  of?  from  them.  When  originating  in  the  latter  way  it  is  usually 
a  hopeless  condition,  but  nocturnal  incontinence  of  children,  or  even  of  adults,  or  that 
due  to  hysterical  or  other  neurotic  conditions,  may  usually  be  benefited.  For  this 
purpose  the  surgeon  should  search  for  the  cause  from  which  the  reflex  proceeds.  This 
may  be  extreme  acidity  of  urine,  the  irritation  of  a  tight  prepuce  in  either  sex,  the  presence 
of  worms,  intestinal  disturbances,  or  any  one  of  a  great  number  of  possible  causes  of 
disturbance  of  nerve  control.  Some  of  them  permit  of  surgical  relief;  others  require 
simpler  measures.  Children  thus  suffering  should  be  given  no  fluid  late  in  the  evening, 
but  should  be  made  to  empty  the  bladder  before  retiring,  and  perhaps  be  aroused  once 
or  twice  through  the  night  for  the  same  purpose.  In  all  cases  the  urine  should  be 
examined  and  hyperacidity  overcome.  All  forms  of  genital  excitement  should  be 
obviated.  In  the  adolescent  and  in  adults  thus  annoyed,  and  in  the  insane,  it  has  been 
shown  to  be  of  great  benefit  to  make  a  few-  intraspinal  injections  of  sterile  salt  solution, 
as  for  local  anesthetic  purposes,  a  little  cerebrospinal  fluid  being  first  withdrawn,  and 
then  from  2  to  10  or  15  Cc.  of  the  solution  being  introduced.  This  seems  to  have  been 
empirically  suggested  by  a  French  surgeon,  but  has  been  found  of  value  by  Valentine 
and  others,  including  the  writer. 

The  above  forms  of  incontinence  are  to  be  distinguished  from  intense  irritability  of 
the  bladder,  with  frequent  calls  to  empty  it,  which  accomjiany  many  such  conditions 
as  cystitis,  tuberculosis,  tumors,  calculi,  and  the  like.  This  is  the  extreme  irritability  of 
local  disease  rather  than  true  incontinence.  But  there  is  also  a  form,  in  women,  charac- 
terized by  falling  aw^ay  of  the  urethra  and  neck  of  the  bladder  from  the  pubis,  due  usually 
to  injuries  received  during  parturition,  with  consequent  sacculation  or  dilatation  of  the 
urethra  and  formation  of  a  cystocele.  (Dudley.)  This  may  also  be  associated  with  other 
results  of  perineal  laceration.  Here  loss  of  urine  is  not  constant,  but  occasional  or  fre- 
quent. For  its  treatment  the  following  methods  have  been  suggested :  the  injection  of 
paraffin;  partial  torsion  of  the  urethra  (Gersuny),  i.  c.,  a  partial  dissection  of  the  urethra 
and  revolution  upon  its  own  axis,  with  subsequent  suture,  by  which  incontinence  may 
be  overcome,  but  at  the  possible  risk  of  sloughing.  Finally,  Dudley  has  proposed  the 
method  of  advancement  of  the  urethra.  He  makes  a  horseshoe  denudation,  between 
the  meatus  and  the  clitoris,  down  on  either  side  of  the  urethra,  and  nearly  its  entire 
length.  Its  anterior  end  is  then  loosened  sufficiently  so  that  the  meatus  can  be  drawn 
forw^ard  and  secured  below  the  clitoris  by  two  sutures.  The  balance  of  the  wound  is 
then  closed,  the  effect  of  the  operation  being  to  replace  and  retain  the  urethra  and  prevent 
its  sagging.  Other  surgical  treatment,  as  for  cystocele,  laceration,  etc.,  may  be  added 
as  needed. 


984 


SPECIAL  OR  HEdlOSAL  SURGERY 


CYSTITIS. 

The  condition  of  true  cystitis-  arises  invarialjly  either  from  the  irritation  of  a  foreign 
hodii  or  the  presence  of  bacteria;  the  former  need  not  necessarily  he  hirtje,  and  minute  and 
irritating  crystals  are  often  sufficient  to  prcKJuce  at  least  some  of  its  features.  Sooner 
or  later,  however,  the  germ  element  enters,  and  from  that  time  on  cystitis  is  a  bacterial 
infection.  Furthermore  this  infection  is  usually  secondary,  rarely  if  ever  primary,  and 
may  come  from  without  or  within.  Thus  it  may  be  the  consequence  of  the  introduction 
of  unclean  instruments;  is  a  very  frequent  consequence  of  gonorrhea,  including  all 
forms  of  urethritis;  or  may  be  the  result  of  local  tuberculous  processes  or  those  travelling 
downward  from  the  kidneys;  or,  again,  of  more  general  toxic  (jr  septic  conditions,  such 
as  typhoid  and  other  infectious  fevers.  Certain  conditions  predispose,  such  as  the 
presence  of  calculi  or  the  occurrence  of  traumatism.  Again,  a  bladder  weakened  by 
overdistention  or  paralysis,  as  in  cases  of  spinal  injury,  loses  its  natural  resisting  power 
and  succumbs  to  infection  abnormally  easily.  It  should  be  emjjhasized  that  the  abso- 
lutely healthy  l^ladder  wall  is  resistant  to  all  germ  activity,  but  this  resistance  is  easily 
lost  or  modified  in  the  presence  of  disease,  either  close  by  or  distant.  A  bladder  whose 
normal  shape  has  been  greatly  changed  by  enlargement  of  the  prostate  is  again  rendered 
not  only  unhealthy,  but  incapable  of  acting  normally.  It  beccmies,  therefore,  easily 
infected,  and  cystitis  is  a  frequent  accompaniment  of  prostatic  hypertrophy. 

Fig.  651 


Internal  appearance  of  bladder  in  some  cases  of  inveterate  cystitis;  mucosa  sacculated  by  columns  of 

hypertrophied  tissue.      (Launois.) 

Symptoms. — ^The  cardinal  symptoms  of  cystitis  are  three  in  number,  i.  e.,  pain, 
frequency  of  micturition,  and  pyuria,  the  latter  being  the  consefjuence  of  changes  in 
the  urine,  as  well  as  in  the  bladder  wall,  while  thejjain  and  the  thamuria  are  expressions 
of  irritation,  especially  of  the  base  of  the  bladder  and  the  posterior  urethra.  In  fact, 
all  the  more  violent  expressions  of  cystitis  are  found  at  the  lower  part  of  the  bladder 
rather  than  in  its  upper  portion.  Obviously,  then,  irritation  of  adjoining  organs  is 
more  easily  accounted  for,  e.  g.,  of  the  urethra,  the  seminal  vesicles,  the  prostate,  and 
the  lower  ends  of  the  ureters. 

The  pain  may  be  severe,  and  is  especially  complained  of  with  each  act  of  urination. 
It  is  referred  not  only  to  the  region  of  tlie  bladflrr  ])roper,  but  along  the  urethra  to  the 
end  of  the  penis  in  the  male,  and  down  the  thighs  in  both  sexes.  With  frequency  of 
urination  there  is  also  distressing  urgency,  so  that  once  the  necessity  be  felt  nothing  can 
restrain  the  promptness  of  the  act.  In  fact  so  powerful  is  the  ex'pulsive  tendency  that 
the  tenesmus  affects  not  only  the  bladder  but  often  the  rectum,  while  the  feeling  or 
desire  to  urinate  continues  after  the  bladder  has  been  emptied  of  its  last  drop,  even  for 
several  minutes,  and  may  cause  the  patient  to  sit  in  agony  for  some  time.     The  distress 


CYSTITIS  9g5 

J)n>(lucv(l  ill  Jifiur  cases  of  cvstitis  is  excessive-,  and  sedatives  and  aiiodyiu^s  coiislitule 
no  small  part  ot"  the  treatment. 

The  amount  of  /jz/.v  contained  in  the  urine  w  ill  vary  with  the  deoree  of  aeuteness  and 
the  staf>;e  of  the  disease.  At  first  it  is  but  sli<>;ht,  but  rapidly  increases,  until  the  urine 
may  contain  thick  mucus  and  pus  up  to  one-third  or  more  of  its  volume.  Finally 
hlood  may  aj)j)ear,  by  whose  appearance  a  serious  deforce  of  inflammation  is  betokened. 
Later,  at  a  variable  date,  the  j)Utrefaetive  element  is  introduced;  and  when  the  urine 
bi'irins  to  smell  of  anunonia — /.  c,  when  (immouiaral  (leroniponifion  has  once  begun — 
the  bladder  is  thereby  the  more  irritated  and  the  ease  made  still  worse. 

No  vesical  mucosa  left  suifiM-iui;'  from  such  acute  inflammation  will  remain  unaft'ected 
in  its  tissue  elements,  but  will  rapidly  become  more  or  less  thickened.  In  fact  the  entire 
bladder  wall  underjjoes  a  process  of  thickenintj;,  from  hypertrophy  of  its  inner  and  its 
muscular  or  middle  coats,  the  latter  due  to  extra  activity  in  consequence  of  the  constant 
tenesmus.  'I'here  results  in  time  a  marked  eccentric,  hijpertrophi/,  whose  result  is  really 
a  contraction  of  the  bladder  cavity  and  a  distortion  of  its  lining.  Under  these  circum- 
stances, also,  the  Tuucosa  becomes  sacculated,  and  mnnerous  little  pockets,  which  may 
contain  decomposino-  urine,  serve  to  complicate  the  situation;  while,  finally,  more  or 
less  incrustation  or  calculous  degeneration  and  ini])lantation  modify  the  character  of  the 
mucous  coat.  For  all  these  changes  to  occur  requires  time,  but  their  combined  effect  is 
such  thickening  and  contraction  of  the  bladder  as  to  permanently  alter  it  and  lead  to  a 
final  coucrntric  hypertrojihy. 

Tuberculous  Cystitis. — ^The  picture  presented  by  tuberculous  disease  of  the  vesical 
mucosa  is,  in  the  beginning,  one  of  miliary  or  disseminated  involvement;  but  later, 
when  ulcerative  changes  have  taken  place,  the  end  results  are  scarcely  different  from 
those  rehearsed  above,  save  that  the  ulcerative  element  is  more  predominant,  and  there 
is  great  probability  of  involvement  of  the  ureters  or  of  any  of  the  adjoining  organs.  As 
conditions  do  not  essentially  vary,  neither  do  symptoms,  and  a  diagnosis  of  tuberculous 
cystitis  often  must,  in  the  early  stages,  be  reached  by  a  process  of  exclusion,  corroborated 
perhaps  by  the  cystoscope. 

Postoperative  Cystitis.— A  different  clinical  type  of  irritation,  or  mildly  infective 
cystitis,  is  kncnvn  to  be  a  sequel  of  certain  operations,  not  alone  those  upon  the  pelvis. 
In  the  majority  of  cases  it  occurs  when  catheterization  has  been  required,  the  first  event 
being  urinary  retention,  by  wdiich  the  bladder  mucosa  must  be  more  or  less  disturbed. 
It  may  be  perhaps  accounted  for  by  the  fact  that  the  urethra  is  practically  never  free 
from  germs,  which,  in  that  canal,  seem  to  be  innocent,  but  which,  carried  upward  into 
an  irritated  bladder  may  excite  serious  inflammation.  These  cases  are  perhaps  more 
frequent  after  pelvic  operations  for  cancer.  There  seems,  however,  no  doubt  but  that 
repeated  catheterization  for  several  days  lowers  bladder  resistance. 

Treatment. — When  the  occurrence  of  cystitis  is  imminent  prophylactic  or  pre- 
ventive treatment  is  recommended.  This  should  consist  in  administration  of  large 
quantities  of  fluid,  with  urinary  antiseptics,  in  lavage  of  the  bladder  itself,  and  in  reliable 
antisL^ptic  precautions  in  catheterization.  Thus  to  ojierate  upon  a  bladder  which  has 
long  held  seriously  infected  or  decomposed  urine,  without  previously  cleansing  it  as 
much  as  possible,  is  simply  to  invite  further  trouble. 

The  medicinal  treatment  of  cystitis,  on  which  w'e  mainly  rely,  consists  in  dilution  of 
the  urine  by  large  amounts  of  fluid  ingested,  in  overcoming  hyperacitlity  by  the  adminis- 
tration of  alkalies,  and  in  combating  putrefactive  conditions,  so  far  as  possible,  by  anti- 
septics w  hich  are  eliminated  through  the  kidneys.  Balsams  have  been  long  held  in  great 
repute;  but  remedies  like  urotropin  and  other  synthetic  compounds  have  taken  their 
place.  Of  them  all,  and  especially  in  the  presence  of  ammoniacal  urine,  urotropin  and 
the  alkaline  salts  of  benzoic  acid  seem  most  reliable.  Excessive  irritability  may  be 
overcome  by  local  measures,  such  as  frequent  hot  rectal  douches,  hot  sitz  baths;  by 
quieting  irritation  of  the  genitospinal  centres  by  administration,  e.  g.,  oi  cannabis  inclica, 
in  doses  pushed  to  the  physiological  limit;  by  local  anodynes,  as  by  opium  suppositories, 
or  in  extreme  cases  by  general  anodynes  like  morphine. 

Theoretically  a  seriously  infected  bladder  should  be  washed  out  and  cleansed  as 
any  other  pus  cavity,  but  when  so  inflamed  the  bladder  becomes  so  intolerant  and  ex- 
quisitely irritable  that  the  mere  act  of  washing  can  only  with  difficulty  be  borne  by  the 
patient.  Retention  of  a  catheter,  which  might  be  advisable  under  most  circumstances, 
may  also  be  impossible  for  the  same  reason.     The  condition  of  a  patient  under  extremes 


986  SPECIAL  OR  REGIONAL  SURGERY 

of  this  kind  is  pitiable,  and  resort  to  jreneral  anodynes  luuivoidable.  Still  it  is  possible 
with  patience  and  the  use  of  selected  drujfs  to  gradually  allay  even  a  most  acute  cystitis. 
Confinement  in  bed  and  an  almost  fluid  diet  are  also  necessary  features  of  treatment. 

If  the  introduction  of  an  instrument  can  be  borne  it  may  be  possible  to  leave  in  the 
bladder  some  soothing  solution  after  it  has  been  washed,  such  as  a  mild  cocaine  solution 
containing  a  little  morphine,  or  olive  oil  containing  orthoform,  or  a  mild  preparation 
of  ichthyol.     Even  if  these  be  retained  but  for  a  short  time  they  will  usually  afford  relief. 

Finally  in  severe  forms  of  cystitis  the  bladder  may  he  opened  for  the  purpose  of  giving 
it  physiological  rest,  selecting  either  the  suprapubic  or  the  median  perineal  route.  The 
relief  thus  afforded  is  usually  gratifying,  while  drainage  may  be  maintained  until  the 
local  treatment  has  been  sufficiently  effective  to  permit  either  spontaneous  closure  of 
the  drainage  opening  or  its  repair  by  suture.  This  measure  is  known  as  cystostomy 
for  the  relief  of  cystitis. 

Obviously  if  cystitis  be  due  to  the  presence  of  any  foreign  body  its  treatment  becomes 
necessarily  surgical,  the  same  being  true  of  those  forms  due  to  or  connected  with  hyper- 
trophy of  the  prostate.  It  is  impossible  to  accomplish  a  cure  here  until  the  mechanical 
difficulty  is  first  overcome. 

VESICAL  CALCULUS. 

In  the  urinary  bladder  as  well  as  in  the  gall-bladder  mineral  elements  held  in  solution 
by  the  contained  fluids  are  precipitaterl,  the  consequence  being  the  formation  of  calculi 
or  stones  in  the  bladder,  which  vary  in  size  from  the  smallest  concretions  to  those  weighing 
many  ounces,  and  in  number  from  one  to  scores,  a  large  proportion  of  these  representing 
original  concretions  passed  down  from  the  kidneys,  i.  e.,  minute  renal  calculi.  Every 
calculus  has  a  nucleus,  and  in  many  instances  this  may  be  a  clot,  or  clump  of  cells 
encrusted  with  salts,  which  have  formed  within  the  bladder  and  not  come  down  from 
above.  Such  foreign  bodies  will  become  the  nidus  for  a  calculus,  while  in  vesical  calculi 
are  frequently  found  pieces  of  catheter,  of  straw,  chewing-gum,  hairpins,  and  the  like, 
which  have  l)een  introduced  from  without.  These  stones  are  constituted  mainly  of  the 
ordinary  urinary  salts,  /.  e.,  phosphates,  urates,  or  oxalates,  deposited  as  described  above. 
Much  more  rarely  rystin  and  xanthin  are  found.  Instead  of  urates  crystallized  uric 
acid  will  be  occasionally  seen.  The  oxalates  are  mostly  those  of  calcium,  while  the 
phosphates  are  those  of  calcium,  magnesium,  or  ammonium,  more  or  less  combined. 
The  first  requisite  for  a  calculus  is  a  nidus,  the  second  the  deposition  of  one  or  more  of 
these  salts.  Calculi  are  sometimes  composite  in  structure,  some  having  a  uric  or  urate 
nucleus  becoming  later  encrusted  with  jihosphates.  The  oxalic  calculi  are  exceedingly 
haKl  and  usually  rough,  being  often  s]:)oken  of  as  viulberry.  They  rarely  attain  large 
size.  The  rapidly  forming  phos])hatic  calculi  are  often  so  small  as  to  disintegrate  or 
break  in  the  process  of  removal.  Thus  there  may  be  great  differences  in  density  of  these 
stones.  Their  formation  is  particularly  favored  by  retention  of  alkaline  urine,  as  in 
many  cases  of  prostatic  enlargement. 

Symptoms.  —Discomforts  and  sym])toms  produced  by  bladder  stone  depend  upon 
their  size,  number,  roughness,  movability,  and  location.  The  larger  and  rougher  stones, 
which  are  more  or  less  easily  moved  inside  a  tender  and  irritable  bladder,  will  cause  a 
large  amount  of  discomfort  and  actual  pain,  while  a  small  calculus,  which  may  be  formed 
within  a  pocket  or  become  encysted  at  some  distance  from  the  urethral  opening  may 
remain  unnoticed  The  indications  of  calcuH  are  essentially  those  of  cystitis,  pai?}, 
frequency  of  urination,  and  pyuria,  sometimes  with  hematuria.  The  pain  is  local  and 
referred,  especially  along  the  urethra,  to  the  glans  in  the  male,  and  is  often  aggravated 
by  the  final  expulsive  movements  of  the  bladder  at  the  termination  of  urination.  I^ocal 
discomfort  is  aggravated  by  active  exercise.  Reflex  pains  have  been  known  in  distant 
parts  of  the  body.  The  frequency  of  urination  is  increased  by  exposure  to  cold  or  by 
activity.  Pyuria  and  hematuria  do  not  differ  from  those  of  non-calculous  cystitis.  A 
most  significant  feature  is  sudden  stoppage  of  the  urinary  stream,  with  more  or  less  pain. 
Statements  to  this  effect,  especially  if  accompanied  by  a  history  of  renal  calculi  in  time 
past,  are  most  suggestive. 

Unless,  however,  particles  of  calcareous  material  have  been  passed  the  positive  diag- 
nosis of  calculus  rests  upon  its  detection  by  examination,  either  with  a  stnjw  searcher  or 
with  the  cystoscope.     The  former  Is  essentially  a  short-beaked,  light  sound,  which  may  be 


VESICAL  CALCUU^fi  C)87 

more  easily  manipulated  after  iutrodiutioii  within  (lie  bladder.  In  usini^  it  the  same 
precautions  are  taken  as  for  catheterization  or  sounding,  while  the  deep  urethra  may  be 
made  less  sensitive  by  a  cocaine  solution.  The  instrument  is  introduced  exactly  as  is  a 
sound,  and  its  beak  is  carried  com|)letely  into  the  bladder.  Sometimes  even  before  this 
has  been  accomplished  will  be  noted  the  rou<];h,  (^riitinti' sensation  which  indicates  contact 
with  a  stone.  At  other  times  it  is  only  after  considerable  search  that  a  small  stone  is 
"touched."  A  stone  easily  found  is  within  the  possibilities  of  unskilled  manipulation, 
but  to  acciH'ately  examine  a  bladder,  cs])ecially  behind  a  lar<>;e  prostate,  is  a  fine  art. 
For  this  purpose  the  bladder  should  be  partially  distended  with  fluid,  the  patient  should 
be  in  the  horizontal  position,  and  the  stone  searcher  so  manipulated  that  its  beak  may  be 
made  to  traverse  every  portion  of  the  k)Wer  part  of  the  bladder  and  to  come  into  contact 
with  its  wall,  for  only  in  this  way  can  an  encysted  calculus  be  discovered.  The  beak 
must,  moreover,  be  rotated  so  as  to  be  carried  down  into  the  pocket  behind  an  eidari>-e(l 
prostate,  as  in  such  pockets  many  calculi  nestle.  Some  stones  arc  felt  even  in  intro- 
ducing a  soft  catheter;  others  are  discovered  only  after  such  manipulation  as  the  above. 
Nothino;  but  necrosed  bone  or  a  foreio-n  l)ody  can  convey  to  the  metal  instrument,  and 
throuoh  it  to  the  finger,  the  peculiar  sensation  j)r<)duce(l  by  contact  with  a  stone.  By 
attaching  an  auscultatory  tube  to  the  instrument  a  characteristic  sound  may  also  be 
heard. 

With  the  cystoscope  in  the  hands  of  an  expert  it  is  possible  to  orient  one's  self  definitely 
concerning  the  size  and  location  of  a  calculus,  but  much  information  can  also  be  obtained 
by  the  use  of  the  ordinary  searcher. 

It  hits  occasionally  happened  that  calculi  have  been  discovered  by  accitlent,  either 
during  a  suprapubic  or  some  other  [)elvic  operation. 

Treatment. — The  presence  of  vesical  calculus  being  established,  there  is  but  one 
rational  treatment,  /.  c,  its  removal.  It  remains,  then,  only  to  select  the  method  of 
operation  and  to  perform  it.  Vesical  calculi  are  removed  by  two  general  kinds  of  opera- 
tions: by  crushing  and  evacuation  of  fragments  through  the  natural  passages,  or  by  a 
cutting  operation  and  extraction  entire.  The  former  is  known  as  lithotrity,  or,  as  now 
performed  in  one  sitting,  lifholapaxy,  and  the  other  as  lithotomy,  which  may  be  performed 
either  above  the  pubis,  through  the  perineum,  through  the  vagina,  or  through  the 
rectum.  Each  method  has  certain  obvious  advantages.  Thus  in  favor  of  crushing 
there  is  freedom  from  an  open  wound,  with  its  dangers  of  infection  and  of  hemorrhage, 
while  it  appeals  to  the  sentiment  of  those  patients  who  "dread  the  knife."  One  objec- 
tion to  it  is  that  even  when  performed  with  skill  assurance  cannot  be  given  that  the 
bladder  shall  be  freed  from  all  calcareous  particles,  one  of  which  may,  by  remaining, 
serve  as  a  nidus  for  another  calculus.  \n  favor  of  the  cutting  operations  are  their  brevity, 
?'.  e.,  the  celerity  with  which  they  may  be  performed,  the  relief  afforded  by  drainage, 
which  can  be  carried  out  through  the  lithotomy  wound,  and  which  is  often  indicated  in 
bladders  that  have  been  I  )ng  tortured  by  the  presence  of  calculi;  while,  finally,  their 
simplicity,  at  least  in  most  instances,  mak(>s  lithotomy  attractive  to  the  operator  of  limited 
ability.  It  may  be  added  that  certain  calculi,  especially  of  the  oxalic  type,  arc  so  dense 
and  resistant  that  even  when  secured  in  the  grasp  of  an  instrument  they  can  scarcely  be 
crushed.  It  may  be  urged  also  that  septic  urine  is  just  as  harmful  in  a  bladder  whose 
mucous  membrane  has  been  slightly  injured  here  and  there  in  the  process  of  crushing  as 
in  one  which  has  been  more  or  less  opened  by  a  lithotomy. 

Between  cutting  methods  choice  varies  also  according  to  the  taste  and  views  of  various 
operators,  as  well  as  the  nature  of  the  case.  When  the  prostate  is  large  a  suprapubic 
operation  was  held  the  simpler  for  the  removal  of  calculus,  and  this  earlier  teaching  is  not 
abandoned.  In  the  young  the  urethra  is  small  and  the  bladder  lies  high  in  the  pelvis, 
and  both  these  conditions  favor  the  suprapubic  method.  Again  it  enjoys  repute  because 
there  is  no  danger  of  injury  to  the  prostatic  urethra  or  the  seminal  ducts  or  vesicles, 
and  because  it  leaves  the  genital  apparatus  absolutely  untouched.  It  is  also  free  of 
possibility  of  harm  to  the  rectum,  which  was  by  no  means  unknown  in  the  hands  of  the 
older  operators  who  resorted  to  the  perineal  route.  But  the  removal  of  a  large  stone 
by  the  suprapubic  route  entails  an  opening  of  considerable  size,  and  it  is  not  unlikely 
that  a  large  calculus  may  need  to  be  fragmented  and  removed  in  pieces  rather  than 
leave  a  large  opening  at  a  point  where  urinary  fistulas  would  likely  ensue.  It  will  be 
seen,  then,  that  even  lithotomy  is  not  always  to  be  performed  without  crushing  of  the 
calculus. 


()88  SPECIAL  OR  REGIONAL  SURGERY 

Of  the  j)C'rineal  routes  only  two  are  in  vogue  today,  the  median  and  the  lafcral.  The 
median  is  resorted  tf)  for  stones  of  moderate  dimensions,  while  the  lateral  will  be  required 
for  large  ealeuli.  The  vaginal  route  is  often  seleeted  in  women,  although,  rather  than 
make  an  extensive  opening  between  the  bladder  and  the  vagina,  it  will  })robably  be  easier 
and  better  to  dilate  the  urethra,  and,  through  it,  erush  a  caleulus  which,  in  the  female, 
could  thus  be  made  more  accessible  than  in  the  male.  Therefore  in  the  female  the 
suprapubic  route  or  a  litholapaxy  is  usually  adopted.  The  operation  through  the  rectum 
has  been  long  since  abandoned. 

After  a  calculus  has  been  removed  by  crushing  a  self-retaining  catheter  should  be 
inserted,  for  at  least  a  day  or  two,  and  the  bladder  washed,  while  at  the  same  time  treat- 
ment for  the  cystitis,  which  is  still  ])resent,  should  not  be  discontinued.  After  opening 
the  bladder  the  wound  is  drained  for  at  least  a  day  or  two.  Drainage  has  this  dis- 
advantage, that  if  long  continued  it  leaves  a  urinary  fistula,  often  slow  to  close,  but 
a  metal,  glass,  or  hard  or  soft  rubber  tube  may  be  placed  in  a  median  perineal  opening, 
around  which  should  be  packed  gauze  to  check  oozing,  and  left  in  this  condition  for 
two  or  three  days.  Usually  within  a  week  after  its  removal  the  deep  sphincters  have 
recovered  their  retentive  power,  and  the  patient  can  retain  urine  for  some  time,  while 
generally  within  two  weeks  the  entire  wound  is  closed.  In  all  these  cases  a  sound  or 
bougie  should  be  passed  at  suitable  intervals  for  the  purpose  of  preventing  stricture 
formation  in  the  deep  urethra  at  the  site  of  the  operation. 

Litholapaxij  is  performed  by  first  crushing  the  stone  between  the  beaks  of  an  instru- 
ment known  as  the  lithotrife,  which  is  constructed  in  various  forms,  yet  all  conforming 
to  one  type,  which  is  introtluced  into  the  bladder  through  the  urethra,  after  which 
its  blades  are  separated  and  manipulated  until  the  stone  is  felt  to  be  entangled  or  secured 
between  them.  By  a  device  at  the  handle  the  blades  are  then  locked,  and  screw  power 
exerted,  also  from  the  handle,  by  which  the  blades  are  forced  together  and  the  stone 
between  them  more  or  less  broken  (Figs.  652  and  653).  By  repetition  of  this  process 
each  fragment  is  seized  separately  and  crushed  until  the  bladder  contains  more  or  less 
debris  resulting  from  the  manipulation.  The  lithotrite  is  then  removed  and  a  washing 
tube  or  catheter  of  large  dimension  inserted,  and  connected  with  a  so-called  washing 
bottle,  which  is  comjiressible  and  permits  a  stream  of  water  to  be  violently  thrown  into 
the  bladder,  thus  stirring  up  the  fragments  and  particles,  and  which  is  an  instant  later 
withdrawn  by  suction  in  such  a  way  as  to  carry  them  with  it.  Escaping  into  the 
washing  bottle  they  drop  by  gravity  into  a  glass  receptacle  at  its  base,  where  they 
become  at  once  visible.  This  process  is  repeated  until  everything  has  been  washed  out 
of  the  bladder  which  will  come.  The  lithotrite  is  then  substituted  and  the  maneuver 
repeatetl,  and  as  many  times  as  may  seem  desirable.  In  this  way  calculi,  especially 
soft  ones  of  large  size,  may  be  tlisintegrated  and  removed  in  small  fragments.  The 
final  test  of  success  is  failure  to  aspirate  any  more  })articles  or  to  tliscover  them  with  the 
cystoscope  (Fig.  654).  The  time  consumed  in  the  o])eration  will  depend  on  the 
operator's  skill  and  the  size  or  hardness  of  the  stone.  It  is  frequently  performed  under 
local  anesthesia,  the  bladder  being  injected  with  a  weak  cocaine  solution,  or  under 
spinal  anesthesia. 

Lithotomy,  by  either  of  the  above  methods,  is  performed  by  utilizing  a  grooved  sound 
known  as  a  staff,  which  is  first  ins:^rted  into  the  bladder,  and  serves  not  merely  the  purpose 
of  a  grooved  director,  but  to  indicate  the  course  of  the  urethra. 

For  the  suprapubic  operation  the  staff  is  passed  deeply,  and  its  handle  depressed 
between  the  thighs,  so  that  the  end  of  the  instrument  rises  behind  the  pubis  and  carries 
the  bladder  up  toward  the  surface.  A  median  incision  above  the  })ubis  perinits  access 
between  the  recti  muscles  to  the  prevesical  space  (space  of  Retzius),  which  is  more  or 
less  filled  with  fatty  and  connective  tissue.  If  the  bladder  has  been  previously  distended 
with  fluid  and  elevated  on  the  point  of  the  staff,  there  is  but  little  danger  of  wounding  the 
peritoneum,  although  its  reflection  may  be  sought  and  carried  out  of  harm's  way.  It 
is  a  convenience  to  pass  a  silk  suture  with  a  stout,  full-curved  needle  through  the  bladder 
wall  after  it  has  been  exposed,  on  either  side  of  the  point  of  the  staff  which  elevates  it, 
and  to  pass  this  through  in  such  a  way  as  to  have  thus  a  double  loop,  or  two  retractors,  by 
which  it  may  be  more  conveniently  manipulated  after  it  has  been  opened  and  would 
otherwise  collapse.  The  bladder  should  be  opened  upon  the  point  of  the  staff,  whose 
groove  may  then  serve  as  a  guide  in  still  further  nicking  or  incising  it,  the  silk  sutures 
on  each  side  preventing  it  from  collapsing  as  it  otherwise  would  after  the  gush  of  escaping 


\  ESICAJ.   CALCUJArH 


989 


lluld.     Tlic  siirjrcoii  should  now  ciulciivor  so  far  as  |)ossil)lr  (o  dilate  ratiicr  (lia^ii  to  merely 
cut  this  openiniT,  and  thus  give  it  a  size  sufficient  to  permit  the  introduction  oi"  tlie  finger, 

Fio.  652 


Method  of  seizing  the  stone  beliind  the  prostate. 
Fig.  653 


Ordinary  position  in  seizing  the  stone. 
Fig.  654 


Receiver 
Bigelow's  lithotrites,  catheters,  and  evacuator. 


OJX)  SPECIAL  OR  REGIONAL  SURGERY 

by  which  intravesical  exploration  and  orientation  are  effected.  Calcnli  having  been 
identified  and  located,  suitable  forcef)s  are  then  introduced,  and  with  them  the  stone  or 
stfjnes  seized  and  withdrawn  thnnifrh  the  o|)eninf^,  which  may  be  stretched  still  farther 
for  the  purpose  unless  their  size  make  it  advisable  to  crush  them  and  remove  them  in 
frao;ments. 

This  is  suprapubic  cystotomy  or  epicystostomy,  according  to  the  purpcjse  f(jr  which  it 
is  intended.  It  serves  not  only  for  removal  of  calculi  but  for  extirpation  of  tumors,  or 
enlarged  prostates,  and  perhajjs  for  permanent  drainage.  By  the  silk  loops  at  first  intro- 
duced the  bladder  wall  may  be  attached  to  the  abdominal  wound,  while  other  stitches 
may  be  added  to  any  desired  extent.  In  most  instances  it  is  desirable  to  reduce  the 
opening,  for  which  purpose  buried  and  suj)erficial  sutures  may  be  used.  As  leakage, 
however,  may  [)roduce  infection  it  is  customary  either  to  provide  for  drainage  by  insertion 
of  a  catheter  through  the  urethra,  or  by  the  implacement  of  a  small  tube,  whose  lower 
extremity  shall  reach  the  base  of  the  bladder  and  serve  for  drainage,  which  latter  may  be 
made  more  effective  by  siphonage. 


PERINEAL  LITHOTOMY. 

Perineal  section  for  exploration,  drainage,  uv  stricture  is  practically  accomplished  as 
follows:  The  patient  is  first  placed  in  the  so-called  lithotomy  position,  i.  e.,  upon  the 
back  with  the  limbs  flexed  and  knees  parted,  the  feet  or  legs  being  held  either  by  assistants 
or  in  suitable  leg  holders  upon  the  operating  table.  This  is  the  position  in  which  nearly 
all  perineal  operations  in  both  sexes  are  made. 

A  grooved  staff,  with  large  curve  and  long  beak,  is  introduced  into  the  bladder,  and 
not  only  held  in  the  vertical  position  by  an  assistant,  but  in  such  a  manner  as  to  make 
its  curve  bulge  the  perineum  as  much  as  })ossible  toward  the  oj^erator.  The  rectum, 
which  should  have  been  previously  thoroughly  cleaned,  may  be  utilized  for  identification 
or  for  necessary  assistance  during  the  operation.  The  scrotum  is  held  up  out  of  the 
way  by  the  assistant  who  holds  the  staff.  The  perineum  being  thus  put  upon  the  stretch 
may  be  most  quickly  opened  by  a  straight,  sharp-pointed  bistoury,  which  is  inserted  a 
little  posteriorly  to  the  scrotal  junction,  its  ))oint  driven  through  the  tissues  and  made  to 
engage  in  the  groove  of  the  staff,  from  which  it  should  not  escape  until  finally  withdrawn. 
As  the  instrument  is  pushed  backward  the  handle  is  depressed;  a  triangular-shaped 
opening  is  thereby  effected,  whose  apex  is  in  the  membranous  urethra  and  whose  base 
occupies  the  raphe  of  the  perineum,  to  the  extent  of  perhaps  one  and  a  half  inches. 
The  entire  incision  may  be  made  with  one  effort.  Its  effect  is  to  open  the  membranous 
urethra.  Into  the  groove  of  the  staff,  the  knife  being  withdrawn,  may  be  introduced 
either  a  species  of  grooved  director  or  the  finger-nail  of  the  index  finger,  which  may  be 
passed  backward  and  made  to  enter  the  pnxstatic  urethra,  while  at  the  same  time  the 
staff  is  withdrawn.  If  the  prostatic  urethra  be  constricted  it  will  be  difficult  to  enter 
the  bladder  with  the  finger,  otherwise  it  will  readily  yield  to  pressure,  and  it  is  thus  possible 
to  enter  the  bladder  within  a  few  seconds  after  the  first  incision  is  begun  (Fig.  655). 

It  is  preferable  in  all  these  cases  to  have  first  washed  out  the  bladder,  and  then  to 
have  filled  it  with  a  mild  antiseptic  solution.  This  will  escape  instantly  an  outlet 
is  made  from  below.  If  there  is  a  small  calculus  within  the  bladder  the  effect  of  the 
stream  will  be  to  carry  it  toward  this  outlet,  where  it  is  identified  by  the  finger. 

The  prostatic  urethra  will  bear  a  considerable  amount  of  gradual  dilatation,  which 
will  make  it  more  than  easily  accommodate  an  ordinary  finger.  In  this  way  a  sufficient 
channel  is  marie,  through  which  forceps  may  be  introduced  and  calculi  of  small  or 
medium  size  withdrawn.  They  should  be  seized  as  carefully  as  possible  within  the 
proper  gras]:)  of  these  instruments,  so  that  a  minimum  of  laceration  may  be  effected  as 
they  are  extracted.  A  small  calculus  will  be  easily  removed;  a  large  and  soft  one  may 
crumble  in  consequence  of  the  pressure  made  upon  it  during  its  extraction.  In  this 
event  the  fragments  should  be  separately  removed,  the  bladder  then  repeatedly  washed 
out,  and  the  finger  finally  used  to  make  sure  that  no  particles  remain. 

Whether  one  stone  or  several  be  present  the  opportunities  for  the  purpose  of  their 
extraction  aft'orded  by  this  median  operation  are  the  same.  The  bladder  having  been 
emptied  and  washed  out  a  self-retaining  drainage  tube,  or  a  hard  rubber  or  metal  perineal 
tube  should  be  inserted,  with  such  gauze  packing  around  it  as  may  be  necessary  for 


PERINEAL   IJTIIOTOMY 


\)\)\ 


its  ntciitioii  Jiiul  lor  tlic  clu-ckiii^'  ol'  lic'Uiorrha",^'.  'V\\v  iiitt-iit  of  tin-  tiiht-  is  a  doiihle 
one,  it  l)ciii<;  intended  to  serve  for  easy  drainage  and  for  j^entle  |)ressure.  Sometinics 
tlu"  prostate  is  more  or  less  torn  in  the  process  of  dilatation,  and  in  this  case  will  bleed 
more  freelv  than  is  comfortable.  Such  oozin<i;  may  be  checked  by  plu^^inif  jrauze  around 
the  draina<:;e  tube. 

Ldtcml  litliofoiiii/  may  be  combined  wilii  median  section,  by  deliberately  passing";  a 
blunt  bistoury  into  the  prostatic  urethra,  and  niakin<f  with  it  an  incision  in  the  prostatic 
substance,  the  cut  bein<;  (Hrected  toward  a  ])oint  midway  between  the  anus  and  the  ischi- 
atie  tuberosity,  and  carried  to  a  depth  of  one-half  or  three-(juarters  of  an  inch.  This 
affords  a  much  larijer  opening  throuj^h  which  to  remove  Iar<rer  calculi.  Obviously  it 
will  bleed  more  freely  and  will  usually  re(|uire  packing.  The  ohl  laieral  method  was  to 
begin  the  external  incision  at  a  j)oint,  in  the  middle  line,  a  little  behind  the  scrotum,  and 
direct  it  for  one  and  a  half  or  two  inches  backward  and  outward  to  a  point  Ix-twcen  the 
tuberositv  and  the  anus.     The  incision  was  then  deepened  through  the  perineal  fascia 

Fig.  655 


Second  stage  of  lithotomy      (Enchsen  ) 

until  the  index  finger-nail  of  the  left  hand  could  identify  the  staff  within  the  urethra, 
after  which  the  urethra  was  opened  at  this  point  (?.  e.,  just  behind  the  bulb),  when  the 
knife  was  again  introduced  and  made  to  divide  the  prostate  obliquely  as  above.  In 
this  way  the  membranous  urethra  and  lateral  aspect  of  the  prostate  were  divided  to  the 
requisite  depth.  If  such  incision  be  extended  too  far  backward  and  outward  the  internal 
pudic  artery  might  be  divided,  which  would  at  least  be  awkward  and  necessitate  ligature, 
and  this  would  be  somewhat  difficult  because  it  would  require  further  division  of  tissues. 
The  same  management  is  required  after  lateral  as  after  median  operation.  Hxcept 
only  when  a  long  and  seriously  inflamed  bladder  requires  almost  pennanent  drainage 
the  ])erineal  tul)e  should  be  removed  within  forty-eight  hours,  and  the  external  opening 
allowed  to  close  as  rapidly  as  possible. 


992 


SPECIAL  OR  REGIONAL  SURGERY 


TUMORS  OF  THE  BLADDER. 

The  most  common  b(Mii<>ii  tumor  of  the  hladdcr  is  papilloma,  which  here  assumes 
almost  invariably  the  villous  form  and  <!;ro\vs  even  luxuriantly.  It  may  he  solitary  or 
multiple.  In  the  bejjjinning  it  is  usually  more  or  less  ix-dunculated,  but  may  grow  in 
great  numbers,  as  in  the  mouth.  A  class  of  denser  tumors  are  the  fihromas,  which  are 
covered  by  a  more  or  less  thickened  mucous  membrane.  Myxomas  gnjw  mainly  in 
children.  Adenomas  have  been  described,  but  are  rare.  Dermoid  cysts  in  or  about  the 
walls  of  the  bladder  have  also  been  described.  The  malignant  tnmors  of  the  bladder 
are  mainly  of  the  epithelial  type,  usually  adenocarcinoma,  of  a  somewhat  peculiar  type, 
due  to  malignant  degeneration  of  an  original  papilloma,  an  unfortunately  common 
event  (Fig.  (iof)). 

Symptoms. — The  symptoms  due  to  tumor  in  the  bladder  do  not  difi'er  much  from 
those  of  calculus,  except  that  there  is  at  first  less  pain.  In  nearly  all  cases  there  will  be 
hemorrhage,  occurring  independently  of  exciting  causes,  as  during  sleep,  not  only  abun- 
dant but  often  frequent.  In  the  early  stages  pain  is  rarely  severe.  In  cancer  it  is  largely 
proportionate  to  involvement  of  the  bladder  wall  and  the  adjacent  organs,  and  is  more 


Fig.  656 


Fig.  657 


Villous  tumor  (pai)illoma)  of  bladder.     (Musee  Dupuytren.) 


Tumor  of  bladder  as  seen  with 
cystoscope.     (Nitze.) 


common  in  cases  of  basal  tumors.  It  is  both  local  and  referred.  With  a  bladder 
filled  or  filling  up  with  a  tumor  mass  there  will  be  reduction  of  capacity  and  freciuency 
of  urination,  while  in  nearly  all  instances  the  essential  features  of  cystitis  are  superadded. 
The  actual  evidences  of  tumor  are  its  detection  by  the  cystosco]_)e.  Its  discovery  by  vaginal 
or  rectal  palpation,  or  Its  recognition  by  fragments  discovered  in  the  urine. 

When  the  cystoscope  Is  used  In  these  cases  It  usually  reveals  the  location,  size,  vascu- 
larity, arrangement,  and  character  of  the  tumor.  Its  use,  however,  is  often  difficult  or 
impossible,  because  the  manipulation  by  which  the  bladder  is  so  distended  as  to  permit 
its  use  causes  hemorrhage  and  obscurement  of  the  field  of  vision  (Figs.  657  and  658). 

With  the  cystoscope  has  been  recognized  also  an  early  condition  of  leukoplaha, 
corresponding  to  that  seen  In  the  mouth  and  on  the  tongue,  which  may  be  regarded  as  a 
precancerous  condition. 

Treatment. — The  only  treatment  which  can  be  made  effective  is  complete  operative 
removal.  There  is  no  reason  why  any  benign  tumor  of  the  bladder  should  not  be 
attacked,  the  most  unpromising  cases  being  those  of  general  papillomatous  involvement, 
where  only  small  areas  of  the  bladder  mucosa  are  left  uninvolved.  Such  a  villous 
condition  as  tills  Is  serious,  and  may  later  justify  an  effort  at  extirpation  of  the  bladder. 
Palliative  treatment  will  include  tlie  arrest  of  hemorrhage  (for  which  a  few  drops  of 


TUMORS  OF   TIIK  BLADDER 


993 


tiir|H-ntiiU'  oil  arc  often  cflV-ctivo),  with  fi;t'ntle  lavajjc  of  the  hhuhler  and  removal  of  clots, 
scciirinif  their  disintcii^ration  by  injectin(>;  an  emulsion  of  ])ejjsin  or  of  ))a{)ain;  while 
tenesmus,  irritability,  find  pain  are  to  he  controlled  by  cannabis,  sn|)j)ositorics,  morphine, 
or  whatever  may  be  needed.  In  inoperal)ie  cases  cystotomy  for  drainage  purj)oses  may 
l)c  the  Hnal  measure  for  relief  pur])oscs. 

Radical  measures  include  opcitiiKj  (if  the  bladder,  either  above  or  below  the  pubis,  as 
the  cystoscope  may  indicate;  or  the  former,  when  the  oystoscope  cannot  be  used,  as  it 
affords  better  means  for  exploration.  Throutrh  this  ojienini;,  whicli  may  be. made 
lar<»er  than  for  mere  exploratory  or  lithotomy  |)ur])()ses,  and  aided  by  artificial  light  (small 
electric  lights  introduced  by  suitable  mechanism,  as  within  a  test-tube),  there  may  be 
removed  with  scissors  or  curette,  or  even  with  the  finger-nail,  by  enucleation,  such  growths 
as  are  met,  while  in  nearly  every  instance  it  will  be  an  advisable  precaution  to  cauterize 
their  bases  with  the  actual  cautery.  Through  mon;  extensive  incisions,  with  the  patient 
in  the  Trendelenburg  position  and  the  prevesical  s|)ace  widely  opened,  the  l)lad(ler 
mucosa  may  be  excised,  and  ample  drainage  provided  both  by  retention  of  a  catheter 
and  insertion  of  a  siphon  tulx;  through  tlie  lower  part  of  the  opening.  The  suprapubic 
route  affords  better  ojiportunities  f(jr  thorough  work  than  does  the  perineal,  the  latter 
being  suitable  only  for  a  limited  class  of  cases. 

Fig.  658 


Illumination  of  anterior  vesical  wall  by  Nitze's  cystoscope. 


Finally  comes  the  question  of  exfirpnfion  or  a  complete  ci/.sierfomi/.  This  radical  and 
difficult  measure  has  been  added  to  the  list  of  possible  surgical  procedures.  In  a  case 
of  general  papillomatous  disease  it  might  be  successful,  but  it  is  questionable  whether 
any  case  of  cancer  which  would  call  for  such  a  measure  can  be  cured  by  it.  The  opera- 
tion has  been  done  much  oftener  in  women  than  in  men,  and  usually  by  a  combined 
procedure  of  suprapubic  opening,  which  may  be  vertical  or  transverse,  with  attack 
from  the  vagina.  If  the  vaginal  wall  be  involved  it  may  also  be  cut  away.  The  ureters 
should  be  isolated  and  preserved,  when,  the  affected  tissues  being  removed,  it  becomes  a 
question  of  what  to  do  with  them.  They  may  either  be  left  to  drain  into  the  vagina, 
which  is  thus  utilized  simply  as  a  conduit,  and  which  may  be  closed  later  and  the  urethra 
thus  utilized,  a  urinal  being  worn,  or  they  may  be  immediately  or  by  a  secondary  operation 
turned  into  the  rectum.  The  latter  procedure  Introduces  fresh  complications,  though, 
if  successful,  it  would  minimize  the  unpleasant  features  of  such  a  case.' 

It  is  thus  possible  to  successfully  extirpate  the  entire  bladder  proper,  conserving  the 
ureteral  orifices  or  not,  as  well  as  the  urethra,  although  the  resultant  condition  can  hardly 
be  considered  brilliantly  satisfactory.^ 

1  Symphysiotomy  may,  when  required,  be  combined  with  suprapubic  operation  as  in  the  case  of  young  children, 
for  removal  of  very  large  stones  or  tumors,  as  has  been  recently  demonstrated  by  Palmer,  of  Persia, 

2  In  a  recent  case  I  have  been  able  to  more  easily  effect  this  procedure  by  raising  a  flap,  including  the  tissues 
of  the  mons,  exsectiiig  a  portion  of  the  symi>hysis  containing  the  insertion  of  the  recti,  by  oblique  division,  in 
such  a  way  tliat  when  re;_-!.nced  the  bone  could  not  be  easily  displaced,  and  in  this  way  uncovering  the  space  of 
Retzius  so  that,  by  combined  manipulation,  it  was  easier  to  detach  the  bladder  wall  from  its  surroundings. 

63 


994  SPECIAL  OR  REGIONAL  SURGERY 

THE  PROSTATE. 

The  prostate,  with  the  duct  extremities  of  the  seminal  vesicles,  are  enclosed  in  a  fibrous 
sheath  or  capsule,  of  more  or  less  density,  which  has  been  called  by  Belfield  the  broad 
ligament  of  the  male.  In  structure  this  body  is  composed  of  a  mixture  of  adenomatous 
and  muscular  (involuntary)  fibers,  with  considerable  connective  tissue,  so  that  in  many 
respects  it  is  the  homologue  of  the  uterus.  It  not  only  serves  as  the  portal  of  the  bladder, 
but  through  it  pass  the  prostatic  urethra  and  the  seminal  ducts.  Infection  proceeding 
from  either  direction  may,  therefore,  travel  along  either  one  of  several  paths,  spreading 
disaster  and  causing  a  variety  of  troubles.  Such  infection  may  be  tuberculous,  gonor- 
rheal, or  of  the  ordinary  septic  type.  There  will  ensue  in  consequence  various  forms 
of  prostatitis:  the  acute,  which  may  lead  to  abscess,  and  the  chronic,  which  will  always 
lead  to  hypertrophy. 

ACUTE  PROSTATITIS. 

Acute  prostatitis  is  generally  the  result  of  gonorrheal  infection,  the  consequence  of  exten- 
sion from  the  urethra  into  the  mucous  follicles  and  the  prostatic  structure.  Primary 
tuberculous  disease  in  this  location  is  rare.  Septic  infection  comes  either  from  the  use 
of  unclean  instruments,  from  the  presence  of  infected  urine,  or  from  the  extension  of 
cellulitis  from  some  adjacent  structure.  It  is  not  infrequently  seen  in  connection  with 
deep  and  tight  strictures  and  accompanying  cystitis,  or  in  connection  with  the  presence 
of  small  concretions,  i.  e.,  prostatic  calculi. 

Acute  prostatitis  is  an  exceedingly  painful  affection,  made  so  particularly  by  in- 
elasticity of  the  capsule,  which  affords  no  accommodation  for  the  swelling  due  to  the 
inflammation.  In  addition  to  the  inevitable  pain  and  tenderness  the  swelling  will  some- 
times practically  close  the  urethra  in  such  a  manner  that  urination  becomes  almost 
impossible.  To  nearly  every  case  will  be  added  some  of  the  symptoms  of  acute  cystitis, 
which  may  have  preceded  the  prostatitis.  Prostatic  inflammation  can  be  made  known 
by  the  exquisite  tenderness  of  the  organ,  discoverable  by  digital  examination  through 
the  rectum.  This  feature,  with  tenderness  in  the  deep  perineum,  and  the  above  symptoms 
make  diagnosis  easy. 

According  to  the  intensity  of  the  lesion  will  be  the  liability  to  suppuration.  Prostatic 
abscess  is  a  frequent  result,  and  its  presence  is  evidenced  by  accentuated  pain  and  ten- 
derness, with  perhaps  considerable  febrile  disturbance.  In  some  cases  fluctuation  can 
be  detected  through  the  rectum.  Such  cases  sometimes  evacuate  themselves  spontane- 
ously, although  often  in  an  undesirable  way,  when  left  untreated,  or  unrecognized, 
discharge  taking  place  usually  into  the  rectum,  but  perhaps  into  the  bladder  or  into  the 
urethra.  Should  pus  burrow  into  the  pelvis  there  will  arise  a  deep  pelvic  cellulitis, 
with  probable  disastrous  consequences. 

When  a  prostatic  abscess  is  suspected  the  patient  should  be  anesthetized,  the  sphincter 
dilated,  the  exploring  needle  used  if  necessary,  and  any  collection  of  pus,  no  matter  how 
detected,  should  be  either  completely  emptied  with  the  aspirator  or  by  free  incision. 


CHRONIC   PROSTATITIS. 

Chronic  prostatitis  may  be  the  residue  of  an  acute  lesion  or  the  gradual  production  of 
a  mild  but  more  or  less  constant  septic  infection.  It  leads  always  to  more  or  less  enlarge- 
ment, is  often  the  basis  for  the  classic  prostatic  hyj:)ertrophy,  and  causes  dull  pain,  referred 
in  various  directions,  often  to  the  sacrum  and  the  back,  with  frequency  of  urination  and 
escape  of  a  viscid  mucus,  the  natural  prostatic  mucus  in  excess,  which  the  patient  will 
usually  consider  semen,  but  which  is  really  the  product  of  the  overworked  prostatic 
glands. 

This  last  phenomenon  is  spoken  of  as  prostatorrhea,  and  deserves  consideration  not 
alone  from  the  alarm  with  which  patients  often  regard  it,  but  because  it  indicates  a 
significant  condition.  A  prostate  whose  glandular  structures  have  been  unduly  active 
will,  in  consequence,  enlarge;  such  a  prostate  is  compressed  with  the  passage  of  every 
bard  stool,  the  consequence  being  the  expulsion  of  some  of  this  fluid  with  each  act  of 


I'ROS'IWTIC   IfYPKUTUorilY  995 

(k'tVcation,  a  feature  interpreted  hv  too  nuiriy  |)atient,s  as  .spennaforrhfM.  The  two 
eoiulitioii.s  are  to  be  diirereiitiated  in  eliiiieal  study,  the  former  heinjr  eommon,  the 
hitter  (|uite  rare.  Ariifc  pms-fatorr/iea  is  also  fre(jiiently  the  eonseciiienee  of  more  or 
less  |)roloii<i;ed  sexual  excitement.  It  corresponds  essentially  to  a  chronic  nasal  catarrh, 
which  is  accentuated  hy  exposure  to  cold  or  to  irritation  of  auy  kind,  and  is  only  the 
overflow  of  a  natural  fluid  under  morbid  conditions.  With  chronic  prostatitis,  further- 
more, the  sexual  appetite  is  often  decreased,  while  sensations  are  more  or  less  disturbed, 
ejaculation  bein>;;  perha])s  |)remature;  the  patient  is  often  made  thereby  despondent, 
and  the  case  reirarded  by  himself,  or  by  the  quack  whom  he  is  led  to  consult,  as  at  least 
incipient,  perhaps  hopeless,  impotence. 

The  |)hysi(al  eridrurcs  of  chronic  prostatitis  are  enlargement,  with  tenderness  not  only 
of  the  j)rostate  itself,  but  of  the  seminal  vesicles  above  it,  and  often  the  appearance  of  a 
few  drojis  of  prostati-;  mucus  at  the  meatus  after  pressure  or  stroking  of  tlie  prostate 
itself  has  exj)elled  them. 

Treatment.  Removal  of  the  cause  is  the  secret  of  success;  if  this  be  a  stricture 
it  may  be  divided  and  dilated;  if  cystitis,  it  must  be  combated;  if  chronic  constipa- 
tion, it  should  be  overcome;  while  excesses,  either  alcoholic  or  sexual,  should  be  con- 
trolled. Some  one  or  nearly  all  of  these  conditions  will  be  seen  in  nearly  every  case  of  this 
character.  To  other  manipulative  features  may  be  advantageously  added  a  certain 
massage  or  "  milking"  of  the  prostate,  at  intervals  (jf  five  or  six  days,  by  which  it  is 
emptied  of  its  accumulated  secretion.  Pkjually  beneficial  is  the  occasional  passage  of 
a  large  sound  through  the  prostatic  urethra  and  into  the  bladd(>r.  Its  effect  also  is  to 
make  pressure,  while  at  the  same  time  it  stimulates  and  does  good  in  a  way  perhaps 
difficult  of  explanation.  Irritation  in  the  prostatic  urethra  should  also  be  controlled 
by  occasional  injections,  with  a  deep  urethral  syringe,  of  a  drop  or  two  of  a  ^  per  cent, 
solution  of  silver  nitrate.  Improvement  in  other  respects  may  be  expected  from 
constitutional,  dietetic,  and  hygienic  measures. 


PROSTATIC   HYPERTROPHY. 

Many  theories  have  been  advanced  as  to  the  etiology  of  prostatic  enlargement.     Those 
worthy  of  any  consideration  may  be  summarized  as  follows: 

1.  That  it  is  of  inflammatory  origin; 

2.  That  it  is  due  to  senile  and  sclerotic  changes; 

3.  That  it  is  produced  by  sexual  excess; 

4.  That  it  is  due  to  ungratified  sexual  desire; 

5.  That  it  is  a  secondary  and  degenerative  change  following  disease  of  the  bladder; 

6.  That  it  is  due  to  some  perverted  testicular  secretion; 

7.  That  it  is  to  be  regarded  as  a  normal  senile  change; 

8.  That  it  is  of  catarrhal  or  septic  origin  secondary  to  bladder  disease; 

9.  That  it  is  to  be  regarded  as  an  adenoma. 

Inasmuch  as  the  prostate  is  to  be  regarded  as  essentially  a  sexual  gland,  many  cases  of 
h}'pertrophy  are  the  result  of  bad  sexual  habits  which  produce  continued  congestion. 
Nevertheless  the  importance  of  previous  infections,  e.  g.,  gonorrheal,  by  which  h}^er- 
trophy  of  glandular  and  cell  elements  may  be  produced,  cannot  be  overlooked. 
Prostatic  enlargement  assumes  one  of  three  principal  types: 

(a)  True  hypertrophy  of  gland  elements,  without  interstitial  particij)ation; 
(6)  The  development  of  more  or  less  distinctly  encapsulated  myomatous  and  adeno- 
matous masses;  and 
(c)  A  mixed  condition  involving  both  of  these  features. 
In  consequence  the  ensuing  enlargement  assumes  one  of  the  three  following  clinical 
types : 

(a)  An  enlarged  soft  prostate ; 
{}))  A  small  contracted  and  sclerotic  prostate ; 
(c)  A  mixed  type. 
These  types  do  not  necessarily  merge  into  each  other,  but  may  remain  distinct.     There 
may  be  atrophy  of  glandular  elements  as  a  result  of  h^q^ertrophy  of  the  muscle  and 
fibrous  elements,  or  vice  t^ersn. 

Much  confusion  has  arisen  regarding  the  so-called  third  lobe,  in  spite  of  the  fact  that 


996 


SPECIAL  OR  RKGIOXAL  SVIiOERY 


the  prostate  i.s  essentially  a  bilohed  organ.  Whenee  has  arisen  the  tendeney  to  speak 
of  the  ''third  lobe,"  or  is  there  sueh  a  thing?  The  exjjlanation  is  that  median  enlarge- 
ment is  a  common  expression  of  prostatic  hj'pertrophy,  occurring  toward  the  interior 
of  the  bladder  at  a  point  where  the  prostate  has  no  capsule,  and  where  growth  occurs  in 
the  direction  of  least  resistance.  That  morbid  specimens  show  an  apparent  "  third 
lobe"  is  true,  l)Ut  that  such  a  condition  exists  normally  is  a  mistake.  It  should,  therefore, 
be  sjioken  of  as  a  median  mlarf/einent  (Fig.  059). 

In  addition  to  the  more  innocent  and  purely  hypertr()])hic  forms  of  prostatic  enlarge- 
ment, it  has  been  recently  shown,  especially  by  Young,  that  the  element  of  cancer  is 
present  in  a  proportion  of  cases  hitherto  quite  unsuspected.  It  may  begin  as  a  small 
indurated  nodule,  in  one  or  both  lobes,  and  while  developing  remains  confined  for  a 
relatively  long  period  by  the  stn)ng  prostatic  capsule.  When  it  extends,  its  line  of  invasion 
is  U[)ward  toward  the  vesicles  rather  than  into  the  bladder.  When  the  latter  has  become 
involved,  if  a  radical  operation  is  to  be  ])ractised,  extirpation  must  include  not  only  the 
entire  prostate,  with  its  capsule,  the  urethra,  the  vesicles,  Inu  the  adjacent  portion  of 


Fi.;.  (-..59 


General  prostatic  enlargement,  with  formation  of  a  median  overgrowth  and  posterior  pocket  or  sac.  Illus- 
trating how  residual  urine  may  be  retained,  as  well  as  the  diflBculties  of  all  kinds  of  instnunentation,  i.  c,  an 
argument,  therefore,  f(>r  radical  treatment.      (Socin  and  Burckhardt.) 

the  base  of  the  bladder.  Early  diagnosis  in  these  cases  is  difficult,  since  it  may  occur 
at  any  age  after  fifty  years,  and,  being  connected  with  In-jiertrophy,  ])roduces  .symptoms 
masked  by  it,  only  the  element  of  pain  being  more  ])rominent.  As  the  condition  develo{)s 
pain  becomes  rather  disproportionate,  spreads  to  the  suprapubic  region,  and  is  intensified 
as  the  bladder  fills.  When  pain  is  referred  also  to  the  rectum  and  lower  extremities 
it  is  a  suspicious  symptom.  The  condition  does  not  necessarily,  at  least  at  first,  cau.se 
enormous  enlargement.  Therefore  the  obstructive  features  vary.  If  the  portions 
involved  can  be  left  they  will  be  found  more  dense  and  hard  than  the  surrounding  tissue. 
One  peculiarity  of  prostatic  cancer  is  that  metastases  occur  more  often  in  the  bones  than 
in  the  lymphatics.  G)nsequently  the  pelvic  nodes  are  not  so  often  affected.  Ulceration 
and  intravesical  tumor  are  rare. 

Diagnosis. — Early  diagnosis  is  based  on  rapidity  of  gro^-th,  disproportionate  pain, 
indurated  contraction  of  the  pro.static  urethra  near  its  ape.x,  and  absence  of  intra- 
vesical enlargement,  as  shown  by  the  cvsto.scope.  ^^^len  there  is  much  residual  urine, 
without  enlargement  of  intravesical  lobes,  suspicion  is  strengthened.     If  after  removal 


PROST  I  Ti( '  iiY pi.irrnnpiiY 


997 


of  such  j)r().sta(r  it  slioiild  he  sliown  (<>  lu-  iii(»r«'  <>r  less  doited  with  "seed  calfnli,"  as  is 
})()ssihi(',  instead  ol"  with  c-aiu-cr,  thi-  hciicfit  and  relief  to  the  patient  would  be  none  the 
less  marked,  while  the  ))ro<>;nosis  would  he  all  the  hetter. 

Prostatic  hy|)ertro|)hy  leads  to  a  collection  of  phenomena  spoken  of  as  pro.ffdt/.sm: 
Tiiese  iiu-lude  mechanical  im])ediment  to  urination,  with  conse((uent  obstruction, 
sometimes  with  comj)lete  retention,  and  to  the  consecniences  of  the  same  in  the  direction 
of  infection  and  cystitis,  witii  athU'd  features  of  |)ain,  tenesmus,  and  pyuria.  ProNtaiism, 
itt  a  maitcr  of  (jradual  (Icirlopmeut.  Its  earliest  symptoms  are  frecjuent  urination  with 
occasionally  some  difficulty  or  slowness  in  the  act.  From  this  as  a  hcfjimiinjj  <'avSes 
become  gradually  aii^jravated,  until  death  finally  ensues  from  retention,  rupture  of  the 
bladder,  ]m>lone])hritis,  or  exhaustion  in  consecjuence  of  the  pain  and  sufferincj  entailed. 

Prostatism  may  be  imitated  in  persons  whose  prostates  are  not  perceptibly  enlar<;ed, 
in  whom  the  difficulty  and  obstruction  are  i\\\v  to  sclerosis  and  contracture  of  the  vesical 
neck.  This  condition  is  especially  common  in  elderly  men,  subjects  of  arterial  sclerosis. 
This  will  account  for  instances  of  ])rostates  which,  on  removal,  are  found  hard  and 
sclerosed,  and  yet  not  enlarged  enough 

to  be    obstructive.     If  such  a    prostate  Fic.  ooo 

could  be  divided  by  the  cautery,  benefit, 
even  permanent  relief,  might  ensue. 
Therefore,  such  a  condition  might  be 
well  attacked  when  diagnosticatetl  (either 
by  suprapubic  operation  or  by  perineal 
section),  with  the  use  of  the  Bottini 
galvanocaustic  instrument,  especially 
tin-ough  a  perineal  opening. 

Prostatic  enlargement  produces  dis- 
tortion of  the  prostatic  urethra,  which 
becomes  longer,  smaller,  and  sometimes 
deviated,  with  elevation  of  the  level  of 
the  vesico-urethral  orifice,  and  causes, 
by  pressure  on  veins,  more  or  less  dis- 
turbance of  the  return  circulation.  En- 
largement with  impediment  produces 
dilatation  of  the  bladder,  with  possible 
involvement  of  the  ureters  or  the  kid- 
neys, and  thickening  of  the  vesical  w^alls, 
often  with  sacculation  of  its  mucosa 
between  its  disturbed  muscle  fibers. 
Finally  come  the  consequences  of  septic 
infection  with  ammoniacal  putrefaction  of 
urine,  pyuria,  and  perhaps  pyelonephritis 
with  uremia,  which  will  be  tenninal. 
While  the  condition  is  generally  regarded  as  belonging  to  the  late  years  of  life  it  may 
begin  by  natural  processes  at  the  forty-fifth  year,  although  uncommon  before  the 
fifty-fifth. 

Symptoms. — When  a  man  past  the  middle  years  of  life,  previously  free  from  urinary 
difhculties,  is  aroused  to  urinate  more  frequently  than  usual,  especially  at  night,  while 
the  desire  to  urinate  and  the  natural  feeling  of  relief  at  the  conclusion  of  the  act  are  more 
or  less  perverted,  the  beginning  of  prostatism  may  be  suspected.  If  in  addition  to  these 
features  the  urine  shows  fermentative  changes,  or  the  presence  of  mucus  or  ]>us,  the 
more  or  less  disastrous  consequences  of  obstruction  have  begun.  Symptoms  similar  to 
these  may  be  caused  by  the  presence  of  calculus.  It  is  therefore  necessary  to  differentiate 
between  this  and  prostatic  enlargement.  This  is  first  done  by  a  careful  tligital  examina- 
tion of  the  empty  rectum,  the  index  finger  being  gently  introduced  and  made  to  so 
completely  palpate  the  prostate,  through  the  anterior  wall  of  the  rectum,  that  an  accurate 
estimate  of  its  relative  size,  as  well  as  of  any  marked  irregularity,  may  be  made.  If 
the  prostate  be  enlarged  the  explanation  is  at  once  afforded.  If  there  be  but  little 
apparent  change  noted  by  this  method  the  surgeon  should  introduce  a  stone  searcher. 
Manipulation  with  this,  in  a  bladder  distended  with  fluid,  should  reveal  the  presence 
of  a  calculus,  or  should  indicate  a  lengthening  of  the  prostatic  urethra,  with  such  dis- 


Enormous  prostatic  hypertrophy,  necessitating  supra- 
pubic cystotomy  because  of  impossibility  of  catheteriza- 
tion from  behiw.      (Socin  and  Burckhardt.) 


998  SPECIAL  OR  REGIONAL  SURGERY 

tortion,  as  might  make  the  introduction  of  the  instrument  difficult,  while  by  further 
manipulation,  its  beak  beino;  gently  revolved,  he  learns  whether  behind  the  jjrostate 
there  is  a  pocket  in  which  residual  urine  may  be  retained.  The  question  of  calculus 
beinf  settled  the  patient  should  now  empty  the  bladder  naturally  and  as  usual,  after 
which  a  catheter  should  be  introduced,  in  order  to  withdraw  such  residual  urine  as  may 
be  retained,  whose  amount  should  then  be  noted.  This  is  a  measure  of  the  size  of  the 
postprostatic  pocket  which  the  patient  fails  to  empty,  and  in  which  decomposition  and 
pathological  changes  are  es[)ecially  likely  to  occur.  Should  such  a  pocket  be  found  in 
a  case  w^ithout  noticeable  other  enlargement  (as  detected  through  the  rectum)  it  will 
indicate  intravesical  growth  and  the  formation  of  the  so-called  "third  lobe"  or  "median 
bar  "  as  it  was  formerly  called  (i.  e.,  an  outgrowth  at  the  posterior  end  of  the  prostatic 
urethra,  projecting  upward  into  the  bladder,  impeding  alike  the  exit  of  urine  and  the 
introduction  of  an  ordinary  instrument).  Those  expert  with  its  use  may  gain  still 
further  information  of  value  by  use  of  the  cystoscope. 

Treatment. — The  diagnosis  thus  established,  the  question  of  treatment  is  raised. 
Views  concerning  what  is  best  have  been  largely  modified  by  the  operative  methods 
recently  introduced,  and  the  advice  given  a  few  years  ago  is  now  frequently  modified. 
So  lono-  as  surgical  treatment  was  unsatisfactory  and  incomplete  it  was  to  be  postponed  as 
lone  as  possible.  Under  those  circumstances  patients  were  taught  to  use  the  catheter 
ancT established  the  "catheter  habit."  Almost  invariably  they  became  careless,  and  the 
catheter  habit  led  invariably  to  cystitis.  Nevertheless  circumstances  may  arise  which 
make  this  good  advice  even  today,  as  in  the  presence  of  other  and  serious  disease,  or  of 
anything  which  makes  radical  operation  inexpedient.  Under  such  circumstances  the 
patient  must  be  impressed  as  profoundly  as  possible  with  the  necessity  for  care  and 
caution.  If  such  a  case  has  progressed  to  the  stage  of  almost  complete  retention  then 
the  catheter  should  be  used  at  regular  intervals.  If  it  be  simply  necessary  to  draw  off 
residual  urine  once  a  day,  then  it  may  be  used  at  night,  at  which  time  it  would  be  well  also 
to  o-ently  and  carefully  wash  the  bladder.  It  is  possible  in  this  way  to  temporize  for  a 
variable  length  of  time,  and  until  more  serious  conditions  supervene. 

When  however,  the  prostate  has  enlarged  so  conspicuously  as  to  be  not  only  a  constant 
impediment  but  a  constant  menace  to  the  comfort  and  even  life  of  the  patient,  one  is 
brouo-ht  to  seriously  consider  which  of  the  various  mechanical  methods  for  relief  should 
be  instituted.  The  choice  must  now  be  governed  by  the  physical  condition  and  the 
surroundings  of  the  patient,  as  age,  degree  and  character  of  the  obstruction,  and  the 
extent  of  septic  infection.  One  has  again  to  choose  between  the  most  radical  and 
usually  the  most  satisfactory  method  of  extirpation  (prostatectomi/) ,  or  one  of  the  less 
radical  and  palliative  operations,  such  as  the  Bottini  operation  with  the  galvanocautery. 

A  few  years  ago  White  and  others  laid  great  stress  on  the  fact  that  after  removal  of 
the  testicles  there  was  notable  atrophy  of  the  prostate,  and  suggested  the  expedient  of 
double  castration  or  orchidectomy  for  this  purpose.  The  method  proved  disappointing, 
although  doubtless  more  or  less  effective  in  some  cases,  and  so  objectionable  to  many 
patients,  for  obvious  reasons,  that  it  has  been  practically  abandoned.  The  less  mutilat- 
ing substitute  of  division  and  exsection  of  a  portion  of  each  vas  deferens  {vasectomy) 
has  for  the  same  reason  been  discarded. 

When  radical  measures  become  necessary  the  choice  should  be  made  between  the 
galvanocautery  {i.  e.,  canalization  of  the  base  of  the  prostate  and  its  median  bar  by  means 
of  the  Instrument  devised  by  Bottini)  and  the  bolder  and  more  radical  method  of  extirpa- 
tion (prostatectomy).  This  prostatectomy  is  done  by  either  the  suprapiddc  or  the  perineal 
route.  As  between  them  there  is  often  room  for  choice,  for  reasons  mentioned  below. 
Each  method  has  its  advocates  and  its  opponents.^ 

Suprapubic  Prostatectomy. — It  is  of  assistance  in  this  method  to  have  the  empty 
rectum  somewhat  distended,  and  held  up  by  the  introduction  of  a  rubber  bag,  which 
may  be  later  distended  with  water  or  with  air.  By  this  means  the  prostate  and  floor  of  the 
bladder  are  pushed  upward  toward  the  operator's  finger.  This  is,  however,  by  no  means 
necessary,  but  simply  advantageous.     The  first  part  of  the  operation  is  essentially  that 

•  The  question  of  credit  and  priority  for  these  operations  has  been  of  late  much  discussed.  To  McGiil,  of  Leeds, 
and  Goodfellow,  of  San  Francisco,  should  be  given  most  of  the  credit  for  the  earliest  perineal  operations,  while 
Fuller,  of  New  York,  who  first  performed  the  suprapubic  operation  in  1894,  should  probably  be  given  credit  for 
the  latter,  although  it  has  been  evidently  unjustly  claimed  for  Freyer,  of  London.  Belfield,  of  Chicago,  was  also 
one  of  the  earliest  advocates  of  extirpation  of  the  enlarged  prostate. 


PROST. \TI('  II y PERTROPHY 


999 


Fig.  661 


(loscrihcd  as  suprapuhic  cystotomy.  'I'lic  l)la(l(l('i'  l)ciii<f  thus  oiuMU'd  and  the  |)rostate 
carried  upward  by  a  sound,  which  should  have  hci-n  inserted  in  the  urethra,  tlie  finger 
first  accurately  notes  its  dimensions  and  the  direction  of  its  enhir<^ement.  Blunt  scissors 
are  now  used,  or  the  sharp  finijer-nail,  for  makin<r  an  openino;  throufjh  the  mucosa  and 
prostatic  coverinij,  throii</h  flic  (■(ip.siilc  of  the  latter,  down  upon  that  body.  This  oj)ening 
is  preferably  made  near  the  urethral  entrance.  The  balance  of  the  operation  consists 
in  blunt  dissection  by  the  end  of  the  finger,  /.  c,  enucleation  of  the  prostate  from  within  its 
enclosing  capsule  and  surrounding  tissues  (Fig.  (Hil).  ^b)re  or  k'ss  disturbance  of  the 
basal  structuri's  is  necessitated,  but  as  the  surgeon  becomes  expert  the  amount  of  thisdis- 
turbance  becomes  relatively  surprisingly  small.  In  most  instances  it  is  possible  also  to 
practically  strip  off  the  prostatic  tissue  from  the  urethra,  so  that  it  is  rarely  necessary  to 
tear  or  to  cut  across  it  in  order  to  lift  the  prostate  out  of  its  bed.  In  the  average  case  it  is 
possible  in  this  way  to  enucleate  the  prostate  in  a  single  piece,  and  to  remove  it  as  an 
entire  onjan.  If,  however,  it  should  ])rove  too  large  for  the  bladder  o))ening  which  has 
})crmitted  the  jirocedure  it  would  be  better  to  morcellate  it,  or  so  far  divide  it  with  scis.sors 
as  to  permit  its  extraction  j)iecenieal.  Its  removal  leaves  a  bleeding  cavity  at  the  base 
of  the  bladder,  with  torn  and  sep- 
arated tissues,  and  a  pocket  where 
the  prostate  used  to  lie,  into  which 
urine  w'ill  be  poured  from  above, 
while  it  cannot  ordinarily  be  at 
first  easily  cmjiticd  from  the  more 
or  less  injured  urethra  connected 
with  it.  From  this  siu'face  there 
w'ill  be  at  first  considerable  oozing, 
mostly  venous.  Should  this  be 
serious  and  prolonged  a  quantity 
of  gauze  may  be  packed  into  it 
through  the  opening,  and  pressure 
thus  made.  Such  packing  should 
only  be  retained  for  a  few  hours. 
Ordinarily  it  is  sufficient  to  pro- 
vide at  once  for  drainage.  My 
own  preference  is  to  make  double 
provision  for  this  by  the  passage  of 
a  catheter  through  the  urethra, 
and  by  the  insertion  of  a  drainage 
tube  from  above,  whose  lower  end  rests  within  the  pocket.  It  is  a  great  desideratum 
to  drain  the  urine  as  fast  as  it  accumulates,  and,  at  the  same  time,  to  keep  the  patient 
dry.  This  is  best  effected  by  a  method  described  later,  of  complete  bladder  siphonage, 
which  can  be  resorted  to  in  either  form  of  operation.  It  is  again  advisable  to  get  the 
patient  into  the  sitting  posture,  which  should  be  done  within  a  day  or  two,  or  as  soon 
as  his  strength  will  permit,  in  order  that  gravity  may  assist  in  drainage.    (Seep.  1003.) 

When  difficulty  is  met  in  enucleation  assistance  is  derived  by  the  introduction  of  one 
or  tw^o  fingers  of  the  disengaged  hand  into  the  rectum,  by  which  certain  manipulation 
can  be  effected  from  below  that  will  be  of  material  help.  Pressure  in  the  perineum  or 
manipulation  of  a  sound  may  also  be  of  assistance. 

So  soon  as  satisfactory  drainage  through  the  urethra  can  be  effected  the  suprapubic 
tube  should  be  removed,  and  the  wound  thus  encouraged  to  close. 

Perineal  Prostatectomy.— Perineal  prostatectomy  constitutes  a  similar  attempt  at  enu- 
cleation, ett'ected  from  a  different  direction.  The  patient  now  being  in  the  lithotomy 
position,  with  the  rectum  not  only  emptied  but  sterilized,  the  perineum  is  widely  opened. 
While  the  removal  may  be  accomplished  through  a  median  incision  it  is  better  to  have 
ample  room,  therefore  by  a  semilunar  flap  a  sort  of  trap-door  should  be  raised,  its  apex 
downward,  through  which  easy  access  to  the  deep  perineum  is  afforded.  It  Is  only 
necessary  to  divide  the  central  tendon  of  the  recto-urethral  muscles  before  the  operator 
arrives  at  the  apex  of  the  prostate  and  the  membranous  urethra.  The  latter,  being 
exposed  at  this  point,  is  usually  divided  upon  a  grooved  staff.  Here,  at  its  junction,  the 
capsule  Is  usually  divided  by  a  free  opening,  through  which  the  finger-tip  is  Insinuated 
and  made  to  strip  the  capsule  from  the  prostate  itself.     By  different  operators  instruments 


Suprapubic  prostatectomy.  Process  of  enucleation  by  finger- 
tip of  one  liand  in  the  bladder,  the  other  hand  making  pressure 
in  the  perineum.      (Hartmann.) 


1000 


SPECIAL  OR  REGinXAL  SURGERY 


have  been  devised  whicli  facilitate  much  of  the  subsequent  work.  Perhaps  the  best  of 
these  is  the  double-blade  retractor  of  Young,  which,  shaped  like  a  sound,  can  be  opened 
after  introduction,  and  made  to  serve  excellent  })urpose  by  traction  uy)on  its  handles. 
If,  now,  the  perineal  route  have  been  larwe  enougli,  and  retracted  sufficiently,  the  pros- 
tate can  be  so  pulled  down  into  the  wound  as  to  be  exposed  to  sight  as  well  iis  to  touch. 


Fig.  662 


First  exposure  of  prostate  after  introduction  of  sound  through  opening  just  in  front  of  it.      (Proust.) 

The  effort  is  sometimes  made  to  enucleate  the  prostate  entire  and  ^\  ithdraw  it  whole,  but 
usually  to  separate  each  lateral  mass  by  itself.  It  is  advisable  to  .seize  with  strong  tenac- 
ulum forceps  and  pull  down  the  loosened  portions  of  the  organ,  in  order  that  it  may  be 
more  easily  separated  at  its  upper  part;  but  it  has  now  been  found  unnecessary  to  either 


Fig.  663 


Fig.  664 


Enucleation  of  a  portion  or  all  of  the  prostate  by  use 
of  the  index  finger.     (Proust.) 


Hemisection  of  prostate,  each  half  being  secured  within 
the  bite  of  vulsellum  forceps.     (Proust.) 


open  the  bladder  above  the  pul^is,  or  even  to  expo.se  it  by  an  opening  through  the  skin 
so  that  it  may  be  pressed  down,  traction  from  below  taking  the  place  of  suprapubic  pres- 
sure, whatever  is  needed  in  the  latter  direction  being  effected  through  the  uninjured 
abdominal  wall  (Figs.  602,  663  and  664). 

The  balance  of  the  procedure  must  depend  on  the  size  and  character  of  the  growth. 


PROSTA TIC  ItVPERTRoril Y 


1001 


To  strip  ofl"  a  naturally  adiicrciit  cai)siilc  is  (initc  easy,  hut  to  dctacli  one  wjiicli  has  hccoinc 
Hrinly  adherent  tlirono;!)  old  iiifianiiiiatioii  oreaiieerons  iidiltratioii  is  sonietiiiies  extremely 
diflieiilt.  Thus  eiuieleatioii  may  sometimes  he  elleetcd  in  two  or  three  minutes.  The 
strippinjf  and  enucleatino;  j)roeess  should  be  earried  around  the  j)rostutic  enlargement 
ami  into  the  bladder,  and  tiie  effort  should  be  to  make  tlu^  smallest  possible  rent  in  the 
vesieal  mucosa,  as  well  as  to  sej)arate  ])rostatic  tissue  from  around  the  urethra  rather 
than  to  tear  or  mutilate  the  latter.  lOxperienee  and  patience  will  ])ermit  the  accomplish- 
ment of  this  to  a  surj)risini;  deo;ree.  Morcellalion  may  be  an  aid  in  removintf  lartre 
masses,  and  no  hesitation  should  be  felt  in  dividing  a  mass  of  tissue  which  does  not  come 
out  easily  through  the  wound  (Fig.  (iOr)). 

The  organ  once  enucleated,  there  results  a  bleeding  cavity,  at  the  base  of  the  bladder, 
which,  however,  is  now  oj)ened  below  and  should  drain  itself  easily.     If  the  surgeon's 

Fig.  065 


Prostate  removed  by  the  perineal  route:   A,  lateral  lobes;  B,  intravesical  growth  particularly  obstructing 

urethral  entrance.     (Proust.) 

finger  and  his  instruments  have  been  kept,  as  they  should  have  been  constantly,  within 
the  prostatic  capsule  there  is  no  possibility  of  harm  to  the  rectum,  which,  however, 
may  be  utilized  for  assistance  in  the  manipulation  should  it  be  required.  There  remain, 
therefore,  after  enucleation  the  checking  of  hemorrhage,  provision  for  drainage,  and 
suitable  narrowing  of  the  w^ound.  The  first  and  second  of  these  are  usually  combined 
by  the  insertion  of  a  tube,  of  sufficient  rigidity  to  permit  a  gauze  packing  to  be  placed 
around  it.  This  should  be  connected  exteriorly  with  a  suitable  drainage  tube,  and 
bladder  siphonage  be  provided.  The  wound  around  the  tube  is  closed  by  two  or  three 
deep  sutures,  usually  of  silkworm-gut,  since  it  tends  naturally  to  close  by  pressure  and 
requires  but  little  further  attention. 

The  greatest  harm  likely  to  be  done  in  this  operation  is  injury  to  the  seminal  vesicles, 
above  the  prostate,  between  which  and  the  prostate  itself  the  surgeon  may  not  distinguish, 
with  unnecessary  mutilation  of  the  posterior  urethra.     Occasionally,  in  spite  of  great  care. 


1002  SPECIAL  OR  REGIONAL  SURGERY 

the  rectum  will  be  .slightly  lacerated.  Injury  or  destruction  of  the  vesicles  might  lead 
to  impotence,  while  mutilation  of  the  urethra  would  l)e  followed  hy  delay  in  repair, 
with  uncertainty  of  subsequent  bladder  action  and  control. 

Subsequent  treatment  consists  in  removing  both  gauze  and  tube  at  the  earliest  possible 
date,  w'hich  should  not  be  later  than  the  fourth  day;  after  this  irrigation  may  be  given 
once  or  twice  a  day,  with  the  least  possible  use  of  instruments. 

In  either  of  these  methods  of  prostatectomy  the  greatest  reliance  is  to  be  placed  upon 
natural  processes  of  repair.  In  some  way,  which  seems  almost  inscrutable,  torn  bladder 
and  more  or  less  mutilated  urethra  come  naturally  together  antl  connection  is  reestab- 
lished. 

After  this  brief  description  of  operative  methods  there  remains  only  to  contrast  them. 
The  especial  advantages  of  the  suprapubic  method  are  the  total  avoidance  of  perineal 
fistula,  of  disturbance  of  the  deep  urethra,  of  the  perineal  structures,  of  the  seminal 
vesicles,  and  a  minimum  of  disturbance  of  the  entire  basal  portion  of  the  bladder,  with 
a  greater  theoretical  possibility  of  speedy  restoration  of  its  function.  It  is  the  method  of 
choice  with  certain  operators  of  large  experience.  It  seems  especially  indicated  in  cases 
of  pronounced  intravesical  enlargement,  but  may  be  made  difficult  in  obese  individuals. 

In  behalf  of  the  perineal  route  must  be  alleged  the  advantage  of  seeing  much  of  what 
one  is  doing,  of  being  really  nearer  to  the  field  of  activity,  and  of  more  perfect  control  of 
the  mass  which  is  to  be  removed,  as  well  as  the  fact  that  the  prostate  is  not  an  intra- 
vesical organ. 

Whichever  method  be  adopted  the  patient  should  be  encouraged  to  be  up  and  about 
as  soon  as  possible.  Subsequent  bladder  control  comes  with  varying  rapidity  to  different 
patients.  Urinary  fistulas  are  not  likely  to  persist  in  patients  who  have  not  worn 
drainage  tubes  too  long.  After  two  or  three  wrecks  it  is  advisable  to  pass  a  sound  occa- 
sionally, in  order  to  maintain  proper  direction  of  the  urethral  canal  and  prevent  formation 
of  stricture.  Bladders  in  which  there  has  been  a  serious  complication  of  cystitis  should 
be  irrigated  through  the  openings  so  long  as  they  are  maintained. 

The  operation  of  itself  is  not  a  very  serious  nor  difficult  measure.  It  is  too  often 
performed  on  feeble  or  septic  patients,  as  a  last  resort,  when  it  is  too  late. 

The  galvanocausfic  operation  is  done  with  an  instrument  devised  by  Bottini,  shaped 
like  a  lithotrite,  with  a  movable  platinum  blade,  which  can  be  heated  to  the  desired 
degree  by  the  electric  current.  This  instrument  is  introduced  into  the  deep  urethra 
until  its  beak  enters  the  bladder,  after  which  the  latter  is  turned  half  around;  then  the 
electric  current  is  turned  on,  the  movable  caustic  blade  gradually  withdrawn  by  a  screw 
mechanism  in  the  handle,  and  made  to  traverse  a  distance  of  one  inch  to  one  inch  and  a  half, 
previously  measured,  and  in  such  a  way  as  to  burn  a  channel  through  the  floor  of  the 
prostatic  urethra,  and  through  any  median  bar  or  obstruction  which  may  exist.  This 
is  the  principle  of  its  use.  At  one  time  it  was  popular,  although  of  late  prostatectomy 
seems  to  have  supplanted  nearly  every  other  method.  Nevertheless  in  certain  cases  it 
will  be  found  of  advantage.  I  have  preferred  to  combine  it,  in  most  cases,  with  a  small 
perineal  opening,  introducing  the  instrument  after  opening  the  membranous  urethra, 
and  having  it  in  this  way  much  more  completely  under  control.  Through  the  opening 
thus  made  subsequent  bladder  drainage  can  be  effected  if  desired.  It  permits  also 
of  more  perfect  exploration  of  the  bladder  with  the  finger. 

CANCER   OF   THE   PROSTATE. 

Extensive  cancerous  invoh-emeni  of  the  prostate  puts  a  case  beyond  the  pale  of  operative 
surgery,  except  for  palliative  purposes,  though  either  perineal  or  suprapubic  drainage 
may  be  made  for  final  and  temporary  relief,  the  case  admitting  of  nothing  else.  As 
mentioned  above  many  apparently  ordinarily  enlarged  prostates  prove  to  contain  can- 
cerous elements.  It  has  been  found  that,  when  not  too  extensively  involved,  prostatec- 
tomv  in  these  cases  orives  as  good  results  as  in  the  absolutely  non-malignant. 


BLA  UDEli  SI  ri  ION  AGE 


1003 


BLADDER  SIPHONAGE. 

A  in:it((>r  of  <xvvAi  liii|)t)rt;inc('  and  conifort  lor  the  ])ati('iit  is  an  ciVcctivc  .slplionage 
of  the  Itladdrr  after  it  has  been  ojx'ncd.  This  has  nsually  In-cn  accomplished  by  the  use 
of  u  Y-shaped  tube,  one  of  thi'  branches  coiuiecting  with  a  suitable  reservoir  for  water, 

Fig. 606 


Siphon  drainage  of  bladder,  with  Qathcart's  S-tube  (its  essential  feature).      May  be  applied  equally  well  to 
perineal  or  urethral  tubes,  or  to  drainage  of  other  cavities. 

hung  above  the  level  of  the  body,  the  other  with  a  tube  connecting  with  the  bladder, 
while  from  the  lower  end  another  tube  connects  with  a  suitable  reservoir  on  the  floor. 
This  is  rarely  effective,  and  can  only  be  made  so  by  inserting  the  S-shaped  tube  devised 
by  Cathcart  in  the  lower  drainage  tube.  With  this,  and  a  suitable  regulation  of  the  flow, 
the  water  can  be  made  to  escape,  drop  by  drop,  and  make  an  effective  suction  that  com- 
pletely fails  without  the  use  of  Cathcart's  tube.     The  device  is  illustrated  in  Fig.  666. 


CHAPTER    LVL 

THE  MALE  GENITAL  ORGANS. 

THE  PENIS  AND  URETHRA. 

The  most  common  congenital  defects  of  the  penis  are  connected  with  elongation  of 
the  prepuce  or  with  abnormahty  in  the  construction  of  the  urethra.  Aside  from  these, 
however,  rare  congenital  abnormalities  have  been  met  with,  as,  for  instance,  a  double 
or  bifid  penis,  or  its  almost  cf)mplete  absence.  The  former  is  perhaps  to  be  regarded  as 
an  atavistic  condition,  having  its  prototype  in  the  kangaroo.  Misplacement  of  the 
organ  is  usually  apparent  rather  than  real. 

PHIMOSIS. 

Except  as  produced  in  consequence  of  disease,  i.  e.,  by  edema  or  inflammation  with 
swelling,  phimosis  indicates  a  congenital  condition,  either  of  elongation  or  constriction 
of  the  jirepuce,  usually  with  adhesions  to  the  glans.  A  considerable  projiortion  of  male 
children  are  born  with  more  or  less  complete  conditions  of  tiiis  kind.  These  are  not 
so  abnormal  anatomically,  but  they  lead  to  serious  complications  later  in  life.  An 
extremely  tight  prepuce  is  often  complicated  with  stenosis  of  the  meatus,  the  combined 
result  being  a  practical  stricture  at  the  end  of  the  urethra,  through  which  the  infant  has 
to  strain  with  each  act  of  urination.  This  is  a  common  predisjiosing  cause  of  hernia. 
Whether  the  prepuce  be  adherent,  or  so  constricted  as  to  make  it  a  retentive  sac,  there 
will  accumulate  between  it  and  the  sensitive  mucous  surface  of  the  glans  more  or  less 
smegma  which,  as  it  decomposes  in  the  course  of  time,  becomes  excessively  irritating, 
and  a  fertile  source  of  reflex  disorders,  involving  even  distant  parts  of  the  body.  Thus 
in  young  boys  especially,  convulsions,  chorea,  epilepsy,  and  various  other  neiu-oses  are 
produced,  while,  in  addition,  its  perpetuation  produces  a  condition  of  unnatural  excit- 
ability which  leads  again  to  habits  of  masturbation  or  to  sexual  irritability  and  unnatural 
excitability. 

Every  newborn  male  infant  should  be  carefully  examined  in  order  that  the  above 
condition,  if  present,  may  be  remedied.  This  remedy  will  consist,  in  mild  cases,  of 
forcible  retraction  of  the  elongated  prepuce,  with  separation  of  any  adhesions  uniting 
it  to  the  glans.  Preputial  stenosis  may  be  overcome  in  some  cases  by  simply  slitting 
up  the  dorsum,  which,  if  not  too  long,  may  be  thus  releaseil  and  not  require  circumcision. 
On  the  other  hand  a  much  elongated  and  contracted  prepuce  should  be  sufficient  justi- 
fication for  prompt  circumcision.  At  the  same  time  any  unnatural  contraction  of  the 
meatus  may  be  overcome  by  trifling  incision.  If  every  boy  baby  were  thus  carefully 
inspected  and  relieved,  if  necessary,  there  would  be  fewer  reflex  disorders  in  young 
children. 

Incidentally  it  may  be  said  that,  in  lesser  degree,  the  same  thing  may  apply  to  girl 
infants,  in  whom  the  clitoris,  although  small,  should  nevertheless  be  freely  uncovered 
by  retraction  of  its  miniature  hood  or  prepuce.  When  this  is  not  easily  possible  it  should 
be  made  so.  Disorders  of  the  same  general  character  as  easily  arise  in  girls,  from  this 
same  general  cause,  as  in  boys,  noctin-nal  incontinence  being  a  frequent  expression 
thereof.  In  my  opinion  the  teaching  of  obstetrics  should  not  be  considered  complete 
without  unmistakable  reference  to  these  matters. 

Phimosis  in  the  adult  may  be  brought  about  by  disease,  especially  in  connection  with 
a  prepuce  already  retentive,  or  elongated  and  difficult  of  retraction.  Retained  secretion 
beneath  such  a  prepuce  is  a  fertile  source  of  danger  of  all  kinds,  as  well  of  venereal  infection 
as  of  cancerous  growth.  Surgeons  in  the  Orient  have  described  calculi,  even  of 
considerable  size,  found  in  this  location  as  the  result  of  retention  of  matter  which  should 
not  have  been  at  all  retained,  this  condition  being  noted  most  often  among  the  Chinese. 
(  1004 ) 


i:i'ISI\\l>l.\S   AM)   IIYI'OSI'ADIAH  1005 

Ini'cclioii,  usiijilly  <!;()n()rrlH"al,  ot"  the  coiuvalcd  sui-racc  of  the  propuco,  wliifli  has  a 
(listinclly  iiiucous  character,  is  known  as  potiiliilis;  that  ot"  the  coveriiitr  ot"  the  jfhins  as 
balanitis;  whili',  in  etl"o(t,  whatever  ajjpears  in  this  location  will  essentially  be  a  halano- 
po.s-lliili.s-.  If  such  11  condition  do  not  easily  subside  by  irrijfation,  with  a  small  nozzle 
introduced  beneath  the  niar<;in  of  the  prepuce,  it  will  then  be  necessary  to  slit  up  the 
dorsum,  or  make  a  complete  circumcision,  in  order  that  the  affected  surfaces  may  be 
made  accessible.  The  same  is  true  in  cases  of  chancroid  and  even  in  cases  of  chancre; 
incision  or  circumcision  being  justifiable  whenever  indicated. 


PARAPHIMOSIS. 

Paraphimosis  imj)lies  an  o])p()site  condition,  where  the  |)repuce,  having;  been  retracted, 
is  cau^i'ht  behind  the  maroin  of  the  i);lans  and  cannot  be  released  nor  brou<rht  forward. 
This  may  be  the  result  of  unilue  effort  to  retract  a  very  tight  but  otherwise  normal  pre- 
puce, or  is  frequently  the  result  of  an  acute  inflammation,  where  edema  and  solid  exudate 
so  solidify  the  tissues  as  to  make  them  inflexible  and  almost  immovable.  In  mild  cases 
of  parai)himosis  cold  applications,  or  pressure  with  patient  manipulation,  may  be 
sufficient  to  restore  the  pr()j)er  condition.  An  extreme  degree  of  such  constriction  would 
threaten  the  nutrition  of  the  glans,  to  the  extent  even  of  possible  gangrene,  and  sloughing 
of  some  portion  of  the  end  of  the  penis  is  not  an  infrecpient  result  of  a  neglected  condition 
of  this  kind.  Under  these  circumstances  constriction  must  be  released,  it  being  usually 
sufficient  to  apjily  or  inject  cocaine,  and  then  with  scissors  or  blunt  bistoury  nick  or 
incise  the  constricting  ring,  to  a  degree  sufficient  to  release  it  and  permit  the  desired 
result;  in  one  way  or  another  this  must  be  attained,  else  more  or  less  sloughing  is  sure  to 
follow. 

Other  rare  malformations  of  the  urethra  include  its  more  or  less  complete  obliteration, 
in  some  portion  at  least,  or,  more  often,  its  sacculation  or  dilatation  in  certain  areas, 
the  residt  being  the  formation  of  pockets  or  pouches.  Such  abnormality  may  persist 
to  adult  life,  and  finally  contain  a  considerable  amount  of  retained  urine. 


EPISPADIAS  AND  HYPOSPADIAS. 

Epispadias  and  hypospadias  constitute  defects  in  the  urethral  construction,  so  that 
urine  escapes  at  some  point  much  nearer  the  body  than  normally  intended.  A  complete 
degree  of  epispadias  nearly  always  accompanies  extroversion  of  the  bladder,  already 
described.  Milder  conditions  may  be  met  in  any  degree.  In  these  cases  the  urethra 
becomes  a  canal  open  above,  and  the  glans  is  more  or  less  defective.  Cases  of  epis- 
padias may  be  divided  into  the  balanic,  where  the  urethra  terminates  on  the  upper 
portion  of  the  glans,  and  the  penile,  where  it  terminates  between  the  glans  and  the 
pubis;  while  cases  of  hypospadias  may  be  divided  into  balanic  and  penile,  similar  to  the 
above,  the  penoscrotal,  where  the  urethra  opens  at  the  junction,  and  the  perineoscrotal, 
where  both  the  perineum  and  scrotum  are  involved.  While  all  of  these  defects  are  more 
or  less  mutilating  and  unphysiological,  none  of  them  menace  life.  The  physiological 
requirements  of  either  case  demand  conditions  permitting  normal  urination,  and  coitus 
to  a  degree  permitting  fecundation.     (See  Fig.  667.) 

jNIost  cases  of  hypospadias  are  accompanied  by  other  defects  on  the  inferior  surface  of 
the  penis  and  the  scrotum,  which,  more  or  less,  bind  them  down  and  interfere  with  the 
normal  method  of  urination  as  well  as  of  insemination.  The  indications,  then,  in  such 
cases  are  to  straighten  the  penis  and  to  restore  the  continuity  of  the  urethra.  The  former 
may  be  accomplished  by  transverse  incisions  through  the  bands  which  cause  the  curvature, 
or,  if  necessary,  tlivision  of  the  intracavernous  septum,  or  even  of  the  sheaths  of  or  the 
cavernous  bodies  themselves.  Wedge-shaped  pieces  of  cavernosa  have  often  been 
successfully  excised.  The  restoration  of  the  urethra  is  a  much  more  difficult  matter, 
especially  in  an  extensive  case,  to  make  it  sufficient  for  insemination.  The  methods 
may  be  grouped  under  simple  canalimtion  or  approximation  and  the  constriiction  of 
"flaps.  Nearly  all  of  these  methods  are  more  or  less  simple  in  theory  but  difficult  in 
practice,  and  frequently  unpromising  because  of  the  difficulties  in  securing  final  union 
of  tissues,  no  matter  how  neatly  united,  where  the  same  may  be  interfered  with  by  the 


1006 


SPECIAL  OR  REGIOSAL  SURGERY 


presence  of  urine  or  the  occurrence  oi  erections.     The  former  may  be  prevented  by  a 
perineal  section,  with  drainage  of  the  bladder,  and  this  is  probably  the  l)est  method  to 


Fig.  667 


Diagrammatic  sections  showing  different  varieties  of  hypospadias:  1.  hypospadias  with  imperforate  glans; 
2,  hypospadias  with  blind  canal  in  glans;  3,  with  barrier  placed  between  penile  iirethra  and  balanitic  groove; 
4,  typical  case  of  hypospadias;  5.  hypospadias  with  normal  meatus:  6.  i>enile  urethra  opening  below  glans;  7. 
absence  of  the  whole  inferior  part  of  the  penile  urethra;  8.  hj-pospadias  with  absence  of  urethra  through  glans; 
9,  case  of  d'Amaud;  10,  case  of  Lacroix;  11,  case  of  Lippert  with  normal  meatus.     (Kauffmann.) 


Fig,  668 


Fig.  669 


Hyposp>adias.      Liberation   of    anterior  urethra    and 
tunnelling  the  glans.     (Hartmann.) 


Hypospadias..    Drawing  the  liberated  urethra  through 
the  tunnel  in  the  glans.      (Hartmann.; 


IIERM.  1  rilRODlSM  ]007 

adopt  in  nearly  all  of  these  eases.  The  latter  is  to  some  extent  overeome  by  drugs, 
but  is  sometimes  produeed  by  the  loeal  irritation  of  the  operation  and  the  dressings. 
To  describe  all  these  methods  would  retpiire  a  long  chapter.  'I'hey  have  included 
efforts  at  fiiniic/liiu/  ihc  (jlaii.s,  by  the  passage  of  a  trocar,  maintaining  the  channel  by 
keeping  within  it  some  bougie  or  foHMgn  body  until  its  interior  has  liealed,  then  con- 
necting this  u})  with  the  balance  of  the  urethra  (Figs.  GGS  and  GG9).  The  urethral 
passage-way  is  rarely  sufficiently  wide  to  permit  of  apj)roximation  of  freshened  edges  by 
stitches,  and  these  will  almost  surely  pull  out.  l^herefore  some  more  plastic  method  of 
formation  of  flaps  must  be  devised.  Many  ingenious  expedients  have  been  suggested, 
among  them  the  utilization  of  a  stri])  of  skin,  dissected  up  on  one  side,  whose  external 
surface  is  turnetl  in  and  made  to  vicariate  as  mucous  membrane,  while  its  raw  surface, 
now  faced  outward,  is  covered  with  another  flap,  raised  either  from  the  penis  itself  or 
from  the  scrotum.  It  is  the  operations  based  on  this  general  jjlan  which  have  given  the 
best  results  in  well-marked  cases,  and  yet  they  have  to  be  conducted  with  great  care. 
American  surgeons,  among  them  particularly  Beck,  of  New  York,  have  done  a  great 
deal  to  advance  tiie  plastic  surgery  of  these  parts  and  for  these  purposes.  He,  for 
instance,  has  especially  exj^loited  the  movability  of  the  urethra,  and  shown  how  by 
dissecting  it  out  it  may  be  drawn  forward  and  made  nuich  more  available.  Beck  has 
suggested  a  similar  method  of  displacement  and  reemployment  of  the  urethra  for 
epispadias. 

Epispadias'  is  far  more  uncommon  than  hy]iospadias,  occurring  in  proportion  of  1 
to  150  cases  of  the  latter,  and  is  rarely  seen  except  in  connection  with  vesical  extroversion, 
except  in  minor  degree,  in  which  the  defect  is  simply  a  little  grooving  of  the  upper  surface 
of  the  glans.  The  best  method  of  dealing  with  the  urethra,  in  epispadias,  is  to  displace 
it,  as  suggested  by  Beck,  separating  the  cavernous  bodies  and  dropping  it  down  to  its 
normal  situation  beneath  them,  and  uniting  with  this  procedure  more  or  less  of  the 
transplantation  suggested  by  him.  It  is  surprising  h(nv  much  can  be  accomplished 
by  this  method,  even  in  extreme  cases.  The  glans,  if  necessary,  may  be  tunnelled,  and 
the  anterior  end  of  the  urethra  may  even  be  given  a  hypospadiac  termination. 


HERMAPHRODISM. 

Hermaphrodism,  spurious  and  actual,  implies  the  existence  of  sexual  organs  of  both 
sexes  in  the  same  individual.  It  is  a  condition  actually  existent  in  many  of  the  low^er 
forms  of  life,  but  its  occurrence  in  the  human  being  is  a  matter  of  extreme  rarity.  There 
are  numerous  malformations  which,  by  the  laity,  are  often  mistaken  for  indications  of 
this  condition,  but  the  actual  co-existence  of  both  testicle  and  ovary — e.  g.,  which  may 
perhaps  be  assumed  as  the  true  test — is  one  of  the  rarest  of  all  phenomena  in  human 
anatomy.  External  malformations  which  more  or  less  simulate  the  appearance  of  the 
organs  of  one  sex  in  those  of  the  other  include  such  conditions  in  the  male,  for  instance, 
as  atrophy  of  the  penis,  hypospadias,  a  more  or  less  complete  division  of  the  scrotum 
into  halves,  retained  testicles  with  atrophy  of  the  external  organs,  and  similar  conditions 
by  which  the  external  genitalia  are  made  to  appear  tlivided  or  relatively  too  small.  In 
the  female,  on  the  contrary,  may  be  seen  occasionally  an  hypertrophj  of  the  clitoris,  which 
causes  it  to  assume  almost  the  proportions  and  even  the  erectibility  of  the  male  organ, 
while  other  deformities  of  the  vulva  simulate  more  or  less  the  scrotum.  Again  in  the 
female  one  meets  occasional  congenital  absence  of  the  uterus  or  of  the  ovaries,  or  con- 
genital atresia,  or  almost  complete  absence  of  the  vagina,  or  vulvas  which  are  almost 
impassable  by  virtue  of  exceedingly  dense  hymens,  w^here  the  natural  appearances  are 
so  perverted  as  to  mislead  the  ignorant.  These  are,  ho'wever,  cases  of  pseudohermaph- 
rodism,  although  in  many  of  them  there  are  certain  general  changes  in  appearance, 
as  of  the  breast,  the  figure,  speech,  and  even  in  manner,  which  are  regarded  as  evidences 
of  eflfeminacy  in  a  male  individual,  or  of  masculinity  in  a  female. 

Strange  mistakes  and  errors  have  thus  arisen,  and  children  about  w^hose  sex  ignorant 
parents  have  been  in  doubt  have  been  mistakenly  brought  up,  even  to  a  point  in  life 
when  it  was  sociologically  almost  too  late  to  remedy  the  error.  Such  cases  require 
careful  study  for  the  actual  determination  of  sex,  especially  in  young  infants. 

True  hermaphrodism  is  not  to  he  denied,  as  certain  historical  cases  have  proved,  and 
as  has  been  demonstrated  in  certain  individuals  who  travel  from  city  to  city,  exposing 


1008 


SPECIAL  OR  REGIONAL  SURGE RY 


thenisc^Ivcs  for  a  consideration  for  scientific  examination.  In  general  it  is  sufficient  to 
say  here  that  true  Iierraaphrodisni  is  a  rare  possibility,  while  spurious  or  pseudo- 
hermaphrodisni  is  a  condition  not  uncommonly  met. 


Fig.  670 


rNJURIES  TO  PENIS  AND  URETHRA. 

The  great  vascularity  of  the  penis  makes  it  peculiarly  liable  to  obstinate  hemorrhage 
in  cases  of  incision  or  laceration.  For  the  same  reason  when  strangulated,  as  may 
occur  in  some  drunken  orgy  or  otherwise,  it  may  swell  enormously  and  cjuickly  become 
gangrenous.  An  actual /rac^ure  of  the  cavernosa  has  occurred,  through  violence  in  the 
erected  condition.  Subcutaneous  lacerations  or  contusions  may  lead  to  extensive  hemor- 
rhao-es,  possibly  with  gangrene  as  the  result.  Any  injury  by  which  the  urethra  is  lacer- 
ated, especially  torn  across,  will  be  followed  by  much  hemorrhage,  probably  with  urinary 
extravasation,  and  perhaps  great  difficulty  in  establishing  the  continuity  of  the  channel. 
Under  any  circumstances  urinary  infiltration  of  any  part,  deep>  or  superficial,  is  likely  to 
be  followed  by  abscess  and  sloughing.  An  absolute  dislocation  oi  the  penis  is  not  un- 
known, it  having  been  displaced  beneath  the  integument  of  the  perineum,  abdomen, 
or  thigh,  especially  in  extremely  obese  individuals. 

Urethral  injuries  are  not  all  accidental.  Some  of  them  are  the  result  of  design,  or  of 
the  introduction  of  foreign  bodies  which  cannot  be  removed  by  the  patient  himself. 
Such  articles  may  also  be  introduced,  during  a  drunken  orgy,  by  another  individual,  or 
under  conditions  of  sexual  perversion  by  the  man  himself;  and  such  bodies  as  pencils, 
slate-pencils,  twigs,  and  almost  every  imaginable  small  object  have  been  found  within 

the  urethra.  Again  it  has  been  seriously  injured  and 
even  punctured  by  the  careless  use  of  sounds,  or  by 
the  wire  stillette  of  the  old-fashioned  linen  catheter. 
Both  the  anterior  and  deep  urethra  may  be  seriously 
injured  by  such  accidents  as  falls  upon  the  external 
g(>nitals,  or  upon  the  perineum,  and  serious  deep 
lacerations,  with  complete  severance  of  the  mem- 
l)ranous  urethra,  and  the  infliction  of  even  greater 
tlamage,  are  by  no  means  unknown  in  such  cases. 

The  first  determination  should  be  as  to  the  pres- 
ence of  any  foreign  body.  This  being  eliminated  an 
effort  should  be  made  to  check  the  hemorrhage,  and 
to  make  sure  that  there  is  no  such  obstruction  of 
the  urethra  as  to  interfere  with  the  freedom  of  the 
urinary  stream.  The  constant  discharge  of  blood 
from  the  meatus,  or  the  admixture  of  blood  with 
the  urine,  is  always  suggestive  and  should  lead  to 
careful  Investigation.  This  should  include  not 
merely  the  gentle  passage  of  a  sound  or  catheter,  or 
at  least  attempt  thereat,  but  perhaps  an  inspection 
of  the  site  of  injury  through  the  endoscope.  When 
the  injury  is  compound,  in  the  sense  of  being  an  ex- 
ternal laceration,  the  deep  conditions  are  more  easily 
ascertained.  If  with  gentleness  and  yet  with  diffi- 
culty a  catheter  can  be  passed  through  the  injured 
portion  of  the  urethra  it  would  be  well  to  leave  it  in 
situ,  at  least  for  several  hours,  perhaps  for  three  or 
four  days.  In  order  that  It  may  act  as  a  splint  and 
the  parts  more  kindly  heal  around  It.  If  the  urethra  be  so  lacerated  as  to  not  permit 
the  passage  of  an  instrument,  the  safer  course  Is  an  external  perineal  section,  for  the 
purpose  of  temporary  bladder  drainage,  or  to  find  a  deep  tear,  while  a  retrograde 
catheterization  may  perhaps  be  practised,  and  an  instrument  introduced  and  carried 
through  in  the  reverse  of  the  ordinary  direction;  this  may  be  possible  even  when  or- 
dinary methods  fail.  Extravasation  of  blood  may  be  extensive  and  serious,  but  extrava- 
sation of  urine  is  always  followed  by  disastrous  consequences,  which  should  be 
prevented  by  external  urethrotomy  and  bladder  drainage. 


Perineal  section  for  deep  rupture  of 
urethra.  Posterior  opening  is  identified 
and  catheter,  which  has  been  introduced 
from  the  meatus,  is  guided  through  it 
into  the  bladder.     (Lejars.) 


I.\./l  lilKS   TO   Pi:.\JS  .\.\JJ   (  RKTJIRA  10(jy 

These  cases  may  not  l)e  seen  until  the  (huifjers  have  already  occurred.  If  it  should  so 
hajjpeii,  an  efiort  should  he  niaile,  hy  dcej)  incision  and  free  dissection,  to  open  up  all 
pockets  containing;  urine  or  blood  and  to  afford  free  outlet  from  the  bladder.  Under 
some  of  these  circumstances,  especially  when  attempted  at  nl<i;ht  with  j)oor  li<;ht,  the 
performance  of  an  external  perineal  urethrotomy  is  by  no  means  an  easy  matter,  since 
the  torn  un-thra  may  be  lost  in  ra<r^cd  and  infiltrated  tissues,  and  may  sometimes  be 
found  only  after  lon<;  and  tedious  search. 

What  to  do  with  a  torn  urethra,  under  these  circumstances,  is  sometimes  a  j)roblem. 
If  it  be  raji^ed  and  more  or  less  torn  away  it  may  sometimes  be  resected,  and  the  ends 
re-united  by  sutures,  if  necessary  with  a  certain  amount  of  dislocation  of  the  urethra  by 
dissectinj;  around  it.  Prin<rle  and  others  have  resorted  to  the  fresh  urethra  of  the  ox, 
for  firaftinif  into  cases  of  recent  or  old  defec-t,  as  in  instances  of  extensive  deep  ruj)ture; 
as  Well  as  in  cases  of  Inpospadias,  with  defect  in  the  floor  of  the  urethra  throuirjujut  its 
entire  j)cnile  j)()rtinn. 

The  rriiioral  of  forn'r/n  bodies-  from  the  uretlira  is  not  easy  when  these  have  passed 
into  its  deeper  portion.  With  sj)ecial  instruments  it  is  sometimes  possible  to  crras|>  and 
extract  them,  althouo;h  a  pointed  extremity  may  interfere  with  the  ease  of  removal.  More 
harm  will  come  from  leaving  them  than  from  removing  them.  Therefore  when  their 
extraction  is  impracticable  there  need  be  no  hesitation  in  button-holing  the  membranous 
or  the  deep  urethra,  and  by  pushing  the  object  dow^n  toward  the  opening,  there  effecting 
its  removal. 

The  urethral  walls  will  take  fine  sutures,  with  every  prospect  of  repair,  jjroviding  their 
vascular  supply  be  not  too  seriously  disturbed.  Therefore  lateral  or  end-to-end  s-uture 
may  be  attempted  whenever  it  appears  promising,  but  in  such  cases  it  would  be  well 
either  to  leave  a  catheter  for  a  few  days  or  to  make  bladder  drainage  back  of  the 
injury. 

Cavernitis  refers  to  an  acute  or  chronic  inflammation  of  the  corpus  cavernosum  on 
one  or  both  sides.  It  may  be  the  result  of  the  exudate  connected  with  an  injury  or  with 
the  process  of  repair.  It  may  ensue  in  consequence  of  a  local  gonorrheal  inflammation, 
or  it  may  be  an  induration  due  to  chronic  syphilis.  The  condition  is  one  which  causes 
local  tenderness  rather  than  pain,  while  the  induration  causes  a  perceptible  lump  or 
tumor,  and  infiltration  of  vascular  tissue  interferes  with  symmetry  during  erection.  Again 
pressure  may  cause  some  ureteral  obstruction.  Cases  of  syphilitic  origin  are  to  be  treated 
by  local  inunctions  of  mercurial  ointment,  perhaps  with  ichthyol,  which  are  of  benefit 
in  any  instance,  while  the  internal  administration  of  the  iodides  is  of  more  or  less  assist- 
ance.    The  non-specific  cases  yield  only  to  time  and  to  massage. 

Gummas  of  the  penis  may  assume  the  above  t}^e,  but  usually  occur  in  more  distinct 
form,  either  in  the  cavernous  bodies  or  between  them.  An  abruptly  limited  nodule  in 
any  such  locality  will  always  naturally  arouse  suspicion  of  specific  disease  and  lead  to 
its  appropriate  treatment. 

Upon  the  glans  and  the  prepuce,  especially,  herpetic  vesicles  frequently  appear,  con- 
stituting an  annoying  local  lesion,  corresponding  minutely  to  the  ordinary  "cold-sore" 
upon  the  lip.  This  is  known  as  herpes  preputialis.  It  is  the  result  usually  of  uncleanly 
habits  or  local  irritation.  It  is  of  no  consequence,  save  that  in  some  individuals  it  occurs 
frecjuently,  with  considerable  local  irritation.  The  broken  surface  thus  produced  is 
liable  to  chancroidal  or  septic  infection,  which  constitutes  its  greatest  danger,  while 
such  a  sore,  irritated  by  caustics  or  injudicious  applications,  is  sometimes  mistaken 
for  a  specific  lesion.     A  chronic  herpes  may  frequently  prove  a  precancerous  lesion. 

The  papillomas,  or  wartij  groicths,  are  frequently  noted  about  the  glans  and  prepuce, 
being  expressions  of  local  irritation,  while,  under  the  conditions  of  local  warmth  and 
moisture  which  prevail,  they  luxuriate  and  may  develop  into  condyloviatoiis  masses, 
known  as  ^'strawberry"  or  "mtdberry"  grow^ths,  which  may  attain  large  size.  In  the 
female  they  occur  on  all  parts  of  the  vulva  and  anal  region;  in  the  male  they  rarely  appear 
except  as  above. 

All  that  such  papillomatous  growths  require  is  complete  excision  or  extirpation  (i.  e. 
destruction),  with  cauterization  of  their  bases  and  subsequent  local  cleanliness.  They 
are  not  infrequently  referred  to  as  venereal  warts,  which,  in  effect,  they  usually  are. 
The  other  benicjn  tumors  of  the  penis  are  rare.  Occasionally  some  dermoid  cyst  or 
small  fatty  or  fibrous  growth  may  be  seen.  Sarcoma  of  the  penis  is  also  rare,  while 
epithelioma  is  not  uncommon,  constituting  the  ordinary  cancer  of  the  penis. 
64 


1010  SPECIAL  OR  REGIOXAL  SURGERY 

Epithelioma  in  tliis  rt'tfion  has  its  origin  around  st)ine  portion  of  the  mucous  surface 
of  the  glans,  spreading  in  time  to  the  prepuce,  more  or  less  involving  the  entire  organ, 
while  by  its  rich  lymphatic  supply  involvement  of  the  inguinal  and  other  nodes  happens 
early,  whereby  the  situation  is  sadly  complicated.  Epithelial  cancer  here  evinces  the 
same  local  tendencies  toward  extension  and  destructive  ulceration  as  elsewhere,  made 
more  rapid  by  exposure  to  surface  irritation.  Its  base  is  indurated,  even  if  sometimes 
everted;  it  orows  irregularly,  but  destroys  everything  with  which  it  comes  in  contact. 

Epithelioma  of  the  penis  should  be  recognized  and  extirpated  early  to  offer  any  [irospect 
of  success.  It  is  usually  as  impromising  a  condition  as  epithelioma  of  the  tongue, 
because  of  the  early  lymphatic  involvement.  A  lesion  of  limited  area  may  justify  local 
excision,  but  a  distinctly  marked  lesion  can  only  be  successfully  treated  by  amputation, 
at  least  of  the  anterior  portion  of  the  organ,  perhaps  of  the  entire  structure  of  the  penis, 
and  thus  ensure  complete  eradication. 

Amputation  of  the  penis  is  easily  effected  with  a  circular  sweep  of  the  knife,  or  by  an 
abrupt  cross-section,  there  being  but  little  choice  of  method,  the  intent  being  only  to 
save  sufficient  of  the  organ  so  that  cleanliness  during  and  after  the  act  of  urination  may 
be  maintained.  "When  any  portion  of  the  pendulous  organ  is  preserved  the  margin  of 
the  divided  skin  should  be  attached  to  that  of  the  urethra  by  a  series,  say,  of  four  sutures, 
placed  at  equal  intervals,  after  hemorrhage,  which  will  be  somewhat  difficult  of  control, 
both  from  the  larger  vessels  and  from  the  cavernosa,  has  been  subdued.  It  may  require 
buried  sutures  through  the  divided  cavernosa  in  order  to  permit  of  such  control. 

If,  however,  it  seem  necessary  to  remove  the  organ  close  to  the  pubis  it  will  probably 
be  found  more  desirable  to  make  a  more  complete  dissection,  taking  out  the  corpora 
cavernosa  entirely,  and  then  making  a  median  incision  in  the  perineum,  dissecting  out 
the  urethra,  bringing  it  out  through  the  wound,  shortening  it  to  the  proper  extent,  and 
fastening  its  termination  to  the  skin  margin,  thus  making,  as  it  were,  a  vulvar  outlet, 
which  will  not  interfere  with  urinary  control,  but  will  ])ermit  urination  to  be  satisfactorily 
accomplished,  though  only  in  the  sitting  posture.  This  is  usually  known  as  Demarquay's 
operation. 

CIRCUMCISION. 

In  children  this  requires  a  general  anesthetic;  in  adults  it  can  almost  always  be  satis- 
factorily performed  under  local  cocaine  anesthesia;  the  intent  being  to  remove  the  redun- 
dant foreskin.  A  circular  incision  is  necessary,  which  may  be  made  with  knife  or  scissors. 
The  parts  being  prepared  for  operation,  the  prepuce  is  drawn  forward,  being  caught 
either  with  forceps  or  fingers  of  an  assistant,  and  the  little  circular  amputation  is  made 
just  in  front  of  the  corona  of  the  glans.  The  first  incision  extends  through  the  skin, 
after  which  there  remains  a  cuff  of  mucous  membrane,  which  is  sometimes  adherent  to 
the  glans,  as  in  children,  or  may  be  infiltrated  with  exudate,  as  by  a  concealed  chancroid 
or  chancre  beneath.  Ordinarily  this  cuff  is  split  in  the  middle  line  of  the  dorsum  and 
removed  in  halves,  in  order  to  avoid  any  possible  Injury  to  the  glans  Itself.  The  cut  Is 
made  somewhat  obliquely  from  above  downward  and  forward,  the  intent  being  to  divide 
It  at  the  frenum,  sufficiently  far  from  the  meatus  In  order  to  not  distort  the  latter  by 
subsequent  cicatricial  contraction.  These  tissues  are  sometimes  inordinately  vascular, 
and  bleeding  ])oints  need  to  be  quite  carefully  secured.  In  one  case  known  to  me  an 
infant  bled  to  death  from  an  unsecured  vessel  near  the  frenum,  the  operator  having 
neo-lected  it  at  the  time  and  having  left  the  patient.  In  a  clean  case,  the  vessels  having 
been  secured,  a  running  suture  of  fine  catgut  should  unite  the  cut  edges  of  the  mucosa 
and  of  the  skin.  It  is  not  necessary  to  apply  sutures  in  a  venereally  infected  case,  for 
raw  surfaces  will  also  become  infected,  and  would  be  best  protected  by  immediate 
cauterization,  In  which  case  primary  union  would  be  prevented. 

The  little  procedure  may  be  modified  In  various  ways  to  meet  Individual  needs.  After 
Its  performance  there  will  occur  considerable  local  swelling  and  edema,  which  can  be 
best  kept  under  subjection  by  a  dressing  moistened  with  c-old  saturated  boric  acid  solu- 
tion or  Its  equivalent.  If  the  sutures  have  been  too  tightly  ajijilied  there  mav  be  a  species 
of  paraphimosis,  with  too  much  constriction,  which  would  require  their  division. 


STRICTURES  OF   TIIK   CRKTJIRA  \{)l\ 


THE  URK'riIllA. 


In  Cliaptcr  XII,  on  (lonorrhca,  wori'  drsc  rihcd  tlic  usual  specific  forms  of  urctliritis, 
with  tlu-ir  couiplicatious  and  results.  To  this  (•lia|)ter  the  reader  is  referred  for  all 
data  re<rardin^  gonorrhea  as  it  involves  this  j)assafi;e-way,  with  its  complications. 
Such  lesions  as  ulcci;s  may  j)ersist  for  some  time,  while  the  papillomatous  outgrowths, 
polypi,  etc.,  connected  with  gonorrhea  and  gleet,  which  are  not  discoverable  from  without, 
are  now  easily  examined  and  estimated  with  the  endoscope.  Specific  ulcers  of  the 
syphilitic  ty|)e,  and  virulent  ulcers  even  of  the  chancroidal  type,  also  occur,  usually 
within  the  first  inch  of  the  urethra,  causing  more  or  less  discharge,  with  local  soreness, 
and  leading,  unless  promptly  recognized,  to  cicatricial  stricture  formation. 


STRICTURES  OF  THE  URETHRA. 

Strictures  of  the  urethra  may  he  of  fraiimatir  origin,  as  when  ])roduced  hy  external 
accident,  with  or  without  laceration,  or  hy  the  introduction  of  fc^rcign  hodies,  or  the 
minor  injuries  inflicted  during  their  extraction.  Deep  traumatic  strirture  is  the  result 
of  serious  injuries  to  the  perineum.  The  common  tj-pe  of  urethral  stricture  is  the  con- 
sequence of  one  or  more  attacks  of  gonorrhea,  which,  not  having  been  promptly  cured, 
has  merged  into  so-called  gleet,  and  this  into  these  inevitable  consequences,  with  more 
or  less  infiltration  of  the  ])eri-urethral  tissues,  and  subsequent  encroachment  upon  the 
caliber  of  the  urethra,  either  by  irregular  new  tissue  formations  or  well-marked  annular 
constriction.  In  addition  to  the  above  conditions  there  is  also  known  a  spasmodic  stricture, 
due  to  involuntary  contraction  of  the  muscular  fi})ers  encircling  the  urethra,  and  of  the 
deeper  perineal  muscles  which  concern  it.  Otis  held  that  such  urethral  spasm  is  a  fre- 
quent accompaniment  of  a  contracted  meatus,  and  taught  that  the  best  method  to  deal 
with  it  is  by  first  enlarging  the  meatus,  as  may  be  easily  done  with  a  simple  bistoury, 
under  local  cocaine  anesthesia  {meatntomy) ,  and  the  subsequent  passage  of  instruments 
of  proper  size. 

To  persistent  and  well-marked  contraction  of  the  urethra  is  given  the  term  organic 
stricture,  and  such  a  stricture  is  generally  the  consequence  of  injury  or  disease,  whereas 
j)urely  spasmodic  stricture,  mentioned  above,  is  a  not  infrequent  occurrence  in  perfectly 
chaste  individuals. 

Organic  stricture  mag  he  single  or  multiple,  of  large  or  small  caliber,  or  even  impassable 
and  impermeable — that  is,  from  before  backward — so  that  even  while  urine  may  leak 
through,  drop  by  drop,  from  behind  it  seems  impossible  to  introduce  an  instrument 
from  the  front.  In  aggravated  cases  three  or  four  inches  of  the  urethral  canal  may  be 
involved  in  lesions  of  this  kind,  which  constitute  a  formidable  condition  for  satisfactory 
treatment.  The  ordinary  non-traumatic  organic  strictures  are  all  in  front  of  the  prostate 
and  more  common  near  the  meatus.  The  size  of  a  stricture  is  determined  either  by  the 
iirethrometer  devised  by  (  )tis,  or,  more  siin))ly,  by  determining  the  diameter  of  the  bulbous 
bougie  which  may  be  made  to  easily  slip  through  it,  the  latter  being  the  common  method. 
These  instruments  are  indicated  by  numbers,  which  refer  to  the  millimeters  in  circum- 
ference of  the  bulb;  thus  Xo.  27  implies  that  the  bulb  has  a  circumference  of  27  Mm. 
The  bulbous  instrument  is  far  better  for  examination  than  the  sound,  since  it  indicates 
the  exact  depth  as  well  as  the  length  of  the  strictured  passage,  and  gives  a  better  idea 
of  its  density  or  resilience.     (See  Figs.  071  and  672.) 

The  indications  of  stricture  are  difficulty  in  micturition,  even  to  the  degree  of  impossi- 
bility, ])ersistence  of  gleety  discharge,  and  slowness  or  impossibility  of  ejaculation,  while 
sometimes  cicatricial  tissue  can  be  felt  from  the  outside. 

The  strictured  urethral  canal  should  be  restored  to  normal  dimensions  at  the  earliest 
practicable  moment.  This  may  be  effected  through  gradual  dilatation  with  a  conical 
steel  sound,  passed  at  intervals  of  two  or  three  days,  or  rapidly,  by  the  improved 
instnunent  of  Otis  known  as  the  dilating  urethrotome,  which,  being  passed  through  the 
stricture,  has  its  blades  expanded  by  a  mechanism  at  the  handle,  while  "the  stricture 
when  it  is  stretched  is  divided  by  the  working  of  a  concealed  blade.  The  Otis  instru- 
ment is  illustrated  in  Fip.  ()7.3. 


1012 


SPECIAL  OR  REGIOXAL  SURGERY 


A  meatus  too  small  to  admit  a  suitable  instrument  should  he  incised  to  the  necessary 
degree. 

Gradual  dilatation  may  be  employed  in  the  milder  cases,  and  has  been  combined 
with  a  method  of  electrolysis,  in  which  I  have  iitde  faith.  Xo  matter  which  method 
be  adopted,  the  patient  should  be  impressed  with  the  fcjrce  of  the  old  adai^c,  "(Jnce  a 
stricture  always  a  stricture,"  and  should  be  warned  that  the  occasional  ])assage  of  an 
instrument  is  necessary  for  a  long  period,  and  that  while  he  may  be  taught  the  procedure 
he  should  not  neglect  it.     This  is  true  alike  of  every  method  of  treatment. 


Fig.  671 


^5 


Bulbous  sound. 


Diculsion  was  a  method  emplcjyed  during  the  past  generation  of  rupturing  a  stricture 
by  forcible  separation  of  the  blades  of  a  divided  instrument,  tearing  it  instead  of  neatly 
cutting  it,  thus  inflicting  a  maximum  in.stead  of  a  minimum  of  local  damage.  Every 
divulsion  thus  led  to  a  sub.sequent  stricture  formation.  The  procedure  has  been  aban- 
doned. ,  Now  by  the  employment  of  the  Otis  in.strument,  or  one  of  its  .substitutes,  the 
stricture  is  first  found,  then  penetrated  with  the  instrument,  and  divided  to  an  extent 
easily  regulated,  thus  permitting  exact  work,  which  is  preferable  to  the  older  methods  of 
drawing  a  large  blade  along  the  urethral  tract. 


Fig.  672 


Otis'  urethrometer. 


In  tight  strictures  the  operator  proceeds  at  first  with  small  filiform  bougies  made  of 
ichalehone,  with  which,  sometimes  after  considerable  effort  with  a  bundle  of  them  in 
the  urethra,  trying  one  after  another,  he  may  .succeed  in  pa.ssing  one  and  causing  it  to 
enter  the  bladder.  The  others  are  then  withdrawn.  It  may  now  be  possible  to  thread 
over  the  whalebone  a  perforated  ti]j  made  for  the  urethrotome,  and  thus  to  slip  the  latter 
down  into  the  depths  over  the  fine  bougie  as  a  guide,  and  then  to  push  it  farther,  u.sing 
now  more  force  because  it  must  necessarily  follow  the  urethral  canal.  ^Vhen,  however, 
what  seems  to  be  judicious  manipulation  by  this  method  is  un.successful  the  metal 
instrument  should  be  withdrawn,  the  whalebone  bougie  remaining  in  situ,  and  thus 
ser\'ing  as  a  guide  for  that  which  is  now  made  necessar}',  namely,  external  urethrotomy.^ 


Fig.  673 


Otis'  dilating  urethrotome. 


External  urethrotomy  is  essentially  a  median  ])erineal  section,  carrierl  down  at  least 
to  the  urethra.  It  is  df)ne  preferably  with  a  guide,  u.sually  a  fine  bougie.  With  it  the 
urethral  channel  may  be  easily  identified;  whhout  a  guide,  in  aggravated  ca.ses,  it  is  often 
a  difficult  matter  to  identify  and  dissect  out  the  urethra,  and  then  to  find  its  tortuous 
passage-way  and  follow  it  into  the  bladder.  Patience  and  a  knowledge  of  the  anatomy 
of  the  perineum  will  lead  to  success.  Sometimes  extensive  dissections  are  necessary, 
and  the  perineal  wound  needs  to  be  widely  retracted  in  order  to  better  expose  the  deep 

1  Van  Hook  has  recommended  the  followng  excellent  expedient  for  the  discovery  of  the  urethral  canal  when 
apparently  lost  in  the  depths  of  a  dense,  deep  stricture:  He  gives  a  dose  of  potassium  iodide  two  or  three  hours 
before  the  operation.  During  the  latter,  and  when  seeking  the  proximal  end  of  the  urethra,  he  drops  a  little 
acetate  of  lead  solution  at  the  point  where  the  urine  is  expected  to  appear.  The  formation  of  the  bright-yellow 
lead  iodide  will  mark  the  actual  appearance  of  the  urine  and  indicate  its  .source, 


Tllh:    TESTICLES,    THE  CORD,    AM)    THE    VESICEEH  1()]3 

tissue.  Oiux-  tlu'  iiri'tlira  is  idi-iitificd  it  may  he  t'ollowcd  in  each  direction,  vlimX  the  case 
shuuUl  not  lu-  left  until  the  entire  canal  has  l)een  restored  to  its  normal  caliher.  In 
these  cast's  it  is  hest  to  leave  a  self-retaiiiin<j;  catheter  in  the  perineal  wound  for  ut  least 
a  day,  after  which  it  is  sometimes  of  lu-ncfit  to  introduce  a  catheter  through  the  meatus, 
and  leave  it  in  the  urethra  for  two  or  three  days.  Such  a  urethra  is  an  infected  channel, 
and  nnist  be  so  cared  for  that  no  retention  or  infection  of  fresh  wounds  occurs. 


PERINEAL  ABSCESS. 

Perineal  abscess  is  the  not  infre(|uent  consequence  of  a  very  tight  and  deep  .stricture, 
having  its  beginnings  as  a  folhriilifi.s,  witli  subsequent  extension  and  j)erforation,  with 
escape  of  urin(>,  and  sometimes  with  the  formation  of  acute,  diffuse  j^hlegmon,  which 
may  even  extend  into  the  scrotum  or  to  the  abdominal  wall.  Ordinarily  it  constitutes 
a  circumsc-ribed  collection  of  pus.  Such  a  ))hlegmon  when  neglected  may  be  followed 
by  extensive  burrowing  of  pus,  or  local  sloughing,  with  gangrene,  and  partial  or  complete 
destruction  of  the  external  genitals.  When  such  a  phlegmon  occurs  above  the  triangular 
ligament  there  will  be  swelling  about  the  prostate,  with  edema  of  the  anterior  rectal 
wall,  while  the  prostate  itself  may  become  later  involved.  Such  a  collection  may  ter- 
minate as  an  ischiorectal  ahscesfi,  associated  with  perineal  fistulas. 

The  inevitable  results  of  such  conditions  have  two  or  three  disastrous  tendencies, 
such  as  burrowing  of  ])us  and  the  formation  of  urinary  fistulas,  sometimes  at  considerable 
distance  from  the  urinary  channels.  The  same  is  true  in  traumatic  cases,  for  in  such 
cases  there  may  be  the  expression  of  an  old  and  neglected  stricture.  To  the  chronic 
condition  may  be  added  that  of  tuberculous  infection. 

Treatment. — The  treatment  of  such  abscesses  and  fistulas  is  based  upon  the  prin- 
ciples of  evacuation  of  pus  and  restoration  of  the  urinary  canal  to  its  proper  size.  This 
may  be  an  easy  or  a  difficult  task,  but  it  should  be  accomplished  by  whatever  method  will 
permit  it  with  the  least  damage  to  tissues.  When  urinary  infiltration  threatens  gangrene 
extensive  incisions  should  be  made.  When  the  scrotum  is  swollen,  as  it  may  be  to 
enormous  dimensions,  free  opening  should  be  made  into  it  to  permit  escape  of  serum 
and  pus  if  present.  Even  the  surrounding  tissues,  including  the  penis,  may  be  enor- 
mously edematous.  This  swelling  will  rapidly  subside  when  pressure  upon  the  deep 
veins  has  been  relieved,  hut  pus,  no  matter  where  present,  must  be  evacuated. 

URINARY  FEVER. 

Instrumentation  of  any  kind  within  the  urethra  may,  in  some  individuals,  be  followed 
by  what  has  been  called  urethral  or  urinary  fever,  including  chill,  pyrexia,  with  sometimes 
the  development  of  an  acute  inflammatory  aft'ection,  either  of  the  urethra  or  even  of  the 
kidney,  with  not  only  retention  but  actu;d  suppression  of  urine.  These  manifestations 
are  ordinarily  regarded  as  due  to  toxemia,  but  are  sometimes  difficult  to  explain,  because 
their  violence  seems  so  disproportionate  to  the  amount  of  intervention.  Thus  I  have 
known  an  individual  to  die,  of  apparently  acute  uremia,  within  four  days  after  the  painless 
passage  of  a  sound  for  dilatation  of  an  old  stricture,  the  same  not  being  followed  by 
any  blood  or  local  disturbance. 

These  accidents  were  more  prone  to  occur  before  the  introduction  of  antiseptic  methods 
in  all  urethral  instrumentation.  At  present  they  are  much  rarer  than  in  former  days. 
Nevertheless  the  passage  of  any  instrument,  even  for  legitimate  examination,  as  for  stone, 
may  be  followed  by  unpleasant  consequences.  These  are  preventable  to  some  degree 
as  well  as  curable,  by  antiseptic  local  measures,  as  well  as  by  the  administration  of 
quinine  or  urotropin,  esjjecially  the  latter,  with  sitz  baths  and  perhaps  general  antifebrile 
measures,  while  any  local  disturbance  thus  set  up  is  to  be  treated  on  general  principles. 

THE  TESTICLES,  THE  CORD,  AND  THE  VESICLES. 

The  testicle  is  originally  formed  by  differentiation  from  the  W'olffian  bodies,  at  a 
level  above  the  pelvis.  Its  migration  from  its  original  location  into  the  pouch  where  it 
normally  belongs  is  known  as  the  descent  of  the  testicle.     When  it  fails  to  appear  at 


1014  SPECIAL  OR  REOIONAL  SURGERY 

the  external  rint:;  it  is  si)()ken  of  as  retained  iestiele,  and  when  detained  outside  the  ring 
above  its  })roper  level  the  condition  is  referred  to  as  hieomplete  (le.sreitf,  these  l)eino;  purely 
arbitrary  terms.  The  reasons  for  incompleteness  of  the  descent  are  as  little  understood 
as  those  for  its  completion,  and  have  but  little  reference  to  clinical  surgery. 

The  surgical  anatomy  of  the  testicle  may  be  only  briefly  considered  here.  Each  is 
essentially  a  double  organ,  consisting  of  the  testis  proper,  the  secreting  portion, 
with  its  more  or  less  com])lete  tlouble  jieritoneal  covering  (originally  peritoneum),  and 
the  epididymis,  or  conducting  portion,  variable  in  size,  and  corresponding  to  the  paro- 
varium in  the  ovary  in  respect  that  it  is  subject  to  cystic  degeneration.  The  j^athway 
made  bv  the  testicleas  it  passes  from  the  abdominal  wall  should  be  completely  ol)literated. 
When  linobliterated  it  facilitates  the  occurrence  of  hernia,  while  when  j)artially  obliterated 
cystic  dilatations  of  the  enclosed  portions  {Jii/drnreles  of  the  eord)  occur.  The  lowermost 
portion  of  the  accompanying  peritoneal  jxnich  is  normally  left  as  a  closed  sac,  which 
constitutes  the  cavity  of  the  tunica  vaginalis  testis.  In  the  ordinary  standing  posture  the 
epididymis  occupies  toward  the  testis  proper  the  same  relative  position  that  the  heel 
tloes  toward  the  anterior  part  of  the  foot,  i.  e.,  it  lies  to  its  posterior  and  inner  sides. 
While  both  portions  of  the  organ  may  be  involved  in  acute  or  chronic  diseases,  each  of 
them  may  be  by  itself  involved  with  a  minimum  of  disturbance  of  the  other. 

RETAINED  TESTICLE,  OR  CRYPTORCHIDISM. 

As  above  indicated  failure  in  descent  varies  in  degree  from  complete  absence  from 
sio-ht  and  touch  to  a  presentation  of  the  testicle  at  a  point  where  it  can  be  both  seen  and 
felt,  but  still  at  too  high  a  level.  Ordinarily  the  condition  is  symptomless,  its  only  signs 
beim>-  those  above  rehearsed.  Strange  to  say  the  condition  sometimes  passes  unrecog- 
nized until  adult  life  is  reached.  Commonly  it  is  early  discovered.  Pain  is  felt  only 
when  friction  or  traumatism  lead  to  the  same  unpleasant  sensations  which  would  be 
produced  by  pressure  upon  a  normal  organ.  Thus  a  testicle  retained  at  the  external 
rino-  may  be  irritated  by  the  clothing,  and  has  been  many  a  time  mistaken  for  an  incom- 
plete hernia,  upon  which  a  truss  pad  has  l)een  applied  with  inevitably  resulting  suffering. 
While  accompanying  malformations  in  other  parts  of  the  body  may  be  found  it  does  not 
follow  that  the  individual  may  not  be  otherwise  perfectly  developed. 

It  is  usually  held  that  an  incompletely  descended  testicle  is  more  or  less  functionless; 
often  it  is  at  least  more  or  less  atrophied.  Its  fimctional  caj^acity  varies.  It  is  usually 
more  or  less  surrounded  by  a  cavity  formed  from  the  peritoneum.  While  the  condition 
is  ordinarily  one  of  minor  im])ortance,  it  has  been  established  by  numerous  observations 
that  retained  testicles  are  relatively  prone  to  undergo  malignant  degeneration.^ 

Treatment. — The  proper  early  treatment  of  cryptorchidism  has  been  a  matter  of 
dispute,  some  advising  to  leave  the  conflition  entirely  untouched  so  long  as  it  be  not 
troublesome;  others  that  early  intervention  should  be  practised.  If  the  organ  be  simply 
displaced  and  not  otherwise  diseased,  whatever  be  done  may  be  limited  to  freeing  it  from 
its  abnormal  surroundings  and  restoring  it  as  nearly  as  possible  to  the  position  where 
it  belono-s.  If  it  be  actually  diseased  it  should  be  removed.  What  may  be  accomplished 
will  depend  much  upon  its  moval)ility  and  its  blood  supply. 

Thus  Keetley  would  liberate  the  testicle,  when  retained  within  the  inguinal  canal,  by 
division  of  the  latter  and  lengthening  of  the  cord  by  blunt  dissection,  with  division  also 
of  the  lateral  portions  of  the  gubernacuhmi  near  the  ])illars  of  the  external  ring  and  as 
far  as  possible  from  the  testicle.  By  traction  upon  this  it  is  then  often  practicable  to 
bring  the  testicle  down,  without  undue  tension,  to  the  lower  part  of  a  new  scrotal  pouch, 
which  is  formed  by  making  for  it  a  nest,  as  it  were,  with  the  finger,  with  an  opening 
at  its  lower  extremity,  through  which  forceps  are  thrust,  passed  upward  and  made  to 
seize  the  end  of  the  gubernaculum,  or  through  which  a  suture  may  be  passed  for  the 
same  purpose.  By  means  of  this  device  the  testicle  is  now  drawn  downward  into  the 
scrotal  pouch,  where,  being  once  present,  it  is  held  by  sutures,  both  direct  and  those 

>  In  the  pathological  museum  of  the  T'niversity  of  Buffalo  I  deposited  s])erimeiis  illustrating  this  fact,  one  testicle 
forming  a  tumor  as  large  as  the  patient's  head,  the  other  as  large  as  a  cocoanut.  These  were  both  successfully 
removed  from  an  adult,  and  without  the  patient  developing  any  subsequent  evidence  of  malignant  infection.  It 
is  thus  important  in  every  case  of  intrapelvic  tumor  in  the  male  to  examine  the  scrotum  and  be  sure  that  both 
testicles  are  in  their  proper  position. 


TlliERCi'LOSIS  OF   Till-:   TESTICLE  1015 

wliicli  dose  the  |)()iuli  ahovf  it.  It  is  tlicii  ;i(l\  isal)lc  to  close  tlie  iii<^uiiial  canal,  as  after 
a  lieriiia  o|)eralioM.  In  order  to  |)revent  u])\var<l  traction  on  the  scrotum  it  is  necessary 
to  attach  its  lower  end  to  the  skin  of  the  thi<>h,  hy  a  suture  w  jiich  should  remain  for 
several  days.  If  this  he  done  on  both  sides  the  limbs  should  he  snu<rly  handai^ed 
toii;ether  and  movement  of  all  kinds  prevented,  ('omj)lete  se|)aration  of  the  scrotum 
from  the  thighs  should  not  he  permitted  for  several  weeks,  unless  unavoidable. 

Beck  recommends  an  incision  from  the  external  rinii;  three  inches  downward  alon"- 
the  cord,  after  which  he  o|)ens  the  ]K)Uch  of  the  testicle,  lifts  it  from  its  bed,  pulls  it 
down,  carefully  (|i\i(liiiii'  all  bands  of  connective  tissue  or  peritoneum  which  tend  to 
iminobilizi'  it.  It  is  then  deposited  in  a  scrotal  pocket,  in  which  it  is  held  by  a  flap 
dissectc-d  from  the  outer  margin  of  the  Intfuinal  rino;,  and  turned  downward  in  such  a 
way  that  it  can  be  attached  to  the  o])j)osite  layer  in  semilunar  shaj)e.  Thus  a  band  of 
ajioneurotic  tissue  is  made  to  surround  the  testicle  "like  a  necktie,"  the  organ  being 
retained  as  in  a  buttonhole,  the  kMigth  of  the  flaj)  being  determined  by  the  extensibility 
of  the  cortl.     The  inguinal  canal  is  then  closed  as  after  any  other  procedure. 

Other  ahnonmiHiies  of  the  testicle  include  corKjenital  atroplii/  or  absence,  while  in  a 
few  cases  a  fhird  testicle  has  bc(>n  found,  it  lying  in  contact  with  one  or  the  other  of  the 
naturally  .separated  normal  pair. 


INJURIES  TO  THE  TESTICLE. 

Injuries  to  the  testicle  are  of  common  occurrence,  on  account  of  their  exposed  position, 
yet  less  common  than  would  otherwise  occur  were  it  not  for  their  extreme  movabillty. 
Aside  from  the  lacerated,  incised,  or  punctured  wounds  wdiich  may  be  inflicted  the 
testicle  suffers  most  often  from  contusions,  always  with  resulting  swelling,  and  .sometimes 
with  considc-rable  effusion,  of  which  a  large  amount  may  be  accommodated  in  a  distended 
tunica  vaginalis. 

HEMATOMA  OF  THE  TESTICLE. 

Hematomas  of  the  testicle  are  also  thus  frequently  produced.  When  of  a  limited 
degree  of  severity  spontaneous  absorption  of  blood  may  be  expected,  and  should  be 
favored  by  physiological  rest,  i.  e.,  confinement  in  bed,  wath  elevation  of  the  scrotum 
and  the  application  of  water  dressings.  Large  extravasations  of  blood,  when  fresh, 
may  be  withdrawn  l)y  the  trocar,  but  when  clotted  will  require  incision  and  evacuation 
of  clots,  which  sh(Hild  always  be  practised,  as  it  leads  to  great  saving  of  time.  Extrav- 
asation is  usually  followed  by  induration,  and  more  or  less  permanent  enlargement, 
which  will  ])e  slow  to  disappear;  absorption  may  be  encouraged  by  the  use  of  a  weak 
mercurial  ointment. 

TUBERCULOSIS  OF  THE  TESTICLE. 

Tuberculosis  of  the  testicle  simulates  very  closely  that  occurring  in  the  lungs,  in  that 
one  may  see  a  disseminated  miliary  process,  with  subsequent  coalescence  and  formation 
of  caseous  nodules,  subsequently  breaking  down  into  abscess  cavities,  while  at  the  same 
time  the  surrounding  membranes,  ?.  e.,  the  tunica  vaginalis,  are  involved,  and  effusion 
(hydrocele)  occurs  just  as  in  the  pleural  cavity.  In  other  words  every  appearance  of 
pulmonary  consumption  may  be  imitated  within  the  small  extent  of  the  testicles  and  the 
epididymis.  Of  these  tw^o  parts  the  latter  suffers  much  more  frequently.  Here  are 
caused  irregular  nodules,  which  may  later  unite,  giving  to  the  entire  epididymis  a  much 
enlarged,  irregular  shape,  with  induration,  frequently  extending  upwarfl  along  the  cord, 
and  always  tending  so  to  extend  unless  the  disease  be  early  seen  and  recognized.  Too 
often  adhesions  to  the  skin  occur,  with  ulceration  and  formation  of  fistulas,  and  perhaps 
more  or  less  extensive  ulcers,  while  in  many  instances  the  entire  length  of  the  vas  becomes 
infected,  and  frequently  even  the  prostate  and  corresponding  vesicle  become  involved. 
By  this  time  there  will  be  more  or  less  involvement  of  the  inguinal  lymphatics,  and  the 
patient  may  be  already  showing  evidences  of  general  tuberculous  infection,  at  least  those 
of  some^  serious  constitutional  impression  made  by  the  local  disease.  One  has  to 
differentiate  as  between  tuberculosis,  syphilis,  and  cancer,  which  may  be  difficult  in 


1016  SPECIAL  OR  REGIONAL  SURGERY 

the  early  stages;  but  vvlicn  tlie  disease  has  extended  beyond  tlie  e])i(H(lymis  itself  it  is 
rarely  difficult  to  recognize,  unless  entirely  masked  by  distention  of  the  tunica  vaginalis 
with  fluid. 

Treatment. — The  treatment  for  tuberculosis  of  tlie  testicle  is  extirpation,  i.  e.,  cas- 
tration, which  includes  the  removal  not  only  of  the  diseased  organ,  but  of  all  the  tissues, 
including  the  skin,  to  which  it  may  be  abnormally  adherent,  and  of  the  spermatic  cord, 
which,  if  necessary,  should  be  followed  into  the  pelvis  by  a  long  incision  extending  up 
along  the  inguinal  canal.  To  remove  a  tuberculous  testis  and  leave  a  tuberculous  cord 
is  to  accomplish  very  little,  while  the  latter,  being  an  extraperitoneal  tissue,  may  be 
followed  with  relative  safety,  even  to  the  depths  of  the  pelvis.  Local  applications  in 
these  cases  give  little  relief.  This  teaching  is  at  variance  with  that  of  some  writers, 
but  is  justified  by  experience. 


SYPHILIS  OF  THE  TESTICLE 

Syphilis  occurs  in  secondary  and  tertiary  manifestations,  usually  first  in  the  testis, 
sometimes  in  the  epididymis,  but  always  in  the  testicle  before  the  cord.  It  produces 
nodules  which  may  be  mistaken  for  those  of  tuberculous  trouble,  l)ut  which  often  attain 
much  larger  size.  They  are  usually  painless.  Nevertheless  a  syphilitic  testicle  is  some- 
times tender,  and  constantly  so,  to  a  degree  causing  no  little  annoyance.  The  occurrence 
of  nodules  in  the  epididymis,  in  connection  with  other  evidences  of  syphilis,  is  regarded 
by  some  as  pathognomonic.  In  this  location  the  condition  yields  readily  to  properly 
directed  treatment. 

CYSTS  OF  THE  TESTICLE. 

Cysts  are  frequently  found  along  the  course  of  the  epididymis.  Some  of  them  are 
expansions  of  the  natural  tubes  of  the  paradidymis,  while  others  are  distinctly  new. 
Dermoids  are  occasionally  met,  and  either  of  these  may  attain  considerable  size.  Cyst 
of  the  epididymis  proj:)er  is  to  be  distinguished  from  encysted  hydrocele  of  the  cord. 
All  of  these  purely  cystic  conditions  are  essentially  innt)cent,  and  need  similar  treatment. 
They  may  be  evacuated  and  injected  with  an  irritant  like  pure  carbolic  acid,  which  is 
sometimes  an  effective  way,  or  they  are  better  treated  by  open  incision  with  extirpation 
of  the  cyst,  which  is,  in  the  end,  far  the  more  satisfactory  course  to  pursue. 


EPIDIDYMITIS  AND  ORCHITIS. 

Each  of  the  separate  portions  of  the  testis  may  have  its  own  nearly  self-limited  inflam- 
mations and  infections,  or  both  may  participate  in  a  common  lesion.  The  most  frequent 
cause  of  an  acute  epididi/mitis  is  gonorrhea,  the  infection  travelling  from  the  urethra 
along  the  vas,  and  causing  acute  and  well-marked  swelling  of  the  epididymis,  which 
becomes  tender  and  painful  in  proportion  to  the  amount  of  exudate.  It  may  come  on 
early  or  late,  during  the  course  of  the  urethritis.  The  condition  is  known  to  the  laity 
as  "swelled  testicle."  It  has  been  frequently  called  orchitis,  which  is  an  error,  since 
however  much  the  testis  may  later  participate  the  primary  trouble  is  in  the  epididymis. 
It  may  be  easily  distinguished  by  palpation,  the  enlarged  and  hardened  epididymis, 
often  very  tender,  being  prominent  behind  the  testis  ])roper.  The  condition  may,  how- 
ever, be  masked  by  the  acute  effusion  likely  to  occur  in  the  tunica  vaginalis,  constituting 
a  mild  degree  of  acute  hydrocele.  This  may  be  expected  in  nearly  all  severe  cases,  and 
serves  to  increase  the  size  of  the  entire  mass.  A  testicle  thus  affected  may  assume 
much  more  than  normal  dimensions,  and,  becoming  thereby  much  heavier,  drag  upon 
the  cord,  which  is  its  normal  support.  More  or  less  fever  and  malaise  accompany 
the  condition,  part  of  which  may  be  due  to  the  toxemia  of  gonorrheal  infection.  Usually 
but  one  side  Is  involved.  Both  are  rarely  affected  simultaneously,  but  one  may  follow 
the  other. 

The  acute  stage  of  gonorrheal  epididymitis  persists  for  a  week  or  ten  days,  even  under 
the  best  of  treatment,  and  is  followed  by  gradual  subsidence,  characterized  by  ameliora- 
tion of  symptoms  and  decrease  in  size. 


TUMORS  OF   Till':   TESTICLE  1017 

Treatment. — Tliis  iinprovrincnl  is  to  he  iiidiirrd,  fii.st,  by  rest  in  bed,  with  elevation 
of  the  serotuni,  and  the  ordinary  eliniinative  treatment  snitable  for  any  febrile  eondition. 
I^jeal  relief  may  eome  from  the  aj)|)lieation  either  of  heat  or  of  iee-l)a<^s,  the  latter  being 
preferable,  but  will  be  made  more  effective  by  the  a|)|)li(ation  over  the  serotuni  of  a  mix- 
tun"  of  two  parts  of  olivi-  oil  with  one  part  of  methyl  salicylate,  or  of  guaiaetjl  reduced 
with  e(|ual  parts  of  oil  or  glycerin.  The  anointed  surface  should  be  covered  with  some 
impervious  material,  and  the  dressing  be  changed  every  few  hours.  L;it(  r,  as  the  acute 
merges  into  the  chronic  condition,  absorption  may  be  stimulated  by  the  ordinary  mercurial 
ichtliyol  ointment. 

In  some  exceedingly  acute  eases  sup])uration  ensues,  the  consequences  Ijeing  a  col- 
lection of  pus  in  the  epididymis,  which  will  give  the  ordinary  signs  and  call  for  the  usual 
evacuation  which  every  collection  of  ])us  dc^nands.  Epididymitis,  more  or  le.ss  acute, 
has  been  known  to  follow  the  introduction  of  the  catheter  or  sound,  even  in  cases  .so 
far  as  known  not  previously  infected.  It  is  difficult  to  explain,  but  recpiircs  the  .same 
treatment  as  above. 

Orchitis,  or  Inflammation  of  the  Testis  Proper. — This  condition  is  rare  except 

as  an  occasional  complication  of  mumps,  or,  much  more  rarely,  of  one  of  the  other 
exanthems.  Why  after  acute  parotiditis  there  should  be  a  tendency  to  inflammation 
of  the  testis  or  the  ovary  has  never  been  fully  explained.  Nevertheless  it  is  sufficiently 
frequent  to  be  well  known  to  the  laity,  and  is  occasionally  so  pronounced  as  to  lead  to 
actual  atro))hy,  with  loss  of  function  of  the  testis  involved.  In  any  true  orchitis  there 
will  l)c  considerable  pain  and  tenderness,  becau.se  the  testis  proper  is  .so  tightly  confined 
within  its  tunica  albuginea,  i.  e.,  a  firm,  inelastic  membrane.  By  proximity  there  will 
al.so  be  .set  up  more  or  less  involvement  of  the  tunica  vaginalis,  with  effusion,  .so  that  .some 
degree  of  acute  hydrocele  may  be  looked  for  in  every  such  instance. 

Treatment. — The  treatment  of  the  condition  above  described  consists  essentially  in 
rest,  with  local  soothing  applications,  of  which  perhaps  nothing  will  be  more  satisfactory 
than  guuiacol,  which,  however,  should  always  be  u.sed  with  caution. 


TUMORS    OF    THE    TESTICLE. 

Dermoid  cysis  and  tumors  and  ieraiomas,  i.  e.,  tho.se  of  mixed  type,  are  frequently 
met  in  this  region.  Their  explanation  is  doubtless  afforded  by  the  extreme  complexity 
of  the  elements  which  help  to  make  up  the  part,  while  in  the  embryonic  condition, 
and  the  confusion  of  tissue  elements  which  may  then  and  there  arise.  These  growths 
of  embryonic  origin  vary  from  single  cysts  to  a  mass  of  cystic  tumors,  which  may  replace 
the  organ,  or  constitute  neoplasms  of  large  size,  while  some  of  the  teratomas  have  features 
causing  them  to  resemble  the  mixed  growths  occasionally  found  within  or  about  the 
ovary.  In  this  way  is  to  be  explained  the  occurrence  in  such  masses  of  hair,  teeth,  and 
other  epiblastic  elements,  as  well  as  of  cartilage  or  bone  or  other  mesoblastic  elements. 
Taken  together  these  growths  constitute  an  interesting  group  for  the  pathologist  to 
study.  For  the  surgeon,  however,  they  require  essentially  the  .same  class  of  treatment, 
namely,  extirpatioyi,  or,  if  this  be  impossible,  complete  removal  of  the  organ,  i.  e.,  castra- 
tion. There  should  be  no  hesitation  in  performing  this  upon  any  such  growth,  as  no 
testicle  thus  affected  is  likely  to  be  functionable,  and  the  individual  suffers  no  possible 
deprivation  of  potency  by  its  removal. 

The  other  benign  and  simple  tumors,  especially  fihromas  and  chondromas,  are  occa- 
sionally met,  and  I  have  described  one  rare  case  of  large  lipoma  within  the  limits  of  the 
testicle  proper. 

Cancer  of  the  Testicle. — This  includes,  usually,  sarcoma,  developing  from  the 
mesoblastic  elements,  although  adenocarcinoma  may  be  met  here,  but  as  an  extension 
from  .some  growth  occurring  first  in  the  skin  or  in  the  immediate  neighborhood.  Deep 
cancer  in  this  region  is  difficult  to  at  first  distinguish  from  the  induration  produced  by 
tuberculosis  or  .s}^hilis.  In  doubtful  ca.ses  the  therapeutic  test  may  be  tried  in  order  to 
ditt'erentiate  it  from  the  latter.  From  the  former  it  is  usually  separated  by  its  more 
consistent  and  regular  (?'.  e.,  its  less  nodular)  character.  In  all  three  cases  the  lymphatics 
of  the  gr(jin  may  be  early  involved,  or  perhaps  not  until  late.  As  a  rule  cancer  is  met 
in  the  later  years  of  life,  while  the  other  conditions  are  more  frequently  seen  In  the  first 
half.     In  the  more  rapid  cases  there  will  be  considerable  pain,  with  dilatation  of  the 


1018  SPECIAL  OR  REGIONAL  SURGERY 

.scrotal  veins,  and  eviflcnccs  of  constitutional  involvement.  Sarcoma  may  jjrow  rapidly 
and  meta.stasis  is  almost  invariably  to  the  hm^s. 

Of  tumors  in  the  testicle,  as  of  tho.se  in  the  breast,  it  may  be  said  that  any  new- 
growth  which  tends  to  enlarge,  become  more  den.se  or  adherent,  to  spread,  or  to  be 
accompanied  by  lymphatic  involvement  fihould  he  removed;  no  mistake  will  be  made  in 
applying  this  rule  in  these  ca.ses,  especially  if  by  the  therapeutic  test  or  otherwise  syphilis 
can  be  excluded.  Malignant  di.sease  sometimes  travels  rapidly  up  the  cord,  and  the 
main  fear  is  not  so  much  of  local  recurrence  as  of  deep  involvement  within  the  pelvis. 
Cases  of  cancerous  growth  of  the  testicle  should  be  not  only  thoroughly  extirpated  from 
the  scrotimi,  but  the  inguinal  canal  should  be  opened,  and  the  cord  followed  aft  far  as 
possible  and  completely  removed. 

Cases  may  arise  where  amputation  of  the  scrotum  may  be  justifiable  for  the  purpo.se 
of  temporary  relief,  in  order  to  avoid  discomfort,  hemorrhage,  or  offensive  ulceration. 


HYDROCELE. 

Strictly  speaking  the  term  hydrocele  means  accumulation  of  watery  fluid  in  any  pre- 
existing cavity.  By  universal  consent,  unless  .some  other  cavity  be  specified,  the  tunica 
vaginalis  is  understootl.  The  con.sequence  is  a  more  or  less  distended  sac  of  serous 
fluid,  which  first  occupies  a  position  in  front,  but  finally  is  spread  around  the  lateral 
portion  of  the  testicle,  and  may  form  a  tumor  the  size  even  of  the  individual's  head. 
It  is  an  innocent  collection  of  serum,  but  the  walls  of  such  a  sac  will  be  thickened  in 
proportion  to  its  age  and  size,  and  may  in  the  course  of  time  undergo  such  degenerations 
as  the  calcareous,  for  instance,  by  which  it  becomes  more  or  less  infiltrated  or  encrusted 
with  calcareous  material.  Thus  I  have  in  my  possession  a  tumor  of  this  kind,  nearly 
the  size  and  almost  as  hard  as  an  ostrich  egg,  the  old  tunic  being  converted  practically 
into  a  .shell. 

Acute  hydrocele  occurs,  as  above  mentioned,  in  connection  with  the  acute  infections, 
but  is  then  ordinarily  a  matter  of  but  a  few  days  or  weeks. 

Hydrocele,  as  usually  implied  by  the  term,  is  an  exceedingly  chronic  and  almost 
jiainless  affection,  which  may  follow^  injury,  but  which  comes  often  without  any  known 
cau.se.  Many  theories  have  been  advanced  to  account  for  it,  but  none  are  generally 
satisfactory.  These  cases,  however,  occur  usually  after  the  fortieth  year  of  life,  but  may 
be  seen  in  the  young.  Their  greatest  unpleasantness  is  that  produced  by  the  weight  of 
the  mass  as  it  drags  upon  the  cord  and  the  scrotum. 

The  tumor  is  pear-shaped,  and  abruptly  circumscribed  at  its  upper  limit,  below 
the  external  ring  (unless  there  be  also  involvement  of  the  cord),  and  gives  no  impulse 
when  the  individual  coughs.  By  the.se  features  it  is  distinguished  from  hernia,  for 
which  it  is  often  inexcusably  mistaken.  A  hernia  is  a  distinct  prolongation  from  above, 
whereas  a  hydrocele  terminates  below  the  hernial  outlet,  and  by  its  smaller  extremity. 
The  distended  sac  will  fluctuate,  and  will  return  clear  fluid  upon  puncture  with  a  hypo- 
dermic needle,  and  is  .so  translucent  that  light  may  be  transmitted  through  it  when  it 
is  interposed  between  a  candle-flame  and  the  surgeon's  eye.  (Serious  thickening  of 
the  sac  may  interfere  with  the  value  of  this  test.)  A  congenital  form  of  hydrocele  is 
also  known,  due  to  failure  of  obliteration  of  the  canal  of  Nuck,  and  it  might  be  possible 
in  .some  such  cases  to  get  a  slight  imj)ulse  on  coughing,  as  when  the  sac  connects  with 
the  abdominal  cavity,  in  which  ca.se  it  should  be  possible  to  gently  press  its  contained 
fluid  back  into  the  abdomen  above.  In  most  congenital  ca.ses  there  is  a  tendency  to 
spontaneous  cure,  at  least  to  obliteration  of  the  canal. 

Occasionally  both  sides  are  involved,  or  the  sacculation  maybe  niultilocular,  or  accom- 
panied by  cy.stic  extensions  along  the  cord. 

Treatment. — In  regard  to  methods  of  treatment,  but  tw^)  will  be  considered  here, 
aspiration  with  injection  of  carbolic  acid,  and  extirpation.  The  former  consists  in  the 
in.sertion  of  an  ordinary  (small)  trocar,  which  is  thrust  in  from  below  upward,  care  being 
taken  that  its  point  avoid  the  testicle,  which  is  always  found  to  the  posterior  and  inner 
side  of  the  sac.  Through  this  trocar  the  contained  fluid  should  be  completely  evacuated, 
so  that  the  sac  is  practically  dry.  Into  it  is  now  injected  with  some  force  from  2  to  6  Cc. 
of  absolutely  pure  carbolic  acid,  after  which  the  trocar  is  instantly  withdrawn,  pressure 
made  upon  the  opening,  and  massage  made  upon  the  scrotum  and  the  contained  testicle, 


VARICOCELE  1019 

in  order  lo  disU-ihiitc  tlic  acid  fro(>ly  over  the  serous  siirrace.  lis  eirecl  is  to  completely 
sear  the  entire  surface  so  (hat  (lie  nioulhs  of  all  the  ahsorhcnts  are  closed.  In  tliis 
way  danjfer  of  carl)olic  |)oisonin<;'  is  (|uite  avoided,  a  danirer  which  would  he  iniininent 
were  the  acid  reduccui  in  strength.  Hut  little  pain  is  caused  by  the  procedure.  Its 
inunediate  (>IVect  is  (o  produce  exudate,  with  some  recurrence  of  swellino;,  which  ordinarily 
rapidly  absorbs,  while  (he  exudate,  coa^ulatin(>',  serves  to  j)ro(luce  obliteration  of  the 
cavity  of  the  sac.  This  is  the  carbolic  method  of  Levis,  who  introduced  the  acid  as  a 
sui)stitute  for  the  iodine  formerly  employed,  upon  which  it  was  a  great  im|)r()vement. 
Vor  cases  of  moderate  age,  whose  sacs  are  not  too  thick,  it  often  proves  satisfactory. 
Having  failed,  or  the  case  being  considered  not  adapted  lo  it,  the  other  method  is  that 
l)y  open  incision  and  extirpation. 

'I'his  open  nicf/iod  consists  in  making  an  incision  through  (he  skin,  down  upon  and 
into  the  sac,  which,  being  thus  instantly  evacuated,  will  collapse.  It  is  now  ])ossible 
to  make  a  more  or  less  complete  enucleation  of  the  sac  wall,  stripping  it  from  the  external 
tissues  to  which  it  adheres,  as  it  is  not  necessary  to  sej)arate  it  from  the  testicle  itself. 
It  has  been  found  that  when  the  major  portion  is  thus  removed  the  condition  is  effect- 
ually combated.  The  cavity  may  be  drained  with  silkworm  strands  or  witii  a  small 
tube,  but  only  for  a  short  time,  if  the  technique  have  been  correct. 

THE  SPERMATIC  CORD. 

The  cord  participates  essentially  by  its  contaiiu^d  vas  deferens  and  li/mphafir.s  in  the 
consequences  of  acute  and  chronic  infections,  travelling  in  either  direction,  and  thus 
it  may  be  involved  in  tuberculous,  syphilitic,  or  malignant  disease.  These  expressions, 
however,  are  secondary  and  the  conditions  have  been  described  above.  Encysted 
hydrocele  of  the  cord  implies  simple  dilatation  of  an  incompletely  obliterated  canal  of 
Nuck,  by  which  there  may  be  formed  along  the  cord  one  or  more  cystic  expansions, 
causing  tumors  rarely  attaining  a  size  greater  than  a  pigeon's  t:'^^,  which  are  innocent 
collections  of  fluid,  corresponding  to  the  ordinary  hydroceles  that  may  occur  below. 
They  are  ordinarily  not  difficult  of  recognition,  and  are  the  most  common  form  of  neo- 
plasms occurring  in  this  region.  They  are  amenable  to  the  same  treatment  as  that 
described  for  hydrocele. 

SPERMATOCELE. 

Spermatocele  implies  a  cystic  tumor  in  w^hose  contained  fluid,  no  matter  what  Its 
soiu'ce,  are  found  spermatozoa,  which  may  be  seen  alive  under  the  microscoj)e  if  examined 
innuediately  after  removal.  Spermatoceles  are  usually  found  at  the  lower  end  of  the 
cord  and  in  close  connection  with  the  testicle.  Their  occurrence  is  not  uncommon, 
but  somewhat  difficult  to  explain,  for  it  implies  connection,  at  least  at  some  time,  between 
the  structures  of  the  cord  and  a  more  or  less  displaced  seminiferous  tubule.  Spermato- 
celes are  rarely  diagnosticated  as  such  until  aspiration  or  evacuation  and  examination 
of  their  fluid  contents,  which  usually  are  of  a  milky  appearance.  In  general  they  are 
to  be  treated  like  any  other  cysts,  and  by  the  same  methods. 


VARICOCELE. 

This  exceedingly  prevalent  afl^ection  is  the  result  of  a  varicose  condition  of  the  pampini- 
form plexuses  and  of  the  spermatic  veins.  It  occurs  in  perhaps  10  or  12  per  cent,  of 
adult  males,  rarely  before  puberty,  and  almost  invariably  upon  the  left  side,  varicocele 
upon  the  right  side  being  as  rare  as  1  in  500  cases.  Its  confinement  to  the  left  side  is 
explained  partly  by  compression  of  the  left  spermatic  veins  beneath  an  overloaded  and 
distended  sigmoid,  and  by  the  disadvantage  at  which  the  blood  current  from  the  left 
spermatic  vein  emjities  into  the  vena  cava,  this  being  on  the  left  side  at  a  right  angle, 
while  on  the  right  the  angle  is  oblique.  It  has  occasionally  to  do  with  accident  or  injury, 
as  well  as  with  occupation  or  habit.  It  occurs  more  frequently  in  those  who  are  long 
in  the  saddle  and  in  those  w^ho  ride  the  bicycle  to  excess.     (See  Fig.  674.) 

Varicocele  is  usually  of  slow  development,  and  discovered  finally  by  accident  or. by 


1020 


SPECIAL  OR  REGIONAL  SURGERY 


attention  being  drawn  to  these  parts  tlirongli  (jvinck  advertisements  or  misleading  state- 
ments. The  eft'eet  is  to  produee  an  elongated  mass  of  varieose  veins,  often  deseribed 
as  feeling  like  a  "bag  of  angle  worms,"  oecupying  the  lower  ])()rtion  of  the  eord  and 
extending  down  upon  the  back  of  the  testicle.     In  the  more  advanced  cases  the  condition 

can  be  traced   almost  to  the  external  ring,  but  is 
Fi<;.  674  always  more   marked  low  down  than  higher  up. 

Sometimes  it  is  so  extreme  that  the  entire  group  of 
veins  corresponds  in  bulk  to  a  hen's  egg;  ordinarily 
it  is  but  a  fraction  of  this  size.  The  consequence 
is  increase  of  weight  and  production  of  dragging 
sensation  upon  the  cord,  often  referred  to  the 
back,  and  displacement  downward  of  the  testicle, 
with  consequent  elongation  of  the  scrotum,  which 
may  so  greatly  relax  that  it  appears  to  be  twice 
its  normal  length  and  contains  this  varicose  mass 
at  its  lower  extremity.  Such  a  condition  will 
naturally  produce  a  certain  degree  of  discomfort 
and  annoyance,  but  beyond  ihis  it  is  innocent, 
save  that  it  is  made  to  cause  much  mental  anxiety, 
mainly  through  ignorance,  and  has  led  thousands 
of  victims  to  quacks,  for  treatment  for  conditions 
dishonestly  represented  and  treated  as  both  dis- 
tressing and  extreme.  It  is  true  that  a  large  mass 
of  enlarged  veins  may  in  time  produce  some 
atrophy  of  the  testicle;  it  is  likewise  true,  also, 
that  virility  or  masculine  potency  may  be  to  a 
trifling  extent  limited  in  this  way.  It  is  not  true, 
however,  that  impotence  can  be  so  produced,  be- 
cause the  affection  is  limited  to  but  one  organ,  so  that  the  impotency  of  which  many 
men  complain  is  mainly  of  psychical  origin.     Such  individuals  need  explanations  and 


Varicocele.      (Hartmann.) 


Fig.  675 


Fig.  676 


Resection  of  scrotum  for  varicocele.     (Hartmann.) 


advice  as'  much   as  treatment,   although  it  is   difficult  to  elevate  many  of  them  from 
the  condition  of  sexual  hypochondria  into  which  they  gradually  fall. 


THE  SEMINAL   VESICLES  1021 

Treatment. — TrcJitnuMit  of  viiricocclf  may  Ik-  palliative,  i.  c,  it  may  consist  of 
su.s|)(-ii.si()ii  of  tiic  overloaded  tcstirlc  and  somewhat  n>laxrd  scrotum  within  a  well- 
httiii^-  .s-ii.s-/)r>i.'<ori/  haiidayi',  and  tiiis  suffices  for  most  mild  cases  in  normally  minded 
individuals.  When,  however,  the  condition  preys  dee|)ly  u|)on  the  mind  or  upon  the 
body,  or  when  it  is  a<'tually  and  anatomically  advanced,  then  radical  operation  is 
le<iitimate  and  humane.  Of  the  many  operations  recommended  in  time  past  only  two 
will  l)i>  described  here  lor  it  seems  to  me  that  all  subcutaneous  and  blind  methods 
are  bad  in  theory  as  in  practise. 

Exci.s-ion  of  the  rariro.se  veins  is  easily  performed  under  local  cocaine  anesthesia. 
It  is  done  by  incision  below  the  external  rino-,  over  the  com'se  of  the  cord,  the  con!  itself 
beino-  exi)osed  for  two  to  three  inches.  Here  the  enlari^cd  veins  aj)pear  usually  in  a 
group  (the  {)ampiniform  j)lexus),  and  as  such  can  be  i.solated  and  separated  from  the 
balance  of  the  cord,  it  being  essential  to  carefully  exriude  the  ras,  as  injury  to  or  division 
of  this  canal  would  naturally  be  followed  by  impotence  of  that  testicle.  The  veins 
involved  being  isolated  to  an  extent  of  two  inches,  are  ligated  above  and  below,  the  inter- 
vening portion  being  then  cxsected,  after  which  it  is  my  custom  to  utilize  the  catgut 
with  which  this  ligation  is  effected,  threading  it  on  each  side  into  a  needle,  using  each 
as  a  suture,  thus  ])roviding  two  sutures,  by  which  the  divided  ends  are  ai)proximated 
and  tied  together,  the  effect  being  to  bring  the  testicle  up  and  make  a  more  effective 
suspensory  of  the  cord  itself. 

Shortening  of  the  Scrotum.— To  the  above  procedure,  when  the  scrotum  is  much  elon- 
gated and  relaxed,  may  be  added  its  .shortening  by  a  .specie.s  of  amputation.  The  entire 
procedure  may  be  practised  as  follows:  The  scrotum  being  stretched  downward  is 
shortened  by  removing  one  and  a  half  to  three  inches  from  the  lower  end  of  the  scrotal 
pouch  of  skin  and  the  contained  connective  tissue,  including  the  septum.  In  this  way 
the  tunical  sacs  and  lower  ends  of  the  testicle  will  be  immediately  exposed.  The  left 
testicle  can  now  be  drawn  down,  and  the  operation,  described  above,  of  exsection  of  a 
portion  of  its  veins,  may  then  be  practised.  This  being  completed  the  scrotal  wound  is 
closed  with  sutures,  with  or  without  catgut  drainage.  The  effect  is  to  not  only  remove  the 
varicose  veins,  but  to  reduce  the  size  of  the  scrotum,  and  to  make  it,  as  it  were,  a  suspen- 
sory of  living  tissue  (Figs.  675  and  676). 

THE  SEMINAL  VESICLES. 

The  lower  ends  of  the  vasa  and  the  seminal  vesicles  themselves  suffer  most  commonly 
from  the  consequences  of  tuherculou.s  or  of  gonorrJieal  infection,  travelling  in  eithtr 
direction,  they  being  easily  invaded  from  the  prostatic  urethra  along  the  seminal  ducts. 
The  consequence  is  seminal  vesiculitis,  which  produces  a  more  or  less  tender  swelling, 
with  discomfort  referred  to  the  lower  end  of  the  rectum,  and  discoverable  by  digital 
examination  above  the  prostate.  When  the  vesicles  are  distended  or  infiltrated  they 
may  be  felt  with  the  finger  in  the  rectum.  In  addition  there  may  be  on  pressure  more 
or  less  discharge  of  ffuld  into  the  prostatic  urethra,  while  the  semen  when  emitted  may 
be  more  or  less  mixed  with  blood. 

It  is  necessary  usually  to  differentiate  between  prostatitis  or  prostatic  hypertrophy  and 
vesiculitis. 

Chronic  involvement  of  the  seminal  vesicles  may  be  best  treated  by  a  species  of 
massage  or  "milking,"  by  which  retained  contents  are  coaxed  along  the  ducts  and  into 
the  urethra.  Its  local  treatment  is  almost  impossible.  When  the  conditions  resulting 
from  infection  of  either  type  have  become  chronic  and  intractable  we  may  take  advantage 
of  recent  advances  and  decide  upon  removal  of  the  vesicles  by  operation.  Fuller  sug- 
gested that  this  l>e  done  by  putting  the  patient  in  the  knee-chest  position  or  a  modified 
Sims  position.  While  it  is  not  difficult  to  reach  the  vesicles  through  the  rectum,  the 
method  has  its  disadvantages  and  the  perineal  route  is  much  the  better.  The  operation 
is  then  effected,  much  as  is  prostatectomy,  by  perineal  opening  and  blunt  dissection 
between  the  rectum  and  the  prostate,  carried  upward  until  the  vesicles  themselves  are 
reached,  after  which  they  may  be  curetted  or  extirpated  by  a  process  of  enucleation. ^ 

J  In  the  treatment  of  infections  of  the  seminal  vesicles,  particularly  those  of  gonorrheal  oiigin,  Belfield  has 
ad\ased  irrigation  and  drainage  of  the  same  through  the  vas  deferens.  He  brings  this  up  against  the  skin  of 
the  scrotum,  where  it  is  easily  identified,  and  then,  through  a  one  to  two-inch  incision,  made  under  local  anesthesia, 


1022  SPECIAL  OR  REGIONAL  SURGERY 


SPERMATORRHEA. 


Accurately  defined  this  term  refers  to  the  e.scajK'  of  semen  under  abnormal  and 
involuntary  conditions,  an  occurrence  M'hich  is  of  jijreat  rarity.  Most  cases  of  so-called 
spermatorrhea  are,  in  effect,  but  the  escape  of  excessive  or  su[)erf]uous  amounts  of 
prostatic  muru.s  (pro.ftatorrlwa),  the  fluid,  whether  it  appear  drop  by  drop  or  in  consider- 
able (piantity,  bein^  mistaken  by  the  j)atient  for  semen.  Thus  with  the  extrusion  of  a 
hard  fecal  mass  there  may  be  sufficient  pressure  upon  the  prcjstate  t(j  express  from  it 
1  Cc.  or  more  of  this  fluid.  True  sjiermatorrhea,  on  the  other  hand,  rarely  occurs  except 
in  connection  with  disease  of  the  vesicles  or  prostate,  and  will  then  be  recognized  rather 
by  the  detection  of  spermatozoa  in  the  urine  than  from  any  phenomenon  noticeable  by 
the  patient.  All  statements,  therefore,  made  by  patients  to  the  effect  that  they  suffer 
from  involuntary  escape  of  semen  should  be  taken  with  the  greatest  allowance,  and 
will  usually  be  found  to  be  misleading. 

All  of  this  might  lead  up  to  a  considerable  discussion  of  matters  included  within  the 
domain  of  sexual  physiology  and  hygiene,  topics  which,  however,  canncjt  be  afforded 
space  in  the  present  work;  all  that  can  l)e  said  being  that  many  patients  are  in  need  of 
accurate  information  who  suffer  acutely  in  mind,  and  .sometimes  slightly  in  body,  for 
lack  of  it,  and  who  are  tempted  by  motives  of  delicacy  to  consult  quacks  and  charlatans 
rather  than  their  family  physician. 


CASTRATION. 

The  only  operation  of  importance  upon  the  external  genitals  not  yet  described  is 
that  of  castration,  i.  e.,  removal  of  the  testicle.  This  is  ordinarily  a  simple  procedure, 
rcfpiiring,  first,  incision  of  sufficient  length.  If  the  disease  condition  include  the  slightest 
infiltration  or  involvement  of  the  overlying  skin  a  little  or  the  greater  portion  of  it,  as 
required,  should  be  included  in  an  oval  incision,  in  order  that  it  may  be  totally  removed. 
The  testicle  and  its  coverings,  being  now  exposed,  are  to  be  loosened  from  all  their  sur- 
roundings, the  organ  pulled  down,  and  the  cord  brought  into  sight.  If  there  be  no  reason 
for  following  up  the  spermatic  cord  it  is  sufficient  to  surround  it  with  a  ligature  (chromic 
gut),  at  a  convenient  height  above  the  testicle,  after  which  the  cord  is  divided  below  it 
and  the  mass  removed.  In  most  instances,  however,  the  disease  which  calls  for  so 
much  operating  will  require  to  be  followed  up  along  the  cord,  and  perha])s  through  the 
inguinal  canal  down  into  the  pelvis.  This  is  done  by  continuing  the  incision  in  the 
proper  direction,  isolating  the  cord,  ligating  bleeding  vessels,  and  finally  dividing  the 
cord  itself  at  a  point  of  election  decided  to  be  above  the  disease.  Previous  generations 
were  hesitant  about  including  the  entire  cord  in  a  ligature,  for  fear  of  tetanus,  but  we 
now  know  that  if  the  technique  be  carefully  carried  out  there  need  be  no  fear  on  this 
score.  The  diseased  mass  being  removed  the  wound  is  closed,  with  or  without  catgut 
drainage  at  one  or  more  points,  as  may  be  indicated. 

exposes  the  vas,  into  which  the  blunted  end  of  a  liypodermic-syringe  needle  may  be  introduced,  by  means  of 
which  a  solution  of  any  desired  agent  may  be  injected.  This  being  thrown  in  the  direction  of  the  seminal  current 
passes  up  through  the  vas  and  into  the  vesicle.  He  has  even  recommended  in  certain  cases  to  attach  the  vas  to 
the  skin  by  a  fine  silkworm  suture,  and  in  this  way  to  make  a  minute  fistula,  which  can  be  used  for  the  purpose  as 
long  as  may  be  necessary.  He  considers  the  method  invaluaVjle  in  the  treatment  of  chronic  gfinorrlieal  vesiculitis 
or  the  chronic  infections  of  the  .seminal  canal  in  the  elderly,  which  are  often  mistaken  for  enlarged  prostate,  as 
well  as  in  cases  of  recurrent  epididymitis  resulting  from  repeated  inva.sion  from  behind.  Thus  he  has  seen  benefit 
follow,  in  tuberculosis  of  the  epididymis,  from  irrigation  with  carbolic  solution.  The  amount  injected  into  the 
vesicle  should  never  exceed  2  Cc. 


CHAPTER   LVII. 

AMPUTATIONS. 

A.Mi'l'TATlONS  arc  jicrformt'd  for  («)  the  results  of  iitjuri/,  (h)  the  re.sidt.s  of  difseaae, 
and  {(■)  removal  of  (Irfornilfi/  or  mulilation,  or  the  pos.sil)l('  rcsult.s  of  coiiircnital  defects. 
While  o-eiierally  tliey  arc  measures  of  necessity,  made  such  by  traumatism  or  l)y  actively 
advancintf  (Hsi-asc,  tliere  are  occasional  instances  where  an  individual  decides  that  an 
artificial  limb  will  be  more  useful  or  that  he  will  be  freed  from  an  intolerable  annoyance  by 
the  sacrifice.  The  principal  diseases  which  may  require  such  mutilaticni  are  the  exceed- 
ingly acute,  e.  g.,  osteomyelitis,  the  slower  destructive  forms  of  ulcer,  tuberculosis  or  of 
sepsis,  the  gangrene  caused  by  vascular  or  diabetic  conditions,  or  the  slow  involvement 
of  tumors,  usually  malignant,  but  sometimes  benign. 

When  a  serious  and  mutilating  injury  has  been  received,  if  there  have  been  complete 
crushing  of  a  limb  or  avulsion,  of  course  no  doubt  exists  as  to  the  necessity.  Amputation 
is  not  now  made  for  compound  fractures  nearly  as  often  as  in  former  times,  for  if  only 
the  vascular  supply  be  good  much  may  be  done  by  resection  of  bone  ends,  wiring,  or 
other  exjiedients;  and  the  attempt  should  always  be  made  to  save  a  limb  unless  it  appear 
that  even  should  the  effort  succeed  the  limb  itself  would  be  too  useless  to  justify  the 
attempt.  With  the  possibilities  of  modern  asepsis,  and  with  immediate  attention  to 
the  injury,  the  question  of  what  should  be  done  with  an  injured  limb  is  largely  a  question 
of  its  blood  supply.  Extensive  contusions  with  lacerations  do  not  of  themselves  necessi- 
tate amputation,  neither  does  injury  to  the  skin  unless  it  be  most  extensive. 

It  is  unfortunate  when  vacillation  or  any  misguided  effort  at  conservatism 
call  for  great  delay.  While  this  may  sometimes  be  advantageous,  at  other  times 
the  favorable  moment  has  passed  before  permission  to  amputate  may  be  obtained. 
Should  delay  seem  advisable  the  surgeon  should  use  his  best  endeavor  to  effect  suitable 
antisepsis,  to  provide  physiological  rest,  and  to  preserve  the  circulation,  all  of  which 
require  a  thorough  antiseptic  technique,  which  will  include  the  removal  of  blood  clot, 
of  fragments,  and  of  all  tissue  which  evidently  cannot  live,  and  suitable  splinting  or 
its  equivalent,  and  of  everything  that  can  be  done  by  local  warmth  and  general  stimu- 
lation to  maintain  the  vigor  of  the  circulation.  When  once  infection  has  occurred,  and 
especially  been  allowed  to  spread,  the  possibility  of  recovery  inheres  only  in  immediate 
amputation. 

Such  mutilations  as  necessitate  immediate  amputation  are  usually  accompanied  by 
])rofound  degrees  of  shock,  as  well  as  perhaps  by  other  complicating  injuries,  whose 
existence  may  change  the  whole  complexion  of  the  case.  For  example,  with  a  patient 
suffering  from  probably  fatal  fracture  of  the  skull  one  would  hardly  seriously  discuss  the 
matter  of  Immediate  amputation  of  a  foot;  nevertheless  he  should  take  such  care  of  the 
local  lower  Injury  as  to  permit  operation  to  be  done  under  still  favorable  circumstances 
should  the  head  condition  justify  It.  Wide  discretion  Is  therefore  called  for  In  all  these 
cases.  Furthermore  the  condition  of  lowered  blood  ])ressure  or  shock  may  be  so  extreme 
that  the  operator  Is  compelled  to  delay,  for  at  least  a  certain  time,  In  order  that  by  the 
employment  of  those  measures  already  considered  In  the  chapter  on  this  subject  the  cir- 
culation may  be  sufficiently  restored  to  make  It  adequate  for  the  purpose,  remembering 
that  scarcely  anything  predisposes  to  Infection  more  than  such  lowered  vitality.  W^hile 
resorting  to  general  stimulation,  hypodermoclysls,  or  Infusion,  with  or  without  adrenalin, 
the  use  of  such  antiseptics  should  not  be  omitted,  as  the  local  condition  may  require  in 
order  to  combat  what  otherwise  may  be  actively  occurring. 

Am[)UtatIons  are  sometimes  referred  to  as  ti/pical,  when  done  according  to  long- 
established  methods,  or  atypical,  when  the  entire  procedure  Is  planned  to  fit  the  necessities 
of  the  case.  Amputation  at  a  joint  Is  usually  spoken  of  as  disarticidation.  Amputations, 
again,  are  classified  as  (a)  immediate,  i.  e.,  before  complete  reaction  from  shock  or  within 
the  first  few  hours;  (b)  primary,  when  done  after  reaction  has  occurred,  but  before  visible 

( 1023 ) 


1024  SPECIAL  OR  REGIONAL  SURGERY 

occurrence  of  inflammatorv  chaiifjcs,  (r)  intermcdiaic,  as  done  when  suppuration  is 
threatenino;,  but  before  its  actual  occurrence;  (r/)  .srcomlari/,  i.  e.,  after  the  occurrence  of 
suppuration. 

The  conirnl  of  honorrliage  is  one  of  the  most  conspicuous  and  necessary  features  of 
any  amjjutation  method.  Below  the  shoulder  and  at  the  hip  this  may  be  effected  by 
the  old-fashioned  toiirniquef,  or  the  modern  elastic  bandage,  which  may  or  may  not  be 
combined  with  the  more  complete  bloodles.s  method  with  which  Esniarch's  name  will 
always  be  connected.  The  pure  rubber  <jum  bandage,  1  believe,  was  introduced  by 
Martin,  of  Boston,  but  the  method  of  its  use  for  bloodless  operations  upon  the  extremities 
is  to  be  credited  to  Esmarch.  The  surjjeon  may  avail  himself  of  this  method  in  all 
suitable  cases,  but  should  never  resort  to  it  in  septic  or  malignant  disease.  It  includes 
the  application  of  a  Martin  elastic  bandatje  from  the  tip  of  the  extremity  to  the  necessary 
height,  by  turns  which  shall  make  gentle  and  equable  pressure,  gradually  forcing  the 
blood  from  the  compressed  tissues  and  out  of  the  limb,  and  up  to  a  height  where  another 
elastic,  or,  at  all  events,  suitable  constricting  band  is  placed  with  a  sufficient  degree  of 
tightness  to  completely  shut  off  access  of  blood.  To  so  apply  a  bandage  in  septic  and 
malignant  cases  would  be  to  coax  septic  and  malignant  material  into  the  veins,  and  would 
evince  the  worst  j)ossible  judgment.  A  sufficiently  strong  rubber  tubing  forms  an 
effective  tourniquet,  which,  however,  should  be  a])plied  over  a  folded  towel,  or  in  some 
manner  so  that  it  does  not  too  deeply  constrict  and  compress  the  soft  tissues  of  the  limb. 
Instead  of  tying  a  knot  it  may  be  secured  with  an  ordinary  clamp  forceps. 

The  tourniquet  should  never  be  applied  over  the  leg  or  forearm,  for  it  can  here  make 
no  impression  upon  the  interosseous  vessels.  Its  application  should  be  begun  by 
pressure  upon  the  vascular,  i.  e.,  the  adductor  side  of  the  limb,  so  that  venous  choking 
may  be  avoided.  After  it  is  once  in  place  the  limb  should  not  be  completely  flexed  nor 
extended,  lest  the  tissues  firmly  enclosed  by  the  constriction  be  more  or  less  spontaneously 
torn;  nor  should  the  tourniquet  be  too  long  left  in  place,  as  injury  to  the  vessels  is  the 
possible   result. 

The  bloodless  method  of  Esmarch  is  furthermore  sul)jcct  to  the  following  disadvan- 
tages. It  is  sometimes  followed  by  serious  and  permanent  paralysis  of  the  limb,  the 
result  of  prolonged  or  excessive  constriction  and  compression  of  the  motor  nerve  trunks. 
Similar  results  (in  the  arms)  follow  the  use  of  crutches  as  well  as  of  pressure  of  the  side 
of  the  operating  table  when  the  limbs  are  allowed  to  hang  over  it.  Again  after  removal 
of  the  bandage  there  is  sometimes  most  pronounced  capillary  oozing  due  to  vasomotor 
])aresis.  This  may  be  controlled  by  the  stimulation  of  hot  irrigation  or  apj)lications,  and 
l)y  more  or  less  massage  of  the  limb.  The  dangers  of  forcing  undesirable  material 
into  the  circulation  have  been  mentioned,  in  addition  to  which  should  be  recorded  the 
increased  absorption  of  toxic  substances. 

When  there  is  good  reason  for  not  using  the  elastic  bandage,  save  as  a  tourniquet, 
much  of  the  desired  effect  may  be  otained  by  holding  the  limb  for  a  few  minutes  in  a 
vertical  position,  so  that  its  contained  blood  is  drained  out  of  it  by  gravity,  after  which 
the  tourniquet  may  be  applied  as  before. 

The  ct)cainization  of  nerve  trunks,  as  they  are  exposed  and  divided,  is  one  of  the  new 
measures  for  the  prevention  of  shock  for  which  we  are  largely  indebted  to  Crile.  It 
has  ])roved  to  be  a  most  valuable  expedient  which  should  not  be  neglected.  (See 
Chapter  XVIII.) 

Under  modern  methods  more  is  expected  of  an  amputation  stump  than  in  days  gone 
by,  and  the  first  demand  is  that  it  shall  be  useful,  to  which  end  it  is  necessary  that  it 
be  both  movable  and  that  its  end  be  not  too  irritable,  nor  the  scar  too  sensitive  to  stand 
at  least  a  certain  amount  of  pressure.  It  is  expected  that  suitable  prosthetic  apparatus, 
/.  e.  artificial  limbs,  shall  take  the  place  of  severed  lower  extremities  and  of  most  arms 
or  hands  removed.  The  .skill  and  the  mechanical  ingenuity  of  the  maker  of  artificial 
limbs  have  noAV  reached  a  point  where  most  acceptable  substitutes  are  thus  providefl, 
but  for  them  suitable  stumps  should  be  afforded  by  the  surgeon,  and  there  should  be 
cooperation  from  each  direction.  Thus  it  used  to  be  held  that  the  bone  end  in  every  stump 
should  be  covered  with  i)eriosteum,  yet  it  has  been  recently  shown,  especially  by  Hirsch, 
that  such  bone  ends  are  as  acceptable,  and  perhaps  more  so,  when  stripped  of  rather  than 
covered  with  this  membrane,  the  latter  Ixing  sensitive,  and  there  being  no  advantage  in 
the  presence  of  such  new  bone  as  may  be  formed  by  its  preservation. 

Many  a  good  stump  may  be  molded  in  various  ways,  but  always  provided  that  the  end 


.4  MPUTA  riOSS  1025 

of  the  l)()iu>  l)t'  smoothly  divided,  and  have  no  corners  or  osteoj)hytic  outi^row  tlis  to 
make  |)ressure  upon  the  sensitive  sear.  For  this  reason  it  should  he  mani|)uhited  as 
early  as  |)ossil)le,  and  should  not  he  allowed  to  under^'o  the  atrophy  noticeable  in  stumjjs 
left  after  old  opi-rations.  If  primary  union  he  (^ained,  so  lon<r  as  the  cicatrix  and  the 
nerve  ends  he  kept  out  of  the  way,  one  may  (  xpect  a  stumj)  which  is  scrviceahle  in  every 
respect.  The  ideal  method  is  that  the  skin  and  the  periosteum  should  retain  their 
normal  relationship,  an  ideal  best  attained  in  the  supracondyloid  operation  after  Gritti's 
method.  N'arious  osteo|)lastic  metlKjds  have  been  devised,  first  by  Walther,  in  1813, 
and  since  him  especially  by  Oilier,  Pirogoff,  Gritti,  and  Bier.  The  latter  would  cover 
every  bone  end  not  merely  with  periosteum,  but  with  a  bone  flap  so  arranged  that  its 
lower  surface  is  one  normally  covered  by  periosteum.  The  introduction  oi  the  a:-rays  has 
|)ermitted  a  more  thorough  study  of  bone  ends  in  stumps  which  are,  on  one  hand, 
extremely  tender,  or,  on  the  other,  extremely  serviceable,  and  the  (xsteoj)lastic  methods 
seem  to  conduce  to  the  latter  condition.  Another  matter  of  great  imj)ortance  is  to  so 
pUwe  the  •scar  fitaf  if  .shall  be  neither  subject  to  pressure  nor  to  traction.  If,  therefore, 
the  sawed  surfaces  be  covered  with  a  periosteum  which  shall  retain  its  normal  relation 
to  its  coverings,  a  minimum  of  disturbance  in  the  scar  is  the  result. 

The  value  of  early  use  of  the  stump  and  of  accustoming  it  to  pressure  is  considerable, 
as  atrophic  stumps  arc  tender,  like  other  disused  parts,  and  there  is,  therefore,  every 
reason  for  resorting  to  prosthetic  apparatus  as  early  as  possible.  As  Kocher  puts  it, 
the  following  is  the  best  jirocedure  f()r  the  normal  operation:  "An  oblicjuc  incision, 
combined  if  necessary  with  a  longitudinal  one,  in  the  form  of  a  racket  or  lanceolate 
incision  through  skin  and  fascia.  After  retracting  the  elastic  skin  the  muscles  are  dividend 
obli(jUely  down  to  the  bone.  The  periosteum  is  also  to  be  divided  obliquely.  Peri- 
osteum is  then  separated  along  ^vlth  the  superficial  layer  of  the  cortex  of  the  bone,  by 
means  of  a  sharp  raspatory  or  chisel,  or,  when  possible,  a  flap  of  bone  having  a  movable 
periosteal  hinge  is  made  by  means  of  the  saw\  Lastly,  if  only  a  thin  shell  of  the  cortex 
have  been  raised  up  along  with  the  periosteum,  the  end  of  the  bone  is  simply  rounded  off, 
while  if  a  distinct  flap  of  bone,  by  any  osteoplastic  method,  have  been  divided,  the  end 
of  the  bone  must  be  sawed  in  a  curved  direction  so  as  to  fit  it.  The  periosteal  or  bony 
flap  is  sutured  over  the  sawed  surface  of  the  bone  to  its  periosteum,  and  the  stumps  of 
the  muscles  or  tensions  are  sutured  to  each  other,  or  to  the  surface  of  the  bone  at  a 
distance  from  the  sawed  surface.  Finally  the  skin  and  fascia  are  sutured;  but  in  case 
where  a  periosteal  flap  or  flap  of  bone  and  periosteum  cannot  be  obtained  in  normal 
relation  to  other  soft  parts  it  is  better  to  remove  the  periosteum  entirely  from  the  end 
of  the  stump,  to  scrape  out  the  medullary  cavity,  and  to  round  off  edges  of  the  bone  as 
dentists  do." 

While  these  methods  give  better  results  than  those  formerly  in  vogue,  they  also  con- 
sume more  time;  but  the  days  of  brilliancy  and  rapidity  in  amputation  are  past,  as  time 
should  be  devoted  to  careful  work,  except  only  in  those  cases  where  emergency  demands 
the  most  rapid  and  dexterous  removal  of  a  limb  in  the  shortest  possible  time,  and  where 
every  other  consideration  is  sacrificed  to  the  principal  interest  of  preserving  life.^ 

'  The  following  is  taken  from  the  article  of  Professor  Matas  in  tlie  third  edition  of  "Surgery  by  American 
Autliors."     It  furnishes  a  brief  but  admirable  introduction  to  the  general  study  of  amputation  methods: 

"From  Hippocrates  to  the  time  of  Celsus  the  surgeon  simply  followed  in  the  wake  of  Nature,  never  venturing 
to  apply  the  knife  for  the  removal  of  a  limb  except  within  the  limits  of  the  mortified  tissues;  and  this  seems  to 
have  prevailed  for  at  least  four  hundred  years.  Celsus,  the  prince  of  Roman  physicians,  who  lived  shortly  after 
the  time  of  Christ,  introduced  the  first  innovation  by  cutting  down  to  the  bone  between  the  living  and  the  dead 
tissues.  It  is  probable,  according  to  the  e\ndence  furnished  by  his  writings,  that  he  was  aware  of  the  value  of  the 
ligature  and  that  he  applied  it  to  control  bleeding  vessels.  Archigenes,  following  closely  after  Celsus,  was  the  first 
to  attempt  prophylactic  hemostasis  by  applying  a  cord  or  band  around  the  limb  to  control  the  hemorrhage  during 
the  amputation.  With  the  fall  of  the  Roman  empire  and  the  advent  of  the  long  night  of  the  middle  ages  the 
Celsian  method  was  lost  in  the  general  darkness  and  the  old  Hippocratic  doctrines  survived,  and  were  maintained 
by  the  all-potetit  influence  of  Galen  and  his  Arabian  commentators.  As  late  as  the  middle  of  the  seventeenth 
century  the  only  hemostatic  was  the  actual  cautery  and  boiling  oil,  though  Guy  de  Chaulia<'  had  revived  the  teach- 
ing of  Archigenes  by  constricting  the  limb,  on  a  level  with  a  joint,  with  a  cord  which  was  allowed  to  remain  in 
situ,  to  ensure  not  only  hemosta.«is,  but  a  certain  mortificatir)n  of  the  stump.  In  nutting  limbs  huge  chisels  and 
mallets  were  u.sed.  At  this  iieriod  Bf>talli  invented  his  guillotine,  consisting  of  a  sharp,  heavy  axe,  which,  being 
allowed  to  fall  from  a  height  upon  the  limb,  severed  it  instantaneously  at  a  single  blow.  The  re\-ived  or  inde- 
pendent rediscovery  of  the  ligature  by  Ambrose  Par<?  in  1.579,  and  the  discovery  of  the  circulation  of  the  blood  by 
Harvey,  in  1628,  led  to  the  invention  of  Morel's  tourniquet  (1674"),  more  commonly  known  as  the  Spanish  wind- 
lass, and  to  the  familiar  instrument,  Pettit's  tourniquet,  which  (introduced  in  1718)  perfected  the  means  of  securing 

65 


1026  SPECIAL  OR  REGIONAL  SURGERY 


AMPUTATION  METHODS. 


With  a  view  to  simplifying  this  subject  us  much  as  possible  the  following  methods 
alone  will  be  considered:  (1)  The  ci/ru/ar  with  its  modifications,  the  oblique,  the  ellip- 
tical, the  ovoid,  etc.;  (2)  the  flap  method;  (3)  the  mixed  or  skin  flap  and  deep  circular. 

Choice  of  method  sometimes  leaves  much,  sometimes  nothing,  to  the  tastes  or  wishes 
of  the  operator.  It  should  be  based  solely  on  the  primary  consideration  of  saving  life 
and  the  secondary  consideration  of  furnishing  the  most  useful  possible  stump.  To  obtain 
the  latter  it  is  necessary  that  the  bone  be  amj)ly  covered,  except  that  its  ccnerings  be  not 
adherent,  that  there  be  a  minimum  of  disturbance  of  blood  supply,  that  nerves  be  drawn 
down  and  divided  as  far  from  the  stump  end  as  possible,  in  order  that  they  may  not  be 
entangled  in  the  scar,  and  that  the  scar  be  so  planned  for  and  arranged  that  it  shall 
be  at  one  side,  at  all  events  in  such  position  that  no  pressure  shall  be  made  upon  it,  and, 
if  possible,  also  no  tension  by  muscle  action. 

Elasticity  of  skin  and  contractility  of  the  muscles  vary  much  in  different  individuals, 
and  it  is  not  always  easy  to  estimate  either  of  them  previous  to  their  division.  Conse- 
quently it  is  much  better  to  make  cuffs  or  flaps  too  long  at  first  rather  than  too  short. 
The  existence  of  previous  disease  will  always  modify  these  local  conditions,  but,  in 
general,  the  rule  is  laid  down  that  the  external  flaps  should  be  longer  than  the  bone 
by  from  one-third  to  one-half  the  diameter  of  the  limb. 

1.  Circular  Method. — The  simple  circular  method  is  the  simplest  and  easiest  of  all. 
It  may  be  so  performed  as  to  furnish  a  solid  musculotegumentary  division,  or  skin  cuffs 
may  be  made,  which  being  turned  up,  permit  a  further  circular  division  of  the  muscles 
and  other  tissues  directly  down  to  the  bone.  The  former  is  preferable  when  possible. 
With  an  ordinarily  long  amputating  knife  the  skin,  down  to  and  including  the  superficial 
fascia,  is  divided  by  one  clean  circular  incision,  made  in  one  stroke;  then  by  further 
circular  cuts  the  muscles  are  divided  in  sections,  the  outer  group  being  allowed  to  retract 
and  expose  the  deeper  layers,  which  are  then  di\i(led  at  a  higher  plane.  In  this  way 
the  periosteum  is  reached.  If  sufficient  time  be  afforded  it  may  be  circularly  divided 
at  the  level  of  the  last  incision  through  the  muscles,  and  then  separated  with  a  strong 
elevator  or,  as  done  by  Kocher,  with  a  chisel,  in  order  that  some  portion  of  the  exterior 
of  the  bone  be  raised  with  it.  In  this  way  a  cuff  of  periosteum,  or  enough  of  it  to  cover 
the  bone  end,  is  detached  upward,  to  the  level  where  the  bone  itself  is  finally  divided. 
The  bone  division  is  done  with  the  ordinary  amputating  saw,  or  with  the  wire  or  chain 
saw. 

The  skin-cuff  (Manchette)  method  differs  in  that  the  exterior  flaj)  is  made  wholly 
of  skin,  which  is  dissected  as  a  cuff  nearly  tip  to  the  level  of  bone  section,  at  which 
point  the  muscles  are  divided  directly  down  to  the  bone.  In  this  method  the  skin,  fat, 
and  superficial  fascia  should  be  raised  together,  and  at  no  points  separated  from  each 
other. 

Modification  of  the  cuff  method,  by  which  it  is  more  easy  to  evert  the  circular  flap, 
is  made  by  one  or  two  vertical  incisions,  by  which  the  cuft"  is  split  some  distance  on  one 
or  both  sides,  thus  transforming  the  cuff  proper  into  two  nearly  square  skin  flaps.  At 
other  times  the  first  method  may  be  similarly  modified,  in  which  case  we  have  to  deal 
with  two  square  flaps,  including  not  only  the  skin,  but  all  the  tissues  down  to  the  bone. 

Neudorfer  still  further  modified  the  circular  method  for  certain  purposes  by  first 
making  an  incision  along  the  outer  or  least  vascular  part  of  the  limb,  carrying  the  knife 
directly  down  to  the  bone,  retracting  the  wound  edges,  and  thus  exposing  the  bone, 
wliich  is  then  divided  with  a  chain  or  Gigli  saw.  After  the  bone  is  divided  the  soft 
coverings  are  lifted  to  a  sufficient  distance  below  the  saw  line  to  ensure  ample  covering, 

prophylactic  and  direct  hemostasis.  From  this  time  onward  the  treatment  of  the  stump  began  to  receive  more 
systematic  attention.  Instead  of  merely  chopping  off  a  Umb,  the  soft  parts  were  detached  from  the  bone,  so  that 
this  could  be  sawed  off  at  a  higher  level,  in  order  to  avoid  the  conical  f)rojection  of  the  stump  which  invariably 
resulted  when  the  primitive  methods  were  adopted.  All  the  methods  of  amputation  that  followed — and  these 
were  numerous — aimed  chiefly  at  celerity,  to  reduce  the  pain  of  the  operation  to  a  minimum;  hence  the  rapid, 
circular  section  of  the  soft  parts  or  the  rapid  transfixion  methods  which  were  so  much  popularized  by  the  brilliant 
work  of  Liston,  Lisfrane,  Desault,  Dupuytren,  Langenbeck,  and  others.  These  finally  yielded,  in  this  modern 
I)eriod,  to  less  rapid  but  more  conservative  and  perfected  methods,  which  aim  chiefly  at  the  preservation  of  useful 
tissue  and  at  securing  the  very  best  functional  prosthetic  stump  for  the  patient.  Such  methods  could  only  be 
perfected  after  the  advent  of  anesthesia  and  antisepsis." 


AMl'lTA  TIOS  METHODS 


1027 


then  divided  as  above.  The  method  is  a  .slow  one  and  is  esf)ecially  serviceable  for 
ampiitatioii  of  the  thi<jh,  at  its  niiddle,  for  diabetic  or  senile  gangrene,  where  it  is  so 
(K'siral)le  to  [irotect  vascular  supply  from  injury  (Fig.  677). 

The  so-called  elliptical  method  is  practi<'ally  a  circular  incision  carried  obliquely 
around  the  limb,  the  upper  and  lower  ends  of  the  ellipse  being  indicated  by  j)revious 
small  incisions  at  the  proper  height.  The  skin  and  supcrhcial  fascia  are  retracted  from 
the  lower  portion  of  the  ellipse  by  turning  them  up  to  the  level  of  the  highest  point,  at 
which  U'vcl  till-  muscles  are  divicled  transversely  by  a  j)lain  circular  incision.  A  modi- 
fication of  this  method  is  the  so-called  omid  or  rncket,  which  is  simi)ly  an  oval  division 
with  a  pointed  end,  the  margins  of  the  flap  being  united  in  the  long  axis  of  the  bone. 
This  method  is  frequently  applied  in  amputation  of  the  fingers.     (See  Fig.  683.) 

2.  Flap  Methods.  —  Fhqjs  are  either  cutaneous  or  musculocutaneous.  In  every 
ca.se  the  skin  surface  mu.st  be  larger  than  the  muscular.  They  are  objectionable  in  that 
the  skin  Ha|)  is  apt  to  slough,  although  least  so  about  joints.  The  fla])  method  is 
advantageous  in  that  one  fla})  may  usually  be  made  much  longer  than  the  other,  and 
the  longer  one  .so  doubled  over  at  its  end  as  to  place  the  .scar  out  of  harm's  way.  In 
certain  injuries  where  the  skin  is  much  more  injured  on  one  side  of  the  limb  than  on 
the  other  the  operator  is  compelled  to  resort  to  flaps,  unless  he  divide  the  limb  much 

Fig.  677 


Neudorfer's  method  of  amputation  by  primary  division  of  the  bone,  before  sliapingthe  flaps.  Neudorfer  used 
the  chisel,  but  one  may  use  the  Gigh  saw  with  special  advantage  in  performing  tliis  operation.  The  method 
is  applicable  to  any  portion  of  the  upper  or  lower  e.xtremity,  especially  in  the  continuity  of  the  long  bones. 
(Matas.) 

higher  than  might  otherwi.se  be  demanded.  Double  flaps  may  be  anteroposterior  or 
lateral.  A  double  flap  practically  results  from  a  circular  incision,  carried  through  to 
the  bone,  with  lateral  division  on  either  side,  while  a  double  flap  with  one  long  member 
may  be  similarly  furnished  by  an  oblique  circular  incision  with  the  lateral  prolongations. 

Flaps  may  be  formed  by  transfixion,  for  which  purpose  a  long,  sharp,  amputating 
knife  is  required.  Inasmuch  as  it  makes  an  oblique  and  irregular  division  of  the 
principal  vessels,  which  are  in  consequence  more  difficult  to  secure,  and  by  which  nutrition 
of  flaps  is  endangered,  it  is  not  to  be  commended,  save  perhaps  in  certain  amputations 
about  the  wrist.  A  better  method  of  making  the  flap  is  to  (livide  the  .skin  and  fascia 
with  an  ordinary  stout  .scalpel,  and  then,  permitting  them  to  retract,  to  divide  the  mu.scles 
obliquely  toward  the  bone  in  such  a  way  as  to  leave  a  flap  wedge-shaped  at  its  ba.se. 
The  anteroposterior  amputations  of  the  foot,  thigh,  and  arm  are  better  performed  in 
this  way,  each  flap  being  in  length  preferably  three-fourths  the  diameter  of  the  limb. 
(Matas.)  An  exten.sion  of  this  method  furnishes  the  possibility  for  various  subperiosteal 
amputations  to  be  described  below^ 

The  osteoplastic  methods  of  today  furnish  desirable  operative  procedures.  One  of 
the  earliest  of  the  good  ones  was  Teale's  method,  as  applied  to  the  leg,  of  double  quad- 
rangular flaps,  the  anterior  being  much  the  longer.     A  minor  degree  of  this  work  Includes 


1028 


SPECIAL  OR  RKdlONAL  SUIUJERY 


simply  the  |) reservation  of  a  cutt"  of  jKM-iostruni,  which  is  supposed  to  afford  j)r()tecti()n 
to  the  marrow  cavity  and  a  smoothly  rounded  hone  end,  without  adhesions  to  the  over- 
lyinfi;  soft  parts;  but  much  more  comj)lete  o])erations  are  afl'orded  by  I'irogoff's  ampu- 
tation at  the  heel,  and  by  Wladimiroff  and  Mikulicz's  amputation  of  tlie  foot  (j)ractically 
an  exsection  of  the  heel),  or  by  Gritti's  and  the  other  methods  of  supraconclyloid  knee 
amputation,  with  ])reservation  of  the  patella.  Bier  and  other  forei<;n  and  donuvstic 
surgeons  have  also  devised  methods  of  reflecting  or  raising  bone  flaps  from  the  continuity 
of  bone  shafts,  which,  being  still  connected  by  ])eriosteal  bridges,  are  so  turned  and 
fastened  in  j)lace  as  to  furnish  a  complete  bone  end  over  the  stump  (Figs.  ()7<S  and  (379). 

The  choice  of  method  must  depend,  to  a  large  extent,  on  the  character  of  the  case. 
Some  injuries  will  leave  parts  so  exposed  that  a  portion  of  a  limb  can  still  be  utilized  if 
only  flaps  be  cut  in  an  atypical  way.  One  need  never  hesitate  to  resort  to  these,  especially 
about  the  hand  and  upper  extremity,  where  it  is  so  desirable  to  save  every  inch  of  tissue. 
It  is  not  necessary  to  preserve  every  possible  inch  of  tissue  in  the  foot  and  leg,  as  the 
makers  of  artificial  limbs  can  adapt  an  artificial  leg  to  any  kind  of  a  stump.  The  intent 
in  making  these  statements  is  that  while  it  is  best  to  follow  conventional  methods  imder 
ordinary  circumstances,  there  need  be  no  hesitation  in  departing  from  them  when 
occasion  demands  it. 


Fig.  678 


Fig.  079 


Bier's  osteoplastic  amputation  of  the  leg  (procedure 
advocated  by  Bier  in  1897  and  1899):  F,  long  anterior 
flap  reflected  on  the  tibia;  .4 ,  cross-section  of  tibia; 
B,  periosteal  flap  after  excision  of  intervening  section 
of  bone;  C,  osteoperiosteal  flap;  D,  projecting  border 
of  periosteum  to  be  sutured  to  tibial  ijeriosteum. 


Bier's  osteoplastic  amputation  of  the  leg,  with  osteo- 
periosteal flap  in  position. 


It  is  essential  in  caring  for  every  stump,  after  the  actual  amputation  has  been  per- 
formed, (1)  that  bleeding  be  absolutely  controlled;  (2)  that  nerve  ends  be  placed  out  of 
the  way  of  cicatricial  entanglement;  (3)  that  proper  drainage  be  provided;  (4)  that  the 
soft  parts  be  so  brought  together  as  to  unite  in  the  promptest  and  most  perfect  fashion. 
The  possibility  of  the  latter  will  depend  very  much  on  the  occasion  for  the  operation 
and  the  condition  of  the  tissues.  Operating  in  the  presence  of  previous  disease,  as  when 
the  parts  are  inflamed  or  edematous,  or  as  when  one  amputates  at  a  point  where  more 
or  less  sloughing  and  separation  of  tissues  have  already  occin*red,  the  surgeon  cannot 
look  for  such  primary  repair  as  furnishes  an  ideal  termination,  nor  should  he  endeavor 
to  make  such  close  suturing  or  approximation  as  he  would  otherwise  attempt.  In 
fact,  under  these  circumstances,  it  is  often  desirable  to  leave  the  wound  widely  open, 
perhaps  packing  it  with  yeast,  in  order  to  hasten  sloughing  and  secure  healthy  granulating 
surfaces,  which  may  be  then  brought  together  by  secondary  suture  or  by  suitable  strapping 
and  bandaging.  Nothing  worse  can  happen  than  imprisonment  of  the  debris  resulting 
from  the  sloughing  process. 

But  an  amputation  wound  made  with  faultless  technique,  and  in  tissues  previously 
healthy,  may  be  closed  with  a  minimum  of  drainage,  or  often  without  any,  providing  it 
be  so  closed  as  to  leave  no  dead  spaces  in  which  blood  clot  may  accumulate.  This 
requires  careful  s-ufuring,  by  numerous  buried  sutures,  of  muscle  to  muscle,  tendon  to 
tendon  or  to  periosteum,  and  the  like,  the  wound  being  gradually  closed  from  its  depth, 
and  finally  so  bandaged  that  equable  pressure  shall  be  made,  with  comfortable  support, 


AMPl'T.\TIOS^  OF   rill-:   rPPER   EXTREMITY 


1029 


l)ii(  without  tiinliic  pressure  at  any  point.  In  aseptic  eases  aniinai  li<;atures  and  sutures 
(ehrouiie  ^iit)  will  |)r(>ve  reliable  and  efficient.  In  septic  cases  it  would  prol)al)ly  he 
better  to  trust  to  (secondary)  silk,  especially  if  parts  are  to  be  lonjf  ex|)Osed,  so  that  it 
can  be  later  removed.     For  tlie  superficial  wound  silkworm  sutures  answer  udniirably. 

For  drainage  a  ijauze  packinti,'  for  tlie  worst  cases,  one  or  two  tubes  for  ordinary  cases, 
and  for  those  wliicli  scarcely  need  it  strands  of  catfijut  or  of  silkworni-<^ut,  or  two  or  three 
little  rolls  of  oiled  silk,  will  be  sufHcient. 

In  this  country  Link  and  in  (Jerniany  Crede  have  practised  the  method  of  brinjrinci; 
parts  toj^ether  merely  by  ecjuable  pressure  and  l)an(la<>in^.  'I'his  has  been  of  lato  modi- 
tied  l)V  the  use  of  strips  of  sterile  adhesive  j)laster;  and  in  certain  instances,  evervthino; 
else  favorinif,  it  has  <>;iven  (i;ood  results.  It  mii:;ht  l)e  advantageously  adopted  in  cases 
where  it  is  feared  tiiat  it  may  be  necessary  to  reoj)en  tiie  wound,  as  it  would  permit  an 
easy  method  of  so  doing. 

Dressings  should  be  copious  and  snugly  applied,  and  the  limb  involved  should  be 
immobilized.  Thus  after  a  leg  amputation  it  is  well  to  bind  the  leg  and  thigh  upon  a 
suitably  arranged  splint,  physiological  rest,  which  is  so  essential  to  success,  being  in 
this  way  attained.     The  same  is  also  true  of  the  arm. 


AMPUTATIONS  OF  THE  UPPER  EXTREMITY. 

Amputations  of  the  Finger  and  Thumb.— It  is  desirable  in  the  upper  extremity 
to  save  every  portion  which  can  be  preserved  and  still  made  useful.  This  is  particularly 
true  of  the  fingers,  where  every  half-inch  adds  to  their  usefulness.  When  it  is  possible 
the  palmar  surface  should  be  saved  and  made  to  cover  the  stump  end,  as  it  is  not  only 
more  sensitive  but  denser  and  stands  wear  better.  This  is  equally  true  of  disarticula- 
tions or  of  divisions  between  the  joint  ends  of  the  phalanges,  which  are  best  exj)osed 
by  bending  the  finger,  cutting  the  dorsal  flap  in  this  position,  then  stretching  it  and 
cutting  the  palmar  flap  (Fig.  G80). 

The  vessels  and  nerves  lying  on  the  lateral  aspect  should  be  secured  against  hemor- 
rhage, and  cocaine  solution  introduced  if  local  anesthesia  is  being  practised.  It  is 
important  also  to  remember  the  arrangement  of  the  common  palmar  synovial  bursa, 
with  the  digital  prolongations  to  the  thumb  and  the  little  finger,  and  that  the  three  middle 
fingers  are  ordinarily  shut  off  from  it.  Nevertheless  if  tendons  be  divided  near  the 
hand,  and  short  finger  stumps  be  made,  it  is  easy  to  infect  this  common  palmar  bursa 
through  retraction  of  the  tendon  and  the  consequent  opening  up  of  a  tunnel  directly 
into  that  cavity. 


Fig.  080 


Fig.  681 


Typical  amputation  of  finger  in  continuity  (Uirough  Tyiiical  or  preferred  method  of  disarticulating  a  finger 

a    plialanx);    long    palmar    and    short    dorsal    flaps.  by  long  single  palmar  flap.     (Farabeuf.) 

(Farabeuf.) 

Figs.  GSO  and  681  illustrate  the  best  methods  of  amputating  fingers  through  a  phalanx 
or  at  the  joints,  w  hlle  Fig.  682  shows  the  best  method  of  closing  the  w^ound.  In  this 
way  a  serviceable  finger-tip  is  preserved  which  will  stand  every  irritation  to  which  it 
will  probably  be  subjected. 

When  the" finger  is  to  be  dimrfindated  from  the  hand  a  modified  oval  flap  is  preferable, 
with  its  long  flap  on  the  radial  side  and  the  scar  on  the  dorsum  rather  than  in  the  palm. 
The  fhumh  is  perhaps  best  separated  at  an  articulation  by  a  single  palmar  flap,  without 
the  preservation  of  the  sesamoids  which  belong  to  its  short  flexor.  Fig.  (583  illustrates 
the  various  flaps  and  methods  preferable  at  the  bases  of  the  different  fingers. 

When  two  or  more  fingers  have  to  be  removed  the  incision  should  be  planned  to  meet 


1030 


SPECIAL  OR  REGIONAL  SURGERY 


the  indications.  When  the  first  three  fini^ers  have  to  he  removed,  with  or  witliout  that 
portion  of  the  hand  to  which  they  are  attached,  leaviiio-  only  the  thumb  and  Httle  finf^er, 
I  have  repeatedly  followed  to  advantage  the  sufjgestion  of  Lauenstein,  and  throuo;h  a 
small  incision  properly  placed  have,  with  cuttino;  forceps,  divided  the  first  and  fifth 
metacarpal  bones  at  about  their  middle,  and  have  then  given  to  each  of  the  remaining 


Fig.  682 


Fig.  G83 


Stump  resulting  from  the  procedure  sliown  in  Fig.  681. 


Illustrating  various  finger  amputation.     (Farabeuf.) 


digits  a  quarter  of  a  revolution  toward  each  other,  in  such  a  way  that  when  their  tips  are 
flexed  there  was  better  prehensile  power,  the  hand  acting  similarly  to  a  more  perfect 
claw.  If  they  are  to  be  maintained  in  this  position  during  healing  they  must  be  suitably 
held  upon  the  splint  to  which  the  entire  hand  and  forearm  should  be  attached. 

When  an  entire  finger  is  to  be  removed  it  is  a  question  whether  the  metacarpal  belonging 
thereto  should  also  be  sacrificed  for  cosmetic  purposes.     In  general  this  is  undesirable 


Fig.  684 


Fig.  685 


Fig.  G80 


Fi.5  687 


Keinoval  of  index  finger. 
(Erichsen. 


Removal  of  little  finger. 
(Erichsen.) 


Results  of  aiuputation  above 
metacarpo-phalangeal  articula- 
tion in  middle,  index,  and  ring 
fingers.      (ICrichsen.) 


Hand  after  removal 
of  metacarpal  bones 
and  three  fingers,  leav- 
ing thumb  and  little 
finger.     (Erichsen.) 


except  in  the  case  of  the  fifth  metacarpal  with  the  little  finger.  This  is  easily  exposed 
by  lateral  incision  along  the  ulnar  border  of  the  hand,  sufficient  to  disclose  the  bone  and 
permit  its  disarticulation  from  the  carpus.  The  same  is  also  true,  in  at  least  some 
instances,  of  the  thumb,  but  it  is  unwise  to  expose  the  carpal  joints  to  the  possibility 
of  infection  when  this  can  be  avoided ;  moreover,  the  deep  palmar  arch  crosses  just  in 


AMPITATIOXS  OF   TJIK   CPPER   EXTliFAflTY 


1031 


front  of  the  l);i.s(\s  of  the  sccoiul  to  the  fourth  iii('t;i(ar|)iils,  where  it  imist  he  carefully 
avoided.  If,  then,  the  metacarpal  is  to  he  sacrificed  this  should  he  done  rather  from  the 
dorsal  side,  while  for  cosmetic  ])ur|)()ses  alone  it  is  usually  sufficient  to  disarticulate 
the  fini^er  at  its  base  and  then  simply  removes  the  head  end  of  the  corresi)ondin(r  meta- 
carpal. Fios.  CkSS  to  ()02  furnish  illustrations  of  how  the  incisions  may  be  best  planned 
to  effect  either  of  tliese  purposes. 

Hand  Amputations  and  Wrist  Disarticulations.— Whil(>  it   makes   but  little 

diflV'rence  whetlier  the  metacarj)als  be  disarticulated  from  the  carj)us  or  the  latter 
from  the  radial  end,  it  is  advisable  to  adopt  whichever  line  of  separation  will  best 
meet  the  indications.  For  a  removal  of  the  Jiand  af  or  near  iJie  wrist  two  fla|)s  usually 
afford  the  mo.st  serviceable  method,  the  palmar  tissues  beiniii;  preserved,  if  |)ossible,  in 
order  that  they  may  cover  the  stump.  This  operation  is  usually  done  for  injury,  and 
it  is  more  than  likely  that  one  will  have  to  plan  his  flap  aceordiiig  to  the  tissues  which 
still  are  serviceable. 


Fig.  688 


Outline  of  amputatioa  of  fingers,  with  their  metacarpals.     (Modified  by  Matas  from  Mignon.) 

In  the  lower  part  of  the  forearm  the  flap  method  furnishes  a  serviceable  stump.  As 
the  elbow  is  approached  the  circular  or  elliptical  methods  are  preferable,  as  illustrated 
in  Fig.  690. 

The  Elbow. — With  elbow  disarticulations  caution  should  be  observed  to  liave 
flaps  of  sufficient  length.  The  joint  is  opened  more  readily  from  its  radial  side.  The 
integument  of  the  back  of  the  elbow  region  lies  closely  upon  the  bone,  is  thin,  and  retracts 
but  slightly.  Anteriorly  there  is  more  muscular  covering  and  consequently  a  tendency 
to  retraction.  Therefore  the  anterior  flap  should  be  made  longer  than  might  otherwise 
seem  to  be  required.  Here  the  ideal  scar  w  ill  be  behind  the  end  of  the  humerus,  but  it 
is  difficult  to  obtain  because  of  the  tendency  to  drag  it  around  beneath  the  end  of  the 
bone.  An  elliptical  incision,  directed  obliquely  downward  and  forward,  is  the  easiest 
method  and  furnishes  the  best  stump.  The  lower  end  of  the  posterior  part  of  the  flap 
should  be  at  a  distance  below  the  articulation,  at  least  equal  to  the  transverse  diameter 


1032 


SPECIAL  OR  REGIONAL  SURGERY 


of  the  joint  itself,  ?'.  r.,  in  an  adult  nearly  one  hand-hreadtli  from  the  line  of  the  joint  to 
the  point  of  dissection.      (Matas.)      (Fiji;.  ()!)().) 

The  Arm. — The  arvi  furnishes  thai  nearly  eylindrieal  outline  best  adapted  for  circular 
amputations.  Here,  as  at  the  elbow,  the  greatest  retraction  is  on  the  flexor  side.  With 
the  arm  should  be  saved  all  that  is  possible  even  up  to  its  upper  extremity. 

Remembcrinsi;  the  oreater  tendency  of  the  flexors  to  contraction  the  truly  circular 
method  should  be  modified  to  a  somewhat  elliptical  incision,  in  order  to  compensate 
for  this  difficulty,  while  an  external  liberating  incision  is  often  of  assistance.  Abrupt 
transverse  division  of  the  muscle  down  to  the  bone  should  be  made  after  the  oblique 
incision  of  the  skin. 

Disarticulation  at  the  Shoulder. — Until  ac(nu-ate  methods  of  blood  control  were 
introduced  this  was  an  amputation  viewed  usually  with  disfavor,  in  spite  of  the  fact 
that  compression  of  the  axillary  artery  in  theory  is  easy.     The  older  methods  comprised 

Fig.  689 


Outline  of  amputation  of  two  fingers  simultaneously  with  their  metacarpals;    also  thumb  with  its 
metacarpal.     (Modified  from  Mignon.) 

this  compression,  either  above  the  clavicle,  or  by  exposure  of  the  vessel  and  its  proximal 
ligation,  or  by  opening  and  separating  the  joint  and  then  seizing  the  vessels  within 
the  inner  flap,  and  controlling  them  by  digital  pressure  until  their  division.  Now 
with  the  use  of  Wyeth's  pins  and  the  elastic  bandage,  effectual  control  may  be  secured 
without  resorting  to  any  of  the  former  expedients.  If  the  removal  is  to  be  a  high  ampu- 
tation, just  below  the  neck  of  the  humerus,  the  method  shown  in  Fig.  691,  of  application 
of  the  tourniquet  and  its  control  by  a  constricting  strap,  may  be  adopted. 

If  the  surgeon  expect  to  disarticulate  he  should  resort  to  the  pins  of  Wyeth  (?'.  e.,  to 
the  use  of  long  mattress  needles),  which  are  passed  through  from  above  downward,  or 
from  the  axilla  upward,  one  of  them  being  passed  anteriorly  and  the  other  posteriorly, 
and  brought  out  at  corresponding  ])oints  on  the  upper  aspect  of  the  shoulder,  where, 
their  points  being  protected  by  sterilized  corks,  they  serve  to  prevent  sliding  of  the  elastic 
bandage  or  tourniquet,  which  is  now  placed  proximally  to  them,  and  is  thus  held  more 
securely  than  is  possible  in  any  other  way. 


PLATE  LVII 


/.   Anterior  oral  or  racquet  incision  for  disarticulation  of  the 
shwitilcr   III/  attacking  the  joint   thronyh  the  delto-pecAoral  (jroove 

(niuilljird  S/u'ikt's  ojienitiou). 

?,  •i'.    ('irndiir  aiDjiiiliition   of  hnrer  and  middle  thirds  of  arm 
raiisfonneil   into  double  s(ini(re  antero-poHlertor  flap  operation  by 


airilatend  or  bilateral  vertical  incisi 


4.  -5.  ^,  7.  f'ircalar  amputation  at  various  levels  of  forearm, 
including  the  disiirticiilatioii  nl  elhoir.  In  all  of  these,  one  or  tuo 
lateral  Uberatlng  incisions,  cut  dou-n  to  the  bone,  may  be  required, 
on  ulnar  or  radial  side,  or  both,  to  permit  easy  retraction  of  solid 
viusculo-tegmnentnry  antero  posterior  Jtaps. 


^,  .9.   Circular  ampntation  at  lower  third   of  forearm  ;   lateral 
liberating  incision  should  be  added  on  ulnar  side,  or  radial  side, 

or  both,  according  to  tonirily  of  limb. 


111.  Long  palmar  projection  of  oval  method  in  disarticulating 
hand. 


Cutaneous  Incisions  in  Amputations  of  tine  Uppei 
Extremity  (Ventral  or  Flexor  Side;. 


PLATE   LVIU 


].    lliH-(iHct  incision  (Larrey)  iniriuMtoid  for  disarticu- 
hitidii  1(1  slionldcr. 


y 


S.  Solid   circnlar  wifh   liberating  inci/^ion.i  for  upper 
third. 


3.  Solid  circidar  with  Uhernting  incisions  for  middle 
third. 


4.  Circidar  nmpuldtidii  tit  loircr  third  of  humerns ; 
incision  sliijhtlji  fiicoiniij  Ihc  flexor  side,  to  ciimpensutc  for 
greater  retraction  ;  liro  luleral  ldjeratiii<i  ineisio)is,  to 
facilitate  retraction  of  inusciilo-cuianeons  Jlajjs  from  bone. 


5.  Nendorfer's  racquet  incision  for  disarticulation 
at  elbow;  preferred  in  all  cases  in  which  a preliiniiiar;/ 
exploration  of  the  elbow,  as  in  advanced  tubercular 
cases,  is  attempted  before  proceeding  to  disarticulate  at 
elbow. 

6.  Elliptical  or  oral  incision  with  long  projection  on 
flexor  side  to  compen.sate  for  greater  retraction  of  skin 
and  muscles  on  flexor  (ventral  side) ;  the  longer  end  of  the 
oral  may  be  advantageously  reversed,  the  long  end  on  the 
exterior  side,  lohen  the  tissues  on  the  flexor  side  are 
injured.  Usually,  a  slightly  elliptical  circular,  with  tiro 
lateral  liberating  incisions,  cut  squarely  to  the  bone  with 
all  the  soft  parts,  including  the  periosteum,  is  the  pre- 
ferred method  in   this  region. 


^SA^s 


7.  Antero-posterior  flap  incision  for  amputation  at 
lower  third  of  forearm ;  tendinous  region. 

S.  Oval  or  elliptical  inci.'iion  in  typical  amputation  of 
the  hand   (radio-carped  disarliculation}. 


Surface  Tracings  showing  Some  of  the  More  Useful  Lines 
of  Skin  Incision  in  Amputations  of  the  Upper  Extremity 
(Dor-sal  or  Extensor  Surface). 


AMPrTATFOXS  OF   THE   UPPER   EXTREMITY 


1033 


Circulation  hciiii;  lliiis  coiilrollcd,  a  iiiodiHi-d  circular  operation  may  he  made  or  a 
loMf  external  and  superior  (lap  cut,  uiatchiu<:;  it  with  another  one  dissected  from  the 
axillary  aspect.  In  the  Tormer  case  the  circular  incision  is  made  on  a  level  a  little 
helow  the  anatomical  axillary  border.     'J'hen  a  cuH"  oi"  skin  beinii;  raised  while  the  arm 


Ki(i.  COO 


Fk;.  691 


Esmarch's  elastic  constrictor  applied  and  lield  in 
place  by  a  bandage  or  a  strap  (Wyeth's  pins  may 
also  be  used  to  hold  the  constrictor  in  place)  in  high 
amputation  of  the  arm.      (S.  Smith.) 

is  held  in  adduction,  all  the  .soft  parts 
are  divided  to  the  bone  and  separated 
from  it.  Now  a  liberating  incision  may 
be  made  from  the  anterior  border  of  the 
acromion  to  the  coracoid  process,  then 
over  to  the  deltoid  groove,  and  along  it  to 
the  first  circular  incision.  Through  this 
all  the  soft  tissues  surrounding  the  glenoid 
margin  are  separated,  and  then  the  bone 
is  enucleated  by  opening  the  capsular 
ligament,  reserving  perhaps  the  detach- 
ment of  the  group  of  scapular  tendons 
until  the  last.  If  one  have  any  fear  as 
to  the  efficiency  of  his  hemostatic  precau- 
tions he  may  secure  the  axillary  ve.ssels 
so  soon  as  they  are  divided  and  then 
proceed  with  the  disarticulation  as  above. 
In  some  cases  it  may  be  preferable  to  cut 
a  wide  flap  from  the  deltoid  region,  preserving  that  muscle  or  not  as  may  be  desired, 
and,  after  having  thus  exposed  the  joint,  make  the  disarticulation,  separating  the 
head  of  the  bone  sufficiently  to  allow  the  passage  of  an  amputating  knife  behind  it 
and  down  along  the  shaft  to  a  distance  sufficient  to  justify  turning  it  abruptly  and 
toward  the  surface,  and  then  cutting  out  the  axillary  flap.  The  attempt  should  be  to  cut 
all  the  vessels  at  right  angles  rather  than  obliquely. 

Plates  LVII  and  LVIII,  prepared  by  Professor  Matas,  afford  a  synoptic  view  of  the 
more  useful  lines  of  skin  incision  in  the  principal  amputations  of  the  arm  and  shoulder. 
Interscapularthoracic  Amputations.  Removal  of  the  Entire  Upper  Extremity. — 
This  includes  removal  not  only  of  the  arm,  but  of  the  scapula  and  clavicle  as  well,  or 
at  least  its  outer  ])ortion.  It  is  not  often  required,  and  inasmuch  as  the  circumstances 
which  justify  it  are  seldom  duplicated,  a  suitable  method  for  each  individual  case 
should  be  planned,  rather  than  try  to  make  one  set  of  directions  cover  them  all.  Much 
w^ill  depend  upon  whether  sufficient  skin  can  be  saved  in  order  to  cover  the  large  defect 
thus  made.  In  general,  however,  an  incision  should  first  be  made  along  the  clavicle, 
exposing  it  and  dividing  it  near  its  middle.  It  is  convenient  to  take  out  the  middle 
portion  at  this  time,  and  in  this  way  to  afford  ample  room  through  which  a  proximal 
ligation  of  the  subclavian  vessels  may  be  made,  they  being  here  carefully  dissected  out, 
secured  by  double  ligation,  and  divided.     From  the  outer   i)art  of  the  above  incision 


Lines  of  amputation  in  lower  third  of  forearm,  of  elbow, 
and  lower  third  of  arm.     ^  Modified  from  Mignon.) 


1034  SPECIAL  OR  mXllOXAL  SURdERY 

another  is  carried  downward  and  outward  toward  the  deltoifl  wroove  and  then  beneath 
the  axilla  to  its  posterior  margin.  The  posterior  flap  is  then  furnished  hy  an  incision 
continuous  with  the  last  one,  which  terminates  belcjw  about  opposite  the  lower  angle  of 
the  scapula,  and  is  then  continued  upward  ahjng  the  inner  scapular  border  and  over 
the  shoulder  until  it  reaches  the  outer  end  of  the  incision  first  made.  In  this  manner 
will  be  furnished  a  sufficient  covering.  The  balance  of  the  operation  consists  in  the 
gradual  separation  of  the  entire  mass  from  the  outer  wall  of  the  thorax.  With  a  pre- 
liminary ligation  of  the  subclavian  vessels  there  will  be  no  hemorrhage  which  cannot 
l)e  easily  checked  by  pressure  and  forceps. 

The  above,  however,  is  only  a  general  description,  which  may  need  to  be  modified 
in  most  cases.  If  the  amputation  be  done  for  injury  all  the  skin  xchich  is-  still  viable 
should  be  utilized,  no  matter  how  shaped,  while  if  done  for  disease  the  incisions  may 
have  to  be  modified  materially,  taking  more  skin  from  one  side  and  less  from  the  other, 
in  order  to  avoid  that  involved  in  the  disease  process. 

In  the  majority  of  cases  the  result  is  satisfactory,  in  spite  of  the  mutilation  thus  afforded. 


AMPUTATIONS    OF    THE    LOWER   EXTREMITY. 

The  most  important  |)hysiological  pur]ioses  of  the  foot  are  those  of  support  and  loco- 
motion, not  mere  tactile  sensibility  nor  prehension.  Its  purposes  being  different 
from  those  of  the  upper  extremity,  the  tenets  previously  held  regarding  the  advantage 
of  conservatism  may  be  changerl  to  some  degree,  for  a  tender  foot  or  leg-stump  is  some- 
times extremely  annoying,  even  disabling,  and  it  is  in  the  end  far  better  to  so  plan  an 
amputation  of  this  extremity  as  to  make  the  stump  most  serviceable,  without  primary 
reference  to  its  exact  length.  As  in  the  hand,  foot-stumps  should  be  covered  with  dense 
plantar  (instead  of  palmar)  tissues,  and  the  long  flap  should,  therefore,  be  made  from 
the  sole.  When  this  is  impossible  it  would  be  wiser  to  shorten  the  stump.  Moreover, 
as  there  will  be  constant  friction  upon  the  resulting  cicatrix,  this  should  be  placed  in 
the  most  protected  location,  on  the  dorsum  of  the  foot. 

The  most  important  indication,  then,  in  all  foot  amputations  is  io  furnish  a  complete 
planffir  fluj)  and  to  place  the  scar  on  top  of  the  foot. 

The  Toes. — Amputations  of  the  toes  are,  by  virtue  of  their  shortness,  nearly  always 
disarticulations.  The  basal  row  of  phalanges  should  be  preserved  when  possible,  and 
even  here  the  covering  of  the  stump  should  be  as  far  as  possible  fashioned  from  the  sole. 

The  bicj  toe  may  be  removed  by  either  internal  or  oval  plantar  flaps,  which  should  be 
long  enough  to  cover  the  metatarsal  head,  otherwise  the  latter  must  be  decapitated. 
These  same  principles  also  apply  to  the  little  toe.  When  all  or  most  of  the  toes  have 
to  be  severed  it  may  as  well  be  done  by  a  single  dorsal  incision,  as  seen  in  Fig.  692, 
which  will  permit  either  their  disarticulation  or  their  removal  along  with  that  of  the 
ends  of  the  metatarsals.     These  methods  are  shown  in  Figs.  692  and  693. 

Amputation  of  a  toe  icith  its  metatarsal  is  best  effectefl  by  a  racket  incision.  This 
may  extend  up  to  the  posterior  tarsal  joint.  Some  have  recommended  to  enucleate 
the  metatarsals  subperiosteally,  through  dorsal  incisions,  all  the  soft  parts  being  scrupu- 
lously left  behind.  With  the  first  and  fifth  toes  the  scar  should  be  so  placed  as  to  be 
removed  from  the  erlge  of  the  foot  (Fig.  693). 

Partial  amputations  of  the  foot  have  been  suggested  and  devised  in  great  numbers, 
and  the  subject  has  been  greatly  complicated  by  the  number  of  methods  that  were  taught. 
Modern  ideas  of  conservative  surgery  have  caused  a  complete  departure  from  the 
anatomist's  standard,  and  it  has  been  shown  that  with  aseptic  technique  there  is  no 
advantage  in  disarticulating  when  it  leaves  irregular  lines.  As  INIatas  says:  "As 
Agnew  taught  long  ago  in  this  country,  and  others  elsewhere,  the  skeleton  of  the  foot 
must  be  considered  a  surgical  unity,  to  be  treated  by  the  knife  and  saw  just  as  the  femur 
and  humerus  would  be,  at  the  exact  point  which  will  yield  the  longest  and  most  useful 
stump  to  the  patient.  What  is  essential  in  every  case  is  the  application  of  the  principle 
of  plantar  flaps — jjreservation  and  scar  protection." 

Concerning  the  utility  of  many  of  these  methods  and  the  usefulness  of  the  resulting 
stumps  we  may  learn  more  from  the  makers  of  artificial  limbs  than  from  almost  any  other 
.source.  Thus,  Truax,  for  instance,  who  has  had  large  experience  as  a  mechanic,  has 
given  this  advice,  as  quoted  by  Matas:     "Avoid  amputation  within  three  inches  of  the 


.\.\fl'l  TATIOXS  OF   Till-:  LOW  EH  EXTREMITY 

Fi.;.  ri02 


1035 


1,  simultaneous  disarticulation  of  all  the  toes;  2,  amputation  of  the  toes  in  their  continuity.     (Migiion.) 

Fic;.  693 


1,  partial  amputations  uf  the  third  and  fifth  metatarsals;  2,  disarticulation  of  the  first  and  fifth  metatarsals. 

(Mignon  ana  Alatas.) 


1036 


SPECIAL  OR  REGIONAL  SURGERY 


ankle-joint;  do  not  amputate  between  tlie  metatarsal  bones  and  the  junction  (jf  tlie  lower 
and  middle  thirds  of  the  tibia.  At  other  points  save  all  you  can,  and  you  will  in  every 
case  have  done  the  best  for  your  patient.'      Should  one  be  rationally  governed  by  this 


Fig.  694 


Tracings  of  intratarsal  amputations  at  various  levels  (outer  side):   1,  subastragaloid;  2,  tibiutarsal;  3,  tibio- 
calcaneal;  the  different  lengths  of  flaps  shown  in  relation  to  skeleton. 

Fig.  095 


Tracings  of  incisions  in  mediotarsal  anipuliuiu,,.^  and  t..tul  .aiaputatinu  ,,f  fifth  toe.      (Mignon  and  Matas.) 


wri'i  'iwno.xs  of  riir.  loweu  iixriiiiMirv 


WM 


advice  :i  lar;,'*'  iiiiiuIxT  of  aiiipiitatioii  iucUkxIs  wliicli  c'Uiii1>(.t  most  k'.\t-l)ook.s  would 
be  discarded. 

For  my  own  part  I  would  advise  to  save  all  ol"  a  foot  that  can  he  saved,  providiiijf  a 
sufficiently  ioii<;  plantar  or  heel  flap  can  In*  retained;  but  if  these  are  not  available,  then 
I  would  advisi'  amputation,  at  least  three  inches  above  the  ankle. 

I  would  advise,  moreover,  to  discard  the  eomplicated  rules  and  technicpu;  of  stilted 
methods  and  to  use  the  saw  whenever  it  can  be  made  useful,  rather  than  to  <,'<>  farther 
back  to  a  row  of  joints  simply  because  they  are  joints  (Fi<;.  ()i)4). 

Fitjs.  (')*)5  and  (')!>()  illustrate  conservative  modern  methods,  which  are  j)erfectly  avail- 
able for  most  jjurposes,  and  from  which  departure  need  be  made  only  when  juMuliar 
circumstances  obtain,  which  so  comi)licate  the  ca.sc  that  none  of  the  ordinary  rules  would 
apply.     A  surgeon  of  judf2;ment  and  experience  is  c()mi)etent  to  devise  a  fhip  for  a  given 


Fic.  (iOii 


1,  ilisarticulatioii  at   the  tarsometatarsal  joint,  showing  length  of  flaps;    2,  disarticulation  of  the  big  toe  in 

continuity.      (Mignon.) 


ca.se,  whether  it  complies  with  standard  methods  or  not.  It  seems  to  me,  therefore, 
worth  while  to  describe  only  the  so-called  mediotarsal  disarticulation  of  C  ho  part,  in  which 
but  the  a.stragalus  and  calcis  remain  of  the  proper  bones  of  the  foot.  The  joint  line 
extends  from  just  behind  the  tuberosity  of  the  scaphoid  to  the  outer  side  of  the  body 
of  the  calcis,  where  a  tubercle  can  be  usually  felt.  Acro.ss  this  line  an  incision  is  carried 
oblitiuely  over  the  dorsum  of  the  foot.  The  plantar  flap  is  the  long  one,  and  the  line  of 
division  is  just  behind  the  balls  of  the  toes.  T^vo  lateral  incisions  can  be  made  to 
facilitate  disarticulation  if  desirable. 

This  operation  sometimes  leaves  the  foot  in  a  bad  equinus  position;  accordingly  it 
is  Avise  to  make  tenotomy  of  the  tendo  Achillis,  as  well  as  to  attach  the  dorsal  or  extensor 
tendons  to  the  stump  end.     (See  Figs.  (il)9  and  700.) 

Amputations  of  the  Foot  (Tibiotarsal). — The  former  favorite  method  of 
am})utating  the  foot  proper  was  that  of  Syme,  illustrated  in  Fig.  701.     This  preserved 


1038 


SPECIAL  OR  RKGIOXAL  SURGERY 


the  {jlantar  surface  and  tij)  of  the  heel,  thus  forminrr  a  cutaneous  hood,  which  was 
made  to  cover  the  lower  ends  of  the  tibia  and  fibula,  whose  malleoli  were  usually  removed 
close  to  their  terminations.  The  incision  is  made  directly  down  to  the  bone,  from  the 
apex  of  one  malleolus  across  the  sole  and  up  to  the  other.  Then  the  foot  is  forced 
into  extreme  flexion  and  another  incision  carried  directly  across  the  dorsum,  by  which 


Fig,  697 


I'm.  t)9S 


Fig.  699 


Fio.  700 


Lisfranc's  tarsometa- 
tarsal disarticulation. 
(Farabeuf.) 


Stump  after  same. 


Classical  mediotarsal 
amputation  (Chopart), 
showing  length  of  plan- 
tar flap.      (Farabeuf.) 


Stump    after    Chopart 's  am- 
putation.    (Farabeuf.) 


the  upper  ends  of  the  first  are  joined.  This  permits  openincr  the  ankle-joint  in  front, 
after  which  the  lateral  ligaments  are  divided  and  the  astragalus  dislocated  forward.  The 
heel  hood  is  nexl  carefully  .separated  from  the  calcis  with  the  knife,  and  it  and  all  the  parts 
retracted  from  the  ends  of  the  leg  bones,  which  are  divided  just  above  the  articular  sur- 
faces, or  the  latter  may  be  left  and  the  malleoli  alone  removed.  Now  the  lieel  hood  is 
raised,  made  to  cover  the  end  of  the  leg,  and  united  to  the  anterior  incision,  drainage  being 

Fig.  701 


Syme's  tibiotarsal  oi>eration,  showing  part  removed  and  lines  of   section,  before  di\-i.-ifin  of  malleoli.     (  Farabeuf.) 

made  by  a  small  opening  on  the  outer  side  of  the  tendo  Achillis,  as  the  plantar  surface 
of  the  flap  should  not  be  opened  (Fig.  703) . 

Fig.  702,  the  complement  o{  Fig.  701,  illustrates  the  appearance  of  the  stump  after 
the  completion  of  the  disarticulation  and  before  the  removal  of  the  malleoli. 

Pirogoff  introduced  a  serviceable  modification  by  obliquely  dividing  the  os  calcis  in 


AM/'CTATIOXS  OF   THE  LOWER  EXTREMITY 


1039 


front  (if  \\\v  Ik'1'1,  tiirnin<^  ii|)  its  sawed  surfarcs  without  any  dissection  of  the  liood  from 
the  heel,  and  unititio;  its  fr(>sh  hone  aspect  with  that  made  by  removal  of  the  articuhir 
ends  of  the  le<,f  l)ones.  Tiiis  would  seem  to  he  preferable  to  Symc's  disarticulation, 
affordini;  a  better  walkino;  stumj).     (See  Fiijs.  704  and  705.) 

A  reverse  of  this  operation  was  sufjfjjested  by  Mikulicz  and  Wladimirolf,  independently, 
and  at  about  the  same  time,  the  heel  being  excised  by  an  incision  across  the  sole  and 

Fig.  701' 


Syme's  amputation  after  disarticulation  of  the  foot  at  the  ankle-joint.     The  soft  parts  are  being  cleared  from  the 
malleoli  preparatory  to  sawing  the  malleoli  and  lower  articular  surface  of  tibia.      (Farabeuf. ) 

then  behind  the  ankle,  the  calcis  being  divided  and  its  posterior  end  removed,  while  the 
articular  surfaces  of  the  leg  bones  are  also  removed.  The  foot  is  then  brought  down  so 
that  these  surfaces  can  be  brought  in  contact,  it  being  expected  that  after  their  reunion 
the  individual  will  walk  in  the  exaggerated  equinus  position  and  upon  the  ends  of  the 
metatarsal  bones.     The  operation  is,  in  effect,  an  exsection  rather  than  an  amputation, 

Fig.  703 


P  s- 

.9,  line  of  incision  for  vSyme's  operation;  P,  line  of  incision  for  Pirogoff's  operation.      (Erichsen.) 

and  is  applicable  to  but  a  very  small  number  of  cases,  in  which,  however,  it  sometimes 
gives  excellent  results.     (See  Fig.   707). 

Amputations  of  the  Leg. — IModern  prosthetic  methods  have  materially  changed 
the  indications  in  amputating  the  leg.  The  pressure  in  artificial  limbs  is  not  borne  upon 
the  end  of  the  stump,  but  is  rather  circumferential  and  borne  by  a  conical  socket.  It 
is  now,  therefore,  an  object  to  preserve  as  much  of  the  limb  as  practicable,  in  order  to 


1040 


SPECIAL  OR  RKdlONAL  SURGERY 


have  better  levera<jc  or  control  of  the  artificial  nicinbcr.     (Consequently  the  point  of 
election  is  now  the  middle  of  the  leg,  unless  the  amputation  may  be  made  even  below 


I'lu.  704 


Fig.  705 


Skeleton  of  stump  after  PirogofF's  osteoplastic 
amputation.  The  sawed  surface  of  the  calcaneum 
in  apposition  with  divided  surface  of  tibia.  (Fara- 
beuf.) 


Stump  after  Pirogoff's  operation.  The  weight  of 
the  body  must  rest  upon  ttie  tliick  plantar  skin  of  the 
heel  and  never  on  the  thin  skin  of  the  retrocalcaneal 
surface.      (Farabeuf. ) 


Fig    706 


Sections  of  bone  in  Pirogoff's  amputation  and  its  modifications:  1,  oblique  section  of  calcaneum  to  correspond 
with  (1)  oblique  section  of  tibia.  (Gunther.)  2,  curvilinear  or  concave  section  of  calcaneum  to  correspond  with 
(2)  convex  section  of  tibia,  (v.  Bruns.)  3",  horizontal  section  of  calcaneum  to  correspond  with  (3)  similar 
section  of  tibia.  (Pasquier  Le  Fort.)  3'",  vertical  section  of  calcaneum  to  correspond  with  (3)  horizontal  section 
of  tibia.     (Typical  Pirogoff.)     (Modified  by  Matas  from  Mignon.) 


AMPinwrioxs  OF  tiie  lower  extremity 


1041 


this  point.  Tlir  ohjcction  to  a  short  Ic^  stuiii|)  is  the  iiifvitahU'  flexion  wliicii  the 
hanis(rini>;  flrxors  will  produce;  in  such  cases  the  ])ressurc  will  he  borne  upon  the  knee, 
while  the  appearance  of  the  stuinj)  is  by  no  means  ideal.  If,  therefore,  one  is  forced 
to  make  a  hi<;h  umputation  of  the  leg  it  would  be  far  preferable  to  make  a  good  knee 
disarticulation,  or,  j)etter  still,  a  supracondyloid  amputation,  with  preservation  of  the 
patella,  thus  furnishing  a  stump  which  affords  j)erhaps  the  only  exception  to  the  general 
rule,  i.  c,  that  wiMght  cannot  be  borne  upon  the  stum})  end. 

Fig.  707 


Osteoplastic  excision  of  foot.      (Mikulicz.) 

Let  us,  then,  consider  but  one  or  two  amputations  of  the  leg — that  low  down  or  near 
the  middle  and  that  at  the  knee.  Whatever  the  method  it  is  most  desirable  that  the 
scar  be  kept  off  to  the  side,  and  especially  away  from  ihe  front  of  the  shin.  This  can  be 
best  accomplished  by  a  modified  circular  (Fig.  708)  or  a  bilateral  flap  method  (Fig.  711), 
or  by  the  oblique  method  with  lateral  incisions,  which  practically  convert  it  into  an 
anteroposterior  operation,  while  for  certain  instances  the  method  of  Teale  may  be 
preferred,  i.  e.,  that  with  a  long  anterior  and  short  posterior  flap,  or  its  modification  by 
which  the  flaps  are  made  more  lateral,  or  the  even  long  flap  method  of  Bell. 

Fig.  708 


Modified  circular  amputation  of  upper  third  of  leg.      (Ericlisen.) 

Whichever  of  these  be  selected,  after  division  of  the  muscles  and  exposure  of  the  bone, 
it  is  usually  helpful  to  retract  the  flaps,  whatever  their  shape,  by  a  cloth  retractor  made 
of  a  piece  of  sterile  bandage  torn  into  three  strips,  the  middle  of  which  should  be  inserted 
between  the  bones  of  the  leg,  the  interosseous  membrane  being  divided  for  this  purpose; 
by  this  they  are  held  more  perfectly  out  of  the  way  during  the  act  of  dividing  the  bones. 
The  anterior  border  of  the  tibia,  which  is  practically  a  sharp  ridge,  should  be  divided 
obliquely  (bevelled),  either  by  a  small  oblique  section  before  the  transverse  division  is 
made,  or  by  effecting  this  later,  in  order  that  there  shall  not  remain  a  sharp  point  to 
66 


1042 


SPECIAL  OR  REGIONAL  SURGERY 


Fig.  709 


])r()jcct  tliroutijh  the  skin  or  he  subject  to  constiuit  irritation.  The  tibia  is  usually 
(Hvided  transversely,  with  the  above  exee})tion.  The  fibula  may  be  divided  slightly 
obliquely.  It  is  eustoniary,  however,  to  make  the  division  simultaneously,  and  to  so 
conduct  the  sawing  process  as  to  divide  the  fibula  completely  before  the  last  strokes 
of  the  saw  cut  through  the  tibia. 

There  is  greater  difficulty  in  the  recognition  and  securing  of  vessels  in  leg  amjiutations 
than  in  any  other,  especially  if  they  have  been  divided  obliquely.  The  principal  vessels 
may  be  found  from  their  known  anatomical  location.  They  nevertheless  sometimes  tend 
to  retract  and  they  must  be  followed  up  in  order  to  properly  secure  them.  The  accom- 
panying nerve  trunks  should  also  be  seized  firmly,  drawn  down,  and  divided  two  or 
three  inches  above  the  line  of  division  of  the  other  tissues,  in  order  that  they  may  retract 
out  of  harm's  way.  Every  nerve  which  can  be  recognized,  even  in  the  skin,  should  be 
thus  treated.  Before  closing  the  wound  it  is  well,  unless  one  is  absolutely  sure  of  his 
w^ork,  to  release  the  tourniquet  and  ascertain  if  any  vessel  which  would  otherwise  bleed 
be  not  yet  secured.  Oozing  may  be  checked  w'ith  hot  water,  wdiile  muscle  surfaces 
which  leak  too  much  blood  may  be  lightly  enclosed  within  catgut  sutures  inserted 
with  a  curved  needle. 

Providing  that  these  stumps  have  well-nourished  flaps,  and  that  no  sharp  or  angular 
bone  ends  interfere  with  subsequent  comfort,  and  that  the  scars  be  kept  away  from 
their  lower  surfaces,  they  serve  their  purpose  admirably. 

Su]:>posing,  then,  that  amputation  is  to  l)e  about  the  middle,  the  first  incision,  made 
with  a  stout  scalpel,  is  begun  at  the  anterior  border  of  the  tibia  and  carried  downward 

along  it  until  it  is  turned  abruptly  backward  to 
the  posterior  aspect,  and  then  upward  until  a 
point  is  reached  opposite  that  of  commence- 
ment. The  skin  is  dissected  up  for  perhaps  an 
inch.  Then  the  flap  on  the  other  side  is  cut 
after  the  same  fashion,  after  which,  wnth  a  short 
or  long  knife,  the  muscles  are  divided  trans- 
versely or  circularly  down  to  the  bone.  Much 
will  depend  now  upon  whether  the  desire  is  to 
resort  to  the  more  modern  osteoplastic  methods 
or  adhere  to  the  old.  In  the  latter  case  it  is  well 
to  separate  the  flaps  for  the  necessary  distance 
from  the  bone,  w  ith  or  without  the  periosteum, 
dividing  the  bones  after  suitable  retraction,  as 
above  suggested.  If  preference  be  for  an  osteo- 
plastic flap  it  is  planned  and  made  at  this  time, 
the  l)one  being  divided  at  the  same  level  as  the 
muscles,  and  the  amputation  being  thus  practically  completed,  after  which  the  osteo- 
plastic flaj)  is  arranged,  it  being  now  necessary  to  carefully  preserve  the  periosteal 
bridge  and  to  again  divide  the  bone  at  the  base  of  this  ]:)eriosteal  flap,  this  being  the 
true  end  of  the  bone  stump.     In  this  case  the  fibula  is  divided  at  a  higher  level. 

It  is  perhaps  less  desirable  to  preserve  periosteum  in  young  children  than  in  adults,  for 
if  bone  be  permitted  to  grow^  too  rapidly  conical  stumps  result,  sometimes  even  with 
protrusion  of  bone  ends.  Oilier  and  his  pupil  Mondan  have  shown  that  this  so-called 
atrophic  elo7ir/ation  of  bone  is  a  consequence  of  abnormally  rapid  grow^th  from  the  upper 
e))iphyseal  direction,  ])ermitted  by  lack  of  pressure  from  below,  and  that  conical  stumps 
will  often  happen  in  children  in  spite  of  every  precaution.  Nevertheless  it  should  not 
be  encouraged,  and  for  this  reason  periosteum  should  not  be  preserved. 

The  method  of  Teale  was  to  cut  a  long  anterior  flap,  raising  the  coverings  from  the 
bone  w^ith  the  least  possible  disturbance,  to  divide  the  bone  at  the  high  level,  then  to 
double  the  flap  upon  itself  in  such  a  w\ay  as  to  bring  the  scar  at  a  level  one  inch 
or  more  above  the  stump  end.  Heine  modified  this  slightly  by  raising  the  periosteum 
with  the  rest  of  the  anterior  flap.  In  cases  which  permit  such  a  long  flap  to  be  formed 
from  one  aspect  of  the  leg  the  method  gives  excellent  results  (Fig.  709). 

Bruns  devised  a  method  which  is  begun  almost  as  an  exsection,  by  an  oblique  circular 
incision,  with  liberating  lateral  incisions,  and  division  of  all  the  tissues  over  the  inner 
border  of  the  til)ia  and  the  outer  side  of  the  fibula;  after  which,  without  disturbing  skin 
attachments  in  front,  the  [jeriosteum  is  sejiarated  from  the  bones  as  high  as  the  liberating 


Teale's  method  of  amputation. 


AMI'lTATIONS  OF   TUE   LOWER   EXTIillM  ITY 


1043 


l;it('r;il  incision.-;  |K'riiiit,  and  (lien  llic  lihula  lirsl  and  later  tlic  lihia  divided.  It  is 
|trac(ii'all_v  a  .snl)|>i'ri(>.steal  excision  of  tlu'  lei;-  hones  and  all'ords  a  well-prolccted  .stump. 
In  ellecl  it  is  an  anten)|)osleri()r  flap  method. 

The  Knee.-  It  was  Hrinton  who,  in  1S72,  suo;oested  tlie  j)reservuti()ii  of  the  semi- 
hmar  carlila;;('s  in  all  knee  disarticuhitions,  as  in  this  way  all  the  normal  relations  arc 
preserved  and  retraction  is  prevented.  But  the  makers  of  jirosthetic  apparatus  have 
m-^'cd  to  ahandon  all  true  disarticulations,  and  to  substitute  for  them  the  su|)racondyloid 
method,  which  affords  ideal  stumps.  Disarticulations  are  supposed  to  produce  less 
shock,  less  loss  of  blood,  and  less  danoer  of  sepsis  from  openintf  uj)  the  bone-marrow, 
while  nuiscle  insertions  are  less  disturbed  and  tlie  stump  covering;  usually  is  mobile  and 
not  very  sensitive.  No  disarticulation  should  be  thou<>ht  of  unless  the  joint  involved 
be  free  from  disea.se  and  unless  about  it  (here  I)e  met  suflicient  healthy  inte<!;ument  to 
furnish   a   satisfactory   flap. 

For  a  true  (ILs-articiilation  Stephen  Smith's  bilateral  method  Is  no\v  almost  universally 
a(lo])te(l.  Here  the  incision  is  begun  one  inch  below  the  tubercle  of  the  tibia  and  is 
carried  directly  down  to  the  bone,  downward  and  forw^ard  around  the  side  of  the  leg,  and 
then  inward  and  upward  toward  the  middle  of  the  j)opliteal  space,  the  lateral  flaj)s 


Fici.  7U) 


Amputation  at  knee  by  lateral  tlap.      (Erichsen.) 


Stump  after  Stephen  .Smith's  amputatiun  at 
knee. 

thus  made  being  nearly  duplicates. 
The  flaps  thus  cut  out  are  com- 
pletely separated  from  the  bone  up 
to  the  joint  level,  where  the  liga- 
ments are  divided,  the  joint  being 
manipulated  as  may  be  necessary  to 
best  expose  them  and  facilitate  di- 
vision. In  this  operation  the  patella 
is  usually  removed,  the  joint  being 
opened  by  separating  its  ligament  at  - 
its  insertion  into  this  bone.  One 
should  remember  that  the  internal 
condyle  is  lower  and  longer  than  the 
external,  and  that  the  internal  flap 
should  be  perhaps  made  on  this  account  a  little  the  longer  of  the  two.  Fig.  710  illus- 
trates the  stump  resulting  from  this  operation  and  shows  the  cicatrix  drawn  up  out 
of  harm's  way  and  resting  in  the  fossa  between  the  condyles.  Fig.  711  illustrates  the 
sim])le  method  by  lateral  flaps. 

Amputation  of  the  Thigh.— Under  this  head,  rather  than  that  of  amputation 
at  the  knee,  should  be  described  the  supracondijloid  amputations  which  give  decidedly 
the  best  results  of  all,  and  which  are  preferable  to  any  others  for  the  middle  of  the  lower 
extremity.  Of  these  the  best  Is  that  suggested  by  Grlttl,  wdiich  consists  in  not  only 
removing  the  condyles  but  saAvIng  off  the  articular  surface  of  the  patella,  which  is 
then  drawn  upward  and  applied  to  the  end  of  the  femur,  the  division  of  the  latter 
being  made  at  a  point  above  the  condyles,  where  the  diameter  of  both  bones  will  nearly 
correspond,  this  latter  perhaps  being  a  suggestion  of  Stokes  rather  than  of  GrittI,  wdio 
did  not  divide  the  bone  quite  so  high.     (See  Fig.  712.) 

Fig.  712  wall  best  illustrate  the  intent  of  the  method  as  well  as  its  performance.  The 
incisions  are  planned  much  as  in  the  Stephen  Smith  disarticulation  method,  only  they 
are  placed  higher,  and  the  patellar  tendon  Is  divided  as  low  down  as  possible,  or  even 
separated  from  the  tibia,  in  ordc  that  it  may  be  made  of  use  In  attaching  the  divided 


1044 


SPECIAL  OR  REGIONAL  SURGERY 


patellar  surface  to  the  femoral  end.  The  rest  of  the  operation  is  performed  as  by  other 
methods,  the  attachment  of  the  patella  beini-;  effected  by  tendon  sutures,  or,  if  necessary, 
by  an  ivory  peg,  or  even  a  metal  tack  or  nail  which  may  be  left  in  place. 

The  beauty  of  this  method  is  that  the  anterior  surface  of  the  patella  is  preserved  with 
its  natural  wanght-bearino;  facilities  and  the  bursa  between  it  and  the  skin,  while  the  latter 
is  undisturbed.  On  the  end  of  this  stump  as  much  weight  can  be  steadily  borne  as 
when  one  ordinarily  kneels,  and  to  it  a  most  serviceable  kind  of  artificial  limb  can  be 
attached,  with  which  one  may  walk  as  though  nothing  had  ever  happened. 


Fig.  712 


Gritti's  osteoplastic  supracondyloid  knee  amputation,  patella  utilized:  a,  shaded  parts  are  those  brought  in 
app(jsition;  h,  appearance  of  Gritti  stump  after  suture;  c,  correct  apposition  of  patella  to  femur;  d,  defective  ap- 
position.    (Farabeuf.) 

Another  osteoplastic  method,  namely,  that  of  Sabanejeff ,  is  illustrated  in  Figs.  713  and 
714.  In  this  instance  the  bone  covering  over  the  end  of  the  femur  is  taken  from  the  upper 
end  of  the  tibia,  the  patella  not  being  disturbed.  It  permits  a  lower  division  of  the 
femur  and  the  formation  of  a  stump  which  is  of  practically  the  same  length  as  the  original 
thiifh. 


Fig.  713 


Fig.  714 


Sabanejeff's  knee  amputation.     (Chalot.) 


Stump  made  as  in  Fig.  713.     (Chalot.) 


Amputation  of  the  Thigh  above  the  Knee.— For  removal  of  the  thigh  it  is 
well  to  preserve  as  much  of  its  length  as  possible,  and  yet  not  at  the  expense  of  all  other 
considerations  A  thigh  stump  too  short  is  likely  to  be  pulled  awkwardly  upward  by 
the  psoas  muscle,  and  upon  such  a  stump  it  is  difficult  to  secure  an  artificial  limb  tolerable 
of  control  against  such  action  of  this  muscle.  On  this  account,  then,  thigh  stumps 
should  be  long.  So  far  as  the  method  is  concerned  the  circular,  or  some  modification 
thereof,  gives  the  best  results  in  the  majority  of  instances.  It  may  easily  be  modified 
into  one  of  the  oblique  methods,  or  liberating  incisions  may  be  used  whenever  they  will 
be  of  service.     If  it  be  absolutely  necessary  to  make  the  amputation  high  hemostasis 


AMinrATIOSS  OF   THE  LOW  ER  EXTREMITY  1045 

can  l)o  secured  1)V  the  saiiu"  methods  that  are  used  in  hi|)-ji)iut  amputations.  The  dense 
and  strorif,'  faseia  hita,  whieli  lies  beneath  the  superlieiai  laseia,  should  he  divided  at 
the  same  level  with  the  skin,  since  it  serves  admirably,  when  secured  by  a  separate  set  of 
sutures,  to  make  a  <jood  covering];  for  the  ends  of  the  muscles,  after  these  have  been  them- 
selves carefully  united  by  buried  sutures.  The  sciatic  nerve  should  be  especially  sou>;ht, 
thorou«;hly  stretched,  and  divided  hi^rh  up.  The  vessels  often  evince  a  tendency  to 
retract  within  Hunter's  canal;  it  is  not,  however,  difficult  to  separate  the  vastus  internus 
from  tlie  adductor  lon«jus,  between  wdiich  they  lie,  and  in  this  way  gain  access  to  them. 
Kven  for  hiuh  work  on  the  thiii;li  one  may,  if  necessary,  do  as  some  have  done  at  the  hij), 
make  a  ])reliminary  ligation  of  the  femoral  artery.  This  may  be  especially  serviceable 
as  an  enuT<'-ency  measure,  or  in  special  cases  of  tumors  which  have  attained  large  size, 
are  placed  Iiigh  uj)  and  call  for  somewhat  aty})ical  methods. 

Tne  Hip-30int. — Amputation  here  is  essentially  a  dimriiculation  and  constitutes 
one  of  the  usually  formidable  and  serious  operations  of  major  surgery.  Although  the 
joint  itself  is  generally  easily  reached  there  are  many  things  to  be  considered  in  the  {)er- 
formance  of  this  operation,  of  which  the  mere  arthrotomy  is  by  no  means  the  most 
important. 

I'reparations  being  all  made,  the  first  consideration  is  the  control  of  hemorrhage,  for 
which  several  methods  have  been  suggested,  but  of  which  but  two  or  three  are  in  general 
use.  Such  procedures  as  compression  of  the  abdominal  aorta,  either  w^ith  the  hand  or 
by  tourniquet,  or  of  tlie  common  aorta  through  the  rectum,  with  a  lever,  as  suggested  by 

Fig.  715 


Wyeth's  bloodless  method:  pins  inserted  and  tube  applied. 


Davey,  or  with  the  hand,  as  suggested  by  Woodbury,  or  the  exposure  of  the  common 
iliac,  either  within  the  peritoneum  as  practised  by  McBurney,  or  externally,  or  exposing 
the  common  femoral  above  Poupart's  ligament,  are  now  adopted  by  very  few  surgeons. 
Langenbeck  used  to  be  fond  of  preliminary  ligation  of  the  femoral  where  it  is  most 
accessible  in  the  groin,  and  this  is  probably  the  best  of  all  of  these  methods.  But  they 
have  been  all  practically  discarded  since  Wyeth  introduced  the  simple  method  of  trans- 
fixing the  limb  with  his  pins  (i.  e.,  long  mattress  needles  or  skewers  made  for  the  purpose), 
these  serving  to  hold  in  place  an  elastic  cord  or  tourniquet  (Fig.  715).  This  has  been 
found  to  be  a  great  improvement  on  the  suggestion  of  Senn,  who  excised  the  femoral 
head  and  then  compressed  each  half  of  the  limb  with  a  separate  elastic  band. 

The  directions  for  the  use  of  Wyeth's  pins  are  simple.  Here,  as  in  other  cases,  it 
may  not  be  practicable  to  use  the  elastic  bandage  from  the  lower  end  of  the  limb,  but 
one  may  at  least  elevate  the  limb  and  thus  coax  the  blood  out  of  it  by  gravity  or  by  gentle 
manipulation.  While  it  is  still  in  this  position  one  of  the  long  pins  is  introduced  just 
below  the  anterosuperior  spine  and  a  trifle  to  its  inner  side,  and  made  to  emerge  on  a 
level  with  and  about  three  inches  from  the  point  of  its  entrance.  The  other  needle  is 
inserted  just  to  the  inner  side  of  the  saphenous  opening,  and  below^  the  level  of  the 
crotch,  and  brought  out  about  one  inch  below  the  tuberosity  of  the  ischium.  Corks 
should  then  be  placed  upon  them  so  as  to  protect  the  needle  points.  Next  a  piece  of 
elastic  tubing  or  band  is  placed  around  the  limb  above  these  pins  and  tightened,  each 
turn  being  made  a  little  tighter,  so  as  to  absolutely  control  the  circulation.     The  effect  of 


1046  SPECIAL  OR  REGIONAL  SURGERY 

tills  is  felt  u])()n  [)ractk'ally  every  vessel  in  that  part  of  the  body,  and  if  the  inetli(jd  be 
properly   praetised   it   affords  absolute  security. 

The  suri^eon  now  has  his  choice  of  various  methods  of  disarticulation,  either  that  by 
antero})osterior  flaps  or  lati'ral  flaps,  or  by  the  circular,  with  the  free  liljcratino;  lateral 
incision;  or  he  may  devise  any  method  of  his  own  which  will  Ix^st  meet  the  indication  in  a 
o'iven  case.  Fig.  715  illustrates  the  employment  of  Wyeth's  pins  and  the  first  circular 
incision  made  as  for  the  circular  method.  Of  these  all  the  latter  seems  preferable  when 
circumstances  permit.  It  should  be  combined  with  a  sufficient  lateral  incision,  which 
should  be  made  to  pass  well  over  the  great  trochanter.  The  cuff'  raised  through  this 
incision  should  extend  down  to  the  deep  fascia  and  up  to  the  level  of  the  lesser  trochanter, 
at  which  level  the  deeper  tissues  are  divided  transversely  or  by  a  circular  cut. 

It  is  well  next  to  lay  down  the  knife  and  secure  the  large  vessels,  after  which  the  deep 
muscles  are  se])arated  from  the  u|)per  end  of  the  shaft  and  the  proximity  of  the  jcnnt, 
while  the  entire  limb  may  be  still  used  as  a  lever  in  so  stretching  the  joint  capsule 
as  to  better  expose  and  divide  it.  So  soon  as  the  capsule  has  been  opened,  and  the 
entrance  of  air  thus  permitted,  it  will  be  easy  to  expose  and  divide  the  teres  ligament, 
after  which  the  balance  of  the  disarticulation  is  easily  effected.  The  large  nerve  trunks 
are  now  sought,  retracted,  and  divided  high  up,  all  visible  vessels  are  secured  firmly, 
after  which  the  elastic  constriction  may  be  gradually  released  and  any  vessels  that  spurt 
may  still  be  secured.  There  will  nearly  always  be  trouf)lesome  oozing  from  the  cut  ends 
of  the  large  muscles,  and  here,  if  hot  water  prove  insufficient  to  check  it,  with  large  curved 
needles  and  catgut  sutures  the  muscle  ends  may  be  secured  by  ligature  en  masse,  before 
they  are  brought  together  for  the  purp<jse  (jf  closing  the  stump. 

Whatever  the  method  selected  as  jierfect  a  closure  of  the  wound  as  possible  should  be 
made,  with  ample  provision  for  drainage.  By  careful  deep  suturing,  with  tiers  of  buried 
sutures,  it  is  possible  to  avoid  leaving  dead  spaces  at  any  point  except  perhaps  the  acetab- 
ulum. Through  retaining  sutures  may  also  be  used  to  advantage.  It  is  most  desirable 
to  so  plan  the  incisions  and  the  closure  of  the  wound  as  to  keep  them,  so  far  as  possible, 
away  from  the  region  of  the  perineum.  Therefore  the  longer  the  inner  flap  or  inside  of 
the  stum])  the  better.  As  conditions  which  necessitate  removal  of  the  limb  at  the  hip- 
joint  are  always  serious,  and  have  each  their  own  peculiarities,  any  method  which  will 
best  serve  the  jnirpose  should  be  used. 

Plates  LIX  and  LX,  designed  by  Prof.  JNIatas,  afford  the  best  and  briefest  epitome 
of  the  choicest  amputation  methods  which  can  be  furnished. 


THE   STUMP. 

An  amputation  having  been  effected,  and  the  stump  closed,  there  is  still  occasion  to 
consider  how  it  may  best  be  treated  to  fit  it  for  its  future  pur))oses.  When  entire  chapters, 
or  even  small  monographs,  can  be  written  on  the  subject  of  "diseases  of  stumps"  it 
would  a])])ear  that  the  consideration  is  not  one  of  merely  trifling  import. 

A  (jood  stump  has  a  regular  outline,  with  a  protected  scar,  and  should  be  firm,  yet  mobile, 
and  without  tender  or  sensitive  surfaces.  It  should  constitute  the  lower  end  of  a  trun- 
cated cone,  and  needs  to  be  of  sufficient  length  to  permit  leverage  within  the  socket  of 
the  artificial  limb  which  will  be  fitted  about  it. 

A  stump  failing  in  these  characteristics  is  a  had  stumj),  the  features  which  especially 
tend  to  make  it  bad  being  undue  conicity  (Fig.  716)  or  sensitiveness  of  surfaces,  ulcera- 
tion from  friction,  or,  worse  yet,  occurring  without  it,  and  neuralgia  from  inclusion  of 
nerve  ends,  or  from  bone  ends  which  present  osteophytic  outgrowths  and  thus  distort 
and  displace  tissues  (Fig.  717).  Acute  osteomyelitis  occurs  in  stumps,  as  do  slower 
carious  processes  which  may  call  for  re-amputation,  jjerhaps  even  at  a  distance.  The 
stump  is  for  a  long  time  more  or  less  tender  and  troublesome,  and  its  owner  may  be  a 
sufferer  from  hyjieresthesia  or  perverted  sensations. 

The  possibility  of  the  production  of  a  conical  stump  in  children  as  the  result  of  atrophic 
elongation,  was  mentioned  early  in  this  chapter.  While  this  cannot  always  be  prevented 
it  may  sometimes  be  foreseen,  and  one  should  be  prepared  at  any  time  in  such  cases  to 
circumcise  the  bone,  forcibly  retract  the  tissues,  and  then  divide  the  bone  ends  on  a 
higher  level. 

An  exquisitely  neuralgic  stump  is  usually  made  so  by  the  entanglement  of  nerve  ends 


PLATE   LIX 


1,  2.   Circular  for  middle  and  upper  thirds  of 
thigh. 


S.  Circular  for  lower  third  of  Ihiijh,  fihowing 
tendency  of  circle  to  incline  dounxvard  on  adduc- 
tor side  to  compensate  for  greater  retraction. 

4.  Incision  for  (iriitVs  or  Garden's  amputations 
at  knee  (single  anterior  flap). 


5,6.  Stephen  Smith's  bilateral  flaps  (posterior 
racquet). 


7.  Antero-posterior  flaps,  cut  solid  (0  the  bone, 
the  soft  parts  being  elevated  from  the  periosteum 
(Marc  See,  von  Brun's  method).  This  is  the  au- 
thor's preferred  method  for  leg  only,  simplified  by 
making  a  simple  circular  vith  two  lateral  liberat- 
ing incisions  on  fibular  and  tibial  sides. 

S,  0,  10.  Circular  vith  posterior  racquet  ex- 
tension to  form  bilaterfd  flaps  {Stephen  Smith). 

11.  Gnyon's  supra-malleolar  amputation. 

12.  Lines  of  Syme's  amputation. 

IS.  Inner  aspect  of  lioux's  tibio-tarsal  amputa- 
tion ;   also  sub(istrag(doid. 

14.  Medio-tnrsal  amputation  (inner  aspect). 

15.  Tavso-metatarsal  disarticulation  {inner 
aspect). 

21       16.   Disarticulation  of  toe  with  its  metatarsal. 
17.   Disarticulation  of  big  toe;  in  front  of  this 
lines  for  amputnting  first   or  terminal  phalanx 
by  long  jdantnr  flap. 


The  Right  Lo^A^er  Limb,  Internal   Lateral  View  (Surface 

Incisions). 


PLATE  LX 


Surface  Outli 


1.  Low  ch'cidar  with  external  incision  (Fnrnennr  Jor- 
iJ(in)  or  (it  a  hiijlier  lerel  (iiluieo-femoral  furroir)  iipplic- 
iihle  to   IVi/elli's  method  of  disarticulating  hip. 

3.  Circular  incision  with  tendency  to  racquet  poste- 
riorly in  middle  third  amputations. 


3.  Circular  with  posterior  vertical  incision  in  amputa- 
tion of  lower  third  of  thigh. 


4-  Long  anterior  flap  for  supra-condyloid  amputation 
of  thigh. 

5.  Racquet  incision  with  long  anterior  flap  for  extreme 
upper  third  of  leg.  Note  long  posterior  tail,  which  facili- 
tates upward  retraction  of  a  solid  muscido-ciitaneous 
flap  cut  down  to  the  periosteum,  resembling  a  bilateral 
flap  operafion  (f<tephen.  Smith).  The  same  incision  cut 
a  little  higher  is  most  serviceable  in  disarticulating  at 
the  knee. 

G.  I^ong-hooded  anterior  flap,  with  posterior  racquet 
(Fitephen  Smith  and  Bier^s  osteoplastic). 

7.  Amputation  by  equal  antero-posterior  flap  (Marc 
See,  von  Bruus). 

8.  Amputation  by  long  anterior  and  short  posterior 
flaps  (TeaMs  principle). 

9.  Amputation  of  leg  at  crtreme  lower  third,  practic- 
ally a  circidar  ampnfation  converted  into  a  solid  antero- 
posterior Hup  by  liberating  incisions  on  fibular  and  tibial 
sides. 

10.  G'uyon's  supra.-malleolar  amputation  of  leg. 

11.  Medio-tarsal  and  intra-tar.ial  amputations  (Cho- 
part  and  if^  derittatives). 

■J      /?.     Tarso-metatarsal  amputation  (Lisfranc  and 
r  derii^afives). 


nes  of  Amputations  Practised  in  the 
Lower  Extremity. 


THE  STVMP 


1047 


Jiiid  tlicir  .sul>si'(|Mc'iil  ciiliirixciiu'iit  into  so-called  (inipiitdfion  .stump  neuromas  (wliicli  are 
liistolof^icallv  lihroiiias),  from  prcssuiv  upon  nrrvi-  tcnniiiaLs.  Under  tlie.se  eireuinstaiices 
their  exeisioii  tliroui«;li  incisions  i)lanned  for  the  |)nr|)ose,  or  tiie  exseetion  of  a  portion 
of  the  nerve  trnnk  at  a  hi^dier  level,  may  he  necessitated  {¥\g.  717). 

While  j)atients  may  prefer  disnse  of  a  stnmp  for  as  lonii;  a  time  as  possil)le  the  jndicions 
surgeon  will  pre{)are  it  as  rapidly  as  he  may  for  early  application  of  the  expected  arti- 


Fio.  71G 


Fiu.  717 


Extreme  case  of  conical  stump. 


Neuromatous  endings  of  nerves  in  a  stump. 


ficial  Hmb.  Inasmuch  as  leg  stumps  allowed  to  hang  downwarfl  become  cyanotic  and 
edematous  it  is  well  to  keep  them  bandaged,  and  the  makers  of  artificial  limbs  prefer  to 
have  the  bandages  kept  wet.  When  the  stump  is  healed,  passive  motion  of  the  remainder 
of  the  limb  should  be  begun,  in  order  that  there  may  be  a  minimum  of  stiti'ening  of 
joints.  If,  then,  such  a  stump  be  bathed,  massaged,  moved,  and  then  bandaged  with 
comfortable  snugness  with  cold,  wet  bandages,  over  which  oiled  silk  may  be  fastened, 
and  if  this  be  done  at  least  once  each  day,  the  stump  will  be  prepared  for  the  artificial 


Fig.  718 


Fig.  719 


Ideal  stump. 


Bad  stump,  because  posterior  flap  was  cut  t<io 
short,  and  there  has  been  great  retraction  of  all 
soft  tissues.     (Farabeuf.) 


limb,  on  the  average,  in  two  to  three  months.  One  should  not  wait  for  this  expiration 
of  time  if  it  be  thoroughly  healed ;  or,  on  the  other  hand,  he  may  have  to  wait  much  longer 
under  unfortunate  circumstances;  but  the  above  general  principles  of  treatment  and 
general  statements  will  be  found  to  prevail.  Figs.  718  and  719  illustrate  the  difference 
between  good  and  bad  stumps,  while  Plates  LIX  and  LX  (reproduced  from  Matas) 
furnish  the  surface  outlines  for  selection  of  the  various  amputations  of  the  lower  limb. 


1048 


SPECIAL  OR  REGIONAL  SVRdERY 


CINEPLASTIC  OR  CINEMATIC  AMPUTATIONS  OF    THE  UPPER  EXTREMITY. 

The  most  pronounced  jind  illustrative  of  recent  methods  is  perhaps  the  "cinematic" 
or  "cinej)lastic"  j)roce(lure  of  Vanghetti.  This  Italian  surgeon  |)roposed  a  j)rosthetic 
method,  in  1898,  which  is  illustrated  in  Figs.  720,  721  and  722.     He  has  shown  that 


Fig.  720 


Fig.  721 


Fig.  722 


Results  i)f  Vanghetti's  "cinematic"  method,  with  preservation  and  utilization  of  tendons. 

tendon  terminations  may  be  left  exposed  in  stumps,  under  favorable  conditions,  and  so 
utihzed  as  to  serve  remarkably  useful  jnirposes — though  under  exceptiojial  conditions. 
For  a  description  of  these  methods  the  reader  is  referred  to  his  monograph.  (G.  Vanghetti, 
Pla.siica  e  Prated  Cinematiche,  Empoli,  190G.) 


INDEX. 


Abdomen,   disoasos   of,   diagnosis 

of,  768 
tlistcntion   of,    in    iippendicitis, 

856 
drainage  of,  776 
general  considerations  an<l  con- 

tlitions  of,  767 
inflation  of,  769 
insiJection  of,  76S 
mea^surement  of,  769 
operation  on,  tcchniciue  of,  77.'; 
jmlpatioii  of,  768 

bimanual,  769 
wovnids  of,   gunshot,   214,   232 
Abdominal    aorta,    anourvsm   of, 
346 

ligation  of,  356 
cavity,   irrigation   of,   775 
diseases,  diagnosis  of,   768 
incisions,  closure  of,  777 
operations,  after-treatment  of, 
777 

embolism   following,    784 

hemorrhage  after,  780 

peritonitis  following,  780 

technique  of,  773 

thrombosis  following,  784 
viscera,   general   considerations 

and  conditions  of,  767 
wall,  abscess  of,  783 

actinomycosis  of,  783 

burns  of,  783 

carcinoma  of,  784 

contusions  of,  781 

cysts  of,   congenital,   783 

endothelioma  of,  784 

epithelioma  of,  784 

erysipelas  of,  783 

fibroma  of,  784 

foreign  bodies  in,  783 

gangrenous  cellulitis  of,  783 

hematoma  of,  781 

injuries  of,  781 

lacerations  of,  781 

osteomyelitis  of,  783 
'     phlegmons  of,  783 

sarcoma  of,  784 

suppurative    spondylitis    of, 
783 

syphilis  of,  783 

tuberculosis  of,  783 

tumors  of,  783 
vascular,  784 

wounds  of,  gunshot,   783 
penetrating,  781 
Abscess  of  abdomen,  783 
atheromatous,  73,  339 
bone,  419,  425 

treatment  of,  426 
of  brain,  567 

prognosis  of,  569 

symptoms  of,  568 

treatment  of,  573 
of  breast,  757 
classification  of,  58 

acute,  58 

cold,  58,  112 

gravitation,  58 


Abscess,    classification  of,  metas- 
tatic, 59 
subacute,  58 
subfacial,  59 
subperiosteal,  59 

cohl,  112 

peri-articular,    treatment   of, 
399 

(•ollar-button,  319 

definition  of,  58 

frontal,  569 

of  heart  wall,  733 

ischiorectal,  879,  1013 

of  liver,  911 

symptoms    of,    912 
treatment  of,   912 

lumbar,  114 

of  lung,  734 

of  mesentery,   939 

metastatic,  59,  91 

occipital,  569 

of  pancreas,  949 

parietal,  569 

peri-appendicular,  860 

perilaryngeal,  704 

perineal,  1013 

treatment  of,  1013 

perinephritic,  961 

perirectal,  879 

treatment  of,  879 

peritracheal,  704 

perityphlitic,  860 

of  prostate,  994 

psoas,  114 

of  rectum,  879 

treatment   of,   879 

renal,  957 

retropharyngeal,  114,  682 

signs  of,  60 

of  spleen,  941 

subphrenic,  753 
treatment  of,  754 

symptoms  of,  60 

temporosphenoidal,  569 

of  tonsils,  662 

treatment  of,  60 
Abstraction  of  blood,    182 
A.  C.  E.  mixture,  198 
Accommodation,  defects  of,  604 
Acetabulum,  migration  of,  453 
Acetonemia,  82 
Acetonuria,  82 
Acheilia,  638 
Achondroplasia,  432 
Acid      intoxication      from      anc -- 

thetics,  203 
Acinous  carcinoma,  290 
Acoustic  nerve,  neurofibroma  of, 

584 
Acromegaly,  437 

Acromial  process,  fracture  of,  494 
Actinomycis,  109 

fungi,  55 
Actinomycosis,  109 

of  abdominal  wall,  783 

of  bone,  432 

of  breast,  759 

definition  of,  109 

diagnosis  of,  110 

of  face,  640 


Actinomycosis  of  intestines,  827 
of   kiflneys,   964 
of  liver,  914 
of  lung,  732,  734 
of  mesentery,  939 
of  mouth,  657 
organism  of,  109 
prognosis  of,  110 
pas  in,  109 
of  skin,  308 
of  thorax,  729 
of  tongue,  659 
treatment  of,  110 
Adenocarcinoma,  285 
of  bladder,  992 
of  pancreas,  953 
Adenoids  of  pharynx,  679 

treatment  of,  680 
Adenoma,  284 
of  bladder,  992 
of  breast,  760 
of  kidney,  969 

congenital,  969 
of  liver,  914 
of  pancreas,  953 
of  rectum,  885 
sebaceous,  285 

cysts,  285 
of  thyroid,  712 
Adenosarcoma,  embryonal,  268 
Adventitious  bursie,  263 
Ainhum,  76 
Air  embolism,  38 
of  veins,  363 
Aleppo  boil,  309 
Alimentary      canal,      infection 

through,  49 
Allantoic  cysts,  2()() 
Alveolar  sarcoma,  274 

suppuration,  664 
Alypin,  207 
Amastia,  755 
Amazia,  755 
Amputations,  1023 
of  arm,  1032 
atypical,  1023 

control  of  hemorrhage  in,  1024 
of  elbow,  1031 
of  finger,   1029 
of  foot,    1037,    1041 
Bruns'  method,  1042 
partial,  1034 
Teale's  method,  1042 
of  forearm,  1031 
of  hand,  1031 
of  hip-joint,  1045 

Davey's  method,  1045 
McBurney's  method,  1045 
Woodbury's  method,  1045 
Wyeth's  method,  1045 
interscapularthoracic,  1033 
of  knee,  1043 

Gritti's  method,  1044 
SabanejefT's  method,  1044 
Stephen      Smith's      method, 
1043 
of  leg,  1039 

Bier's  osteoplastic,  1028 
circular,  1041 
Pirogoff's  method,  1040 

( 1049  ) 


1050 


INDEX 


Amputations  of  lower  extremity, 

1034 
iiiediotarsal  of  Chopart,  1037 
method  of,  1026 

circular,  1026 

Hap.  1027 

osteoplastic,  1027 
of  penis,  1010 
of  shoulder,  1032 
stump  after,  1046 
bad,  1046 
good,  1046 

neuromas,  1047 
suiiracondyloid,  1043 
of  thigh,  1043 

above  knee,  1044 

Gritti's  method,  1043 

Stokes'  method,  1043 
of  thumb,  1029 
tibiotarsal,  1037 
of  toes,   1034 
typical,  1023 
of  upper  extremity,  1029 
cinejjlastic,  1048 
entire,  1033 
of  wrist,  1031 
Anastomosis  of  arteries,  aneurysm 

by,  344 
gastric,  816 
of  intestines,  842 
Anastomotic  varix,  364 
Anel's  method  of  treating  aneu- 
rysm, 347 
Anemia,  30 
pernicious,  30 
primary,  30 
secondary,  30 
splenic,  31 
Anesthesia  and  anesthetics,  192 
A.  C.  E.  mixture,  198 
accidents  from,  201 

arrested  respiration,  202 
treatment  of,  202 

cardiac  failure,  201 
acid  intoxication  from,  203 
administration  of,  193 
anesthol,  200 
chloroform,  195 

accidents  from,  196 

action  of,  196 

administration  of,  197 

death  from,  196 
choice  of,  200 
dangers  of,  201 
discovery  of,  192 
ether,  193 

accidents  due  to,  194 

action  of,  194 

narcosis  by  rectum,  195 

petroleum,  199 

secjuels   from   administration 
of,  195 
ethyl  bromide,  198 

chloride,  199 
local  use  of,  199 
intraspinal,  207 
local,  205 

alypin,  207 

anesthesin,  207 

beta-cucaine,  207 

cocaine,  205 

liquid  air,  205 

nervanin,  207 

orthoform,  207 

stovaine,  207 
magnesium  salts,  209 
management  of,  192 
methylene  bichloride,  198 
morphine,  205 
nitrous  oxide  gas,  200 
scopolamine,  205 
somnoform,  199 
Anesthesin,  207 
Aneurysmal  bruit,  341 
varix,  363 


Aneurysms    of   abdominal    aorta, 
346 

arteriovenous,  344 

of  axillary  artery,  345 

of  carotid  artery,  345 
external,  345 
internal,  345 

cirsoid,  278,  339,  344 

classification  of,  342 

diagnosis  of,  345 

diffuse,  339,  342 

(hssecting,  339,  342 

false,  339,  343 

of  femoral  artery,  346 

fusiform,  339,  343 

of  lieart.  732 

hernial,  339 

of  iliac  artery,  340 

of  innominate  artery,  345 

intracranial,  345 

of  liver,   914 

of  neck,  701 

of  orbit,  592 

progress  of,  341 

pulsation  of,  341 

racemose,  344 

rupture  of,  341 

sacculated,  339,  342 

spontaneous,  339 

of  subclavian  artery,  345 

traumatic,  339,  343 

treatment  of,  346 
by  extirpation,  348 
by      introduction     of      wire, 

348 
by  ligation,  347 

Anel's  method,  347 
Brasdor'y  method,  347 
Hunter's  method,  347 
Wardrop's  method,  347 
by  open  division,  347 
by  opening  and  suture,  348 

true,  339 

varicose,  339,  342,  363 
Angina,  Ludwig's,  658,  703 

Vincent's,  703 
Angiocholitis,  desquamating,  919 
Angioma,  277 

arterial,  278 

capillary,  277 

cavernous,  277 

of  omentum,  935 

of  orbit,  592 

plexiform,  278 

of  veins,  366 

treatment  of,  307 
Angiosarcoma,  275 
Angiotribe,     control     of     henn)r- 

rhage  by,  236 
Ankle,  dislocations  of,  544 

excision  of,  414 
Ankyloblepharon,  603 
Ankyloglossum,  652 
Ankylosis,  403 

contractures,  403 

of  hip,  404 

of  jaw,  667 

of  knee,  404 

treatment  of,  405 

true,  403 
Annular  thrombosis,  35 
Anthrax,  106 

bacillus  of,  54 

definition  of,  106 

incubation  in,  107 

postmortem     ajipearances     in, 
107 

prognosis  of,  107 

prophylaxis  of,  108 

syinptoms  of,  107 

treatment  of,  107 
Antisepsis,  243 
Antiseptic    applications,   248 

solutions,  248 
Antiseptics,  toxic,  175 


Antitoxin    treatment   of   tetanus, 

101 
Antrum  of  Ilighmore,  operations 

on,  611 
Anus,  absence  of,  873 
artificial,  839 

congenital   defects  of,   872 
fissures  of,  87G 
im]jerforate,  873 
malformations  of,  872 
Aorta,    abdominal,    ancm-vsm   of, 
346 
ligation  of,  356 
Aplasia  cranii,  547 
Aponeunjtoiny,  327 
Apoplectic  cysts,  952 
Apoplexia  neonatorum,  564 
Apoplexies,  compression,  560 
Ai)pendicitis,  bacteriology  of,  852 
causes  of,  854 

chronic,   operation   for,   866 
complications  of,  855 
diagnosis  of,  857 

from    acute    obstruction    of 
bowel,  858 
pancreatitis,  858 
from  cholecystitis,  857 
from  colitis,  857 
from  enterocolitis,  857 
from  floating  kidney,  858 
from  gastric  ulcers,  857 
from  intestinal  ulcers,  857 
from  lead  colic,  858 
from    mesenteric     embolism, 
858 
thrombosis,  858 
from  peritonitis,  857 
from   psoas   abscess,    859 
from  pyosalpinx,   858 
from   ruptured   extra-uterine 

pregnancy,  858 
from     strangulated     hernias, 
858 
McBurney's  point  in,  855 
recurrent,  854 

operation  for,  866 
symptoms  of,  859 
acute,  855 

abdominal  distention,  856 
bowels,  856 
jaundice,  856 
muscle  spasm,  855 
pain,  855 
pulse,  856 
temperature,  856 
tenilerness,  855 
tumor,  856 
vomiting,  856 
treatment  of,  861 
non-operative,  862 
operative,  862 

indications  for,  862 
in  typhoid  fever,  859 
Appendicostomy,  850 
Appendicular  colic,  853 
Appendix,  vermiform.   Sec  Vermi- 
form appendix. 
Aprosopia,  638 
Arlt's     operation     for     blepharo- 

plasty,  602 
Arm,  amputation  of,  1032 
Arrow  poisoning,  173 
Arterial  angioma,  278 
Arteries,  abdominal  aorta,  aneu- 
rysm of,  346 
ligation  of,  356 
aneurysm  of,  339 
by  anastomosis,  344 
arteriovenous,  344 
cirsoid,  339,  344 
classification  of,  342 
diagnosis  of,  345 
diffuse.  339,  342 
dissecting,  339,  342 
false,  339,  342 


INDEX 


1051 


Ailorii's,    aiiciirvsm    of,    fii.sifonn, 

luTiiial,  'M\) 

pronross  of,  'A\  1 

pulsation  of,  341 

rui'cinosc,  ■S44 

niutdrc  of,  ;141 

sacculiitcd,  ;«!),  :M2 

spoiitaiH'ods,  'SM 

tiautiiatir,  :«!>,  ;i4;J 

treat iiK-iit.  of,  340 

true,  ;i;}!) 

varirosi',  .330,  344 
axillary,  aiicurysni  of,  345 

ligation  of,  3.')5 
brachial,  lif^ation  of,  355 
cak'ilii'ation  of,  339 
carotiil,  aiu'iirysni  of,  345 

common,  ligation  »)f,  351 

extt-rnal,  aneurysm  of,  345 
excision  of,  352 
lif^ation  of,  352 

injuries,  563 

internal,  aneurysm  of,  345 
ligation  of,  352 
circumflex,  ligation  of,  359 
epigastric,  ligation  of,  359 
facial,  ligation  of,  352 
fatty  degeneration  of,  339 
femoral,  aneurysm  of,  34G 

ligation  of,  359 
iliac,  aneurysm  of,  346    . 

common,  ligation  of,  35G 

external,  ligation  of,  357 

internal,  ligation  of,   357 
innominate,  aneurysm  of,  345 

ligation  of,  350 
ligation  of,  350 

gangrene  from,   73 
lingual,  ligation  of,  352 
middle  m.eningeal,   injuries   of, 

563 
occipital,  ligation  of,  352 
popliteal,  ligation  of,  360 
ratlial,  ligation  of,  356 
subclavian,    aneurysm    of,    345 

ligation  of,  354 
surgical  diseases  of,  337 
temporal,  ligation  of,  352 
thyroid,    inferior,    ligation    of, 

"353 
tibial,  anterior,  ligation  of,  360 

posterior,  ligation  of,  360 
ulnar,  ligation  of,  356 
vertebral,  ligation  of,  353 
Arteriorrhaphy    in    treatment    of 

aneurysm,  348 
Arteriosclerosis,  339 
Arteriotomy,  183 
Arteriovenous  aneurysm,  344,  564 
Arteritis,  338 
Arthrectomy,  400 
Arthritis,  382 
chronic,  386 

treatment  of,   386 
deformans,  387 

treatment   of,   389 
gonorrheal,  392 
postgonorrheal,  152,  392 

of  jaw,  667 
rheumatoid,  387 
syphilitic,  385 
tuberculous,  393 

diagnosis  of,  398 

pathology  of,  394 

symptoms  of,  397 

treatment  of,  398 
Arthropathic  joint  disease,  394 
Arthrotomy,  400 
Artificial  respiration,  204 

Howard's  method,  204 

Marshall  Hall's  method,  204 

in  shock,  180 

Sylvester's  method,  204 
Ascites,  chylous,  368 


Ascitic     tuberculous     [icritonitis, 

791 
Asepsis,  243 

sterilization,  243 

by   boiling  water,  244 
of  tlressings,  247 
by  formalin,  244 
fractional,  244 
of  hands,  245 
by  heat,  243 
of  instruments,  24(> 
by  mustard  Hour,  245 
of  sponges,  247 
of  suture  materials,  247 
Aseptic     wound     fever,     85.      tScr 

Surgical  fever. 
Aspergillus  fungi,  56 
Aspiration,  paracentesis  by,  184 
Asthma,  thymic,  163 
Astomia,  638 
Astragaleclomy,  4(57 
Astragalus,  dislocation  of,  544 
Atheroma  of  arteries,  339 
Atheroinatous  abscess,  73,  3.'5!) 
cvsts  of  neck,  707 

■  of  skin,  310 
ulcer,  339 
Atresia  of  rectum,  872 
Atrophic  elongation  of  bones,  43() 
Atrophy  of  bone,  422 
of  brain,  578 
definition  of,  26 
of  muscles,  332 

treatment  of,  332 
pathological,  26 
physiological,  26 
senile,  26 
of  skull,  547 
of  testicle,  1015 
trophoneurotic,  27 
of  veins,  361 
Auricle,  rodent  ulcer  of,  606 
Auricles,  supernumerary,  605,  638 
Auto-intoxication,  79 
cause  of,  79 
ferments  in,  79 
intestinal  putrefaction  in,  81 
osmotic  pressure  of  blood  in, 

80 
potassium  salts  in,  SO 
treatment  of,  general,  S3 

venesection  in,  80 
urea  in,  80,  81 
Axilla,  syphilis  of,  751 
tuberculosis  of,  751 
Axillary  artery,  aneurysm  of,  345 
ligation  of,  355 


B 


Bacillus    aerogenes    capsulatus, 
55 
anthracis,  54 
bubonic  plague,  54 
chancroid,  55 
coli  communis,  53 
diphtherise,  54 
lepris,  54 
mallei,  54 

cedematis  maligni,  54 
pneumonifE,  54 
proteus,  53 
pyocyaneus,  53 
of  Rauschbrand,  55 
of  rhinoscleroma,  54, 
tetani,  54 
of  tuberculosis,  54 
typhi  abdominalis,  53 
Bacteria  of  pus  formation,  51 
facultative  pyogenic,  53 
bacillus  aerogenes  cap- 
sulatus, 55 
anthracis,  .54 
bubonic  plague,  54 


Bacteria  of  i)us   formation,   facul- 
tative       pyogenic 
bacillus,  chancroid, 
55 
diphtheria;,  54 
lepne,  54 
mallei,  54 

(I'dcmatis  maligni, 54 
proteus,  ,5.3 
])neuiuonia>,  .')4 
of  Haus<libran<l,  .5.5 
of  rhinoscleroma,  54 
tetani,  54 
tuberculosis,  .54 
tvphi    abdominalis, 
■  53 
obligate  pyogenic,  52 

bacillus,    pyocyaneus, 
53 
coli  coninuniis,  r>'i 
colon  bacillus,  ft'.i 
dii)lococcus     pneumo- 
nia", 53 
micrococcus        gonor- 
rhcea;,  53 
lanceolatus,  .53 
tetragenus,  53 
staphylococcus      pyo- 
genes albus,  52 
aureus,  52 
epidcrmidis,  52 
streptococcus  erysipe- 
latus,  52 
pyogenes,  52 
Bacterial  determination  of  pus  as 
an  indication  to  treatment,  57 
Balanitis,  149,  1005 
Balanoposthitis,  149,  1005 
Bandage,    elastic,    for    control    of 

hemorrhage,  234 
Bandaging,  189 

kinds  of,  189,  190,  191 
naaterials  used  in,  191 
Banti's  disease,  31,  942 
I^arbadoes  leg,   372 
Barrel-shaped  chest,  719 
Barton's  head  bandage,    191 
Basedow's   disease,    713 
Bassini's  operation  for  hernia,  902 
Bastard  clap,    148 
Bed-sores,  a  cause  of  gangrene,  74 
Bees,  poisoning  by,   172 
Bell's   palsy,   640 
Bellocq's  cannula,  681 
Bennett's  fracture,  506 
Beta-cocaine,  207 
Beta-eucaine,  207 
Bichat,  fatty  ball  of,  641 
Bier's  osteoplastic  amputation  of 
leg,  1028 
permanent  hvperemia  in  tuber- 
culosis, 120 
treatment     of     tuberculosis    of 
joints,  399 
Biett's  collarette,  131 
Bifid  penis,  1004 

tongue,  652 
Biliary   calculi,   922 
diagnosis   of,   925 
symptoms  of,  924 
treatment  of,  926 
colic,  922 

symptoms  of,  924 
ducts,  stricture  of,  921 
fistulas,  917 
intestinal,  917 
pathological,  917 
postoperative,  917 
passages,  catarrh  of,  acute,  918 
treatment  of,  918 
chronic,  918 
injuries  of,  918 
operations  on,  927 
perforation  of,   921 
ulceration  of,  921 


1052 


INDEX 


Biliary     passages,    ulceration    of, 
symptoms  of,  922 
treatment  of,  922 
Billroth's  chain-stitch  suture,  241 
Biskra  button,  309 
Bladder,  adenocarcinoma  of,  992 
adenoma  of,  992 
calculi  of,  986 

symptoms  of,  986 
treatment  of,  987 
congenital     malformations     of, 

977 
dermoid  cysts  of,  992 
ectopia  of,  978 

treatment  of,  978 
examination  of,  977 
exstrophy  of,  978 

treatment  of,  978 
fibroma  of,  992 
foreign  bodies  in,  982 
inflammation  of,  984 

symptoms  of,  984 

treatment  of,  985 
injuries  to,  981 

treatment  of,  981 
myxoma  of,  992 
papilloma  of,  992 
siphonage  of,  1003 
tuberculosis  of,   118 
tumors  of,  992 

symptoms  of,  992 

treatment  of,  992 
wounds  of,  233 
Blastomj^cetic  dermatitis,  309 
lesions  of  mouth,  658 
pus,  56 
Blennorrhea,     146.     See     Gonor- 
rhea. 
Blepharitis,  601 

marginalis,  601 
Blcpharoplasty,  602 

Arlt's  method  for,   602 
Dieffenbach's  method  for,   603 
Fricke's  method  for,  603 
Richet's  method  for,  603 
Blood,  abstraction  of,   182 

by  arteriotomy,  183 

by  cupping,   183  ' 

by  leeching,    183 

by  venesection,  182 
extravasation  of , gangrene  from, 

73 
foreign  bodies  in,  35 
formed   elements  of,   29 
glycogen   in,   33 
infusion  of,   185 

intravenous,    186 
iodine  reaction  of,  33 
osmotic    pressure    of,    in    auto- 
intoxication, J-O 
microorganisms  in,  35 
platelets,  30 

surgical  pathology  of,  28 
transfusion   of,    185 
Bloodvessels,  injuries  of,  216 
suture   of,   349 

end-to-end,  350 

lateral,  349 
wounds  of,  216 
Boils,  304 
oriental,  309 
treatment  of,  304 
Bones,  abscess  of,  419,  425 

treatment  of,  426 
achondroplasia,  432 
acromegaly,  437 
actinomycosis  of,  432 
atrophic   elongation  of,  436 
atrophy  of,  422 
caries  of,   427 
cavalryman's,   331 
cavities,  filling  of,  431 
cranial,  acromegaly  of,  548 

injuries  of,  552 

leontiasis  of,   548 


Bones,   cranial,    osteomyelitis   of 
548 
periostitis  of,  548 
dancer's,  331 
diseases  of,  parasitic,  432 

trophoneurotic,  432 
epiphysitis  of,  acute,  421 
exostoses  of,  441 
fencer's,  331 
fibroma  of,  438 
fragility  of,  435 

senile,  436 
hydatid  disease  of,  432 

treatnaent  of,  432 
hyperostoses  of,  441 
hypertrophy  of,  422 
injuries  of,  218 
leontiasis  of,  438 
myeloma  of,   442 
myxoma  of,   441 
necrosis  of,  428 
pathological,  428 
toxic,  428 

treatment  of,  428 
traumatic,  428 
osteoarthropathic     hypertro- 

phiante   pneumicjue,   436 
osteoma  of,  441 
osteomalacia  of,  434 
prognosis  of,  434 
treatment  of,  435 
osteomyelitis  of,  acute,  416 
complications  of,  419 
diagnosis  of,  419 
etiology  of,  419 
organisms  at  fault  in,  417 
pathology  of,  416 
prognosis  of,  418 
symptoms  of,  418 
treatment  of,  419 
chronic,    421 

tuberculous,  423 
latent,  421 
osteoporosis  of,  422 
osteopsathyrosis,  435 
()stc()scl(>rosis   of,    422 
ostitis  deformans,  436 
Paget 's  disease  of,  436 
periostitis,  acute  infectious,  420 
causes  of,   421 
treatment  of,  421 
albuminosa,  421 
rachitis,  433 
rider's,  331 
sarcoma   of,    441 

treatment  of,  441 
sequestrum    formation   of,   429 

treatment  of,  429 
of  skull,  incomplete  formation 

of,  547 
syphilis  of,  135,  426 
transplantation  of,  431 
tuberculosis  of,  116,  422 
acute  miliary,  423 
pathology  of,  423 
symptoms  of,  423 
treatment  of,  425 
tu:nors  of,  438 
cartilaginous,  440 
Boric  acid,  toxic  effects  of,  175 
Bow-leg,  465 

treatment  of,  465 
Brachial  artery,  ligation  of,  355 

plexus,  operations  on,  623 
Brain,  abscess  of,  567 
symptoms  of,  568 
prognosis  of,  569 
treatment  of,   573 
atrophy  of,   578 
compression  of,  560 
symptoms  of,  561 
prognosis  of,  562 
treatment  of,  562 
concussion  of,  559 
treatment  of,  559 


Brain,  contusion  of,  559 
symptoms  of,  560 
treatment  of,  560 
cysts  of,   congenital,  578 
foreign  bodies  in,  565 
hernia  of,  566 

treatment  of,  566 
jjrolapsus  of,   566 

treatment  of,  566 
substance,  injuries  of,  564 
lacerations    of,    564 
prognosis  of,  564 
symptoms  of,  565 
syphilis  of,   138 
tumors  of,   582 
symptoms  of,  583 
treatment  of,  operative,  585 
Brasdor's      method     of      treating 

aneurysm,  347 
Breast,  abscess  of,  757 
actinomycosis  of,  759 
adenoma   of,   760 
anomalies  of,  755 
cancer  of,   761 

treatment  of,  703 
contusions  of,  756 
cysts  of,   760 
fibroma  of,  700 
hemorrhages   from,    755 
hypertrophy  of,   756 
inflammation   of,    756 
injuries  of,  756 
lipoma  of,  760 
neuralgia  of,   758 

treatment  of,  758 
nipple  of,  chancres  of,  759 
eczema  of,  316 
fissure   of,    756 
Paget 's  disease  of,   316,   756 
operations  on,  764 
syphilis  of,  759 
tuberculosis  of,  759 
treatment  of,  759 
tumors  of,   760 
treatment  of,  760 
Bronchocele,  712 
Brophy's      operation 

palate,  654 
Bruns'     method    of    amputation 

of  foot,   1042 
Bubo,  chancroiilal,  144 

syphihtic,  128 
Bubonic    plague,    bacillus    (jf,    54 
Bubonocele,  893 
Bunion,  263,  311 

radical  cure  of,   333    (note) 
treatment  of,   311 
Burba,   exostosis,   272 
Burns,  300 

of  abdominal  wall,  783 
of   face,    639 

of  respiratory  passages,  675 
treatment  of,  301 
Bursic,  adventitious,  263 
prepatellar,    263 
surgical  diseases  of,  332 
synovial,  332 
syphilis  of,  136 
tutjerculosis  of,  116 
Bursal   cysts  of  neck,  707 
Bursitis,  acute,  333 
chronic,  333 


Calcification  of  arteries,  339 
of  thrombus,  36 
of  veins,  361 
CalcuU,  biliary,  922 
diagnosis  of,  925 
symptoms  of,  924 
treatment  of,  926 
of  nose,  672 


f(jr      cleft 


INDEX 


1053 


Calculi,  pancrcatip,  954 

of  tonsils,  06.3 
Calcuhis,  ri'iial,  ()().') 
(liaj^iiosis  of,  UC>5 


005 
90(5 


nsfi 


)f.  2(il 


syuiptoiiis  of 
treat int'iit  of 
of  uri'tcr,  973 
vfsic-al.   986 
symptoms  of 
treatment   of,  9.S7 
Canal  of   Niick,  liydroccii 
CaiifiT.      Srr   Carcinoma. 

vn  cuirasse,  2S9,  784 
Cancerous  ulcers  of  intestines,  827 
Cancers   of   branchiogenio   origin, 

698,  709 
Cancrum  oris,  75,  658 
Cajiillary  angioma,  277 
Capsulotomy,  956 
Caput  succedaneum,  549 
Carbolic  aciil,  toxic  effects  of,  175 
Carbuncle,  305 
of  neck,  704 
treatment  of,  305 
Carcinoma,  289 

of  abdominal  wall,  784 
acinous,  290 
of  breast,  761 

treatment  of,  763 
characteristics  of,  289 
colloid,   289 
corset,  289 

diagnosis  of,  from  sarcoma,  293 
duct,  290 
encephaloid,  289 
of  esophagus,  744 
of  gall-bladder,  927 
general  considerations  of,  294 
of  heart,   336 
of  intestines,  large,  870 
small,  828 

treatment  of,  828 
jacket,  289 
of  jaw,  668 
of  kidnev,  969 
of  liver,  914 
of  lung,  732 

of  lymph  nodes,  289,  376 
mesenterv,  939 
miliary,  289 
pancreas,  953 
prostate,  1002 
rectum,  886 

treatment  of,  887 
relation   of,    to   other   diseases, 

295 
scirrhus,  289 
of  skin,  315 
of  spine,  462 
of  spleen,  943 
of  stomach,  801 
symptoms  of,  802 
treatment  of,  803 
of  testicle,  1017 
of  thorax,  730 
treatment  of,   295 
liquid  air  in,  296 
;  radium  in,  296 

toxins  of  erysipelas  in,  296 
ultraviolet  light  in,  296 
x-rays  in,  297 
Cardicentesis  of  pericardium,  330 
Cardiolysis,  337 
Cardiospasm,  798 
operation  for,  80S 
symptoms  of,  798 
treatment  of,  798 
Carias  of  bone,  427 
dental,  657,  604 

treatment  of,  665 
of  hip,  452 

diagnosis  of,  454 
prognosis  of,  454 
symptoms  of,  453 
treatment  of,  454 


Caries  of  spine,  444 
Carotid  arteries,  aneurysm  of,  34.') 
conmion,  ligation  of,  .'^.51 
external,  excision  of,  3.52 

ligation  of,  3.")2 
injuries  of,  .563 
internal,  ligation  of,  .3.52 

body,  diseases  of,  709 
Carpus,  dislocations  oj,  536 
Cartilages,  semiliuiar,  dislocation 

of,  543 
Ciistration,  1022 
Cataract,  597 

Catarrh  of  biliary  passages,  acute, 
918 
treatment  of,  918 
chronic,  918 
Cat.arrhal  cholecystitis,  919 

ulcers  of  rectum,  876 
Catgut,  sterilization  of,  247 
Catheterization,  186 

catheters  used  in,  186 

complications  of,   187 

ureteral,  958 
Catheters,  care  of,  186 
Cautery,  actual,  184 
CJavalry man's  bone,  331 
Cavernitis,  1009 
Cavernous  lymphangioma,  278 

tumors,  277 
Cecum,  cancer  of,  870 
Celiotomy,  773 

Cellulitis,  gangrenous,  of  abdomi- 
nal wall,  783 

of  orbit,  592 

of  scalp,  545 
Celluloid  thread,  sterilization  of, 

248 
Cementoma,  281 
Cenencephaloceles,  577 
Centipe<l(>s,  poisoning  by,  172 
Cepiialalgia,  treatment  of,  582 
Cephalliematoma,  263 

neonatorum,  549 
Cephalocele,  576 

treatment  of,  578 
Cerebellar  tumors,  treatment   of, 

operative,  585 
Cerebral  conchtions  in  rickets,  162 

palsies,  478 

treatment  of,  478 

sclerosis  in  rickets,  162 
Cervical  lymph  nodes,    affections 
of,  705 

plexus,    deep   posterior,   opera- 
tions on,  618 

sympathetic   nerve,    operations 
"  on,  618 
Chalazion,  601 

Chancre,  diagnosis  of,  frf)m  chan- 
croid, 145 

of  nipple,  759 

of  rectum,  876 

syphihtic,  126 
Chancroid,  144 

bacillus  of,  55 

bubo  in,  144 

diagnosis  of,  144 
from  chancre,  145 
from  herpes,  145 

extragenital,  145 

mixed,  145 

phagedenic,  144 

prognosis  of,  145 

treatment  of,  145 
Chancroidal  bubo,  144 
Charbon,  106.      See  Anthrax. 
Charcot's   artery   of  hemorrhage, 
564 

disease  of  elbow,  390 
Cheek,  tumors  of,  dermoid,  641 
Cheiloplastic  operations,  648 
Chemotaxis,  41,  44 

negative,  45 

positive,  45 


CliRst,  concussion  of,  721 
treatment  of,  722 
contusion  of,  721 

treatment  of,  722 
wounds  of,  722 
treatment  of,  723 
Chilblains,  299 
Chimney-sweeper's      cancer,     287 

310 
Ciiin,   galoclie,   6.38 

malformation  of,  638   - 
Chlorosis,  31 
("liolangiostomy,  928 
Cholangiotomy,  928 
Cholangitis,  acute,  918,  920 
treatment  of,  918 
chronic,  918 
suppurative,  919 
diagnosis  of,  920 
sj'inptoms  of,  919 
treatment  of,  921 
C'holecystectomy,  929 
Cholecystendysis,  930 
Cholecystenterostomy,  928 
Cholecystitis,  acute,  919 
diagnoses  of,  920 

from  appendicitis,  857 
phlegmonous,  920 
.symptoms  of,  919 
treatment  of,  921 
chronic  catarrhal,  919 
gangrenous,  920 
obliterans,  919 
Cholecystostomy,  929 
Cholecystotomy,  929 
Choledochenterostomy,  928 
Choledochostomy,  928 
Choledochotomv,  928 
Cholclici)atopexV,  933 
Cholelithiasis,  922 
diagnosis  of,  925 
symptoms  of,  924 
treatment  of,  926 
Cholelithrotrity,  928 
Cholera,    secondarj'    infection    in, 

166 
Chondritis,  683 
Chondroma,  271 
of  jaw,  668 
of  testicle,  1017 
of  thorax,  7.30 
treatment  of,  272 
Chondrosarcoma,  274 
Chopart,  mediotarsal  amputation 

of,  1037 
Chordee,  149 
Chorion    epithelioma,    malignant, 

292 
Choroid,  tuberculosis  of,  595 
Chromicized  gut,  247 
Chromocystoscopy,  958 
Chylocele,  372 
Chylothorax,  735 
Chylous  ascites,  368 
fistula,  368 
hydrocele,  372 
hvdrothorax,  368 
Chyluria,  373 
Cicatrices,    horns    growing    from, 

283 
Cicatricial  keloid,  70 
Ciliary  body,  diseases  of,  598 
Circumcision,  1010 
Circumflex  artery,  ligation  of,  359 
Cirrhosis  of  pancreas,   9.50 
Cirsoid   aneurysm,   278,   339,   344 
Clap,   146.     See  Gonorrhea. 

bastard,  148 
Clavi,  311 

Clavicle,   dislocations  of,  529 
congenital,  718 
treatment  of,  529 
fractures  of,  493 
treatment  of,  493 
Cleft  palate,  652 


1054 


INDEX 


Ck'ft  palato,  operation  for,  054 
Clitoris,  hypertrophy  of,   1007 
Clove  hitch  knot,  241 
Clulvfoot,  465 
congenital,  40(5 
treatment  of,  466 
Coagulation  necrosis,  57 
Cocaine,  205 

Cocainization,  intraspinal,  207 
Coccidioidal  granuloma,  309 
Coccodynia,  636 
Coccygeal  sinus,  635 
tumors,  627 
congenital,  635 
Coccygodynia,  636 
Cohiiheim's   embryonal   hypothe- 
sis of  cause  of  tumors,  256 
Cold  abscess,  112 

diagnosis  of,  113 

himVjar,  114 

peri-articular,    treatment    of, 

399 
psoas,  114 

retropharyngeal,  114 
treatment  of,  114 
Colic,  biliary,  922 

diagnosis  of,  925 
symptoms  of,  924 
treatment  of,  926 
renal,  964 

treatment  of,  964 
Colitis,  diagnosis  of,  from  appen- 
dicitis, 857 
Collapse,  177 

Collar-button  abscess,  319 
Colics'  fracture,  503 
treatment  of,  504 
law  in  syphilis,  139 
Colloid  goitre,  713 
C'oloboma,  600 
Colon  bacillus,  53 
syphilis  of,  809 
tuljerculosis  of,  869 
Colopexy,  850 
Colostomy,  874,  888 
Coma  carcinomatosum,  82 
Compression   apoplexies,    560 
of  brain,  560 

prognosis  of,  562 
symptoms  of,  561 
treatment  of,  562 
Concussion  of  brain,  559 
treatment  of,  559 
of  chest,  721 

treatment  of,  722 
of  spine,  628 

treatment  of,  629 
Condyles,  fracture  of,  498 
Condylomas,  282  312 
Congenital  abnormalities    of    tes- 
ticle, 1014 
adenoma  of  kidney,  969 
affections  of  thyroid,  710 
anomalies    and  defects  of  kid- 
neys,  955 
of  intestines,  large,  809 

small,  822 
of  neck,  698 
of  pancreas,  944 
of  spleen,  940 
of  ureters,  955 
coccygeal  tumors,  635 
conditions  of  skull,  547 
cysts  of  abdominal  wall,  783 

of  brain,  578 
defects  of  anus,  872 
of  diaphragm,  752 
of  lips,  638 
of  mouth,  652 
of  penis,   1004 
of  rectum,  872 
dislocations,  526 
of  liip,  471 

diagnosis  of,  473 
treatment  of,  474 


Congenital  disjilacements  of  liver, 
910 
hernia,  890 

tliaphragmatic,  897 
inguinal,  897 
hypertrophy,   definition   of,   26 
lymphangioma  of   ear,   606 
macroglossia,  652 
malformations  of  bladder,  977 
of  ear,  604 
of  esophagus,  737 

treatment  of,   738 
of  respiratory  passages,   671 
of  stomach,  793 
of  thorax,  718 
occlusion  of  lymph  vessels,  369 
rickets,  161 
tumors  of  scalp,  540 
varices,  364 
venous  nevus,  367 
Congestion,  19 

neuroparalytic,  20 
neurotonic,  20 
results  of,  22 

acute  swelling,  22 
chronic  swelling,  22 
gangrene,  22 
nutritional  changes,  23 
resolution,  22 
treatment  of,  23 
Conical   stump,   definition   of,   27 
Conjunctival   sac,    diphtheria   of, 
599 
gonorrhea  of,  599 
Continuous   suture,   241 
Contractures  of  muscles,   332 

treatment  of,  332 
Contusions,  211 

of  abdominal  wall,  781 
of  bloodvessels,  216 
of  brain,  559 

symptoms  of,  560 
treatment  of,  560 
of  breast,  756 
of  chest,  721 

treatment  of,  722 
of  face,  639 
of  muscles,  329 
of  testicle,  1015 
treatment  of,  212 
of  viscera,  219 
Copremia,  83 

Coracoid  process,  fracture  of,  495 
Cord,   spermatic.     See  Spermatic 
cord, 
spinal.     See  Spinal  cord. 
Cornea,  diseases  of,  598 

syphilis  of,  137 
Corns,  311 
Corpora    cavernosa,    syphilis    of, 

138 
Corpus     cavernosum,     inflamma- 
tion of,  1009 
Corrosive  sublimate,  toxic  effects 

of,  175 
C'ouiiterirritation,  183 
by  actual  cautery,  184 
by  rubefacients,  183 
by  seton,  184 
by  vesicants,  184 
Cowperitis,  150 
Coxa  vara,  475 

diagnosis  of,  476 
svmptoms  of,  476 
Coxitis,  452 

Cranial      bones,     acromegaly    of, 
548 
injuries  of,  552 
leontiasis  of,  548 
osteomyelitis   of,    548 
periostitis  of,  548 
meningoceles,  263 
nerves,  injuries  of,  612 
rickets,  547 
Craniectomy,  580 


Craniofacial     sinuses,     accessory, 

operations  on,  608 
Craniotabes,  547 
rachitica,  162 
Craniotomy,  580 

Cranium,  injuric^s  of  soft  parts  of, 
551 
operations  on,  587 
septic  affections  within,  567 
abscess  of  brain,  567 
encephalitis,  513 
leptomeningitis,  572 
meningitis,  571 
pachj'meningitis  externa, 
572 
interna,  572 
sinus  phlebitis,   571 
thrombosis,  570 
trephining  of,  587 
wounds  of,  gunshot,  565 
treatment  of,  565 
Crile's   pneumatic   suit   in  shock, 

180 
Croupous  exudates,  23 
Crural  nerve,  anterior,  operations 

on,  623 
Cryptogenetic   septicemia,   87 
Cryptorchidism,  1014 
treatment  of,  1014 
Cupping,  183 
Cutaneous  horns,  283,  311 

growing  from  cicatrices,  283 
nail,  283 
sebaceous,  283 
treatment  of,  311 
warty,  283 
myxoma,  276 
Cylindroma,  275 

of  skin,  315 
Cystic  degeneration,  264 
of  testicle,  260 
kidney,  969 
Cysticercus,  310 
Cystinuria,  82 
Cystitis,  984 

gonorrheal,  151 
postoperative,  985 
symptoms  of,  984 
treatment  of,  985 
tuberculous,  985 
Cystoma,  ovarian,  284 
Cystoscope,  Nitze's,  993 
Cystoscopic  examination,  958,  977 
Cysts,  259 

of  abdominal  wall,  congenital, 

783 
apoplectic,  952 
of  bladder,  992 
of  brain,  congenital,  578 
of  breasts,  760 
degeneration,  264 
dermoid,  264 
glandular,  261 
hydatid,  263 
hydroceles,  261 
of  iris,  594 

of  liver,  hydatid,  913 
treatment  of,  913 
of  lung,  echinococcus,  732 

hydatid,  732 
lymph,  278 
of  mesentery,  940 
of  neck,  7f)7 

atheromatous,  707 
bursal,  707 
dermoid,  707 
sanguineous,  701,  707 
thyrohyoid,  707 
neural,  263 
of  omentum,  935 
of  orbit,  dermoid,  593 

parasitic,  593 
of  pancreas,  951 
diagnosis   of,  952 
symptoms  of,  952 


INDEX 


1055 


Cysts  of    paiuTras,  t  rc;iliiiciit    of 

952 
pseiido-,  262 
retention,  259 
sel)jic(-<)ns,  2S5 
of  skin,   :il(» 

atheronmtous,  310 

cehinoeoeeiis,  310 

sebaceous,  310 

tivatnienl  of,  310 
of  spine,  (127 
of  sple.-n,    943 
of  Stenson's  duct.  ('>  tl 
of  testicle,  lOUl 
of  tonf!;ue,  retention,  (i.">!) 
tubulo,  2(>() 


Dacryo-adf.xttis,  acute,  599 
Dacrvocvstitis,  (>0() 
treatnient  of,  000 
Dacryo))ic  cvsts,  202 
Dactylitis,  136 
Dancer's  bone,  331 
Davey's    method    of    amputation 

of  iiip-joint,  1045 
Deciiluoina  inalignum,  292 
Degeneration,  cj'stic,  264 
Delhi  boil,  309 
Delirium  tremens,  174 
treatment  of,  174 
Dental  caries,  657,  664 

secondary    infection    in,    109 
treatment  of,  665 
Dentigcrous  cysts,  666 
Dermatitis,  blastomycetic,  309 
calorica,  299 

treatment  of,  299 
of  radio-active  origin,  303 
Dcnnatolysis,  313 
Dermoid  cj-st  of  bladder,  992 
of  neck,  707 
of  omentum,  935 
of  orbit,  593 
of  scalp,  546 
of  testicle,  1010 
tumors  of  cheek,  641 
of  lung,   732 
Dermoids,  264 
ovarian,  267 
sequestration,  265 
tubulo,  266 
Desault's  bandage,  190 
Desmoids,  271 

treatment  of,  271 
Diabetes  a  cause  of  gangrene,  74 
Diaphragm,  congenital  defects  of, 
752 
paralysis  of,  753 
rupture  of,  721,  753 
treatment  of,  722 
tumors   of,   753 
wountls  of,  725,  753 
treatment  of,  726 
Diaphraginatic  hernia,  897 
acquired,  897 
congenital,  897 
Dieffenbach's  operation  for  bleph- 

aroplasty,  603 
Digital    compression    for    control 

of  hemorrhage,  235 
Dilatation    of  stomach,   793,   795 
acute,  795 

symptoms  of,  790 
treatment  of,  790 
chronic,  796 
operation  for,  Sll 
Diphtheria,  bacillus  of,  54 
of  conjunctival  sac,  599 
of  mouth,   657 
secondary   infection  in,   108 
Diphtheritic    exudates,   23 
Diplococcus  pneumonise,  53 
Disarticulations,   1023 


I  (islocations,  .524 
of  ankle,  544 
of  astragalus,  544 
of  carpus,  .536 
of  clavicle,  .529 

treatment   of.  .529 
coniplicatetl,  .524 
compound,  524 
congenital,  .524,  .520 
diagnosis  of,  .52.5 
of  elbow,  .5.34 

treatment  of,  5.30 
of  fibula,  .544 
of  foot,   .544 

treatment   of,    544 
haliitual,  .524 
of  hand,  .530 
of  hip,  .5.37 

classification  of,  ,5.37 

congenital,  471 
diagnosis  of,  47.3 
treatment  of,  474 

signs  of,   538 

symptoms   of,   .5.38 

treatnient  of,  .539 

imreduced,  542 
of  jaw,  667 

lower,  527 

treatnient  of,  .528 
of  knee,   543 

symptoms  of,  544 

treatment  of,   544 
of  larynx,  528 
of  lens,   604 
metacarpophalangeal,  536 

treatment  of,  5.37 
of  nerves,  624 
of  patella,   543 

treatment  of,  543 
pathological,  524,  526 
of  penis,   1008 
of  radius,  536 
recurrent,  524 
of  ribs,  529 

of  semilunar  cartilages,  54.3 
of  shoulder-joint,  .530 

anterior,  530 

diagnosis  of,  532 

downward,  530 

posterior,  530 

subclavicular,  531 

subcoracoid,  531 

subglenoid,  531 

subspinous,  532 

svmptoms  of,  532 

treatment  of,  532 

Koclier's  method,  .533 

upward,  530 
of  spine,  631 

treatment  of,  032 
of  sternum,  528 
svmptoms  of,  525 
of  tendons,  330 
of  tibia,  543 
traumatic,  524 
treatment  of,  527 
of  ulna,  536 
of  wrist,  536 
Dissecting  aneurj-sm,  339,  342 
Diverticulitis,  822 
Diverticulum,  Meckel's,  202,  822 
pharyngeal,  262 
vesica',  262 
Downes'  electrothermic  clamp, 230 
Drainage    tubes,   sterilization   of, 

248 
Dressings,   sterilization  of,   247 
I  )uct  carcinoma,  290 

salivary,   fistulas  of,  649 

foreign  bodies  in,  04.S 
thoracic,    injuries  to,  725 
treatment  of,  720 
Duodenal    ulcers,   82.5 

symptoms    of,    825 

treatment  of,  826 
Duodenostomv,  806 


Duodenotomy,  928 
Dupuytren's  contraction,  319 

treatment  of,  320 
Dvsenteric    ulcers    of    intestines, 

"827 
Dvsentery,  secondarv  infection  in, 

106 


E 


lv\i{,  auricles  of,  supermmierary, 
005 
congenital     malformations     of, 

604 
epithelioma  of,  00.5 
external    auditory    canal,    dis- 

ea.ses  of,  007 
foreign  bodies  in,  606 
keloid  of,  005 
lymphangioma  of,  006 
mifldle,  diseases  of,  607 
neojjlasms  of,  605 
overlajjping,  005 
papilloma  of,  60.5 
rodent  ulcer  of,  606 
syphilis  of,  137 
tumors  of,  00.5 
Ecchondroses,  272 
Echinococcus  cvst  of  lung,  732 

of  skin,  310 
Ectasine,  85 
Ecthyma,  132 
Ectopia  of  bladder,  978 

treatment  of,  978 
Eczema  of  nipple,  316 
Edema,  definition  of,  22 
gangrene  from,  73 
of  glottis,  699 
of  larynx,  683 
malignant,  75,  108 
bacillus  of,  54 
definition  of,   108 
postmortem  appearances  of, 

108 
prognosis  of,   108 
symptoms  of,  108 
treatment  of,  108 
Edematous  ulcers,  67 
Effusion,   definition  of,  22 
Elbow,  amputation  of,  1031 
Charcot's  disease  of,  390 
dislocations  of,  534 
treatment  of,  536 
excision  of,  41  fj 
Electrocoiiducti\-ity  of  urine,  959 
Electrothermic  clamp,  236 
Elephantiasis,  370 
of  hand,  370 
of  leg,  370 
of  penis,  370 
of  scrotum,  371 
of  vulva,  371 
Elongation  of  nerves,  612 

of  uvula,  082 
Embolism,  38 
air,  38 
fat,  39 

prognosis  of,  40 
symptoms  of,   40 
treatnient  of,  40 
following     abtlominal    opera- 
tions, 784 
gangrene  from,  73 
of  mesenteric  vessels,  938 
of  veins,  363 
Embrj'onal  atlenosarcoma,  268 
hypothesis  of  the  cause  of  tu- 
mors, 2.50 
Emplwsema,  gangrenous,  75,  108 
Emprosthotonos,  100 
Empyema  of  appendix,  860 
definition  of,  62 
of  gall-bladder,  919 
of  hmg,  7.36 
Encephalitis,  .573 
Encephalocele,  576 


1056 


INDEX 


Enceplialocele  of  orbit,  593 
Encysted    hydrocele    of    testicle, 

260,  261 
Endarteritis,  338 
Endocarditis,      secondary      infec- 
tion in,  169 

ulcerative,  in  septicemia,  88 
Endoscope,  use  of,  158 
Endothelioma,  274 

of  abdominal  wall,  784 

of  jaw,  668 

of  Uver.   914 

of  lung,   732 

of  orbit,  593 

of  thyroid,  712 
Endotracheal  goitre,  713 
Enterocele,  892 
Enterocolitis,   diagnosis   of,    from 

appendicitis,  857 
Enteroplication,  850 
Enteroptosis,  967 
Entcroscjisis,  83 
JMitcrostoniv,  789,  849 
iMitropion,  601 

iMuiclcation  of  globe  of  eye,  596 
Mosinophilia,  30 
l';))icanthis,  600 
lOpiilcrmoids,  264 
I'Ipididymitis,  151,  1016 

treatment  of,  1017 
llpij^astric  artery,  ligation  of,  359 
l'4jiglottis,    diseases    and    injuries 

of,  683 
Epilepsy,   Jacksonian,  581 

treatment  of,  581 
Epiphysitis,    acute,   421 
Epiplocele,  892 
Epispadias,  1005 

balanic,  1005 

penile,  1005 
Epistaxis,  680 

treatment  of,  681 
Epithelial  molluscinn,  312 

odontomas,  281 
Epithelioma,  286 

of  abdominal  wall,  784 

diagnosis  of,  from  tuberculosis, 
293 

of  ear,  605 

of  face,  640 

of  jaw,  668 

of  larynx,  687 

lymph  nodes  in,  286 

malignant  chorion,  292 

microscopic  appearances  of,  285 

of  orbit,  593 

of  penis,  1010 

seats  of,  286 

of  skin,  315 

diagnosis  of,  315 
treatment  of,  315 

suprarenal,  292 

of  tongue,  660 
treatment,  660 
Epulis,  270,  668 
Ecjuinia,  105.      See  Glanders. 
Erectile  tumors,  277 
I'irethistic  ulcers,  66 
Eruptions  in  septicemia,  88 
Erysipelas,  93 

of  abdominal  wall,  783 

definition  of,  93,  94 

diagnosis  of,  95 

epidemic  form,  93 

etiology  of,  93 

idiopathic,  93,  94 

of  mouth,  657 

organism    relation    to    strepto- 
coccus, 93 

pathology  of,  93 

phlegmonous,  75,  93 

postmortem  appearances  of,  95 

prognosis  of,  95 

of  scalp,  545 

symptoms  of,  94 


Erysipelas  toxin   in  treatment  of 
carcinoma,  296 

traumatic,  93,  94 

treatment  of,  95 

wandering,  94 
Erysipelatous  laryngitis,  95 

pneumonia,  95 
Erythroblasts,  definition  of,  29 
Esmarch's  bandage,  234 
Esophageal  bougies,  743 

hemorrhoids,  365 

snare,  740 
Esophagectomy,  745 
Esophagismus,  742 
Esophagoscope,  740 
Esophagotomy,  745 
Esophagus,  anatomy  of,  737 

cancer  of,  744 

diverticula  of,  737 

externalization  of,  746 

foreign  bodies  in,  739 
treatment  of,  740 

hemorrhage  of,  744 

malformations  of,  737 

operations  on,  745 

perforation  of,  742 

resection  of,  transthoracic,  745 

rupture  of,  741 

stricture  of,  742 

wounds  of,  741 
Esthiomene,  876 
Estliinder's    cheiloplastic    opera 

tion,  648 
Ether,  193 

accidents  from,  194    ■ 

action  of,  194 

administration  of,  195 

narcosis  by  rectum,  196 

petroleum,  199 
Ethmoidal  sinus,   operations  on, 

610 
Ethyl  bromide,  198 

chloride,  199 

local  use  of,  199 
Eucaine,  207 
Excision  of  ankle,  414 

of  elbow,  410 

of  fingers,  412 

of  foot,  415 

of  hand,  412 

of  heel,  414 

of  hip,  412 

of  joints,  407 

of  knee,  413 

of  shoulder,  409 

of  wrist,  411 
Exophthalmic  goitre,  713 

treatment  of,  714 
Exophthalmos,  594 

treatment  of,  594 
Exostoses,  272 

of  bone,  441 
Exstrophy  of  bladder,  978 

treatment   of,   978 
Extragenital  chancre,  127,  145 
Extravasation     of     blood,      gan- 
grene from,  73 
Exudates,  23 

croupous,  23 

difference   between    hyperemic 
and  inflammatory,  23 

diphtheritic,  23 

fibrinous,  23 

interstitial,  23 

mixed,  23 

mucous,  23 

parenchymatous,  23 

serous,  23 
Eye,    accommodation   of,   defects 
of,  604 

globe  of,  enucleation  of,  596 

muscles  of,  defects  of,  604 

nerves  of,  disturbances  of,  604 

sclerotic  of,  rupture  of,  604 

syphilis  of,  136,  597 


Eyeball,  injuries  of,  603 

treatment  of,  604 
LOyelids,  blepharitis,  601 
marginalis,  601 

chalazion,  601 

coloboma,  600 

ectropion,  602 

Arlt's  operation  for,  602 
Dieffenbach's   operation   for, 

603 
Fricke's    operation    for,    603 
Richet's    operation    for,    003 

entropion,  601 

epicanthis,  600 

hordeolum,  600 

stye  of,  600 

trichiasis,  601 

xanthelasma,  601 


P 


Face,  absence  of,  638 
actinomycosis  of,  640 
arteries  of,  ligation  of,  352 
burns  of,  639 
contusions  of,  639 
epithelioma  of,  640 
gangrene  of,   640 
malforniations  of,  acquired,  639 
nerves  of,  injuries  of,  640 
operations  on,  642 
syphilis  of,  640 
tuberculosis  of,  640 
tumors  of,  641 
ulcers  of,  640 
wounds  of,  229,  639 
Facial  artery,  ligation  of,  352 
bones,   fractures  of,  489 
nerve,  operations  on,  616 
neuralgia,  640 
palsy,     neuro-anastomosis    for, 

616 
paralysis,  640 
Facultative   pyogenic   organisms, 

53 
Farcy,   105.     See  Glanders. 
FasciiE,  contraction  of,  319 

treatment  of,  320 
Fat  embolism,  39 
prognosis  of,  40 
symptoms  of,  40 
treatment  of,  40 
Fatty    degeneration    of    arteries, 
339 
of  veins,  361 
Fecal  fistula,  839 

impaction,    intestinal    obstruc- 
tion from,  832 
Feet,  arthritis  deformans  of,  388 
Fehleisen's  coccus,  93 
Felon,  328 

Femoral  artery,  aneurysm  of,  346 
ligation  of,  359 
hernia,  895 

treatment  of,  908 
Femur,  fractures  of,  509 
diagnosis  of,   511 
lower  end,  513 

treatment  of,  513 
prognosis  of,  511 
shaft,  513 
treatment  of,  512 
Fencer's  bone,  331 
Fetal  infection,  48 
rickets,    181,  433 
Fibrin,  28 

Fibrinoplastic     tuberculous    peri- 
tonitis, 791 
Fibrinous  exudates,  23 
Fibro-adenoma,  284 
Fibro-epithelioma,  282 
Fibrokeratomas,  311 
Fibroma,  269 

of  abdoininal  wall,  784 


INDEX 


1057 


Fibroniii  of  hliuUU'r,  9!)2 
«)f  boiif,  4."i,S 
of  breast ,  7(U) 
ilcsmoiils,  271 
f|)ulis,  270 
of  jaw,  (KiS 
keloid,  270 
of  liver.  014 
inollusciiin,  :il3 

treatment  of,  3i:{ 
of  nasopliarynx,  (17'.) 
of  nerves,  (122 
)>sanunoiMa,  271 
of  testicle,   1017 
of  thorax,  720 
I''il>rous  odontomas,  2S1 
l''ibwla,  dislocations  of,  511 
fractures  of,  510 
treatment  of,  521 
l-"i(IHre-of-S-bandafie    of    le,!;,     IN! 
I'iiaria    medini-nsis,    300 
l'"iliform  warts,  311 
FiiiKt'r,  ani]mtatiou  of,  1020 
excision  of,  412 
trifiger,  320 

treatment  of,  320 
l'"inney's  pyloroplasty,  SIO 
Finseu     light     in     treatment     of 

cancer,  206 
Fissured   ulcers,   06 
Fissures  in  ano,  876 
Fistula,  63 
causes  of,  63 
congenital,  ()3 
foreign  bt)dies,  03 
necrosed  material,  63 
preexisting  abscess,  03 
traumatic     destruction     of 
tissue,  63 
chylous,  308 
definition  of,  03 
fecal,  830 
lacrymal,  000 
treatment  of,  0.3 
Fistulas,  biliary,  017 
gastric,  801 
of  lips,  038 
perineal,  1013 

treatment  of,  1013 
rectal,  880 

treatment  of,  880 
of  salivary  ducts,  040 
Fistulous  ulcers,  06 
Flat-foot,  408 
Floating  liver,  910 

symptoms  of,  910 

treatment  of.  Oil 

Follicular  odontomas,  2S1 

compound,  281 
Folliculitis,  149,  307,  1013 
Foot,  amputation  of,   1037,    1041 
Bruns'  method,  1042 
partial,  1(J34 
Tcale's  method,  1042 
club-,  405 

congenital,  400 
treatment  of,  400 
dislocations  of,  544 
treatment  of,  544 
excision  of,  415 
flat-,  408 
fractures  of,  523 
Madura,  110 

treatment  of,  110 
ulcer  of,  perforating,  00,  310 
Forearm,  amputation  of,  1031 
fractures   of,   501 
treatment  of,  501 
Foreign  bodies  in  abdomen,   783 
in  bladder,  982 
in  blood,  35 
in  brain,  505 
in  esophagus,  730 

treatment  of,  740 
in  knee-joint,  402 
in  pharynx,  673^^ 

67 


lOrcMgn      bodies       in       pharvnx, 
treatment   of,  073 

in   rectinn,   874 

in    respiraloi'V    ])assages,    672 

in  salivary  ducts,  648 

in  stomach,  704 
operations  for,  8()() 
symptoms  of,  701 
treatment  of,  704 

in  tonsils,  603 

in  urethra,   1000 
l'"ormalin  gut,  247 
I'Vactures,  470 
Bennett's,  .506 
of  clavicle,  403 

t  reatment  of,  401} 
Colics',  .503 

treatment  of,  504 
conuninvited,  470 
com])lete,  470 
compound,  480 

treatment    of,    4S7 
delayed  imion  in,  485 
dentated,  470 
de]iressed,  479 
diagnosis  of,  481 

by  fliioroscope,  482 

by  skiagram,  482 
extra-articular,  479 
of  facial  bones,  480 
of  femur,  500 

diagnosis  of,   511 

prognosis  of,  511 
of  fibula,  510 

treatment  of,  521 
fissure,  479 
of  foot,  523 
of  forearm,  501 

treatment  of,  501 
green-stick,  479 
gunshot,  480 
of  hand,  507 
of  humerus,  495 

condyles  of,  49S 
external,  499 
internal,  499 

epicondyles  of,  497 

iiitercondvloid,  499 

shaft  of,  496 

siijiracondyloid,  497 

surgical  neck  of,  496 

treatment  of,  495 
of  hyoid,   491 
impacted,  479 
incomplete,  479 
intra-articular,  479,  482 

-uterine,  481 
of  larynx,  491,  676 
of  leg,  518 

treatment  of,  521 
longitudinal,  479 
of  malar,  489 
of  maxilla,  inferior,  490 
treatment  of,  490 

superior,  489 
multiple,  479 
non-union  in,  485 
of  nose,  489 
oblique,  479 
of  olecranon,  501 
partial,  479 
of  patella,  516 

treatment  of,  517 
pathological,  479 
of  pelvis,  507 

treatment  of,  508 
of  penis,  1008 
of  radius,  502 

lower  end  of,  503 

treatment  of,  504 

and  ulna,  503 
repair  of,  483 
ribs,  491 

svmptoms  of,  492 

treatment  of,  492 
of  scapula,  494 


I'ractures    of   scapula,     acromion 
|)n)cess    of,    404 
roracoid   ])rocess  of,  495 
surgi<-al  neck  of,  405 
single,  470 
of  skull,  540,  552 
base  of,   .').56 

diagnosis  of,  .5.')7 
])rogii()sis  of,  .557 
treatment  of,  558 
vertex  of,  .552 

commimited,  552 
diagnosis  of,  554 
gunsliot,  553 
splintered,  552 
t  real  nient  of,  555 
of  s|)iMe,   620 
spiral,  470 
spontaneous,  4.34 
of  sternum,  401 
svmptoms  of,  402 
treatment-  of,  492 
of  thigh,  500 
of  tibia,  518 

treatment  of,  .521 
t  ransverse,  479 
traumatic,  470 
treatment  of,  486 
of  ulna,  501 

treatment  of,  501 
of  wrist,  5t)7 
of  zygoma,  480 
Frambcrsia,  308 
Frank's   method  of  gastrostomv, 

807 
Fricke's    operation    for    hlepharo- 

pla-sty,  603 
Friedliinder,  bacillus  of,  54 
I'Voiital  abscess,  560 

sinus,  operations  on,  609 
Frostbite,  302,  630 
gangrene  from,  73 
treatment  of,  302 
Fungi,  55 

actinomycis,  55 
aspergillus,  56 
leptothrix,  56 
Madura  foot,  56 
Fungous    granulations    in    tuber- 
culosis, 115 
hematodes,  276 
ulcers,  06 
Fvmicular  hernia,  801 

hydrocele,  261 
Furuncle,  304 
definition  of,  60 
treatment  of,  304 
Fusiform  aneurysm,  339,  343 


Galactocele,  700 
Gall-bladder,  anatomy  of,  915 

cancer  of,  927 

empvcma  of,  919 

fistulas  of,  917 

hour-glass,  910 

malformations  of,  910 

operations  on,  927 

after  management  of,  932 
anastomotic,  932 

tumors  of,  927 
Gall-ducts,  operations  on,  928 
Gallstones,  922 

diagnosis  of,  925 

intestinal  obstruction  from,  833 

symptoms  of,  924 

treatment  of,  920 
Galoche  chin,  638 
Ganglion,  327 
Gangra?na  oris,  75 
Gangrene,  22,  73 

angioneurotic,  76 

bed-sores  a  cause  of,  74 

causes  of,  73 


1058 


INDEX 


Gangrene,     causes     of,    constitu- 
tional, 74 
infectious,  75 
local,  73 
traiunatic,  73 

from  chemical  agents,  74 

from  edema,  73 

from  embolism,  73 

from  frostbit(%  73 

from  extravasation  of  blood,  73 

from  ligation  of  arteries,  73 

from  thrombosis,  73 

from  tumors,  74 

of  face,  640 

foudroyante,  75,  108 

definition  of,  73 

diabetic,  74 

dry,  76 

gazeuse,  108 

gross  appearances  of,  76 

hospital,  75 

of  lung,  734 

moist,  76 

line  of  demarcation  in,  76 

mummification  in,  76 

noma,  75 

phagedenic,  77 

senile,  76 

signs  of,  77 

of  spleen,  941 

spontaneous,  76 

symmetrical,  74,  76 

symptoms  of,  77 

of  tongue,  659 

treatment  of,  77 

visceral,  76 
Gangrenous  cellulitis  of  abdomi- 
nal wall,  783 

cholecystitis,  920 

emphysema,  75,  108 

pancreatitis,  946 

septicemia,  108 

stomatitis,  75,  658 
Gaspard,   putrid  fever  of,  81 
Gasserian  ganglion,  operations  on, 

614 
Gastrectasis,  796 
Gastrectomy,  813 
Gastric  anastomosis,  816 

chlatation,  793,  795 

fistulas,  801 

intra-abdominal,  801 

tetany,  798 

ulcer,  799 

diagnosis    of,     from    appen- 
dicitis, 857 
operations  for,  811 
symptoms  of,  800 
treatment  of,  800 
Gastritis,    phlegmonous,   804 
symptoms  of,  804 
treatment  of,  805 
Gastro-enterostomy,  799,  811,  817 
Gastrojejunostomy,  816 
Gastropexy,  797,  811 
Gastroplication,  811 
Gastroptosis,  793,  797 

Rovsing's  operation  for,  813 

treatment  of,  797 
Gastrorrhaphy,  806 
Gastrostomy,  806 

Frank's  method,  807 

Witzel's  method,  807 
Gastrotomy,  794,  806 
Genitalia,  chancroid  of,  144 

syphilis  of,  138 
Genito-urinary      tract,      infection 

through,  49 
Genu  valgum,  463 

varum,  463 
Giant-cell  sarcoma,  274 
Gigli  saw,  588 

Gila  monster,   poisoning  by,    172 
Gingivitis,  interstitial,  657 

ulcerativ^e,   664 
Glanders,  105,  308 


Glanders,  diagnosis  of,  IOC) 
etiology  of,   105 
incubation  in,  1(J5 
organism  of,  105 
prognosis  of,  106 
symptoms  of,  105 
treatment  of,  106 
Glands,  salivary,  inflammation  of, 
649 
tumors  of,  650 
Glandular  cysts,  261,  284 
Glaucoma,  597 

treatment  of,  597 
Gleet,      155.     Sec     Gonorrhea, 

chronic. 
Glioma,  279 

of  retina,  595 
Glossitis,  658 
Glottis,  edema  of,  699 
Gluteal   hernia,  897 
Glycogen  in  blood,  33 
Glycosuria,  945 

a  cause  of  gangrene,  74 
Goitre,  283,  712 
colloid,  713 
endotracheal,  713 
exophthalmic,  713 

treatment  of,  714 
malignant,  715 
Gonococcus  myositis,  331 
pyemia,  152 
septicemia,  152 
tendovaginitis,  331 
Gonorrhea,  146 
chronic,  155 

treatment  of,  156 
classification  of,  148 
complications  of,  149 
balanitis,  149 
Cowperitis,  150 
cystitis,  151 
epididymitis,  151 
folliculitis,  149 
gonorrheal   rheumati-sm,    152 
lymphangitis,  151 
peri-\ir('t  liritis,  149 
postgonorrheal  arthritis,   152 
prostatitis,  150 
treatment  of,  152 
of  conjunctival  sac,  599 
course  of,  149 
diagnosis  of,  147 
of  joints,  392 
of  lymph  nodes,  376 
secondary  infection  in,   169 
of  seminal  vesicles,  1021 
of  testicles,  151 

treatment  of,  151 
treatment  of,  152 
in  women,  158 
treatment  of,  159 
Gonorrheal  proctitis,  875 
rheumatism,  152 
synovitis,  385 
Grafting  of  nerves,  612 

of  tendons,  324 
Granny  knot,  241 
Granulation    tissue,    relation    of, 

to  infection,  96 
Granuloma,    coccidioidal,   309 

of  thorax,  729 
Graves'  disease,  713 
Gritti's    method    of    amputation 

of  knee,    1044 
Groin,  spica  bandage  of,  189 
Guinea  worm,  309 
Gumma  of  penis,  1009 

of  syphilis,   133 
Gummas  of  tuberculosis,  114 
Gummatous  syphilide,   134 
Gums,  retrocession  of,  657 
Gunshot  wounds,  220 
of  abdomen,  232 
of  bladder,  233 
of  chest,  722 
diagnosis  of,  225 


Gunshot  wounds  of  far  c,  229 
foreign  material  iii,  Z'2\ 
of  head,  228,  565 

treatment  of,  565 
of  heart,  231 
hemorrhage  from,  223 
<if  joints,  228 
kev-hole,  225 
of  "kidney,  233 
localizing  symptoms,  223 
multiple,    224  , 

of  neck,  229 
pain  from,  223 
])rognosis  of,  225 
of  respiratory   passages,   675 
shock  from,  223 
of  small  intestines,  823 
of  s])inal  column,  230 
of  spleen,  233 
of  thorax,   230 
treatment  of,  225 


Hall's,    Marshall,    methoil    of 

artificial  respiration,  204 
Halstead's    operation    for    cancer 
of  breast,  766 
for  hernia,  904 
Hammer-toe,  321 

treatment  of,  321 
Hand,  amputation  of,  1031 
arthritis  deformans  of,  388 
dislocations  of,  536 
elephantiasis  of,  370 
excision  of,  412 
fractures  of,  407 
Hands,  sterilization  of,  245 
Harcourt  inhaler,  197 
Hare-lip,  638 

operation  for,  645 
Head,  arteries  of  ligation  of,  ,".')2 
injuries  of,  545 

previous    and    during    birth, 
549 
caput  succedaneum,  549 
cephalhematoma  neonato- 
rum, 549 
depression  of  skull,  549 
fractures,  549 
surgical  diseases  of,  545 
wounds  of,  gunshot,  228,  565 
treatment  of,  565 
Heart,  aneurysms  of,  732 
carcinoma  of,  336 
malposition  of,  334 
rupture  of,  336,  732 
surgical  diseases  of,  334 
tumors  of,  336 
wall  of,  abscess  of,  733 
wounds  of,  334,  733 
gunshot,  231 
suture  of,  335  (note), 
treatment  of,  335 
Heel,  excision  of,  414 
Hematoma  of  scalp,  218 

of  testicle,  1015 
Hematorrhachis,  625,  634 

treatment  of,  634 
Hematomyelia,  625,  634 

treatment  of,  634 
Hematuria,  959 

treatment  of,  959 
Hemiglossitis,  659 
Hemoglobin,  33 

Hemorrhage  after  abdominal  oj)- 
erations,  780 
from  breast,  755 
control  of,  234 

in  amputations,  1024 

by  angiotribe,  236 

by  chemical  agents,  235 

by  cold,  235 

by  destructive  methods,  23 

by  digital  compression,  23r5 


INDEX 


lO.")!) 


1  Iciiiorrliajir,  rout  ml  of,  I>y  rl:i>l  i( 

by  I'lcftrollicriiiic  fUimp,  ■_';{(• 

by  forced   llcxioii,  23o 

by  pclatiii,  2'.\'i 

by  hoat,  2:i.'j 

h\  linaturf,  '2'M\ 

by  liciiiostals.  •JHC. 

by  nu'chaiiical  means,  '2'M\ 

by  i)ressnre,  2;i5 

by  sty]>(ies,  2H5 

by  torsion,  2IUj 

by  touriii(|iiet ,  'JlVt 
of  csoi)liagiis,  744 
from  puiisliot  wonntls,  '2'2\i 
iiitraeraiiial,  5()3 
intra-ocular,  ()()4 
intra-orbital.  592 
of  larynx,  (JS3 
secondary,  237 

sipns  of,  237 

treatment  of,  237 
of  s|)inal  cord,  ()25,  ()34 
subdural,  r)()4 

traiunatic  intravei\tricular,  504 
lU>morrhagic  panereatitis,  946 
uleers,  (i(j 

treatment  of,  72 
Hemorrhoidal  veins,  phlebitis  of, 

362 
Hemorrhoids,  364,  882 
esophageal,  365 
treatment  of,  8S3 
Hemostats,  control  of  lieniorrhagc 

by,  236 
Hemothorax,  736 
Hepatic  abscess,  911 

symptoms  of,  912 

treatment  of,  912 
Hepaticostomy,  928 
Hepaticotomy,  928 
Hepato-cholango-enterostomv, 

932 
Hermaphrodism,  1007 
Hernia,  890 
acquired,  890 
causes  of,  890 
cerebri,  566 

prognosis  of,  566 

treatment  of,  566 
classification  of,  890 
congenital,  890 
diaphragmatic,  897 

acquired,  897 

congenital,  897 
femoral,  895 

treatment  of,  90S 
funiculi  umbilicalis,  896 
fimicular,  891 
gluteal,  897 
incarceration  of,  892 
infantile,  891 
inflamed,  892 
inguinal,  893 

congenital,  894 

direct,  893 

indirect,  893 

treatment  of,  908 
inguinoproperitoneal,  898 
interstitial,  898 
ischiatic,  897 
Littre's,  898 
lumbar,  897 
of  lung,  725 
of  muscles,  330 
obturator,  897 
ovarian,  897 
pelvic,  897 
perineal,  897 
postoperative,  896 

treatment  of,  909 
properitoneal,  891,  897 
reducibility  of,  892 
retroperitoneal,  891,  897 
Richter's,  898 
scrotal,  895 


FIcrnia,  signs  of,  892 

st  riiiigiilatcd,  diagnosis  of,  from 
appendicilis,  .S.'iS 
intestinal    obstruction    from, 
S29 
strangulation  of,  892 
svinptoms  of,  893 
tiixis  in,  S99 
traumatic,  890 
treatment  of,  898 

Hassini's  operation,  902 
Ilalsted's  operation,  904 
Kocher's  o])eration,  904 
McArthur's  operation,  904 
Park's  oi^eration,  905 
radical  cure,  901 
umbilical,  896 

treatment  of,  909 
varieties  of,  893 
ventral,  896 

treatment  of,  909 
Hernial  aneurysm,  339 
Herpes,  diagnosis  of,  from  chan- 
croid, 145 
preputialis,  1009 
zoster,  728 
Hcteroplasty,  602 
Highmore,  antrum  of,  operations 

on,  611 
Hip,  ankylosis  of,  404 
caries  of,  452 

diagnosis  of,  454 
prognosis  of,  454 
symptoms  of,  453 
niuscle  atrophy,  453 

spasm,  453 
pain,  453 
treatment  of,  454 
dislocations  of,  537 
classification  of,  537 
congenital,  471 
diagnosis  of,  473 
treatment  of,  474 
signs  of,  538 
symptoms  of,  538 
treatment  of,  539 
unreduced,  542 
excision  of,  412 
-joint,  amputation  of,  1045 
Davey's  method,  1045 
McBurney's  method,  1045 
Woodbury's  method,  1045 
Wycth's  method,  1045 
tuberculosis  of,  424 
llodgen  suspension  splint,  515 
Hodgkin's  disease,  376 
diagnosis  of,  377 
symptoms  of,  377 
treatment  of,  378 
Hordeolum,  600 
Hornets,  poisoning  by,  172 
Hour-glass  gall-bladder,  916 

stomach,  793 
Housemaid's  knee,  333 
Howard's     method     of     artificial 

respiration,  204 
Hueter's    incision    in    excision  of 

elbow,  410 
Humerus,  fractures  of,  495 
condyles  of,  498 
external,  499 
internal,  499 
epicondyles  of,  497 
intercondvloid,  499 
sliafts  of,  496 
supracondyloid,  497 
surgical  neck  of,  496 
treatment  of,  495 
Hunterian  chancre,  127 
Hunter's  method  of  treating  an- 
eurysm, 347 
Hutchinson's  teeth,  140 
Hydatid  cysts,  263 
of  liver,  913 

treatment  of,  913 
of  lung,  732 


Hydatid  cysts  of  omentum,   935 
of  si)leen,  943 

tliseiise  of  bone,  -V.Vl 
treatment  of,  432 
Hydalidiforin  mole,  292 
Hydramnios,  2()3 
Hydrarthrosis,  386 
Hvd rencei)haloceles,  577 
Hydroceh'S,  261,  1018 

of  canal  of  Nuck,  2()1 

chylous,  372 

of  cord,  261 

encysted,     of     spermatic     cord, 
1019 
of  testicle,  260 

funicular,  261 

of  neck,  261 

o\arian,  261 

treatment  of,  1018 
Hydrocephalus,  263,  578 

meningeus  or  externus,  578 

prognosis  of,  579 

in  rickets,  162 

treatment  of,  579 

ventriculorum  or  intcrnus,  578 
Hydrocholecyst,  259 
Hydrometra,  259 
Hydronephrosis,  971 

treatment  of,  973 
Hydrophobia,  102 

diagnosis  of,  104 

dumb,  103 

furious  form,  102 

incubation  in,  103 

paralytic  type  of,  103 

postmortem  changes  in,  104 

symptoms  of,  103 

treatment  of,  104 

virus  of,  102 
Hydrops,  333 
Hydrothionemia,  82 
Hydrothorax,  736 

chylous,  368 
Hygroma,  333 

Hyoid  bone,  fractures  of,  491 
Hyperemia,  19 

active,  20 

of  dilatation,  21 

of  paralysis,  21 

passive,  21 

results  of,  22 

acute  swelling,  22 
chronic  swelling,  22 
gangrene,  22 
nutritional  changes,  23 
resolution,  22 

treatment  of,  23 
Hyperinosis,  28 
Hypernephroma,  292,  970 
Hyperostoses  of  bone,  441 
Hyperplasia,  definition  of,  22,  25 
Hyperthyroidism,  713 
Hypertrophy,  25 

of  bone,  422 

of  breast,  756 

of  clitoris,  1007 

congenital,  26 

of  lips,  638 

pathological,  26 

physiological,  25 

of  prostate,  995 
diagno.sis  of,  996 
sj'niptoms  of,  997 
treatment  of,  998 

senile,  26 

of  skin,  311 

of  spleen,  941 

of  thymus,  717,  751 

of   thyroid,    acute     idiopathic, 
711 
intra-uterine,  711 

of  tonsils,  chronic,  662 

of  veins,  361 
Hypinosis,  28 
Hypodermoclysis,  186 
Hypognathy,  638 


1060 


IXDEX 


Hypopyon,  62.  598 
Hypospadias,  1005 

balanic,  1005 

penile,  1005 

penoscrotal.  lOii.') 

perineoscrotal.  KJfJ.j 
Hypostatic  inflammation,  47 

pneumonia,  21 


Idiopathic  erysipelas,  93,  94 
hypertrophy  of  thyfoid,  711 
pyemia.  91 
Ignipuncture,  184 
Ileus,  828 

Iliac  artery,  aneurysm  of,  346 

common,  ligation  of.  356 

external,  ligation  of,  .357 

internal,  ligation  of,  357 

Imperforate  anus,  873 

rectum.  872 
Implantation  dermoids,  266 
Incised  wounds,  214 

of  bloodves-sels,  216 
Incontinence  of  urine,  982 
Indolent  ulcer,  66 
Indurated  ulcer,  67 
Infantile  hernia,  891 

scorbutus,  161 
Infection,  auto-,  79 

circumstances  favoring,  46 

association    of    organisms, 

46 
fetal  infection,  48 
habits    and    en\-ironincnt, 

47 
hereditary'  influence,  46 
local  predisposition,  47 
preexisting  disease.  47 
\-irulence  of  organism,  46 
classification  of,  50 
mixed,  51 
primary,  50 
pyogenic,  51 
secondary-,  .51 
terminal,  51 
tertiary,  51 
relation    of   granulation    tissue 
to,  96 
of  lymph  nodes  to,  96 
sources  of.  48 

alimentary  canal,  49 
from  flies,  .50 
from  within  system,  50 
from  without,  50 
genito-urinary  tract,  49 
milk  in  lacteals,  50 
mucoiLS  membranes,  48 
respiratory  tract,  49 
skin,  48 
tonsils,  49 
Inflammation,  43 

ameboid  movement  of  cells  in, 

43 
as  cause  of  tumor,  256 
of  bladder,  984 
sjinptoms  of,  984 
treatment  of,  985 
of  breast,  756 
chemotaxis  in,  44 
of  corpus  cavernosum,  1009 
diapedesis  of  leukocj-tes  in,  43 
hypostatic,  47 
of  iris,  .598 
of  jaw,  667 
of  kidnev,  956 
of  lar>-nx,  683 
leukocytic  increase  in,  44 
of  mediastinum,  728 
opsonins  in,  44 
of  pancreas,  946 
phenomena  of,  43 
of  prostate.  994 
of  rectum,  875 


Inflammation   of  salivarv  glands, 
649 
specific  irritants  in,  45 
of  spleen,  941 
of  stomach  wall,  804 
of  thymus,  717 
of  tongue,  658 
of  veins,  361 
Influenza,  secondary  infection  in, 

167 
Infra-orbital     nerve,     operations 

on,  613 
Infusion  of  blood,  185 
intravenous,  186 
Ingrowing  toe-nail,  318 
Inguinal  hernia,  893 
congenital,  894 
direct,  893 
indirect,  893 
treatment  of,  908 
Inguinoproperitoneal  hernia,  898 
Inhaler.  Harcourt's,  197 
Innominate  arters',  aneur\-sm    of, 
345 
ligation  of,  350 
Insane,  othematoma  of,  605 
Insanity,       traumatic,       surgical 

treatment  of,  582 
Instruments,  sterilization  of,  246 
Intercondvloid  fracture  of  hume- 
rus, 499" 
Intercostal  neuralgia,  728 
Interrupted  suture,  241 
Interscapularthoracic        amputa- 
tions. 1033 
Interstitial  exudates,  23 
gingivitis,  657 
hernia,  898 
pancreatitis,  950 
Intestinal  biliarv-  fistidas,  917 
diverticula,  2(32.  822 
ulcers,    diagnosis   of,   from   ap- 
pendicitis, 857 
Intestine,  large,  anomalies  of,  869 
cancer  of,  870 
obstruction  of,  870 

from   intussusception,   870 
from  volvvdus,  870 
stricture  of,  870 
syphilis  of,  869 
tuberculosis  of,  869 
operation  on,  840 
anastomotic,  842 
appendicostomy,  850 
colopexy,  850 
colostomy,  849 
enteroplication,  850 
enterostomy,  849 
small,  822 

actinomycosis  of,  827 
cancer  of,  828 

treatment  of,  828 
malformations    of,   acquired, 
823 
congenital,  822 
obstruction  of,  acute,  828 
from  bands,  833 
fecal  impaction,  832 
gallstones,  833 
intestinal  loops,  834 
intussusception,  829 
causes  of,  830 
symptoms  of,  831 
treatment  of,  832 
invagination,  829 
neoplasms,     extrinsic, 
833 
intrinsic,  833 
peritonitis,  833 
slits  and  apertures,  834 
strangulated    hernias, 

829 

strictures,  832 

voh-ulus.  832 

postoperative,  834 

symptoms  of,  834 


^  Intestine,  small,    obstruction    of, 
I  acute,  treatment  of,  836 

chronic,  838 

symptoms  of.  838 
treatment  of,  839 
stricture  of,  827 

obstruction  from,  832 
s^^nptoms  of.  828 
treatment  of,  828 
syphilis  of,  827 
tumors  of,  828 
ulcers  of,  825 
cancerous,  827 
duodenal,  825 

symptoms  of,  825 
treatment  of,  826 
dysenteric,  827 
tuberculous,  827 
symptoms  of,  827 
treatment  of,  827 
tj-phoidal,  826 
s\Tnptoms  of,  826 
treatment  of,  826 
wounds  of,  823 
gunshot,  823 

s-\-mptoms  of,  824 
treatment  of,  824 
suture  of,  840 
Lembert's,  841 
Murphy  button,  844 
Intoxications,    acid,    from    anes- 
thetics, 203 
acute,  174 
Intra-abdominal   gastric    fistulas, 

801 
Intracanalicular       adenofibroma, 

285 
Intracranial  aneur\-sm.  34.5 

development,  defects  of,  treat- 
ment of,  580 
hemorrhage,  .56.3 
suppurations,  treatment  of,  573 
tumors,  582 

symptoms  of,  583 
treatment  of,  operative,  585 
vessels  and  sinuses,  injuries  of, 
563 
aneurysms  following, .564 
sources  of,  563 
subdural       hemorrhage, 

564 
tramnatic  intraventricu- 
lar hemorrhage,  564 
Intracystic  villous  papilloma,  282 
Intralarj-ngcal  tumors,  686 
symptoms  of,  687 
treatment  of,  687 
Tntramammarj-  abscess,  7.57 
Intra-ocular  hemorrhage,  604 

tumors.  594 
Intra-orbital  hemorrhage,  .592 
Intraspinal  cocainization,  207 
hemorrhage.  6.34 
treatment  of,  6.34 
Intratracheal  tumors,  686 
Intra-uterine  hypertrophy  of  thy- 
roid, 711 
rickets.  432 
Intraventricular  hemorrhage, trau- 
matic, 564 
Intubation  of  lan,-nx,  693 
Intu.ssusception     of        intestines, 
large.  870 
small.  829 
Invagination,    intestinal   obstruc-- 
tion  from,  829 
of  rectum,  881 
treatment  of,  882 
Iodine  gut,  247 

reaction  of  blood.  33 
toxic  effects  of,  175 
Iodoform,  toxic  effects  of,  175 
Iris,  cysts  of,  594 

inflammation  of,  598 
Iritis.  .598 
Irritation  as  cause  of    tumor,  255 


INDEX 


lOGl 


Ischintic  luTuia,  S07 
Isohioifctal  absc-ss,  879,  101. < 
Ivy  puisuiiing,  173 


Jacksoniav      oy>ilo|)sy,      siirRiial 

treatment  of,  581 
.larvis'  snare,  078 
Jainulire  in  a]>i)eiulicitis,  8.")r> 
Jaws,  ankylosis  of,  ()()7 
ilislocat  ion  of,  (>(i7 
inflammation  of,  {j()7 
lower,  tlisloeations  of,  527 

treatment  of,  52S 
operations  on,  (idS 
osteomyelitis  of,  ()(i7 
periostitis  of,  ()()7 
postfjonorrlieal       arthritis       of, 

(107 
synovitis  of,  aeiite,  067 
tumors  of,  008 
Jejumun,  ])eptie  ulcer  of,  810 
Joints,  ankylosis  of,  -KK? 
treatment  of,  405 
arthritis  of,  382 
chronic,  380 

treatment  of,  380 
gonorrheal,  392 
osteo-,  387 

treatment  of,  389 
])ostgonorrheal,  392 
.syphilitic,  385 
tuberculous,  393 
diagnosis  of,  398 
pathology  of,  394 
symptoms  of,  397 
treatment  of,  398 
disea-ses  of,  arthropathic,  394 
neuropathic,  389 
diagnosis  of,  392 
treatment  of,  392 
osteopathic,  394 
surgical,   379 
excision  of,  407 
of  ankle,  414 
of  elbow,  410 
of  fingers,  412 
of  foot,  415 
of  hand,  412 
of  heel,  414 
of  hip,  412 
of  knee,  413 
of  shoulder,  409 
of  wrist,  411 
hysterical,  392 

treatment  of,  392 
inflam^mation  of,  382 
injuries  to,  380 
knee-,  foreign  bodies  in,  402 
movable  bodies  in,  401 
diagnosis  of,  402 
symptoms  of,  401 
treatment  of,  402 
pannus  of,  395 
scrofula  of,  393 
.sprains  of,  380 

symptoms  of,  380 
treatment  of,  380 
synovitis  of,  382 
acute,  383 

treatment  of,  383 
chronic,  386 

treatment  of,  386 
dry,  383 
gonorrheal,  385 
purulent,  383 

symptoms  of,  383 

treatment  of,  385 

treatment  of,  385 

syphilis  of,  135 

wounds  of,  gunshot,  228,  381 

amputation  in,  381 

excision  in,  381 

penetrating,  381 


K.Mit.F.ii'.s  disease  of  bone,  442 
ivangaroo     tendons,    sterilization 

of,  248 
Karvokinesis,  44 
Keel-shai)ed  chest,  718 
Keller's     method     of     extirpating 

varicose  veins,  300 
Keloid,  270,  312 
cicatricial,  70 
of  I'ar,  005 

treatment  of,  271,  313 
Ki'ratosis  of  skin,  .314 
treatment  of,  314 
Key-hole  wountls,  22.5 
Kidney,  abscess  of,  957 
absence  of,  95.5 
actinomycosis  of,  964 
adenoma  of,  909 
congenital,  969 
anomalies  of,  9.55 
calculi  of,  90.5 
diagnosis  of,  90.5 
symptoms  of,  90.5 
treatment  of,  900 
carcinoma  of,  969 
cystic,  969 

decapsulation  of,  960 
floating,  diagnosis  of,  from  ap 

jiendicitis,  S.")S 
hemorrhage  from,  959 

treatment  of,  959 
horseshoe,  955 
hydronephrosis  of,  971 

treatment  of,  973 
hypernephroma  of,  970 
infection  of,  9.56 
inflammations  of,  956 
injuries  to,  9.55 
movable  and  floating,  966 
symptoms  of,  967 
treatment  of,  967 
multicystic,  969 
operations  on,  974 
pain  in,  956 
polycystic,  969 
pus  in,  961 

treatment  of,  961 
pyohydronephrosis  of,  972 
pyonephrosis  of,  972 
sarcoma  of,  969 
surgical,  956,  957 
symptoms  of,  957 
treatment  of,  957 
svphilis  of,  138,  964 
tuberculosis  of,  118,  961 
diagnosis  of,  962 
symptoms  of,  961 
treatment  of,  963 
tumors  of,  969 
wounds  of,  gunshot,  23.3 
Xnee,  amputation  of,  1043 
Gritti's  method,  1044 
Sabanejeff's  method,  1044 
Stephen  Smith's  method, 
1043 
ankylosis  of,  404 
arthritis  deformans  of,  388 
dislocations  of,  543 
symptoms  of,  544 
treatment  of,  544 
excision  of,  41.3 
housemaid's,  333 
-joint,  foreign  bodies  in,  402 
tuberculous  disease  of,  456 
treatment  of,  456 
Knock-knee,  463 

treatment  of,  464 
Xnots,  242 

clove  hitch,  241 
grannv, 241 
reef,  241 

Staffordshire,  241 
Kocher's  operation  for  hernia,  904 
on  tongue,  661 


Kocher's    treatment    of     disloca- 
tions of  shoulder-joint,  533 
Konig's    cheiloplastic    operation, 
648 
incision   for   excision   of   ankle, 
415 
Kyphosis,  444 


Laceratioxs,  212 

of  abdominal  wall,  781 
f)f  bladder,  981 
of  blood ve.ssels,  216 
of  brain  suVjstance,  564 
prognosis  of,  564 
sNinptoms  of,  565 
of  hnig,  721 

treatment  of,  722 
of  urethra,  1008 
Lacrymal  fistula,  600 

tract,  diseases  of,  .599 
I^actcals,       milk       in,       infection 

tlirough,  50 
Laminectomy,  6.36 
Langenbeck's operation  on  tongue 

662 
Laparotomy,  773 

exploratory,  773 
I^aryngeal  phthisis,  084 

polypi,  080 
Laryngectomy,  689 
Laryngismus  stridulus,  164 

in  rickets,  162 
Laryngitis,  erysipelatous,  9.5 
Laryngoceles,  707 
Larynx,  chondritis  xjf,  683 
dislocations  of,  528 
edema  of,  683 
epithelioma  of,  687 
fracture  of,  676 
hemorrhage  of,  683 
inflammation  of,  683 
intubation  of,  693 
malformations  of,  671 
operations  on,  688 
papilloma  of,  686 
perichondritis  of,  683 
sarcoma  of,  687 
strictures  of,  684 
symptoms  of,  684 
treatment  of,  684 
syphilis  of,  1.38,  686 
treatment  of,  686 
tuberculosis  of,  684 
treatment  of,  685 
wounds  of,  675 
treatment  of,  675 
Leeching,  183 
Leg,  amputations  of,  1039 
Bier's  osteoplastic,  1028 
circular,  1041 
Pirogoff's,  1040 
elephantiasis  of,  370 
figure-of-8-bandage  of,  189 
fractures  of,  518 
treatment  of,  521 
Leiomyoma,  277 
Lembert's  suture,  841 
Lens,  dislocation  of,  60' 
Lcontiasis,  438 
Leprosy,  308 

bacillus  of,  54 
Leptomeningitis,  572 
diagnosis  of,  573 
prognosis  of,  573 
suppuration,  572 
symptoms  of,  572 
traumatic  basilar,  572 
treatment  of,  753 
Leptothrix  fungi,  50 
Leukemia,  32 
lymphatic,  32 
pseudo-,  32 
splenomeduUary,  32 


1062 


INDEX 


Leukocytes,  classification  of,  30 
count,  differential,  32 
definition  of,  29 
diapcdesis  of,  43 
migration  of,  43 
physical  properties  of,  40 
Leukocytosis  in  septicemia,  88 
Leukoderma,  131 
Leukokcratosis,  137 
L('uk<)|)t'nia,  30 
Leukoplakia,  137,  659 

treatment  of,  659 
Ligation  of  arteries,  350 
abdominal  aorta,  356 
axillary,  355 
brachial,  355 
carotid,  common,  351 
external,  352 
internal,  352 
circumflex,  359 
epigastric,  359 
facial,  352 
femoral,  359 
gangrene  from,  73 
iliac,  common,  356 
external,  357 
internal,  357 
innominate,  350 
lingual,  352 
occipital,  352 
popliteal,  360 
radial,  356 
temporal,  352 
thyroid,  inferior,  353 
tibial,  anterior,  360 

posterior,  360 
ulnar,  356 
vertebral,  353 
Ligatures,  236 
fate  of,  237 
IJngua  plicata,  C52 
Lingual     artery,     ligation      of, 
352 
nerve,  operations  on,  616 
Lipoma,  269 
of  breast,  760 
dolorosa,  269 
subcutaneous,  269 
subserous,  269 
subsynoviul,  269 
of  testicle,  1017 
of  thorax,  729 
Lips,  absence  of,  638 

congenital  defects  of,  638 
fistulas  of,  638 
hypertrophy  of,  638 
operations  on,  645 
Liquid  air,  205 

in  treatment  of  cancer,  296 
Lister's    incisions    in    excision    of 

wrist,  411 
Litholapaxv,  987,  988 
Lithotomy,"  987,  988 

perineal,  990 
Lithotrity,  987 
Litigation  spine,  628 
Littre's  hernia,  898 
Liver,  abscess  of,  911 
symptoms  of,  912 
treatment  of,  912 
actinomycosis  of,  914 
adenoma  of,  914 
aneurysms  of,  914 
carcinoma  of,  914 
congenital     displacements     of, 

910 
cysts  of,  hydatid,  913 
treatment  of,  913 
endothelioina  of,  914 
fibroma  of,  914 
floating,  910 

symptoms  of,  910 
treatment  of  911 
injuries  of,    911 
sarcoma  of,  914 
syphilis  of,  138,  914 


Liver,  tumors  of,  914 

wounds  of,  911 
Lizards,  jwisoning  by,  172 
Lock  finger,  320 

treatment  of,  320 
Lockjaw,  97.     Sec  Tetantis. 
Lordosis,  461 

Ludwig's  angina,  658,  703 
Lumbar  abscess,  114 

liernia,  897 
Ivumpy  jaw,  109 
Lungs   abscess  of,  734 

actinomycosis  of,  732,  7?A 
carcinoma  of,  732 
decortication  of,  750 
dermoids  of,  732 
echinococcus  cysts  of,  732 
empyema  of,  736 
endothelioma  of,  732 
gangrene  of,  734 
hernia  of,  735 
hydatid  cysts  of,  732 
laceration  of,  721 
rupture  of,  725 
sarcoma  of,  732 
syphilitic  gumma  of,  732 
tvunors  of,  732 
wounds  of,  724 
treatment  of,  726 
Lupus  vulgaris,  306 
Luxation,  524.     See  Dislocations. 
Lymph  cysts,  278 
nodes,  375 

arrangement  of,  369 
carcinoma  of,  376 
cervical,  affections  of,  70.5 
treatment  of,  706 
syphilis  of,  705 
tuberculosis  of   705 
gonorrhea  of,  376 
in  Hodgkin's  disease,  370 
injuries    and    diseases    of, 

368 
relation    of,     to    infection, 

96 
syphilis  of,  376 
tuberculosis  of,  376 
tumors  of,  378 
vessels,  arrangement  of,  369 
injuries      and    diseases      of, 

368 
occlusion  of,  369 
acquired,  369 
congenital,  369 
Lymphangiectasis,  370 
Lymphangioma,  278 
cavernous,  278 
circumscriptum,  374 
treatment  of,  374 
of  ear,  congenital,  606 
lymph  cysts,  278 
lymphatic  nevus,  278 
of  skin,  315 

treatment  of,  315 
treatment  of,  279 
Lymphangitis,  374 
clironic,  375 
gonorrheal,  151 
treatment  of,  375 
Lymphatic  chlorotic  constitution, 
163 
constitution,  163 
leukemia,  32 
nevus,  278 
Lymphatics,       tuberculosis      of, 
116 
tumors  of,  378 
Lymjihatism,  163 
Lymphedema,  369 
Lymphocytosis,  30 
Lymphodermia  pernicio.sa,  164 
Lymphoma,  378 
malignant,  32 
Lymphorrhagia,  372 
Lymphosarcoma,  273,  37S 
Lyssophobia,  104 


M 

McAktiiur's  operation  for  liernia, 

904 
McBurney's   method   of   amputa- 
tion of  hip-joint,  1045 

point  in  ajipendicitis,  855 
Macrocheilia,  373,  638 
Macroglossia,  373,  G60 

congenital,  652 
MucroineUa,  373 
Macrostoma,  638 
Madura  foot,  110,  309 
fungi,  56 
treatment  of,  110 
Malar  bones,  fractures  of,  489 
Malformations  of  anus,  872 

of  bladder,  977 

of  chin,  638 

of  ears,  congenital,  604 

of  esophagus,  acquired,  737 
congenital,  737 
treatment  of,  738 

of  face,  ac(iuired,  639 

of  gall-bladder,  916 

of  intestines,  large,  869 

small,  acquired,  823 

congenital,  822 

of  larynx,  671 

of  nasal  septum,  671 

of  nose,  676 

of  nostrils,  671 

of  pharynx,  671 

of  rectum,  872 

of  respiratory    passages,    ac- 
quired, 671 
congenital,  671 
treatment  of,  671 

of  soft  palate,  671 

of  sternum,  718 

of  stoniacli,  acciuired,  793 
congenital,  793 

of  teeth,  652 

of  thorax,  718,  719 

of  tongue,  652 
Malgaigne's    operation    for    hare- 
lip, 647 
Malignant     edema,      108.  See 

Edema,  malignant. 

pustule,  106.     See  Anthrax. 
Mania,  traumatic,  175 
Marasniic  thrombosis,  36 
Mastitis,  756 

chronic,  757 

treatment  of,  758 
Mastodynia,  758 
Mastoid  disease,  574 

operation,  575 
Matas'    metliod  of  treating   aneu- 
rysm, 348 
Maxilla,  inferior,  fractures  of,  490 
treatment  of,  490 

superior,  fractures  of,  489 
Maxillary    sinus,     operations    on, 

611 
Measles,    secondary    infection    in, 

167 
Meatotomy,  155 
Meckel's  diverticulum,  822 
Median  nerve,  operations  on,  623 
Mediastinitis,  728 

treatment  of,  728 
Mediotarsal   amputation  of   Clio- 

l)art,  1037 
Mfi;al( .Masts,  definition  of,  29 
Mehuioma,  275 

of  skin,  316 

treatment  of,  317 
Melanosarcoma,  275 
Melon-seed  bodies,  322 
Meningeal  artery,  middle,  injuries 

of,  563 
Meningitis,  571 

treatment  of,  572 
Meningocele.  576 

cranial,  263 


INDEX 


1063 


MeninRocolo,  sjiinal,  025 
Mi'iiiiinomyfUicflc,  (>2(( 
MiTcurial  nccrttsis  of  Ixmc,  -fJS 
MiTcurv.  ti>xi<'  ctTccts  of,  175 
Mfsartcritis,  ;WS 
Mi'sciitfric  i)lil(>l)itis.  'M\2 
Mcsfiitfry,  absoiu-o  of,  030 
Hctiiiomyoosis  of,  030 
anatomy  of,  037 
c-aiictT  of,  030 
cysts  of,  040 
I'lnbolisni  of,  03S 
injuries  of,  038 
syphilis  of,  030 
tiiro!ubosis  of,  03S 
tuberi-ulosis  of,  030 
troatmont  of,  030 
Metacarpophalangeal  dislocations , 
536 
treatment  of,  537 
Metastasis,  01 
.Met:istatip  abscess,  91 

osteomyelitis,  02 
Metatarsalgia,  470 

treatment  of,  470 
Methylene  bichloride,  108 
MicroVilasts,  definition  of,  20 
Micrococcus  gonorrluiue,  53 
lanceolatus,  53 
tetragenus,  53 
Microorganisms  in  blood,  35 
Microstoma,  638,  652 
Mikulicz's  disease,  650 
Milk  in  lacteals,  infection  through, 
50 
leg,  362 
Milzbrand,  106.      See  Anthrax. 
MoUuscum  contagiosum,  312 
Morphine,  205 

Morrison's    operation    on    omen- 
tum, 036 
Mortification,  73.     See  Gangrene. 
Morton's  disease,  470 
treatment  of,  470 
Mother's  marks,  367 
Mouth,  absence  of,  638 
actinomj'cosis  of,  657 
bacteria  of,  657 
blastomycetic  lesions  of,  658 
congenital  defects  of,  652 
diphtheria  of,  657 
erysipelas  of,  657 
injuries  of,  658 
syphilis  of,  657 
tuberculosis  of,  657 
wounds  of,  658 
Movable  bodies  in  joints,  401 
diagnosis  of,  402 
symptoms  of,  4(J1 
treatment  of,  402 
Mucous       membrane,       infection 
through.  48 
syphilis  of,  132 
tuberculosis  of,  115 
polyp,  283 
Mulberry  growths,  282 
Multicystic  kidney,  069 
Mumps,    secondary    infection    in, 

168 
Murphy  button,  820,  844 
Muscles,  atrophies  of,  332 
treatment  of,  332 
contractures  of,  332 
treatment  of,  332 
contusions  of,  320 
of  eves,  defects  of,  604 
hernia  of,  330 
injviries  of,  218 
myalgia,  330 

treatment  of,  331 
myositis,  331 
ealcificans,  331 
ossificans,  272,  331 
syphilitica,  136,  331 
tuberculosa,  331 
paralytic  affections  of,  332 


Muscle-s,    paralytic  affections    of, 
treatment  of,  .332 

jiarasitic  alTections  of,  332 

rupture  of,  .320 
treatment  of,  .3.30 

sprains  of,  320 

strains  of,  .320 

syjihilis  of,  136,  331 

tuberculosis  of,  .3.31 

woinids  of,  .330 
Musculospiral    nerve,    operations 

on,  623 
Mvalgia,  330 

"treatment  of,  .331 
Mvcetoma,  300 
Mycosis  fungoides,  .308 
Mycotic  i)hlcbitis,  90 
Myeloid,  274 
Myeloma  of  bone,  442 
Myosarcoma,  274 
Myo.sitis,  331 

ealcificans,  331 

gonococcus  of,  331 

ossificans,  272,  331 

syphilitica,  136,  331 

tuberculosa,  331 
Myotomy,  327 
Myxoma,  276 

"of  bladder,  902 

of  bone,  441 

cutaneous,  276 

neuromyxoma,  276 

polypi,  276 


N 


N.ML  horns,  283 

Xaphthalin,  toxic  effects  of,  175 

Xares,  anterior,  plugging  of,  681 

Nasal  cavities,  neoplasms  of,  677 

symptoms  of,  078 

treatment  of,  678 

deformities,  676 

polypi,  677 

septum,  malformations  of,  671 
submucous  resection  of,  677 
Nasopharynx,  fibroma  of,  679 
Neck,  aneurysms  of,  701 
canal  of,  hydrocele  of,  261 
carbuncles  of,  704 
congenital  anomalies  of,  698 

treatment  of,  698 
cy'sts  of,  707 

atheromatous,  707 
bursal,  707 
dermoid,  707 
sanguineous,  701,  707 
thyrohyoid,  707 
hydroceles  of,  261 
injuries  of,  698 
muscles    of,    injuries    of,    700, 

701 
nerves  of,  injuries  of,  700,  701 
phlegmons  of,  70(J,  703 
diagnosis  of,  703 
treatment  of,  703 
tumors  of,  706 
veins  of,  wounds  of,  700 
wounds  of,  698 

air-embohsm  in,  699 
gunshot,  220 
Necrosis  of  bone,  428 
pathological,  428 
toxic,  428 

treatment  of,  428 
traumatic,  428 
coagulation,  57 
of  skull,  549 
Nephritis,  chronic,   treatment   of, 
operative,  0.50 
indications  for,  960 
septic,  956 

symptoms  of,  957 
treatment  of,  057 
Nephrolysis,  960 


N(^laton's  incision  in  excision   of 
elbow,  410 

operation  for  hare-lip,  647 
.Neoplasms  of  ear,  60.") 

intestinal  obstruction  from,  .S33 

of  nasal  cavities,  677 

of  s|)lecn,  043 
.Nephralgia,  056 
.Nephrectomy,  060,  074 
.Nephrolitiiotoniy,  066 
.\e|)hrnpcxy,  OOS 
.NejjliroiJtosis,  067 
Nephrotomy,  060 
.Nervanin,  207 

Nerves,  acoustic,  neurofibroma  of, 
.584 

anterior  crural,  operations  on, 
623 

brachial  plexus,  operations  on. 
623 

cervical  plexus,  deep  posterior, 
operations  on,  618 
sympathetic,    operations   on, 
"  618 

cranial,  injuries  of,  612 

dislocation  of,  624 

elongation  of,  612 

of  eye,  disturbances  of,  604 

of  face,  injuries  of,  640 
operations  on,  616 

fibroma  of,  622 

fifth,  operations  on,  613 

Gasserian   ganglion,   operations 
on,  614 

grafting  of,  612 

infra-orbital,  operations  on,  01.3 

injuries  of,  217 

lingual  operations  on,  616 

median,  operations  on,  623 

musculospiral,     operations    on, 
623 

optic,  tumors  of,  593 

peripheral,  diseases  and  injuries 
of,  622 

radial,  operations  on,  623 

resection  of,  613 

sciatic,    great,    operations    on, 
623 

seventh,  operations  on,  616 

spinal  accessory,  operations  on, 
617 

stretcliing  of,  612 

supra-orbital,    operations      on, 
613 

suture  of,  612 

tibial,  operations  on,  623 

trunks,  upper,  injuries  to,  725 
treatment  of,  726 

tumors  of,  622 

ulnar,  operations  on,  623 

W'Ounds  of,  612 
Nervous  system,  syphilis  of,  138 
Nettle,  stinging,  poi.soning  by,  173 
Neural  cysts,  263 
Neuralgia  of  breast,  758 
treatment  of,  758 

facial,  640 

intercostal,  728 
Neurectomy,  612 
Neuro-anastomosis       for       facial 

palsy,  616 
Neurofibroma  of  acoustic   nerve, 
584 

of  skin,  313 
Neuroma,  280 

amputation,  1047 

malignant,  280 

plexiform,  280,  622 
Neuromyxoma,  276 
Neuroparalytic  congestion,  20 
Neurorrhaphy,  612 
Neurotonic  congestion,  20 
Nevi  of  tongue,  6.59 
Nevus,  277 

lymphatic,  27.S 

pignientosus,  314 


1064 


INDEX 


Nevus,  venous,  307 
congenital,  3G7 
Newborn,  tetanus  of,  97,  99 
Nipple,  chancre  of,  759 

eczema  of,  316 

fissures  of,  756 

Paget 's  disease  of,  316,  756 
Nitze's  cystoscope,  993 
Noma,  75,  658 

Normoblasts,  definition  of,  29 
Nose-bleed,  680 

calculi  of,  672 

fractures  of,  489 

malformations  of,  676 

operations  on,  644 
Nostrils,  malformations  of,  671 


O'Dwyer's  intubation  tubes,  693 
Obligate  pyogenic  organisms,  52 
(Obstruction   of    intestines,  acute, 
828 
from  intussusception,  829 
causes  of,  830 
symptoms  of,  830 
treatment  of,  831 
from  invagination,  829 
from  strangulated  hernias, 

829 
from  volvulus,  832 
large  intestines,  870 
Obstructive  thrombosis,  36 
Obturator  hernia,  897 
Occipital  abscess,  569 
artery,  ligation  of,  352 
cephalocele,  576 
Occlusion  of  1_\  mph  vessels,  309 
acquired,  369 
congenital,  369 
Odontoma,  281 
cementoma,  281 
composite,  281 
epithelial,  281 
fibrous,  281 
follicular,  281 

compound,  281 
of  jaw,  668 
radicular,  281 
of  teeth,  665 
Oidiomycosis,  310 
Oidium  albicans  of  thrush,  657 
(Oiled  silk,  sterilization  of,  248 
Olecranon,  fractures  of,  501 
Oligocythemia,  29 
Ollier's    incision    in    excision     of 
elbow,  410 
of  hip,  411 
of  knee,  413 
of  shoulder,  410 
of  wrist,  411 
Omentopexy,  936 
( )mentosplenopexy ,  936 
Omentum,  anatomy  of,  934 
cysts  of,  935 
injuries  of,  935 
operations  on,  936 
torsion  of,  935 
tumors  of,  935 
Onychia  maligna,  318 
Operations,  abdominal,  773 
on  biliary  passages,  927 
on  breast,  764 
for  cure  of  hernia,  901 
on  esophagus,  745 
on  face,  642 
on  gall-bladder,  927 
on  intestines,  840 
on  jaws,  668 
on  kidneys,  974 
on  larynx,  688 
on  lips,  645 
mastoid,  574 
on  nose,  644 
on  omentum,  936 


Operations  on  prostate,  998 
on  spine,  636 
on  spleen,  943 
on  stomach,  805 
Ihoracophistic,  748 
on  tiiorax,  74() 
on  tongue,  661 
on  trachea,  (591 
for  tumors  of  brain,  585 
on  ureters,  97(5 
(Ophthalmitis,   symjiathetic,  595 

treatnu'iit  of,  596 
Opisthotonos,  100 
(Opsonins  in  inflammation,  44 
Optic  nerve,  tumors  of,  593 
Orbit,  aneurysms  of,  592 
angioma  of,  592 
cellulitis  of,  592 
cysts  of,  dermoid,  593 

parasitic,  593 
encephalocele  of,  593 
endothelioma  of,  593 
epithelioma  of,  593 
injuries  of,  592 

treatment  of,  593 
sarcoma  of,  593 
syphilis  of,  597 
tumors  of,  593 
cystic,  593 
vascular,  593 
wounds  of,  592 
Orchitis,  1017 

treatment  of,  1017 
Oropharynx,  svphilis  of,  137 
Orthoform,  207 
Osseous  system,  surgical  diseases 

of,  416 
Osteo-arthritis,  387 
treatment  of,  389 
Osteo-arthropathic     hypertro])hi- 

ante  pneumi<iue,  436 
Osteogenesis  imperfecta,  435 
Osteoma,  272 
of  bone,  441 
of  jaw,  668 
of  skull,  548 
of  thorax,  730 
Osteomalacia,  434 
prognosis  of,  434 
treatment  of,  435 
(Osteomyelitis  of  abdominal  wall, 
783 
acute,  416,  548 

com])lications  of,  419 
diagnosis  of,  419 
etiology  of,  419 
organisms  at  fault  in,  417 
patliology  of,  416 
prognosis  of,  418 
symptoms  of,  418 
treatment  of,  419 
chronic,  421 

tuberculous,  423 
of  jaw,  667 
latent,  421 
metastatic,  92 
Osteopathic  joint  disease,  394 
Osteoporosis,  422,  436 

adii)osa,  416 
Osteopsathyrosis,  435 
Osteosarcoma,  274 
(Osteosclerosis,  422 
Ostitis  deformans,  436 
Othematoma  of  insane,  605 

traumatic,  605 
Otis'   dilating   urethrotome,    157 
1012 
urethrometer,  1012 
(Ovarian  cystoma,  284 
glandular,  284 
papillary,  284 
dermoids,  267 
hernia,  897 
hydrocele,  261 
papilloma,  282 
(Ovary,  tuberculosis  of,  IIS 


'  Overlapping  ears,  605 
(Ozena,  137,  671 


PAnrYDEnMATOCELE,   313 

Pachymeningitis  externa,  572 

interna,  572 
Paget's  disease  of  bones,  436 

of  nipple,  316,  756 
Palate,  cleft,  operation  for,  654 
soft,    diseases   and    injuries   of, 
682 
Palsy,  Bell's,  640 

fatnal,     neuro-anastomosis    for, 
616 
Palsies,  cerebral,  47S 

treatment  of,  478 
Panarthritis,  tuberculous,  395 
Pancreas,  abscess  of,  949 
adenocarcinoma  of,  953 
adenoma  of,  953 
affections  of,  acute,  946 
chronic,  950 

diagnosis  of,  951 
treatment  of,  951 
anomalies  of,  944 
calculi  of,  954 
cancer  of,  953 
cirrhosis  of,  950 
cysts  of,  951 

diagnosis  of,  952 
symptoms  of,  952 
treatment  of,  952 
injuries  to,  947 
neoi)lasms  of,  951 
non-traiunatic  surgical  diseases 

of,  946 
sarcoma  of,  953 
tumors  of,  953 
Pancreatic  cysts,  262 
Pancreatitis,  acute,  946 
diagnosis  of,  947 

from  appendicitis,  858 
symptoms  of,  947 
treatment  of,  948 
chronic,  950 
gangrenous,  946 
hemorrhagic,  946 
interstitial,  950 
subacute,  949 
diagnosis  of,  949 
symptoms  of,  949 
treatment  of,  950 
suppurative,  946 
Pannus  of  joints,  395 
Panophthalmitis,  595 

treatment  of,  595 
Papillary  cystoma,  284 
Pai3illoma,"282 
of  bladder,  992 
cutaiieovis  horns,  283 
of  ear,  605 
of  larynx,  686 
ovarian,  282 
of  penis,  1009 
of  tongue,  659 
treatment  of,  283 
villous,  282 

intracystic,  282 
warts,  282 
Paracentesis,  184     / 
l)y  as|)iration,  184 
by  incision,  185 
of  pericardium,  336,  733 
by  tapping,  185 
Paraffin  cancer,  316 
Paralysis,  diaphragmatic,  753 
facial,  640 
hyperemia  of,  21 
of  nerve  of  eye,  604 
Paralvtic    affections    of    muscles, 
332 
treatment  of,  332 
Paraphimosis,  1005 


INDEX 


1065 


Parasitic    affections    of    imisclcs, 
332 
cysts  of  orbit,  593 
diseases  of  bone,  432 
Panitiiyroids,  diseases  of,  710 
I'areiK-iiyniatous  exudates,  23 
I'arietal  al)seess,  50'.) 

thrombosis,  35 
Parli's  club-foot  brace,  4(>9 
operation  for  hernia,  !)()") 
I'aroophoiitic  cysts,  2((0 
Parovarian  cysts,  2()() 
PateUa,  ihslocations  of,  513 
treatment  of,  543 
fractures  of,  51(i 
treatment  of,  517 
Pelvic  hernia,  Si)7 
Pelvis,  fractures  of,  .')07 
treatment  of,  5()S 
rachitic,  deformities  of,  102 
Penis,  aV)sence  of,  1004 
amputation  of,  1010 
balanitis  of.  1005 
balanoposthitis,  1005 
congenital  defects  of,  1004 
dislocation  of,  1008 
double,  1004 
elephantiasis  of,  370 
epithelioma  of,  lt)10 
fracture  of,  lOOS 
gumma  of,  1009 
herpes  of,  1(W9 
injuries  of,  1008 
misplacement  of,  1004 
paraphimosis  of,  1005 
phimosis  of,  1004 
posthitis  of,  1005 
warts  of,  1009 
Peptic  ulcer  of  jejunum,  816 
Perforating  ulcer  of  foot,  310 
Perforations  of    biliary  passages, 
921 
symptoms  of,  922 
treatment  of,  922 
of  esophagus,  742 
Peri-appendicular  abscess,  860 
Peri-arteritis,  338 
Peri-articvilar  cold  abscess,  treat- 
ment of,  399 
Pericanalicular  adenofibroma,  285 
Pericarditis,  733 
Pericardium,  cardicentesis  of,  330 

paracentesis  of,  336 
Perichondritis,  683 
Perigastritis,  804 
Perilaryngeal  abscess,  704 
Perilymphangitis,  374 
Perineal  abscess,  1013 
treatment  of,  1013 
fistulas,  1013 

treatment  of,  1013 
hernia,  897 
lithotomy,  990 
prostatectomy,  999 
\  Perinephritis,  961 

sj'mptoms  of,  961 
'       treatment  of,  961 
Periostitis,  acute,  548 
infectious,  420 
causes  of,  421 
treatment  of,  421 
albuminosa,  421 
of  jaw,  667 
Peripheral    nerves,    diseases    and 
'       injuries  of,  622 
Perirectal  abscess,  879 
treatment  of,  879 
'-  Peritheliomas,  275 
Peritoneum,  diseases  of,  7S5 

tuberculosis  of,  116,  118 
Peritonitis,  785 

circumscribed,  786 
classification  of,  786 
consecutive,  786 
diagnosis     of,     from     appendi- 
citis, 857 


Peritonitis  diffuse,  780 

following  abdominal  operations, 

7S() 
intestinal  obstruction  from,  833 
l)re\-ention  of,  251 
])utrid,  780 
symiitoms  of,  78(» 
traumatic,  780 
treatment  of,  7S7 
tuberculous,  7S0,  700 
ascit  ic,  791 
fibrinoi)lastic,  701 
tri-atment  of,  791 
ulcerative,  791 
Peritracheal  abscess,  704 
I'erityphlitic  abscess,  800 
Peri-urethritis,  149 
Pes  cavus,  471 
Petroleum  ether,  IT.O 
I'hagedenic  chancroid,  144 

ulcers,  06 
Phagocytosis,  30,  40 
I'haryngc;il  diverticula,  202 
I'liaryugotoiuy,  external,  004 
subhyoid,  004 
transhyoid,  664 
Pharynx,  adenoids  of,  079 
treatment  of,  OSO 
foreign  bodies  in,  073 
treatment  of,  073 
malformations  of,  071 
Phimosis,  1004 
Phlebectases,  304 
Phlebitis,  361 
acute,  361 
chronic,  362 

symptoms  of,  362 
treatment  of,  363 
mycotic,  90 
obliterans,  362 
sinus,  362,  571 
Phleboliths,  36,  362,  364 
Phlegmasia  alba  dolens,  302 
Phlegmonous    affections    of    rec- 
tum, 879 
treatment  of,  879 
cholecystitis,  acute,  920 
erysipelas,  75,  93 
gastritis,  804 

symptoms  of,  804 
treatment  of,  805 
Phlegmons  of  abdominal  wall,  783 
of  axilla,  751 
of  neck,  700,  703 
diagnosis  of,  703 
treatment  of,  703 
Phosphorus  necrosis  of  bone,  42S 
Phthisis,  laryngeal,  684 
Pigeon-breast,  162,  718 
Piles,  364,  882 

treatment  of,  883 
Pilonidal  sinus,  635 
Pirogoff's  amputation  of  leg,  1040 
Pituitary  adenomas,  285 
Pleura,  rupture  of,  724 
wounds  of,  724 
treatment  of,  726 
Pleurosthotonos,  100 
Plexiform  angioma,  278 

neuroma,  280,  622 
Pneumatocele  of  scalp,  545 

treatment  of,  546 
Pneumocele,  725 
Pneumonectomj',  750 
Pneumonia,  bacillus  of,  54 
erysipelatous,  95 
secondary  infection  in,  167 
Pneumopericardium,  337 
Pneumotomy,  750 
Poikilocytes,  definition  of,  29 
Poisoning,  arrow,  173 
by  bees,  172 
by  hornets,  172 
ivy,  173 
by  lizards,  172 
by  scorpions,  172 


Poisoning  by  snake-bites,  171 
by  spiders,  172 
by  wasps,  172 
Poliomyelitis,  anterior,  477 
Polycystic  kidney,  909 
Poly((yt hernia,  29 
Polyhydronephrcjsis,  972 
Polymastia,  755 
Polymazia,  755 
Polv]),  mucous,  283 
PolyiH,  270 
laryngeal,  OSO 
nasal,  077 
rectal,  885 
P<)ly|)oi(l  degeneration,  078 
P()|')lit.-al  artery,  ligation  of,  360 
Porencephalon,  580 

in  rickets,  1()2 
Port- wine  mark,  277 
Posthitis,  1005 
Postgonorrheal  arthritis,  152,  392 

of  jaw,  6()7 
Postoperative  biliary  fistulas,  917 
cystitis,  985 
hernia,  896 

treatment  of,  909 
mania,  175 
Pott's  disease,  444 
causes  of,  445 
complications  of,  440 
diagnosis  of,  448 
laminectomy  in,  637 
prognosis  of,  448 
sequelte  of,  446 
symptoms  of,  445 
treatment  of,  448 
by  apparatus,  448 
bj'  forcible  reduction,  450 
Powell's  electric  saw,  588 
Prepatellar  bursse,  263 
Procidentia,  881 

treatment  of,  882 
Proctitis,  875 

gonorrheal,  159,  875 
symptoms  of,  875 
treatment  of,  875 
Prof  eta's  law  in  syphilis,  139 
Prolapse  of  rectum,  881 

treatment  of,  882 
Prolapsus  cerebri,  566 
prognosis  of,  566 
treatment  of,  566 
Pronated  foot,  468 
Propagated  thrombosis,  36 
Properitoneal  hernia,  891,  897 
Prostate,  absence  of,  994 
cancer  of,  1002 
hypertrophy  of,  ,995 
diagnosis  of,  996 
symptoms  of,  997 
treatment  of,  998 
inflammation  of,  994 
operations  on,  998 
Prostatectomy,  perineal,  999 

sui)rapubic,  998 
Prostatic  adenoma,  285 
Prostatitis,  150 
acute,  994 
chronic,  994 

treatnient  of,  995 
Prostatorrhea,  994,  1022 
Protozoa,  56 
Pruritus  ani,  878 

treatment  of,  879 
Psammoma,  271 
Pseudocysts,  262 
Pseudoleukemia,  32 
Psoas  abscess,  114 
Ptosis,  604 

Puerperal  state,  secondary  infec- 
tion in,  169 
Punctured  wounds,  213 
Pus,  absorjition  of,  62 

bacterial  determination  of,  as  an 

indication  to  treatment,  57 
blastomycetic,  56 


1066 


INDEX 


Pus, clinical  characteristics  of , from 
different  agencies,  57 

encapsulation  of,  62 

formation,  bacteria  of,  51 

facultative  pyogenic,  53 
obligate  pyogenic,  52 

ichorous,  59 

pointing  of,  58 

sanious,  59 

subfacial,  collection  of,  59 

subperiosteal,  collection  of,  591 
Pustular  syphilides,  132 
Pustulocrustaceous  syphilides,  132 
Putrid  fever  of  Gaspard,  81 
Pvarthrosis,  metastatic  forms  of, 
384 

treatment  of,  399 
Pvi'lcctoniv,  976 
Pyelitis,  956 

symptoms  of,  957 

treatment  of,  957 
Pyelonephritis,  956 

symptoms  of,  957 

treatment  of,  957 
Pyemia,  90 

chronic,  92 

complications  of,  91 

idiopathic,  91 

postmortem  appearances  of,  92 

prognosis  of,  92 

pyarthrosis  of,  92 

spontaneous,  91 

symptoms  of,  91 

treatment  of,  92 

wound, 92 
Pvl(  phlebitis,  362,  918 
Pylorect.nny,  813 
Pyloric    stenosis,    operations    for, 

808 
Pylorodiosis,  808 
Pyloroplasty,  808 

Finney's,  810 
Pylorus   stenosis  of,  799 
symptoms  of,  799 
treatment  of,  799 
Pyogenic   organisms,    facultative, 
53 
obligate,  52 
Pyonephrosis,  961,  972 

treatment  of,  961 
Pyopericardium,  336 
Pyorrhea  alveolaris,  664 
Pyosalpinx,     diagnosis    of,     from 

appendicitis,  858 
Pyothorax,  736 


Racemose  aneurysm,  344 
Rachitis,  161.     ,See  Rickets. 
Radesyge,  308 
Radial  artery,  ligation  of,  350 

nerve,  operations  on,  623 
Radicular  odontomas,  281 
Radium  in  treatment  of  cancer, 

296 
Radius  and  ulna,  fractures  of,  503 

dislocations  of,  536 

fractures  of,  502 
treatment  of,  504 

lower  end  of,  fractures  of,  503 
Railway  spine,  628 
Ranula",  261,  660 
Rauschbrand,  bacillus  of,  55 
Raynaud's  disease,  74 
Rectal  fistulas,  880 

treatment  of,  880 
Rectovaginal  fistula,  839 
Rectum,  abscesses  around,  879 
treatment  of,  879 

adenoma  of,  885 

atresia  of,  872 

cancer  of,  886 

treatment  of,  887 

congenital  defects  of,  872 


Rectum,  ether  narcosis  by,  196 
examination  of,  871 
fistula  of,  880 

treatment  of,  880 
foreign  bodies  in,  874 
imperforation  of,  872 
inflammation  of,  875 
injuries  of,  874 
invagination  of,  881 
treatment  of,  882 
malloruKitions  of,  872 
phlegmonous  affections  of,  879 

treatment  of,  879 
polypi  of,  885 
prolapse  of,  881 

treatment  of,  882 
strictures  of,  877 

treatment  of,  877 
syphilis  of,  138 
tumors  of,  885 
ulcers  of,  876 
catarrhal,  876 
chancroidal,  876 
symptoms  of,  877 
syphilitic,  876 
treatment  of,  877 
tuberculous,  877 
typhoid,  877 
Reef-knot,  241 
Regnoli-Billroth     operation       on 

tongue,  661 
Reindeer  tendons,  sterilization  of, 

248 
Renal  abscess,  957 
actinomycosis,  964 
calculus,  965 

diagnosis  of,  965 
s3'mptoms  of,  965 
treatment  of,  966 
colic,  964 

treatment  of,  964 
syphilis,  964 
tuberculosis,  961 
Repair,  process  of,  67 

cells  in,  embryonal,  67 
epithelioid,  67 
formative,  67 
giant,  68 
granulation  tis.sue  in,  67 
karyokinetic  activity  in,  68 
scar  formation  in,  69 
of  wounds,  215 

by  first  intention,  215 
granulation  tissue  in,  215 
by  si'cond  intention,  216 
by  third  intention,  216 
Resection    of    esophagus,    trans- 
thoracic, 745 
of  nerves,  613 
Respiratorv   passages,    burns    of, 
675" 
foreign  bodies  in,  672 
fractures  of,  675 
infection  through,  49 
injuries  of,  675 
nialformation  of,  671 

treatment  of,  671 
wounds  of,  gunshot,  675 
Retention  cysts,  259 

of  urine,  982 
Retina,  detachment  of,  604 

glioma  of,  595 
Retromainmary  abscess,  757 
Retro])erit(.nca'l  hernia,  891,  897 
lletropharvngcal  abscess,  114,  682 
Rhabdomyoma,  274,  277 
Rheumatism,  gonorrheal,  152 
Rheumatoid  arthritis,  387 
Rhinoliths,  672 
Rhinophyma,  313,  641 

treatment  of,  314 
Rhinoplasty,  644 
Rhinoscleroma,  308,  641 

bacillus  of,  54 
Ribs,  dislocations  of,  529 
fractures  of,  491 


Ribs,  fractures  of,  symptoms  of, 
492 
treatment  of,  492 

malformations  of,  718 
Rice-grain  bodies,  322 
Richet's   operation   for   blepharo- 

plasty,  603 
Richter's  hernia,  898 
Rickets,  161 

causes  of,  161 

cerebral  conditions  in,  162 

congenital,  161 

cranial,  547 

deformities  of  bones  in,  162 

fetal,  161,  433 

hytlrocephalus  in,  162 

laryngismus  stridulus  in,  162 

pathology  of,  161 

porencephalon  in,  162 

symptoms  of,  162 

treatment  of,  162 
Rider's  bone,  218   331 
Riedel's  lobe,  910 
Riggs'  disease,  664 
Rodent  ulcers,  66,  67,  288 

of  auricle,  606 
Roe's  operation  for  pug-nose,  645 
"Rose,  the,"  93.     Sec  Krysipelas. 
Roseola  syphilitica,  131 
Rotz,  105"      See  Glanders. 
Rovuid-cell  sarcoma,  273 
Rovsing's   operation   for  gastrop- 

tosis,  813 
Rubber  tissue,  sterilization  of,  248 
Rubefacients,  183 
Ruptures  of  bladder,  981 

of  diaphragm,  721    753 

of  esophagus,  741 

of  heart,  336   732 

of  lung,  725 

of  muscles,  329 

of  pleura,  724 

of  stomach,  794 

of  trachea,  699 

of  veins,  363 


S 


S,\b.\nejeff's  method  of  amputa- 
tion of  knee,  1044 
Sacculated  aneurysm,  339,  342 
Sacro-iliac  disease,  452 
treatment  of,  452 
Saddle-nose,  489,  039,  644 
Salivary  calculi,  651 

ducts,  fistulas  of,  649 
foreign  bodies  in,  648 

glands,  inflammation  of,  649 
tumors  of,  650 
Saphenous    vein,    internal,    extir- 
pation of,  366 
Sapreinia,  86 

chronic,  87 

treatment  of,  87 

symptoms  of,  86 

treatment  of,  87 
Sarcoma,  273 

of  abdominal  wall,  784 

alveolar,  274 

angiosarcoma,  275 

of  bone,  441 

treatment  of,  441 

chondrosarcoma,  274 

cylindroma,  275 

diagnosis  of,    from    carcinoma, 
293 

endothelioma,  274 

general  characteristics  of,  275 

giant-cell,  274 

of  jaw,  668 

of  kidney,  969 

of  larynx,  687 

of  liver,  914 

of  lungs,  732 

melanosarcoma,  275 


INDEX 


1067 


Sarcoma,  luycloid,  274 

of  onicnl  iitii,  935 

of  orbit,  .VXi 

ostcosarfoiiKi,  274 

of  pancreas,  '.).'J3 

roiiiid-ccll,  272 

of  .skin,  :U() 

spindlc-ccll,  273 

of  spleen,  043 

of  llioiax.  730 

of  thyroid,  712 
Sardonic  ^rin,  11)1) 
Sayre's  incision  in  excision  of  liiji 

411 
Scabbard  trachea,  713 
Scalds,  3(H) 

treatment  of,  .301 
Scalp,  cellulitis  of,  54.') 

erysi])elas  of,  545 

heniatoma  of,  traumatic,  21 S 

pneumatocele  of,  .54.5 
treatment  of,  54(5 

tumors  of,  .546 
ac<iuired,  .540 
benign,  546 
congenital,  546 
gaseous,  545 
malignant,  546 
Scapula,  fractures  of,  494 
acromion  process,  494 
coracoid  process,  495 
surgical  neck,  495 
Scarlatina,  secondary  infection  in 

167 
Sciatic  nerve,  operations  on,  623 
Scleroderma,  313 

pathology  of,  313 

treatment  of,  313 
Sclerosis,  cerebral,  in  rickets,  162 
Scoliosis,  459 

etiology  of,  460 
Scopolamine,  205 
Scorbutus,  infantile,  161 
Scorpions,  poisoning  by,  172 
Scrofula  of  joints,  393 
Scrofuloderma,  306 
Scrotal  hernia,  895 
Scrotum,  elephantiasis  of,  371 

shortening  of,  1021 
Scurvy,  160 

pathology  of,  160 

symptoms  of,  160 

treatment  of,  160 
Sebaceous  adenomas,  285 

cysts,  285 
of  skin,  310 

horns,  283 
Seborrheic  warts,  312 
S^dillot's    operation    on    tongue, 

662 
Semilunar  cartilages,  dislocations 

of,  543 
Seminal  vesiculitis,  1021 
Septicemia,  87 

complications  of,  88 

cryptogenetic,  87 

eruptions  in,  88 

gangrenous,  108 

leukocytosis  in,  88 

postmortem  evidences  of,  SS 

spontaneous,  87 

symptoms  of,  88 

treatment  of,  89 

ulcerative  endocarditis  in,  88 
Septicopyemia,  90 
Serjuestration  dermoids,  265 
Sequestrum    formation    in    bone, 
429 
treatment  of,  429 
Serous  exudates,  23 
Seton,  counterirritation  bv,  184 
Shingles,  728 
Shock,  177 

diagnosis  of,  179 

from  gunshot  wounds,  223 

symjitoms  of,  179 


Shock,  treatment  of,  179 

types  of,  179 
Shouhler,     amputation     of,     1032 
excision  of,  409 
-joint,  dislocations  of,  530 

anterior,  .530 

diagnosis  of,  .532 

downward,  530 

jwsterior,  530 

subclavicidar,  531 

subcoracoitl,  .531 

subglenoid,  .5.31 

sul)spinous,  .5.32 

svmptoms  of,  .5.32 

treatment  of,  .532 

Kocher's  method,  .5.33 

upward,  530 
spica  bandage  of,  190 
Sialoadcnitis,  649 
Sialolithiasis,  651 
Sigmoidopexy,  870 
Silk,  sterilization  of,  248 
Silkworm    gut,    sterilization  of, 

248 
Sincipital  hydrencephalocele,  577 

meningocele,  .577 
Singer's  nodes,  686 
Sinus,  63 

accessory     craniofacial,    opera 

tions  on,  608 
causes  of,  63 

congenital,  63 

foreign  bodies,  63 

necrosed  material,  63 

preexisting  abscess,  63 

traumatic  destruction  of  tis- 
sues, 63 
ethmoidal,  operations  on,  01 0 
frontal,  operations  on,  609 
intracranial,  injuries  of,  56.3 
maxillary,  operations  on,  611 
phlebitis,  362,  571 

symptoms  of,  571 
pilonidal,  635 

sphenoidal,  operations  on,  610 
thrombosis,  570 

diagnosis  of,  570 

prognosis  of,  571 

symptoms  of,  570 

treatment  of,  573 
treatment  of,  63 
Skin,  actinomycosis  of,  308 
appendages  of,  317 
carcinoma  of,  315 
cylindroma  of,  315 
cysts  of,  310 

treatment  of,    310 
epithelioma  of,  315 

diagnosis  of,  315 

treatment  of,  315 
grafting,  187 

1'hiersch  method,  188 
hypertrophies  of,  311 
infection  through,  48 
infections  of,  acute,  304 

chronic,  306 
keratosis  of,  314 

treatment  of,  314 
Ij^mphangioma  of,  315 

treatment  of,  315 
melanoma  of,  316 

treatment  of,  317 
sarcoma  of,  316 
syphilis  of,  130,  308 
'  tertiary,  133 
tuberculosis  of,  11.5,  306 
tumors  of,  benign,  311 

malignant,  315 
vascular  growth  of,  314 

treatment  of,  314 
xanthoma  of,  314 
Skull,  acute  osteomyelitis  of,  54S 

periostitis  of,  .548 
aplasia  cranii,  ,547 
atrophy  of,  547 

senile,  547 


Skull,  bones  of,  incomplete  forma- 
tion of,  .547 
congenital  conditions  of,  .547 
eraniotabes,  .547 
depression  of,  549 
diseases  of,   non-inflanmiatory, 

547 
fractures  of,  549,  .552 
of  base,  .5.56 

<liagnosis  of,  5.57 
prognosis  of,  .557 
treatment  of,  .558 
of  vertex,  .5.52 

comminuted,  552 
diagnosis  of,  .5.54 
gmishot,  .553 
splintered,  .552 
treatment  of,  555 
necrosis  of,  549 
osteoma  of,  .548 
rachitis  of,  162 
surgical  anatomy  of,  550 
wounds  of,  incised,  552 
penetrating,  552 
Sloughing  ulcers,  66 
Smith,   Stephen,   method   of   am- 
putation of  knee,  1043 
Snake-bites,  171 

symptoms  of,  171 
treatment  of,  171 
Soft  palate,  malformations  of,  671 
Somnoform,  199 
Sounds,  bulbous,  15.5 
Spasmotoxin,  98 
Specific  irritants  in  inflammation, 

45 
Spermatic  cord,  encysted   hydro- 
cele of,  1019 
malignant  diseases  of,  1019 
spermatocele,  1019 
syphilis  of,  1019 
tuberculosis  of,  1019 
varicocele,  1019 
treatment  of,  1021 
Spermatocele,  1019 
Spermatorrhea,  1022 
Sphacelus,  73.      See  Gangrene. 
Sphenoidal  sinus,    operations    on, 

610 
Sphygmomanometer,  u.se  of,  177 
Spica  bandage  of  groin,  189 

of  shoulder,  190 
Spiders,  poisoning  by,  172 
Spina  bifida,  625 
occulta,  626 
treatment  of,  626 
Spinal   column,    diseases   and   in- 
juries of,  625 
sprains  of,  628 

treatment  of,  629 
cord,  hemorrhages  of,  625,  634 
injuries  of,  difTerential  diag- 
nosis of,  635 
syphilis  of,  138 
tumors  of,  621 
diagnosis  of,  622 
symptoms  of,  621 
treatment  of,  622 
wounds  of,  gunshot,  230,  624 
penetrating,  624 
meningocele,  625 
Spindle-cell  sarcoma,  274 
Spine,  arthritis  deformans  of,  388 
cancer  of,  462 
caries  of,  444 
concus.sion  of,  628 

treatment  of,  629 
curvatures   of,   forward,   461 
rotary,  lateral,  459 
etiology  of,  460 
prognosis  of,  460 
treatment  of,  460 
cysts  of,  627 
dislocation  of,  63 1 

treatment  of,  632 
fractures  of,  629 


10G8 


INDEX 


Spine,  fractures  of,    diagnosis  of, 
629 
injuries  of,  629 

differential  diagnosis  of,  635 
kyphosis  of,  444 
loidosis  of,  461 
operations  on,  636 
Pott's  disease  of,  444 
causes  of,  445 
complications  of,  446 
diagnosis  of,  448 
prognosis  of,  448 
sequela?  of,  446 
symptoms  of,  445 
treatment  of,  448 
by  apparatus,  448 
by  forcible  contraction, 
"450 
spondylitis  of,  444 

traumatic,  462 
spondylolisthesis,  462 
diagnosis  of,  463 
symptoms  of,  462 
treatment  of,  463 
tuberculosis  of,  424 
typhoid,  462 
wounds  of,  gunshot,  624 
penetrating,  624 
Spirocha^ta  pallida,  123 
Splay-foot,  468 
Spleen,  abscess  of,  941 
anomalies  of,  940 
carcinoma  of,  943 
cysts  of,  943 
displacements  of,  942 
gangrene  of,  941 
hypertrophies  of,  941 
injuries  of,  941 
neoplasms  of,  943 
operations  on,  943 
splenectomy,  943 
splenopexy,  942 
splenotomy,  943 
sarcoma  of,  943 
syphilis  of,  138 
wounds  of,  233 
Splenectomy,  943 
Splenic  anemia,  31 

fever,  106.     See  Anthrax. 
Sijlciiitis,  suppurative,  941 
Splfnomcdiillary  leukemia,  32 
Splenomegaly,  942 
Splenopexy,  942 
Splenotomy,  943 
Spondylitis,  444 

suppurative,     of     abdominal 

wall,  783 
traumatic,  462 
Spondylolisthesis,  462 
diagnosis  of,  463 
s\'^mptoms  of,  -102 
treatmetit  of,  463 
Sponges,  st<>rilization  of,  247 
Sprains  of  joints,  380 
symptoms  of,  380 
treatment  of,  380 
of  muscles,  329 
of  spinal  column,  628 
treatment  of,  629 
Sprengel's  deformity,  458 
Staffordshire  knot,  241 
Staphylococcus    pyogenes    albus 
52 
aureus,  52 
epidermidis,  52 
Staphvlouia,  598 
Staphyiorrliaiihy,  654 
Status  l\'mphaticus,  163 
diagnosis  of,  164 
treatment  of,  165 
thymicus,  163 
Steatomas,  310 
Stenosis,   pyloric,   operations   for 

808  "     . 

Stenson's  duct,  cysts  of,  641 
Stercoremia,  83 


Sterilization  by  boiling  water,  244 
of  dressings,  247 
by  formalin,  244 
fractional,  244 
of  hands,  245 
by  heat,  243 
of  instruments,  246 
by  mustard  flour,  245 
of  sponges,  247 
of  suture  materials,  247 
Sternum,  dislocations  of,  528 
fractures  of,  491 
symptoms  of,  492 
treat  tneiit  of,  492 
maHonnations  of,  718 
r.tlllicidiuni,  9S2 
otokes'  method  of  amputation  of 

thigh,  1043 
Stomach,  anastomosis  of,  816 
cancer  of,  801 

symptoms  of,  802 
treatment  of,  803 
dilatation  of,  acute,  795 
symptoms  of,  796 
treatment  of,  796 
chronic,  796 
operations  for,  811 
fistulas  of,  SOI 
foreign  bodies  in,  794 
operations  for,  806 
symptoms  of,  794 
treatment  of,  794 
hour-gla.ss,  793 
injuries  of,  793 
leather-bottle,  793 
malformations  of,  accpiired,  793 

congenital,  793 
nerves  of,  793 
operations  on,  805 
gastrectomy,  813 
gastro-enterostomy,  811,  817 
gastrojejunostomy,  816 
gastrorrhaphy,  806 
gastrostomy,  806 
gastrotomy,  806 
j)ylorect()my,  813 
pylorus  of,  stenosis  of,  799 
symptoms  of,  799 
treatment  of,  799 
rupture  of,  794 
syphilis  of,  795 
tetany  of,  798 
tuberculosis  of,  795 
tumors  of,  801 
ulcer  of,  799 

symptoms  of,  800 
treatment  of,  800 
wall  of,  inflammation  of,  804 
wounds  of,  794 

penetrating,    operations    for, 
805 
Stomatitis,  657 

gangrenous,  75,  658 
ulcerative,  657 
Stovaine,  207 
Strains  of  muscles,  329 
Strangulated  hernia,  diagnosis  of, 
from  appendicitis,  858 
intestinal    obstruction    from 
829 
Strawberry  growths,  367 
Streptococcus  erysipelatis,  52 

pyogenes,  53 
Streptothrix  madura;,  100 
Stretching  of  nerves,  612 
Stricture  of  biliary  ducts,  921 
of  esophagus,  742 
of  intestines,  large,  870 
obstruction  from,  832 
symptoms  of,  828 
treatment  of,  828 
small,  827 
of  larynx,  684 

symptoms  of,  684 
treatment  of,  684 
of  rectum,  877 


Stricture  of  rectum,  treatment  of, 
877 
of  ureter,  973 
of  urethra,  1011 
Struma,  283,  712 
fibrosa,  284 

parenchymatosa  nodosa,  284 
Strumitis,  717 
Stye,  600 
Stypticin,  235 

Styptics    for    control    of    hemor- 
rhage, 235 
Subclavian  arterv,   aneurvsm  of, 
345 
ligation  of,  354 
Subclavicular  dishjcations,  531 
Subcoracoid  dislocations,  531 
Subcutaneous  tubercle,  painful,  of 

skin,  313 
Subdiaphragmatic  abscess,  753 

treatment  of,  754 
Subdural  heniorrliagi's,  564 
Subglenoid  dislocations,  531 
Subhyoid  pliaryngotomy,  664 
Subluxation,    524.     See    Disloca- 
tions. 
Submaxillary    angina,  infectious, 

703 
Subphrenic  abscess,  753 

treatment  of,  754 
Subspinous  dislocations,  532 
Subungual  exostoses,  272 
Sunburn,  303 
Suppression  of  urine,  982 
Suppuration,  57 
Supracondyloid      amjiutations, 
1043 
fracture  of  humerus,  497 
Supra-orbital  nerve    operations 

on,  613 
Suprapubic  prostatectomy,  998 
Suprarenal  epithelioma,  292 
Surgical  diseases,  79 

common    to  man    and    ani- 
mals, 97 
fever,  85 
cause  of,  85 
diagnosis  of,  from  poisoning 

by  drugs,  85 
erysipelas,  93 
pyemia,  90 
sapremia,  86 
chronic,  87 
septicemia,  87 

cryptogenetic,  87 
spontaneous,  87 
methods,  177 
principles,  177 
sequela;  of  disease,  166 
cholera,  166 
dental  caries,  169 
diphtheria,  168 
dysentery,  166 
endocarditis,  169 
gonorrhea,  169 
influenza,  167 
measles,  167 
mumps,  168 
pneumonia,  167 
puerperal  state,  169 
scarlatina,  167 
syphilis,  169 
typhoid  fever,  167 
variola,  169 
Sutures,  240 

Billroth 's  chain-stitch,  241 
of  bloodvessels,  349 
end-to-end,  350 
lateral,  349 
continuous,  241 
of  heart  wounds,  335  (note) 
interrupted,  241 
of  intestines,  840 
modified  plate,  241 

quill,  241 
of  nerves,  612 


INDEX 


1  ()(■)<) 


Sutures,  ri'iiiuval  of,  'J42 
of  (ciidoiis,  .'{'J-l 
tninsfixioii,  "Jl  1 
Swfllinf;,  iiciilf,  -"2 

cliroiiic,  122 
Sylvester '.><    inetlioil    of    iiiliruiii 

i-espiratioii,  204 
Syinl)l<-i)li;ir(>ii,  W.i 
Sympiit heeloiiiy,  714 
Syiiipiithetic  ojjht liiilriiitiH,  .V)r> 

treat ineiil  of,  5'M 
S>iiclieili:i,  (').'<!' 
Syiicytioma,  2'.I2 
Syii()\ial  cysts,  2(i2 
Synovitis,  'AH2 
acute,  .S83 

treatment  of,  3S3 
chronic,  :?S() 

treatment  of,  386 
dry,  383 
(lonorrheal,  385 
of  jaws,  aciite,  667 
]nirulent,  383 

syn>i)ton»s  of,  383 
treatment  of,  385 
treatment  of,  385 
Syphili.ies,  130 
pustular,  132 
ecthyma,  132 
rupia,  132 
])iistulocrustaceous,  132 
S(|uamous,  131 
Syphilis,  122 

of  abilominal  wall,  783 
of  axilla,  751 
of  bones,  135,  426 
of  brain,  138 
of  breast,  759 
of  burste,  136 

of  cervical  lymph  nodes,  705 
chancre,  126 
bubo,  128 
diagnosis    of,    from    ci)itheli- 

oma,  127 
dry  papule,  126 
extragenital,  127 
Hunterian,  127 
lyn)]ihatic     invohcment     in, 
■   128 

mixed,  127 
pathology  of,  128 
superficial  erosion,  127 
treatment  of,  128 
in  children,  139 
Colles'  law,  139 
Profeta's  law,  139 
of  colon,  869 
constitutional,  129,  132 
of  cornea,  137 
of  corpora  cavernosa,  138 
of  ear,  137 
eruptions  of,  130 
papular,  131 
lenticulo,  131 
miliary,  131 
pustular,  132 
pustvilocrustaceous,  1 32 
evolution  of,  123 
of  eye,  136,  597 
of  face,  640 
of  genitalia,  138 
gumma  of,  133 
Hutchinson's  teeth  in,  140 
induration  of,  126 
initial  lesion  in,  126 
of  intestines,  827 
of  joints,  135 
of  kidneys,  138,  964 
of  larynx,  138,  686 
treatment  of,  686 
lesions  of,  124 
of  liver,  138,  914 
of  lymph  nodes,  376 
manner  of  contagion  of,  123 
of  mesentery,  939 
of  mouth,  657 


S\pliilis     of  mu<'oiis    memliraric 
1  32 

of  muscles,  136,  .331 

of  nervous  system,  138 

of  orbit,  597 

of  oropharynx,  137 

primary  lesion,  location  of,  1: 

of  rectvnn,  138,  876 

secondary  infi-ction  in,  169 
lesion,"  129 

secretions  of,  124 

of  skin,  130,  308 

of  spermatic  cord,  1019 

of  spinal  cord,  138 

of  spleen,  138 

of  stomach,  795 

teetli  in,  140 

of  tentloiis,  136 

tertiary,  132 
of  skin,  133 

of  testicle,  138,  1016 

of  tongue,  659 

of  tonsils,  662 

treatment  of,  140 

ulcer  of,  symptoms  of,  125 

of  uvula,  683 

of  vascular  system,  135 

virus  f)f,  123 
Syphilitic  arthritis,  385 
"bubo,  128 

gumma  of  lung,  732 
Syphilodermas,  130 
Syringomyelia,  621 
Syringomyelocele,  263,  626 


Tabes  mesenterica,  939 
Taenia  solium,  310 
Tagliacozzi's    method    of     rhino- 
plasty, 644 
Talipes",  465 
calcaneus,  471 
eciuinoyarus,  466 

treatment  of,  466 
cquinus,  470 
causes  of,  470 
treatment  of,  471 
yalgus,  468 

etiology  of,  468 
treatment  of,  4(j9 
Talma's   operation   on  omentum, 

936 
Tapping,  paracentesis  by,  185 
Tarantula,  poisoning  bj',  1 72 
Tarsectomy,  467 
Tartar  on  teeth,  657 
Tattoo  marks,  318,  720 
Taxis,  899 
T-bandage,  191 
Tcale's  method  of  amputation  of 

foot,  1042 
Teeth,  caries  of,  657,  664 
treatment  of,  665 
cysts  of,  666 
eruption  of,  faulty,  665 
extraction  of,  666 
accidents  from,  666 
instruments  recjuired,  666 
malformations  of,  652 
odontoma  of,  665 
re-implantation  of,  667 
tartar  of,  657 
tumors  of,  665 
Telangiectasis,  277 
Temporal     artery,    ligation      of, 

352 
Temporomaxillary  joint,  ankylo- 
sis of,  667 
dislocation  of,  667 
postgonorrheal    arthritis    of, 

667 
resection  of,  668 
synovitis  of,  acute,  667 
Temporosphenoidal  abscess,  569 


TeiidoM    sheaths,    tuberculosis   of, 

118 
Tendons,  dislocation  of,  330 
grafting  of,  324 
itijuries  of,  21  8 
ligation  of,  326 
siwgical  diseases    of,  321 
suttu-e  of,  324 
syi)hilis  of,  136 
traiis|)hintat  ion  of,  324 
Tendoplasty,  322 
Tendosj'novitis,  321 
chronic,  322 

treatment  of,  322 
Kup])urative,  321 
treatment  of,  321 
Tendovaginitis,     gonococcus     of, 

331 
Tenorrhaphy,  324 
Tenotomy,  327 
Teratomas,  2()8 
embrvonal  adenosarcoma,  2(>8 
of  thyroid,  712 
Tertiary  syphilis,   132 
Testicle,  absence  of,  1015 
atrophy  of,  1015 
cancer  of,  1017 
chondroma  of,  1017 
congenital      abnormalities      of, 

1014 
contusions  of,  1015 
cystic  degeneration  of,  2(;0 
cysts  of,  1016 
epididymitis,  1016 

treatment  of,  1017 
fibroma  of,  1017 
gonorrhea  of,  151 
hematoma  of,  1015 
hydrocele  of,  encysted,  260 
injuries  to,  1015 
lipoma  of,  1017 
orchitis,  1017 

treatment  of,  1017 
retained,  1014 

treatment  of,  1014 
syphilis  of,  138,  1016 
tuberculosis  of,  118,  1015 

treatment  of,  1016 
tumors  of,  1017 
Tetanin,  98 
Tetanotoxin,  98 
Tetanus,  97 
cephalicus,  99 
chronic,  100 
death  in,  100 
diagnosis  of,  101 

from  hysteria,  101 
etiology  of,  97 
hydrophobicus,  99 
of  newborn,  97,  99 
parasitic  nature  of,  98 
postmortem     appearances     in, 

100 
prognosis  of,  100 
toy-pistol,  97 
treatment  of,  101 
Tetany,  bacillus  of,  54 

gastric,  798 
Thecitis,  328 
Thiersch  method  of  skin  grafting, 

188 
Thigh,  amputation  of,  1043 
above  knee,  1044 
fracture  of,  509 
diagnosis  of,  51 1 
prognosis  of,  511 
treatment  of,  512 
Thoracentesis,  736,  746 
Thoracic  duct,  injuries  to,  725 
treatment  of,  726 
viscera,  injuries  to,  724 
walls,  diseases  of,  726 
Thoracoplastic  operations,  748 
Thoracotomy,  747 
drainage  in,  747 
irrigation  in,  747 


1070 


INDEX 


Thorax,  ac-tiiioinycosis  of,  729 
carcinoma  of,  730 
cliomlroma  of,  730 
fibroma  of,  729 
{jramiloma  of,  729 
injuries  to,  721 
lipoma  of,  729 
malformations  of,  71S,  719 
operations  on,  746 
osteoma  of,  730 
sarcoma  of,  730 
tumors  of,  729 

treatment  of,  730 
wounds  of,  gunshot,  230 
Thromho-arteritis,  91 
Thrombophlebitis,  37,  90 
Thrombosis,  34 
annular,  35 
causes  of,  35 
following    abdominal    o|)era- 

tions,  784 
gangrene  from,  73 
infective,  3fi,  570 
niarasmic,  36,  570 
mechanical,  36 
of  mesenteric  vessels,  938 
obstructive,  36 
parietal,  35 
primary,  35 
propagated,  36 
sinus,  570 

diagnosis  of,  571 
prognosis  of,  571 
symptoms  of,  570 
treatment  of,  573 
traumatic,  36 
valvular,  35 
Thrombus,  calcification  of,  36 
decolorization  of,  36 
organization  of,  36 
softening  of,  37 
Tlirush,  o'idium  albicans  of,  657 
Thumb,  amputation  of,  1029 
Tliymic  asthma,  163 
Thymus,  hypertrophy  of,  717,  751 

inflammation  of,  717 
Thyroglossal  duct,  710 
Thyrohyoid  cysts  of  neck,  707 
Thvroid  arteries,  inferior,  ligation 
of,  353 
body,  adenoma  of,  712 
bronchocele,  712 
congenital  affections  of,  710 
endothelioma  of,  712 
goitre  of,  712 

hypertrophy   of,    acute    idio- 
pathic, 711 
intra-uterine,  711 
sarcoma  of,  712 
struma  of,  712 
teratomas  of,  712 
tumors  of,  711 
dermoids,  267 
Thyroidectomy,  715 
Thvroidism,  82 
Thyroiditis,  711 
Thvroids,  accessorv,  710 
Thyrotomy,  674,  688 
Tibia,  dislocations  of,  543 
fractures  of,  518 
treatment  of,  521 
Tibial  arteries,   ligation  of,  360 

nerve,  operations  on,  623 
Tibiotarsal  amputations,  1037 
Tic  douloureux,  640 
Toe-nail,  ingrowing,  318 
Toes,  amputation  of,  1034 
hammer,  321 

§eatment  of,  321 
e,  absence  of,  652 
lonivcosis  of,  659 
bifid,  652 

cysts  of,  retention,  659 
epithelioma  of,  660 
treatment  of,  660 
gangrene  of,  659 


Tongue,  inflammation  of,  658 
leukoplakia  of,  t)59 
treatment  of,  659 
macroglossia  of,  660 
malformations  of,  652 
nevi  of,  659 
operations  on,  661 
Kocher's,  661 
I.angenbeck's,  662 
Regnoli-Billroth's,  661 
Sedillot's,  662 
Whitehead's,  661 
papilloma  of,  659 
ranula  of,  660 
svphilis  of,  659 
-tie,  652 

tuberculosis  of,  659 
tumors  of,  659 
Tonometer,  use  of,  177 
Tonsillotomy,  663 
Tonsils,  absence  of,  662 
calculi  of,  663 
enlarged,  662 
foreign  bodies  in,  663 
hypertrophy,  662 
infection  through,  49 
syphilis  of,  662 
tuberculosis  of,  662 
tumors  of,  664 
Torsion, control  of  hemorrhage  bv 
236 
of  omentum,  935 
Torticollis,  457 
diagnosis  of,  458 
pathology  of,  457 
treatment  of,  458 
Tourniquet  for  control  of  hemor- 
rhage, 234 
Toxic  antiseptics,  175 
Toj'-pistol  tetanus,  97 
Trachea,  operations  on,  691 
rupture  of,  699 
scabbard,  713 
tumors  of,  687 
wounds  of,  699 
Tracheal  tugging,  345 
Tracheocele,  707 
Tracheotomv,  691 
Trachoma,  599 
Transfixion  suture,  241 
Transfusion  of  blood,  185 
Transhyoid  pharyngotomy,  664 
Transplantation  of  bone,  431 

of  tendons,  324 
Transudates,  23 
Trauma  as  cause  of  tumor,  255 
Traumapnea,  724 
Traumatic  abscess  of  brain,  567 
erysipelas,  93,  94 
fever,  85.      See  Surgical  fever, 
hematoma  of  scalp,  218 
hernia,  890 
insanitv,  surgical  treatment  of, 

582  ' 
intraventricular       hemorrhage, 

564 
mania,  175 
neuroma,  280 
othematoma,  605 
peritonitis,  786 
spondylitis,  462 
thrombosis,  36 
Treatment  of  abscess,  60 
of  bone,  426 
of  brain,  573 
of  hver,  912 
of  rectum,  879 
of  actinomjxosis,  110 
of  acute  catarrh  of  biliary  pas- 
sages, 918 
cholecystitis,  921 
pancreatitis,  948 
after  abdominal  operations,  777 
of  adenoids  of  pharynx,  680 
of     aneurvsm     of     abdominal 
aorta,  346 


Treatment    of  angioma  of    veins, 

367 
of  ankvlosis,  405 
of  anthrax,  107 
of  arthritis,  chronic,  38f) 

deformans,  389 

tuberculous,  398 
of  atrophy  of  muscles,  332 
of  biliarv  calculi,  926 
of  boils," 304 
of  bow-leg,  465 
of  bunions,  311 
of  burns,  301 

«-ray,  304 
of  carbuncle,  305 
of  carcinoma,  295 

of  breast,  763 

of  intestines,  828 

of  rectum,  887 

of  stomach,  803 
of  cartliospasm,  798 
of  caries  of  hip,  454 
of  cerebral  palsies,  478 
of    cervical    Ivmph-node    affec- 
tions, 706 
of  chancre,  128 
of  chancroid,  145 
of  cholelithiasis,  926 
of  chondroma,  272 
of    chronic    affections    of    pan- 
creas, 951 

pancreatitis,  950 

prostatitis,  995 

sapremia,  87 

tendosynovitis,  322 
of  cold  abscess,  114 

peri-articvilar,  399 
of  compression  of  brain,  562 
of  concussion  of  brain,  559 

of  chest,  722 

of  spine,  629 
of  congenital  anomalies  of  neck, 
698 

club-foot,  466 

dislocation  of  hip,  474 
of  congestion,  23 
of  contraction  of  fascia',  320 

of  muscles,  332 
of  contusions,  212 

of  brain,  560 

of  chest,  722 
of  cryptorchidism,  1014 
of  curvature  of  spine,  460 
of  cutaneous  horns,  311 
of  cystitis,  985 
of  cvsts  of  pancreas,  952 

of  skin,  310 
of  dacryocystitis,  600 
of  delirium  tremens,  174 
of  dental  caries,  665 
of  dermatitis  calorica,  299 
of  desmoids,  271 
of  dilatation  of  stomach,  796 
of  dislocations,  527 

of  clavicle,  529 

of  elbow,  536 

of  foot,  544 

of  hip,  539 

of  jaw,  528 
of  knee,  544 

metacarpophalangeal,  537 
of  patella,  543 
of  shoulder,  532 
of  spine,  632 
of  duodenal  ulcers,  826 
of  Dupuytren's  contraction,  320 
of  ectopia  of  bladder,  978 
of  epididjmaitis,  1017 
of  epistaxis,  681 
of  epithelioma  of  skin,  315 

of  tongue,  660 
of  erysipelas,  95 
of  exophthalmic  goitre,  714 
of  exophthalmos,  594 
of  exstrophy  of  bladder,  978 
of  fat  embolism,  40 


INDEX 


1071 


'IVcaliiicril  iif  lihroiiiii  iiiulluscum, 

;u;i 

of  fistula.  <i:{ 

of  rt-ct  uiM,  SSd 
of  lloaliiif;  liver,  !1II 
of  forcinn   Ixulics  in  «'.so))lianils, 
740 
ill  i)liai>ii\,  (>7.'{ 
ill  stoiiiacli,  7'Jl 
of  fract  lire's,  4S(i 

of  clavicl.',  41)3 

("olios',  r>()4 

of  fcnnir,  /il.S 

of  fibula,  r>2l 

of  forearm,  f)!)! 

of  hiuiieiiis,  4il.') 

of  inferior  maxilla,   I'.K) 

of  Icfi,  Ml 

of  patella,  fjl? 

of  pelvis,  508 

of  radius,  ■')04 

of  ribs,  4<)2 

of  skull,  base,  558 
vertex,  555 

of  sternum,  492 

of  thifih,  512 

of  tibia,  521 

of  ulna,  501 
of  frostbite,  ;i02 
of  furuiu'le,  304 
of  gallstones,  920 
of  ftanprene,  77 
of  gastric  ulcer,  800 
of  gastroptosis,  797 
of  glantlers,  106 
of  glaucoma,  597 
of  gonorrhea,  152 

complications,  152 

of  testicles,  151 

in  women,  159 
of  hammer-toe,  321 
of  hematomyelia,  634 
of  hematorrliachis,  634 
of  hematuria,  959 
of  hemorrhage,  234 

secondary,  237 
of  hemorrhoids,  883 
of  hernia,  898 

of  brain,  566 

femoral,  908 

inguinal,  908 

postoperative,  909 

umbilical,  909 

ventral,  909 
of  Hodgkin's  disease,  378 
of  hydatid  cysts  of  liver,  913 

disease.  432 
of  hydrocele,  1018 
of  hydrocephalus,  579 
of  hydronephrosis,  973 
of  hydrophobia,  104 
of    hypertrophy     of    prostate, 

998 
of  hysterical  joints,  392 
of  injuries  of  eyeball,  604 

of  orbit,  593' 

to  thoracic  duct,  726 

to  upper  nerve  trunks,  726 
of  intestinal  obstruction,  acvite, 
836 
chronic,  839 
of  intraspinal  hemorrhage,    634 
of  intussusception,  832 
of  invagination  of  rectum,  882 
of  keloid,  271,  313 
of  keratosis  of  skin,  314 
of  knock-knee,  464 
of  laceration  of  lung,  722 
of  leptomeningitis,  573 
of  leukoplakia,  659 
of  lock  finger,  320 
of  lymphangioma,  279 

circumscriptum,  374 

of  skin,  315 
of  lymphangitis,  375 
of  Madura  foot,  110 


rreatmeiil     of      iiialfoiiiiat  ion 
esophagus,    73S 

of  respiialoiy  passages,  671 
of  iiialigiiaiit  edema,  108 
of  mastitis,  758 
of  iiuistodynia,  758 
of  iiiediasl'iiiitis,  728 
(if  melaiioiiia  of  skin,  317 
of  Mifiiiiigit  is,  572 
of  iiietatarsalgia,  470 
of  Morton's  disease,  471 
of  movable  and  floating  kidney, 
967 

l)odies  in  joints,  402 
of  myalgia,  331 
of  necrosis  of  bone,  428 
of  neoplasm   of    nasal    cavities, 

()78 
of  neuralgia  of  breast,  758 
of  neuropathic  disease  of  joints, 

392 
of  orchitis,  1017 
of  osteo-arthrif  is,  389 
of  osteomalacia,  435 
of  osteomyelitis,  419 
of  paiiophtlialniitis,  595 
of  papilloma,  283  _ 
of  paralytic  afTections  of  mus- 
cles, 332 
of  perforations  of   biliary  pas- 
sages, 922 
of  perineal  abscess,  1013 

fistulas,  1013 
of  perinephritis,  961 
of  periostitis,  421 
of  perirectal  abscess,  879 
of  peritonitis,  787 
of  phlegmonous     affections     of 

rectum,  879 
of  phlegmons  of  neck,  703 
of  piles,  883 

of  pneumatocele  of  scalp,  546 
of  Pott's  disease,  448 
of  procidentia,  882 
of  proctitis,  875 
of  prolapse  of  brain,  566 

of  rectum,  882 
of  pruritus  ani,  879 
of  pyelitis,  957 
of  pyelonephritis,  957 
of  pyemia,  92 
of  pyoneplirosis,  961 
of  renal  calculus,  966 

colic,  964 
of  retained  testicle,  1014 
of  rhinophynia,  314 
of  rickets,  162 
of  rupture  of  diaphragm,  722 

of  muscles,  330 
of  sacro-iliac  disease,  452 
of  sapremia.  87 
of  sarcoma  of  bone,  441 
of  scalds,  301 
of  scleroderma,  313 
of  scoliosis,  460 
of  scuryy,  160 
of  septic  nephritis,  957 
of  septicemia,  89 
of  sequestrum  formation,  429 
of  shock,  179 
of  sinus,  63 

thrombosis,  573 
of  snake-bites,  171 
of  spina  bifida,  626 
of  spondylolisthesis,  463 
of  sprains,  380 

of  spinal  column,  629 
of  status  lymphaticus,  165 
of  stenosis  of  pylorus,  799 
of  strictures  of  intestines,  828 

of  larynx,  684 

of  rectum,  877 
of  subphrenic  abscess,  754 
of  suppurative    tendosynovitis, 

321 
of  surgical  kidney,  957 


f  Treat  iiieiit     of    sympathetic  oph- 
I  thalmitis,  596 

of  synovitis,  385 
ai'iite,  383 
chronic,  386 
purulent,  385 
of  syphilis,  140 
of  talipes  e(|uinovarus,  460 
eqiiinus,  471 
\:ilgiis,  4()9 
of  tetanus,  101 
of  torticollis,  458 
of  traumatic  insanity,  582 
of  trigger  finger,  320 
of  tuberculosis,  120 
of  ])oiu',  425 
of  breast,  759 
of  joints,  398 
of  knee,  456 
of  ki(hieys,  903 
of  larynx, 085 
of  mesentery,  939 
of  i)erit()neum,  791 
of  skin,  307 
of  testicle,  1016 
of  tuberculous  hyilrojis,  399 

ulcers  of  intestines,  827 
of  tumors,  258 
of  bladder,  992 
of  brain,  585 
of  breast,  760 
of  larynx,  687 
of  spinal  cord,  622 
of  thorax,  730 
of  typhoid  ulcers  of  intestines, 

826 
of  ulcerations    of    biliary    pas- 
sages, 922 
of  varices,  365 
of  varicocele,  1021 
of  varicose  veins,  365 
of  vascular  growths  of  skin,  314 
of  vesical  calculus,  987 
of  warts,  312 

venereal,  312 
of  wounds,  238 
of  chest,  723 
contused,  212 
of  diaphragm,  726 
gunshot,  225 
of  head,  565 
of  heart,  335 
of  intestines,  824 
of  larynx,  676 
of  lung,  726 
open,  239 
of  pleura,  726 
punctured,  214 
of  wryneck,  458 
of  xanthoma  of  skin,  314 
Trephining  of  cranium,  587 
Trichiasis,  601 
Trigger  finger,  320 

treatment  of,  320 
Trismus,  97.     See  Tetanus. 
Tropacocaine,  207 
Trophoneuroses,  310 
Trophoneurotic  atrophy,  27 

diseases  of  bone,  432 
Tuberculides,  307 
Tuberculin  in  tuberculosis,  121 
dose  of,  121 

manner  of  preparation,  121 
Tuberculosis,  111 

of  abdominal  wall,  783 
of  axilla,  751 
bacillus  of,  54 
of  bladder,  118 
of  bone,  116,  422 
acute  miliary,  423 
chronic     tuberculous     oAeo- 

myelitis,  423  ^ 

pathology  of,  423 
s^Tnptoms  of,  423 
treatment  of,  425 
of  breast,  759 


1072 


IXDEX 


Tuborciilosis  of  brea;st.  trratniciil 
of,  7.5<» 
of  bwr.s:t',  lis 
of  clioroiil,  595 
cold  abscess  in,  112 
diagnosis  of,  113 
lumbar,  114 
jisoas,  114 

retropharyngeal,  114 
treatment  of,  114 
colon,  809 

degenerative  dianges  in,  111 
diagnosis  of,  120 

from  epithelioma   293 
of  face,  640 

fungous  granulation  in,  115 
giant  cells  in.  111 
gummas  in,  114 
of  joints,  393 

diagnosis  of,  398 
pathology  of,  394 
symptoms  of,  397 
treatment  of,  398 
of  kidney,  118,  961 
diagnosis  of,  962 
symptoms  of,  961 
treatment  of,  963 
of  knee-joint,  456 

treatment  of,  456 
of  larynx,  684 

treatment  of,  685 
lupus,  115 
of  lymph  nodes,  376 

cervical,  705 
of  lymphatic  structures,  116 
of  mesenterv,  939 

treatment  of,  939 
method  of  healing,  112 
absorption,  112 
calcification,  112 
caseation,  112 
encapsulation,  112 
suppuration,  112 
miliary  tubercles  in,  111 
of  mouth,  657 
of  mucous  membrane,  115 
of  muscles,  331 
of  ovary,  118 
l)aths  of  infection,  119 
of  peritoneum,  116,  118 
of  rectum,  876 
of  seminal  vesicles,  1021 
of  skin,  115,  306 
folliculitis,  307 
lupus  vulgaris,  306 
painful  subcutaneous,  313 
scrofulodcrm,  306 
treatment  of,  307 
verruca  necrogenica,  306 
verrucose,  306 
of  spermatic  cord,  1019 
of  stomach,  795 
of  tendon  sheaths,  118 
of  testicle,  118,  1015 
treatment  of,  1016 
of  tongue,  659 
of  tonsils,  662 
treatment  of,  120 
constitutional,  120 

tuberculin  in,  121 
local,  120 

amputation  in,  121 

Bier's    permanent   hj'pere- 

mia,  120 
excision  in,  121 
ignipuncture  in,  121 
iodoform  injections  in,  120 
Tuberculous  cystitis,  985 
hydrops,  treatment  of,  399 
panarthritis,  395 
peritonitis,  786,  790 
ascitic,  791 
fibrinoplastic,  791 
treatment  of,  791 
ulcerative,  791 
ulcers  of  intestines,  827 


Tuberculous   vilcers  of    intestines, 
symptoms  of,  827 
treatment  of,  827 
Tubulo  cvsts,  260 
allantoic,  260 

of  vitcllo-intestinal  duct,  260 
of  \\olffian  body,  260 
dermoids,  266 
Tumid  ulcer,  67 
Tumors,  255 

of  abdominal  wall,  783 

vascular,  784 
albus,  393,  456 
of  bladder,  992 
s^•mptoms  of,  992 
treatment  of,  992 
of  bone,  438 

cartilaginous,  440 
of  brain,  582 

symptoms  of,  583 
treatment  of,  585 
of  breast,  760 

treatment  of,  760 
of  cheek,  641 
classification  of,  259 
connective  tissue,  269 
cysts,  259 
dermoids,  264 
epithelium,  281 
of  nerve  elements,  279 
teratomas,  268 
clinical  observations  of,  257 
coccygeal,  627 

congenital,  635 
comparative  pathology  of,  256 
connective  tissue,  269 
angioma,  277 
chondroma,  271 
exostoses,  272 
fibroma,  269 
lipoma.  269 
lymphangioma,  27S 
myoma,  277 
myxoma,  276 
osteoma,  272 
sarcoma,  272 
cysts,  259 

glandular,  261 
hydrocele,  261 
pseudo-,  262 
retention,  259 
tubulo,  260 
derived  from  epithelium,  281 
adenoma,  284 
carcinoma,  289 
epithelioma,  286 

malignant  chorion,  292 
suprarenal,  292 
fibro-adenoma,  284 
fibro-epithelioma,  282 
goitre,  283 
hydronephroma,  292 
mucous  polyp.  283 
f)dontoma,  281 
ovarian  cystoma,  284 
papilloma,  282 
struma.  283 
<lermoids,  264 
ovarian,  267 
sequestration,  265 
tubulo,  266 
f)f  diaphragm,  753 
of  ear,  605 
embrN'onal  hj-pothesis  of  Colin- 

heim,  256 
of  face,  641 
of  gall-bladder,  927 
gangrene  from,  74 
of  heart,  336 
heredity  of,  256 
inflammation  as  cause  of,  256 
inoculation  experiments  on,  257 
of  intestines,  828 
intralaryngeal,  686 
intra-ocular,  594 
intratracheal,  686 


Tumors,  irritation  as  cau.se  of,  255 
of  jaw,  668 
of  kidney,  969 
of  larynx,  686 
of  liver,  914 
local  infectivity  of,  257 
of  limg,  732 
of  lymphatics,  378 
metiistasis  of,  257 
microscopic  appearances  of,  257 
of  neck,  706 
of  nerve  elements,  279 
glioma,  279 
neuroma,  280 
of  nerves,  622 
nomenclature  of,  258 
of  omentum,  935 
of  optic  nerve,  593 
of  orbit,  593 

cystic,  593 

vascular,  593 
of  pancreas,  953 
parasitic  theory  of,  256 
of  rectum,  885 
of  salivary  glands,  650 
of  scalp,  546 

acquired,  .546 

congenital.  546 

gaseous,  545 
of  skin,  benign,  311 

malignant,  315 
of  spinal  cord,  621 
diagnosis  of,  622 
symptoms  of,  621 
treatment  of,  622 
of  stomach,  801 
of  teeth,  665 
teratomas,  268 
of  testicle,  1017 
of  thorax,  729 

treatment  of,  730 
of  thyroid,  711 
of  tongue,  659 
of  tonsils,  664 
of  trachea,  687 
trauma  as  cause  of,  255 
treatment  of,  258 

of  operable,  259 
Pyphoid    fever,    .secondary   infec- 
tion in,  167 
spine,  462 

ulcer  of  intestines.  820 
symptoms  of,  826 
treatment  of,  826 

of  rectum,  876 


Ulcer,  65 

atheromatous,  339 
of  auricle,  rodent,  606 
of  biliary  pa,ssages,  921 
symptoms  of,  922 
treatment  of,  922 
callous,  67 
causes  of,  05 

constitutional,  06 

local,  05 

traumatic,  65 
duodenal,  825 

symptoms  of,  825 

treatment  of,  826 
edematous,  67 
erethistic,  66 
of  face,  640 
fissured,  66 
fistulous,  00 

of  foot,  perforating,  310 
fungous,  66 
gastric.  799 

diagnosis   of,   from   appendi- 
citis, 857 

operations  for,  81 1 

symptoms  of,  800 

treatment  of,  800 


INDEX 


1073 


Ulcer,  lioalfliy,  fifi,  G7 
lii'iuorrlmnii",  ("><> 
iiidoli'iit.  M) 
iii(lui:iti-(l,  (>7 
iiitlaiiii-<l,  (57 
of  iutcstiiios,  S25 
rancorous,  S27 
tliiiKiiosis   of,   from    aiiiM'iidi- 

citis,  sr)7 
(liiodcnal,  S2."> 

treatment  of,  S2(l 
(lyseiiteric.  .S27 
t  uherciilous,  S27 

treatment  of,  827 
ty])lioi(lal,  S2(j 

symptoms  of,  820 
treatment  of,  S2C> 
irregular,  (JG 
irritable,  GG 
livid,  G7 

])eptic,  of  jejunum,  SIG 
l)hage(lenic,  GG 
jirocess  of  repair  in,  G7 
of  rectum.  S7G 
catarrlial,  S7G 
chancroidal,  S7G 
symj)toms  of.  877 
svi)liilitic.  87G 
treatment  of,  877 
tuberculous.  S7G 
ty()lioid,  87G 
regular,  GG 
rodent,  GG,  G7,  288 
sloughinfT,  66 
treatment  of,  70 
tumid,  67 
undermined,  G7 
of  urethra,  1011 
venereal,  144.     See   Chancroid 
Ulceration,  65.      See  Ulcers. 
Ulcerative  endocarditis  in  septi- 
cemia, 88 
gingivitis,  664 
stomatitis,  657 
tuberculous  peritonitis,  791 
I'Ina,  dislocations  of,  536 
fractures  of,  501 
treatment  of,  501 
Ulnar  artery,  ligation  of,  356 

nerve,  operations  on,  623 
I'mbilical  hernia,  896 
treatment  of,  909 
vein,  i)hlebitis  of,  302 
Upper  extremitv,  amputations  of, 
1029 
entire,  1033 
Uranoplasty,  654 
Urea  in  auto-intoxication,  SO 
Ureteral  catheterization,  958 
Ureters,  anomalies  of,  955 
calculus  of,  973 
operations  on,  976 
stricture  of,  973 
I^rethra,     congenital    defects    of, 
1004 
episjjadias,  100.5 
foreign  bodies  in,  1009 
hypospadias,  1005 
injuries  of,  1008 
lacerations  of,  1008 
strictures  of,  1011 
ulcers  of,  1011 
Urethritis,  147 

gonorrheal,  in  women,  159 
Urethrometer,  155 

Otis',  1012 
Urethrotome,  Otis'  dilating,  157, 

1012 
Urine,  electroconductivity  of,  959 
incontinence  of,  982 
retention  of,  982 
suppression  of,  982 
Uveitis,  596,  598 
Uvula,  elongation  of,  682 
syphilis  of.  683 

68 


V.\LVi'i..\R  thrombosis,  35 
N'anghi'l ti's  cinenuitic  method  of 

amputation,  1048 
Varici's,  .3()4 
congenital,  364 
symptoms  of,  .365 
treatment  of,  3(>.") 
N'aricoceli-,  3()4,  1019 
treatment  of,  1021 
Varicose  aneurysm,  339,  342 
veins,  363 

extirpation  of,  36() 
symptoms  of,  365 
treatment  of,  365 
Variola,    secondary    infection    in, 

169 
Varix,  anastomotic,  3G4 
aneurysmal,  363 
compound,  367 
Vascular  growth  of  skin,  314 
treatment  of,  314 
svstem,     surgical    diseases    of, 
334 
syphilis  of,  135 
Veins,  air  embolism  of,  363 
angioina  of,  366 

treatment  of,  .367 
atrophy  of,  3G1 
calcification  of,  361 
fatty  degenerations  of,  361 
hemorrhoidal,  phlebitis  of,  362 
hypertrophy  of,  361 
inflammation  of,  361 
inj>iries  of,  217,  363 
treatment  of,  364 
mesenteric,  phlebitis  of,  362 
rupture  of,  363 
umbilical,  phlebitis  of,  362 
varicose,  363 
Velpeau's  bandage,  189 
Venereal  ulcer,  144.     See     Chan- 
croid, 
warts,  treatment  of,  312 
Venesection,  182 
Venous  nevus,  367 

congenital,  367 
Ventral  hernia,  896 

treatment  of,  909 
Vermiform    appendix,    actinomy- 
cosis of,  852 
anatomv  of,  851 
cysts  of,  852 
diseases  of,  851 
empyema  of,  860 
foreign  bodies  in,  852 
inflammation  of,  851 
tuberculosis  of,  852 
tumors  of,  852 
Verruca  necrogenica,  306 
Verruca^,  311 
Vertebral     arterv,    ligation     of, 

353 
Vesical  calculus,  986 
symptoms  of,  986 
treatment  of,  987 
diverticula,  262 
Vesicants,    counterirritation     bv, 

184 
Vesicovaginal  fistula,  839 
Villous  papillomas,  282 

intracystic,  282 
Vincent's  angina,  70.3 
Viscera,  wounds  of,  219 
V'itello-intestinal   duct,    cv.sts   of, 

260 
Volvulus,  832,  870 
von  Langenbeck's  incision  in  ex- 
cision of  elbow,  410 
of  wrist,  411 
von  Mosetig-Moorhof 's  incision  in 

excision  of  elbow,  410 
\'ulva,  elephantiasis  of,  371 
gonorrhea  of,  158 


W 

Waonkr's   osteopla.stic    resection 

of  cranium,  590 
Wandering  erysijjclas,  94 
liver,  910 

symptoms  of,  910 
treatment  of,  91 1 
\\'ardrop's  metinjd  of  treating  an- 
eurysms, 347 
Wart.s,  282,  311 
filiform,  311 
seborrheic,  312 
treatment  of,  312 
venereal,  trj'atment  of,  312 
Warty  liorns,  2X3 
Wasjjs,  poisoning  by,  172 
Weir's  oi)eration  for  .saddle-nose, 

644 
Wens,  285 
AVhite  swelling,  393 
A\'hitehead's   operation   for   hem- 
orrhoids, 884 
on  tongue,  GGl 
Whitlow,  328 
Witzel's  method  of  gastrostomv, 

807 
Wolffian  body,  cj\sts  of,  260 
Woodbury's   method   of  amputa- 
tion of  hip-joint,  1045 
Woolsorters'    di.sea.se,    106.        See 

Anthrax. 
Wounds  of  abdominal  wall,  gun- 
shot, 783 
penetrating,  781 
of  bladder,  981 
of  chest,  722 

treatment  of,  723 
contused,  211 

of  bloodvessels,  216 
of  tendons,  218 
treatment  of,  212 
of  viscera,  219 
of  diaphragm,  725,  753 

treatment  of,  726 
of  esophagus,  741 
of  face,  639 

fever,   aseptic,  85.     See  Surgi- 
cal fever, 
gunshot,  220 

of  abdomen,  232 
of  bladder,  233 
diagnosis  of,  225 
of  face,  229,  639 
foreign  material  in,  224 
of  head,  228,  565 
of  heart,  231 
hemorrhage  from,  223 
of  intestines,  823 
of  joints,  228,  381 
kev-hole,  225 
of  kidney,  233 
localizing  svmptoms  of,  233 
multiple,  224 
of  neck,  229 
pain  from,  223 
prognosis  of,  225 
of  respiratory  passages,  675 
shock  from,  223 
of  small  intestines,  823 
of  spinal  cord,  624 
of  .spine,  230,  624 
of  spleen,  233 
of  thorax,  230 
treatment  of.  225 
of  heart,  334,  733 
suture  of,  335  (note) 
treatment  of,  335 
incised,  214 

of  bloodvessels,  216 
of  .skull,  552 
of  intestines,  823 
lacerated,  212 

of  bloodvessels,  216 
of  muscles,  218 


1074 


INDEX 


Wounds  of  larynx,  675 

treatment  of,  675 
of  liver,  911 
of  lung,  724 

treatment  of,  726 
of  naouth,  658 
of  muscles,  330 
of  neck,  698 
of  nerves,  612 
open,  treatment  of,  239 
of  pancreas,  945 
penetrating,  of  joints,  3S1 

of  chest,  722 

of  orbit,  592 

of  skull,  552 

of  spinal  cord,  624 

of  spine,  624 

of  stomach,  805 
of  ]5leura,  724 

treatment  of,  726 
punctured,  213 


Wounds,  punctured,  of  abdomen, 
214 
treatment  of,  213 
repair  of,  215 

of  respiratory  passages,  675 
of  stomach,  794 
of  trachea,  699 
treatment  of,  238 
drainage  in,  239 
Wrist,  amputation  of,  10.31 
dislocations  of,  536 
excision  of,  411 
fractures  of,  507 
Wryneck,  457 
diagnosis  of,  458 
pathology  of,  457 
treatment  of,  458 
Wyeth's    exsector    in   excision   of 
joints,  409 
method  of  amputation  of  liip- 
joint,  1045 


Xanthei.as.ma,  601 
Xanthoma  of  skin,  314 

planum,  314 

treatment  ()f,  314 

tiilierosum,  314 
X-ray  burns,  303 

treatment  of,  304 

in  treatment  of  <-ancer,  297 


Yaws,  308 
Yeasts,  55 


Zygoma,  fractures  of,  489 


RD31 


P212 


LULuiviDiH  uijivcnsi  I  r  LiDnwiMti  insi  SIXI 

RD31P212C.1 

The  pnncinlfts  anfl  iiiMclirc  nt  mnriprn  <;ii 


2002108704 


